Monday, May 27, 2013

I get it! I'm a fish! - Communication as a prerequisite to improvement

I had an interesting conversation last week with someone who shares my enthusiasm/impatience to move ahead with health system improvement.  He offered me a new perspective on a point that has been frustrating me for years, that is, we seem to be able to make fairly rapid improvements within our Urology group, but change at the provincial level is often slow.

Even though Saskatchewan is seeing amazing improvements through some focussed initiatives (see Sask Surgical Initiative and wait time trends chart), I want the changes to be faster and deeper.  "Faster" speaks for itself, but "deeper" is a little elusive.

Many of the changes we've made in Saskatchewan are "first-order", that is they're incremental and happen within the existing structure.  For example, we're doing more surgery to reduce the backlog and waiting list.  But, if the underlying mechanisms and culture that created the backlog in the first place aren't themselves changed, we're in danger of backsliding.  As the Surgical Initiative enters its last of 4 years, we're going to invest in processes designed to maintain surgical wait times at the desired levels.  That is, we're going to spend money pushing back against a resistant system.

A second-order change involves new ways of working and thinking about a process.  In the context of reducing surgical wait times, we might reward (not necessarily financial!) providers for their ability to deliver timely care.  Or, we might look closely at whether or not a particular operation is actually appropriate for a given patient.  If someone is unlikely to benefit from surgery, or, after being fully informed of risks, benefits and alternatives, decides against having surgery, wait times may be maintained by reducing demand.  Ultimately, we might change the system deeply enough that the disease currently treated with surgery no longer exists (quit smoking!).

Of course, second-order change requires a profound commitment to improvement, and investment in building communication and cooperation.  That's where my friend offered me insight into why I'm frustrated by the generally slow pace of change in the provincial healthcare system.

He follows some of the work described in this blog, and in particular our recent work on rapid improvement through 5-minute huddles.   He knows that I've challenged the need for week-long RPIWs (Rapid Process Improvement Workshops) that occupy huge amounts of staff and administrator time, sometimes to accomplish seemingly trivial results.  If our Urology service can move forward an improvement project over 1-2 weeks in 5 minute daily aliquots, why can't other services/departments do  the same?  His answer to me: Much RPIW time is spent establishing the team and setting context, whereas our urology team is already highly functional and knowledgeable about our own practice.

A-ha!  Our Urology group is already used to working cooperatively and collegially, discussing issues frankly, and developing consensus.   We've have regular times to meet and expectations that process improvement is part of our daily work.  In the same way that fish don't see the water they're swimming in, we're so used to being immersed in a supportive environment that we don't notice it anymore!

So, how do we make more fish? Or, maybe it's the water we need...

Training all healthcare staff and administrators in process improvement techniques is a toe in the water; it's first order change.  To get everyone to jump into the pool will take a more profound intervention.  I think that formal communication training is the key.  I flattered myself a couple of paragraphs back when I congratulated us for our collegial urology environment.  But, it's easy to get along when you all live essentially the same professional life: hospital rounds, take out a kidney, clinic, repeat.  Urologists have similar training, goals and professional culture.  It's much more difficult trying to communicate with someone from a different tribe.

A proposal: Rather than investing in training lots of people deeply in a specific process improvement methodology that they may use only occasionally, let's train everyone in healthcare in a common communication methodology.  That training would be used every day.  Healthcare would be safer, and better communication would obviate some of the process messes we're trying to fix.  Smaller numbers of process improvement experts could then be deployed to coach others in project teams, which would hit the water swimming because communication and teamwork would already be second nature to them.


  1. Often high performing, quality driven organizations are referred to as 'learning organizations'. You have nailed it - education/orientation in improvement science is insufficient to build such a 'learning organization'. We are committed to learn by doing. Teamwork (a generalist skill) is essential - and is linked to strong communication (dialouge), conflict resolution, alignment, establishing shared purpose and direction, cultivating the organizational culture and protecting/dedicating time. With respect to the latter, think of it as a gestation period - it will take the time it takes irrespective of how impatient we are and how many resources we throw at it. Many organizations have failed in creating a 'learning organization' because they were on a sugar high of improvements - utilizing the tools and techniques - and eventially began ignoring the heart and culture and team and customer. They saw the gold and in an effort to obtain it more rapidly -they killed the goose. Second order change is required. First order change can get people to the table. The real discipline will be to realize that process and outcome both matter. A true 'learning organization' involves everyone - leaves no member behind.

    The water you currently swim in Kishore is much more catalytic, diverse and inviting than you realize. It is that way because of you, your team, your approach, and the culture that has been cultivated (the way you and those around you do things). For others, they have yet to build that coral reef.

    Daily Kaizen by 45,000 providers is our ultimate aim. In order to get there, we need teamwork and culture. Our aim is the catch up with you (and we will). Don't wait for us.

    Deputy Dan

  2. Thanks, Dan. Insightful and inspiring. (As always!)

    Love the "gestation" metaphor - echoes a great line from Linda Duxbury I heard at a presentation yesterday: No matter how much you want to have a baby, 9 women pregnant for 1 month each won't do it.

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  6. I heard at a presentation yesterday: No matter how much you want to have a baby..

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