Dealing With Whole Systems

Jigsaw 2‘Inch wide, mile deep’ is a standard mantra in many Lean teaching packages. The phrase promotes an in-depth understanding of the area in which the work is being done, while staying focused. Projects sometimes bog down because they are trying to cover too large an area. The advice to spend time achieving a rich understanding of the processes is good. People working on improvement projects often worry, however, about where the precise boundaries of their work should lie.

Sometimes the ability of one service to do its job is affected by the processes on either side. For example, delays in sending a referral, or problems with the information supplied, can affect flow in to a service. If there are delays in diagnostic results arriving, or problems in another part of the process (e.g. community service availability) then that can, in turn, affect flow in a service.

Common advice is to focus on a relatively small part of the process, and to improve the part that you can. Later work can focus on earlier, later, or parallel parts of the process. This is reasonable counsel, but it is important to consider impact on other parts of the service. There are several ways this can be addressed:

  • Involve people whose services feed in to the work, or who take patients from the service, in improvement work. This has three benefits. They can bring information on their service; the participant leaves with a much fuller understanding of the other service, and when they come to undertake improvement work, they have already seen the process in practice. It is easy for staff to see all problems as being located in other services, and increasing mutual knowledge has a lot to recommend it.
  • Develop balancing measures. When agreeing what will be measures as the metrics of the project, consider where unwanted effects might be seen, and think about how to measure them. Improvement work is never finished, and identifying unintended consequences as quickly as possible allows action to be taken.

Lean projects are often directed at parts of the system that are seen as bottlenecks. This is in line with the Theory of Constraints, a system associated with Eliyahu Goldratt. There’s an interesting discussion of the similarities and differences between Lean and the Theory of Constraints in this post.

Keeping awareness of the wider system is challenging. It is easy to focus down on technical details of a process, and to lose sight of how it affects the service user (the point of Lean work, after all) and of how it affects other parts of the process. Several organisations have tried ways to maintain the focus on the patient, and to stop Lean projects happening in isolation.

The Esther Project is work in Sweden, that focuses on what services would be needed by a composite patient (an older, frail person called ‘Esther’), and what qualities are needed in those services. This is in line with Lean ideas of focusing on value for the patient. The idea has been used in other areas, and information on the topic can be obtained on the 1000 Lives Plus website. Ideas like this could be of use in Lean projects, in keeping the work focused on the user of the process.

Another idea is a variation on the oobeya process.  Oobeya means ‘open big room’ Toyota seem to have developed the concept, and used it to bring together people from different parts of the organisation involved in a specific project development.  There’s a description of the original process by Takashi Tanaka on the Lean Enterprise Academy site, here, and a video of Tanaka talking about oobeya and its on-line variants here.

The process was designed for product development, but it has been used in health care, most notably in the UK in Sheffield. Box 5 of this report has a description of how the method was adapted for use in the NHS, promoting involvement of different staff groups, and of people working in different parts of the same clinical process. In Sheffield, this was used as part of a large process change, which had many individual elements.

However you do it in practice, keeping sight of the impact of your work on the activities of other people is important. That’s not a reason for delaying work, but paying attention to it should help your own improvement project, and make it easier to identify unintended consequences so that you can act to minimise their impact.

Photo by Michael Connors

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