Good versus Great – Four Ways of Increasing the Effectiveness of Quality Improvement Work

Big and little dog

Big and little dog

In the last month, I’ve heard report outs on about ten Rapid Process Improvement Workshops (RPIW). Some of these were report outs from a new RPIW, while others were reports on progress on a previous project. I’ve also heard or watched reports from other organisations and settings. The striking thing to me is how varied the results, or work in progress, can be.

In a previous post, available here, I reported on a series of Improvement Events in a health care organisation that started off well. but gradually produced less and less change. I did not see the same pattern in those I attended – it was much more mixed than that, and many had produced substantial change – but it did encourage me to think about success, set backs and context.

Virginia Mason, one of the pioneers of the use of Lean in health care, reported in their book that they repeated many of their early improvement events because they had real difficulty in sustaining gains. Mark Graban argues that one of the reasons for this is that large, set piece events don’t always engage staff for a sustained period, which pushes him towards a view that supporting staff to make continuous improvements at any time has more direct benefit. I am sympathetic to this view, but I do not think the two positions are mutually exclusive.

Compared to the combined experience of the Virginia Mason Institute, and of Mark Graban, I am very new to Lean. The organisation in which I work has undertaken just under 30 RPIWs – using mainly the North East Transformation System, a version of Lean, provided introductory training to around 2.500 staff, and trained 18 Lean Leaders, and this, combined with the chance to hear and see progress in other settings,  and to discuss Lean with experienced coaches, has led me to some preliminary views on the factors affecting the effectiveness of Lean, particularly when using improvement events.

Selecting the right time

Service changes can be a good time to look at processes. This depends on scale of change, however. At times, people can be willing to look at new options, and can see changes as a new start. My experience so far is that there can be service change that is so far reaching, so time consuming or so demanding of mental energy that it can simply be the wrong time to support the service through further change. Examples could include a service which is being considered for external tendering, a service moving location or ward, and a service in the midst of a significant management re-structuring.

Preparing for the work

I tend to avoid Japanese terms, but the word ‘nemawashi‘ does seem to apply. There is a good post about nemawashi here, describing its Japanese use. It refers to a process of meetings with individuals and groups to understand their views on a proposal, revising it in the light of feedback – and, if necessary, abandoning the work, at least temporarily, in the light of disagreement. Waiting for complete consensus may not always be practical, but it does make sense to understand views, and to learn from them. In some cases, this can result in a shift in focus – or scope, as it is often called, based on the advice and experience of the staff and service users.

Picking realistic changes

This is the choice that inspired the selection of the Great Dane photo above! What is best? A small change you can make now, or an enormous change you can make – or may be able to make – in the future? My view is that Lean is about continuous quality improvement, and this is usually a series of small, achievable steps, rather than one giant leap. Identifying a spectacular improvement – a new facility, an extension to an existing facility, a new IT system etc. – can feel like a great solution – but it may not be deliverable in a realistic timescale. There is nothing wrong with coming up with transformational changes, and identifying an ideal future state is an important part of many Lean processes. It can be an alternative to action in other cases. There are few systems in which the only improvable challenge relates to premises or IT systems.

Supporting Change

The choice of the person who follows up improvement events is important. The individual is often selected because they play a key role in the service. Usually this works well, but thinking about the identity of the Process Owner – the person who keeps the work going – is essential. Getting the support for them right, and being sure that they have the background knowledge, time, interest and management support, are all essential.

So, making change happen, and making change stick are challenges – but the alternative to applying a systematic approach is to have no structure at all. Most people accept that, if we do what we have always done then we will obtain the results we have always had. Lean is a very useful process by which to help people to look at their services with fresh eyes, but it does need careful support, application and persistence.

Photograph by Ellen Levy Finch, published on Wikimedia Commons.

One thought on “Good versus Great – Four Ways of Increasing the Effectiveness of Quality Improvement Work

  1. Pingback: Improving Patient Flow | Lean Health Services

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