Mark Graban, a long-standing Lean advocate and author, has an excellent podcast, which has over 200 editions. In a recent podcast edition, he re-posted a recording of his interview with a health care technology programme. In the course of the interview, he commented that ‘problems are treasure’. This chimed with me. I’ve heard this said as ‘problems are gold’ – but I like Graban’s turn of phrase, which captures the true value of identifying problems in the system.
Either way, this feels counter-intuitive – but it cuts to the heart of how services are managed. Health services are a large proportion of Government expenditure, and politicians understandably take a keen interest in their operation.
Many politicians feel that targets are part of the answer. This is reasonable. Health services cost a great deal of money, they matter to people, and those of us who work in them should be accountable for what we do.
So far, so good. In some cases, however, there are blatantly unhelpful responses to targets. NHS examples include ‘hello nurses’ in the 1990’s, when the A&E waiting time target could be met – well, by saying ‘hello‘, rather than by speeding up treatment. More recently, there were concerns in England that treatment time targets encouraged hospitals to ‘stack’ patients in ambulances outside A&E Departments rather than bring them in to the building, which would have started the clock ticking on the treatment target.This reveals people who feel they will be blamed.
Lean is a combination of methods, management approach and philosophy. Part of the shift in thinking is to focus on understanding rather than blame – asking ‘why‘ rather than ‘who‘. Managers need to understand problems, and they need to know that they exist. If people feel that they will be blamed, or punished, then they may conceal problems or work around them. They are certainly likely to avoid publicising them.
Problems are, however, an important part of continuous improvement. Paradoxically, they become even more important as systems improve. When a system is truly chaotic, it can be difficult to work out what is disrupting the flow, because it is very difficult to see what is happening. As systems improve, and flow becomes relatively smooth, it is easier to see problems. I use the analogy of a Highland stream: when rainfall is heavy, and the water is rolling and tumbling, it’s impossible to see barriers to flow in the stream. When the volume drops a little, it is easier to see the rocks and boulders, the pools and eddies. Problems in a health service therefore become the keys to where the blockages lie, where the information swirls, and where the processes pause.
If staff are to reveal problems in a timely manner, they have to have faith in the response. Everyone understands that individual errors occur, but the key is trying to work out what causes errors. Managers have to show that they are interested, that they begin from the assumption that staff want to do a good job, and that they want to reach a shared understanding of the problem. Staff very quickly recognise whether a manager’s behaviour is aligned to their stated values, or not. When managers conspicuously welcome being informed of problems, listen thoughtfully, ask why the problem occurs, and work alongside staff to identify solutions, then the likelihood of future reporting increases markedly.
Managers cannot control government targets, but they can control how they react to problems in their own service, and the approach they take. No system is perfect, and working closer to perfection depends on identifying problems in systems and responding to them in a positive and engaged way. This, in turn, relies on moving away from a search for blame to a search for understanding the cause of problems, and doing it consistently over time.