I am going to fax this to the airline. The airline will then call you back as soon as they can. They will inform you then of the date and time of your trip.  You can probably expect your flight to leave somewhere between 6 to 12 weeks from now, but if they deem your trip to be very important you might be able to go within 7 days.

This would be crazy in the travel industry of course (or almost any other industry … except perhaps phone and cable companies). Sadly, this is what the majority of referrals in health care looks like. Surgical services, community care, children’s services, mental health, you name it.

When referring patients, we usually can’t tell them: 1) when the next step is; 2) when they’ll find out when the next step is; and, 3) what the availability of the next step is. We sure can’t say what 1, 2,& 3 are for all organizations.

Everybody is so used to this approach to referrals in healthcare, but we think it doesn’t need to be this way.

The network of Community Support Services in Waterloo Wellington agrees, and have decided to do something innovative about it.  They’ve created a process where a client always knows exactly what and when the next steps are, before the referral is even complete.  More than a year into their journey and they have served over 2000 people so far. You can learn more about it here.

Under-performance in healthcare is a story about management focus. Today, managers know a lot about:

• staff performance appraisals
• training (the ‘chalk and talk’ type)
• writing proposals
• creating budgets
• occurrence and risk management (tracking, prioritizing, fixing mistakes)
• managing contracts (buying units of service etc)

The problem is, these activities don’t lead to fundamental and dramatic performance improvement. Feel free to challenge me on this, but in my experience, most managers readily agree.  They are perceived as required, often by the funder or other stakeholder, and they are always time consuming. A scarcity of management resources means efforts to control and improve how care is delivered don’t get addressed.  This causes frustration and a sense of resignation among managers.

As one small example, in my earlier management career I spent many hours administering the legalities and administrative procedures of effective competitive purchasing. Meanwhile, I would dread the staff meetings where the issues of service wait times were raised, repeatedly. These wait times were caused, in part, by the procurement approach itself. We had management time available for procurement, but not nearly enough for improving the service experience.

What great organizations like Toyota understand is that the transformation is in the nature of management itself, and the set of beliefs managers hold. They create a management approach concerned with how work is designed to deliver customer value. Transformed performance comes from changing the perspective of management from top-down to inside-out. In this approach, the customer is at the centre, pulling value from the organization.

For healthcare service delivery organizations, this means leadership gets a heartfelt understanding of what patients value. They know how patient demands present to the organization, and the capability of their organization’s processes to meet demand. They are regularly finding this out…directly.

We need to rebalance healthcare management’s focus away from deploying projects and rolling out activities conceived far from the ‘gemba’.  This is hard. It sounds very intelligent to speak in board rooms of system planning, governance and funding, performance incentives, managing compliance or rolling out shared IT solutions. Conventional management, and management consulting, in health care are replete with people who can speak smartly in these areas. We think we need to find ways to shift management effort towards designing and implementing, alongside staff, systems of work that deliver value to patients.

Our greatest successes in consulting have been when we help organizations alter their management approach, while also working with them on improving care processes. We have refined a three pronged approach that resonates with managers and clinicians alike- identifying value, understanding reality, and taking action. The results are dramatic and often unexpected.

The trick is in not copying WHAT other organizations, like Toyota, do. (Unless we are building cars!)  The goal is to transform management thinking so that we focus resources on the effective design of systems that meets patient demand, without fail. This will take unlearning some of our current management habits in health care.

Processes are the things that weaves people, tools and information together in health care. Health care process design is, to a manager, what a paint brush is to an artist.

What are you doing when you are changing your health care processes? Are you improving them? Maybe you’re streamlining them, making them more efficient or more value adding?

Or do you try to make them beautiful?

Other ways of thinking about processes can fall short:

• Making processes efficient: Efficiency is a dirty word in some circles, and can be used to justify all kinds of nasty things. Some invoke efficiency in the name of firing staff, cutting budgets or making something better for one person at the expense of another. A single minded focus on efficiency is cold. In health care, most processes are about the flow and experiences of people rather than movement and assembly of parts without waste. People deserve something more than an efficient process. A beautiful process is probably efficient, but much much more.
• Process Improvement: Improvement is a better term, it teases at the idea of building on past success, and that we should be continuously getting better at what we do. The saying “Improvement is a journey, not a destination” is the strongest element of the “improvement” concept. However, the term “improvement” is often incorrectly used in place of the word “change”, which may or may not yield any improvement at all. Furthermore, a process can be improved … but remain a poor experience for patients and contain tremendous amounts of waste. Aiming for an “improved” process often isn’t enough.
• Making the process lean: This term is great with people and organizations that have embraced and understand the concept. The reality is, the typical staff member doesn’t immediately know anything more about lean than a penguin knows about pineapples. Lean contains vital ideas for the quality improvement practitioner like making value flow at the pull of the customer, reducing waste, etc. People can be taught, and integrating this type of knowledge is the essence of management, but it takes time.

Your customers/client/patients interact with you through your processes. Your staff spend most of their working lives in your processes. Is it possible to make a process fun, a pleasure to be a part of, an experience to look forward to, joyful, to make it … beautiful?

I don’t think we strive to this level of achievement with processes, but we should.

