There’s something very exciting and very odd about applying strategies like Lean and Six Sigma to healthcare.
On the one hand, those methods are clearly needed. The focus of Lean is to reduce waste, which amounts to billions of dollars in the US. Six Sigma aims to reduce “defects” in outputs as close to 0% as possible. Compared to current patient safety data, that sounds like a miracle.
Those ideas and others like it came from manufacturing, though. By its nature, healthcare is complex. Even ignoring interactions with patients (which, of course, you shouldn’t), healthcare is a social activity among the professionals who practice it. Copying an improvement system that moves inert items along an assembly line into healthcare is going to have an impact, but only on what can be improved along the assembly line. I’m certified in Lean, and don’t misunderstand: there’s nothing inherently inhuman about Lean methods or Six Sigma. One of the things I love about Lean is its principle that people on the front lines of the work know best how to improve the work. Healthcare obviously needs to reduce waste and ramp up the number of processes completed within relevant tolerances. Any improvement in healthcare, though, is going to have to take its humanity into account.
This paper by Lanham et al. focuses on that question: how can we improve healthcare, knowing that we need to improve not just the linear flow of parts, but the interconnected webs of people?
“Practice improvement efforts such as continuous quality improvement, which aim to improve organizations one component or one process at a time, are often less effective than expected. We believe that this is due to a misconceptualization of quality as something that can be achieved using strategies rooted in reductionism (a perspective that quality is improved by focusing on the parts/components of a system).”
The question of “quality” is a crucial one: if we use Lean and eliminate waste, that’s a huge win. If we use Six Sigma and get all of our individual processes outputting near-perfect results, that’s amazing. Is either of those things—in and of themselves—”quality”?
The authors take the view that quality is not a linear improvement of the parts of the system, but a knitting together of the nonlinear relationships between the actors in a system. The common view is that “quality is designed/imposed/planned” and “achieved,” but in reality “quality is emergent” and “evolves”: We pay particular attention in this article to the property of emergence. Emergent properties are system-level properties that arise over time from the local interactions among agents.
Improving healthcare is difficult for the same reason that improving any work culture is difficult. People are complex and their relationships are exponentially dynamic. Advice on improving people’s working relationships usually ends up sounding twee. Foster trust. Be respectful. Communicate well. From this point of view, it’s no wonder improvement systems from manufacturing are widely adopted. When faced with our unpredictable humanity, there are days when working with empirical tools on repeatable, tidy, linear processes sounds refreshingly straightforward.
At first, this paper by Lanham, et al. reads like it’s going to go the route of a standard management listacle. They detail seven elements of relationships in successful practices. It contains some items you’d expect, like “trust” and “respectful interaction”. The element that surprised me most was “heedfulness”:
“Heedfulness occurs when an individual pays attention to his or her specific task at hand1 as well as to the task of the larger group. In heedful practices, people watch to see how their actions influence the actions of the group, and they seek awareness about how their actions are intertwined with the actions of other members of the practice.”
It’s not just that “heed” and “heedfulness” aren’t terms I use every day. The notion of heedfulness touches both the social nature of health work, and improvements in safety and quality. It’s a recognition by each person that what I do matters to me, to the patient, and to everyone else that will be interacting with this patient and their health.
Thankfully, this study doesn’t just list these qualities. The authors build on previous work which demonstrates that these qualities can be built and strengthened by “reflection” and “sensemaking and learning”. When quality is short of standards or when adverse events occur, some kind of consensus will form about what happened and why. This process may start at the individual level, but it is ultimately a social process. If the process is deliberate, reflective, and committed to learning, it can be an opportunity to improve quality and the relationships and processes that contribute to it. If the process is blindly automatic or seeks to blame an individual, the organization will learn nothing and likely not improve. As the authors succinctly state, not all sensemaking is beneficial to organizations.
This component of deliberate sensemaking is where storytelling is essential. Stories inherently focus on what is novel in a given situation and the cause and effect chains that spiral from that initial novelty. Narratives are the primary way we make sense of the social world and loop learning back into practice. If we hear them, tell them, and reflect on them deliberately, it helps start the feedback loop that makes quality an emergent property:
Because sensemaking is a social activity, we believe that practice relationships are critical to the quality of the sense that is made from unexpected events. Learning is also a social act. One way to improve health care quality is to encourage a culture of learning—learning from mistakes, learning by doing, and learning by experiencing history richly.2 Our model relies on the logic that effective learning can improve the quality of care delivered by a practice. … Effective sensemaking and learning can improve a practice’s capacity to make decisions and take actions that lead to better health care quality.
Sources
The article reviewed: Lanham, Holly J., Reuben R. McDaniel, Benjamin F. Crabtree, William L. Miller, Kurt C. Stange, Alfred F. Tallia, and Paul A. Nutting. “How Improving Practice Relationships Among Clinicians and Nonclinicians Can Improve Quality in Primary Care.” The Joint Commission Journal on Quality and Patient Safety 35, no. 9 (September 1, 2009): 457–AP2. https://doi.org/10.1016/S1553-7250(09)35064-3.
1 Weick, Karl E., and Karlene H. Roberts. “Collective Mind in Organizations: Heedful Interrelating on Flight Decks.” Administrative Science Quarterly 38, no. 3 (September 1993): 357. https://doi.org/10.2307/2393372. ↑
2 March, James G., Lee S. Sproull, and Michal Tamuz. “Learning from Samples of One or Fewer.” Organization Science 2, no. 1, (1991): 1–13. ↑
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