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Existing Change Models: Why the Traditional Healthcare Models Are Struggling

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Performance (and performance improvement for that matter) in healthcare is not where it needs to be. Instead of critiquing the solutions implemented and working from there, Ian D. Wedgwood looks instead at the improvement methodologies used, in this chapter from Lean Sigma--Rebuilding Capability in Healthcare.
This chapter is from the book

Traditional Change Models

As described in the Preface, the general consensus is that performance (and performance improvement for that matter) in healthcare is not where it needs to be. Numerous articles and publications each year identify the problems or argue the root cause. The intent here is not to delve too deeply into the argument, but to highlight one key problem (in this case with the performance improvement methods utilized) and then, in the chapters to come, to demonstrate a solid solution to that problem. Consider the following symptoms:

  • There is a sense of resource overloading—it is difficult to get team time to even start a project..
  • Most improvement is incremental; there is little in the way of breakthrough change.
  • Hard savings are just that: hard to come by and even harder to measure.
  • It is difficult to attribute any measured success to specific changes made.
  • Improvements fail to stick.

Not all organizations exhibit all these symptoms, but they are certainly commonplace, whether in a small clinic, a hospital, or a system. So if the symptoms are clear and abundant, why, with all the effort under way, are the symptoms still the norm?

The usual approach is to critique the solutions implemented and work from there. Here the suggestion is to look at things in a different way. The place to look is not at the solutions implemented, but rather at the improvement methodologies used—the route to solution and implementation.

To better understand this statement, first let’s examine facets of the traditional improvement methods. Improvement is often undertaken as follows:

  • Multiple groups are sanctioned (often independently) to make improvements, to bring agile responsive change.
  • Operations and clinical managers are measured on the improvements they make.
  • All quality and operations staff in the process are encouraged to make changes and test improvements, to develop change quickly, and to rapidly take advantage of potential improvements.
  • Small group efforts are focused on a localized part of the process to alleviate the problem, and then the group moves on to the next focus area.
  • Changes made require a consensus of as many stakeholders as possible to ensure buy-in from the people who will do the new process or be affected by it.
  • A key source of improvements is from benchmarking other organizations, typically in relatively close proximity or from recent literature, to gain quick, proven solutions.
  • The change model is based on continuous improvement using a cyclical PDCA1 (Plan, Do, Check, Act) change model—looping through the cycle again and again to gain higher and higher levels of performance.
  • Stand-alone quality groups own process improvement in the organization, so that operational staff aren’t drawn away from their operations duties.
  • The focus is on getting better leaders, managers, and communication by developing the existing people or recruiting better people.

At first glance this seems to be a robust set of operating approaches for change, which accounts for their longevity in the healthcare industry. Why, then, do the majority of other industries and organizations not use these approaches? They do seem reasonable—until, that is, we start to line up the symptoms with the change model, and then the flaws become very apparent. This is best shown through an example, as follows. Consider a scenario of operations or clinical managers trying to meet assigned targets, perhaps to increase patient satisfaction by 10% or similar. They do what they’ve been trained to do: they talk to as many people as possible to find a solution that seems to work well in another hospital or institution; on returning to home base they bring together as many people in the process as possible to gain some kind of consensus; they educate key personnel on the solution and commence operations with the new method; they then track the metric (in this case patient satisfaction) to see what, if any, change has occurred.

Oftentimes the metric will improve, but sometimes not, and commonly over time it drops back to where it was before. Sometimes it even gets worse than it was when the change initiative started.

Meanwhile, others in the organization are going through the same motions for the same process (usually under the direction of a different change group). They, too, are finding the “best solution” and bringing it back home, training a few people, and measuring impacts.

Over time, change is continuously occurring, but performance improvement doesn’t necessarily follow.

The problems here are actually quite simple to categorize, and we’ll examine each in more detail in the remainder of this chapter:

  • There are disparate change groups.
  • There is uncontained change.
  • There is no standard change approach.
  • The belief is that simple tools can fix the problems.
  • There is a reliance on benchmarking to provide the solutions.
  • Changes are not made based on data, or on the right data.
  • Changes are made based on symptoms, not causes.
  • Focus is on systems rather than processes.
  • Focus is on people, not on processes.
  • There is a lack of context for solutions, and in particular an unclear understanding of the Voice of the Customer (VOC).
  • Solutions involve adding extra activities to the process (patching) instead of subtracting activities from the process (streamlining).
  • Implementation is poor and limited in magnitude. There is little or no emphasis on sustaining the improved process, or control.
  • There is confusion regarding the roles of management versus leadership.

To an objective observer, some of these issues are readily apparent. To those in the heat of battle of patient care, they are considered part of everyday life, are accepted norms, and are overlooked or aren’t perceived as the key issues to be addressed.

Let’s take a look at each in turn and how they can combine to have such a negative impact on future performance.

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