No health care process is too mundane to beautify. Phone calls can be a pleasure, forms can be satisfying and communication can be enriching. Making a health care process beautiful respects the impact that it has on people and their lives. A beautiful process would deliver what people need, is not wasteful, and would be uplifting to experience.

Isn’t beauty – the experience of pleasure and satisfaction often in the presence of another – what makes life worth living? Save some room for considering beauty when designing a health care process.

We have an awesome school with very dedicated teachers and one of the best principals I have ever experienced. There have been huge changes in the past few years, systematic improvements, particularly in the reading program. I tucked my kids story in the back of my mind for future inquiry. Why would a school with such commitment to learning be sending the kids to watch movies when they also report having so little time to get through the curriculum? My spidey-senses were tingling (ok, wrong super hero).

Speaking to teachers and others behind the scenes shows the cause… A new report card web-based tool was deployed to hundreds of teachers across the school board. This software had a noble beginning. It was to replace the current electronic process with a more centralized method of making reports cards shareable across teachers and sites. The result included something else. It was a tool that even technically savvy teachers struggled with over many hours on their own time, spanning weeks. As desperation set in and deadlines approached, classroom time was redirected to completing the report cards.

So what was a typical problem with the tool? The reporting form only permitted 250 characters in the space provided for a comment. Clearly not enough for many scenarios. Worse yet, the teacher would only be triggered to going over the limit when they tried to save the form. Time was then spent locating the offending comment field by counting each field’s characters, and then rewriting the comments to fit in to the magic 250. The really keen teachers identified that ‘w’s counted as two characters. Staff were losing the battle.

The result was a a principal forced to re-deploy an excellent group of teachers away from spending time with kids to form filling. The bottom line was Kung Fu Panda, not curriculum, and a report card that incidentally had even less information on it for parents than the previous one.

This is a storyline all too familiar to health care workers. New assessment tools, admission forms, status reports, activity tracking forms and applications that involve lengthy handling times when they are rolled out to the front line, and poorly tested in a real care scenarios. There are only so many nurses, case managers, physicians and therapists so the result is inevitable. Less care for people who need care. A simple, well designed, intelligent assessment form, devoid of repetitive gathering, only containing information people really use, is all too uncommon.

So what might high performing community care organizations be doing? Firstly, they are redrawing the old battle lines. They are engaging in a process-oriented discussion with their partners and starting a superhero-like battle against pure waste across departmental and organizational boundaries. With limited resources, leadership is driving a culture that sees over-processing of information and useless travel, for example, as the new enemies. Conversely, they are agreeing on what value really means to clients, regionally, by asking them directly and setting about to improve results across the whole process spanning several agencies. With laser beam precision they are using their collective powers to remove activities, policies and procedures that get in the way of care. High performing managers are recognizing that even small process changes to high volume processes have a massive impact on the client experience, with staff feeling more valued because they are delivering value.

Those not doing this might start asking their aging patients which movie they would like to watch while they wait for care to arrive… Gone With The Wind may be appropriate.

When a process is evolutionary, patched and labour intensive, it’s success ultimately depends on the vigilance of the people in the process. Consider the following examples:

A nurse writes down an order for supplies and hands it to a clerk, who types the order into the supplier order system. A clerk from the supplier then prints out the order and hands it to Joe the supply picker. Joe reads the order for “30 cases of gauze” and since he has been a picker for 8 years, Joe knows that the nurse meant “30 boxes”, and changes the order. When 30 boxes arrive at the hospital, the nurse never even knew that something when wrong.

Now, if Joe had only been a picker for 1 month, the nurse would have received 30 cases, and had to send most of them back. But, the process worked, and nobody was worse for wear.

The challenge is, we rely on people like Joe everywhere in health care. Often it works, but sometimes it doesn’t. Most drug errors can be attributed to handwriting errors, and we rely on Joe to catch it. In fact, the institute of medicine reported that transcription errors are so prevalent that a patient can expect to be subject to a medication error for every day that they are in the hospital.

Modern Manufacturers build fail-safes into every part of their system. Go work at Toyota and just try to lose a finger, you won’t be able to do it. The machine will turn off, or a supervisor will stop you or some other intervention will occur. This is because they designed the requirement for human vigilance out of the system.

The health care industry has seen some success primarily in the area of devices, such as safe sharps.

Though not a safety issue, the opportunity to design “out” the change to make mistakes exists for business processes as well, such as documenting assessments, referral handling and supplies ordering.

The solutions might take the form of technology, process changes, or even something as simple as redesigning the usability of a form.

When redesigning a process, look for the opportunities for error, and make the error impossible to perform. Engineering tools such as Fault Tree Analysis are excellent ways to shed light on the problem

The objective of this blog is simple:

To share insights and thoughts on how quality improvement techniques and existing/emerging technologies can apply to improvement in the health care sector.

The authors of this blog have a particular interest in Community Care, thus most entries will likely relate to that topic (The term “Community Care” usually refers to health services provided outside the hospital or other institutions. Home Care is an example).

We have much planned for this blog. We hope to make it as much of a conversation as possible, so visit and comment often. We look forward to meeting you.