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This chapter is from the book

Uncontained Change

When change is made by so many disparate groups, it occurs in a nonuniform, uncontained, and often poorly understood way. Change is unmanaged, with one change overlapping the next, and the process is never allowed to settle. Deming3

gave a wonderful demonstration of rolling a marble around a funnel to hit a spot on the floor. By consciously trying to manipulate the dropping process to improve it, an operator only makes things worse (the operator is in fact merely adding variability to the process). It is not until the operator lets the process settle, and doesn’t add change after change after change, that the process begins to perform consistently and in fact better.

If a process is constantly in flux, it is virtually impossible to get a pulse on how well it truly can perform, since any snapshot in time is essentially of a different process. Also, as performance does improve, it is very difficult, if not impossible, to understand which change the performance improvement can be attributed to and hence which changes to keep.

The greatest problem with uncontained change then occurs: a potentially well-performing process is overwritten with a poorer one. Uncontained change leads to no standardization or consistency across units or shifts or even individuals on the same shift, and the process literally just keeps changing and changing and often never truly improves. This phenomenon, aptly named “1-sigma churn,”4 is absolutely the norm across hospitals.

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