If health care legislation has done anything, it has made everyone aware that we must find better ways to do our work if we are to provide care at a cost we can afford. Finding better ways will require us to try new things. But the willingness to experiment accepts the possibility we might fail, and in health care, we believe there is little tolerance for failure. Any patient interaction deemed unacceptable, any budget not met exactly, or any bad outcome is viewed as a failure.
Certainly, we must treat each patient in a way that gives the best opportunity for a successful outcome. But we have extrapolated this fear of failure to other aspects of our work, so that experimenting with how we do our job, how we deliver our care, and how we view our patients is not acceptable in this zero-tolerance environment. Paradoxically, this hinders our ability to learn how to do our work better. Because we can't fail, we propose only solutions that must work. The irony is that this often results in proposed solutions that do fail.
Loss aversion — the fear of failure — is a deep-seated instinct for good reasons. The saber tooth tiger lurking in the forest trumps any benefit from harvesting crops we just learned to grow. Don't believe this? Look at how we handle patient complaints: discussion with the director, phone calls for damage control, reports to administration, corrective actions. What about a patient compliment? Does anyone call to find out what really worked so well? This is not to diminish the significance of a complaint, but what about the other 750 patients the doctor saw that quarter?
Our brains learn by comparing what our senses tell us against a pattern of expected outcomes and adjusting the pattern to this new information. To learn and be better requires experimenting and challenging what we know.
So try being a scientist. View proposed solutions not as the answer but as a hypothesis. If tested and proved true, then we have a successful response; if not, then we have learned what doesn't work, and this moves us closer to knowing what does. Either way, there is success in the learning; there is no chance for failure.
The most enduring solutions are crafted when everyone involved gets some benefit. To achieve this:
* Gain agreement on the problem to get everyone on the same page. Tie the problem to the bigger goals to decide whether this issue, of all the pressing issues, is the right one to address next. Then understand the problem deeply by seeking each person's view. Consider a problem like a prism. To see the entire prism requires learning how each person views their facet. Agree on how the problem is currently being handled to kn0ow where to begin.
* Gain agreement on the parameters for success to learn what each person needs from the solution.
* Only then, gain agreement on the proposed solution to test as the hypothesis, to discover the inevitable unintended consequences that hinder the proposed solution from performing as envisioned.
* Adjust to incorporate what is learned.
This is the essence of continuous improvement, working through obstacles step by step to achieve the defined target. It works with your brain, not against it; it helps your organization feel more comfortable to experiment; it enables you to innovate and find better ways to do your work.
Lean methodology uses the A3 report, so named by the 11×17 size of paper, as a structured format to create dialogue about an issue, document progress as more is learned and the process evolves, and share the results. By using a consistent reporting format, everyone gets on the same page. Condensing what is known on a single piece of paper requires a very detailed understanding of the issue, and anyone can more easily grasp the story if it is so well assembled.
Draw a line down the center of the page, but remember the layout is less important than the process to guide learning. Answer each question before moving to the next. Revise the answers as you learn more. Commit to completing the left side before giving any thought to the right side.
The left side seeks the issue's root cause:
* Problem: What is the issue?
* Background: Why is this important? Who is involved?
* Target: What would an ideal solution look like? What measurement might demonstrate whether a proposed solution is a success?
* Current situation: Draw what everyone agrees is the current process, if any, for dealing with this issue.
* Analysis: What problems keep the current process from achieving the target characteristics?
The right side documents the hypothesis:
* Several different countermeasures are proposed that might close the gap between current and target conditions; stimulate debate by including one that takes no new resources, and can be implemented immediately.
* The most promising countermeasure is chosen, and a test is devised.
* Establish the time line and responsibilities to get testing done.
* Decide when to check results to keep the experiment on track.
This seems like a lot of time and energy to expend when all we really want is a specific answer to a specific problem, but spending this time up front is more than offset by the time and energy saved in achieving what you really need.
So be the scientist you are. Test this hypothesis for yourself the next time you identify something at work that gets in the way of the ED being successful.
Dr. Jaben is a board certified emergency physician who has practiced in the community setting for 26 years. He spent the past year working in New Zealand, implementing a Lean approach in his hospital and health district.
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