Guiding Principles For Excellent Healthcare

This is the first in a series of blog posts where we will discuss our current thinking on each of the principles that work together as a system to guide the thinking and actions behind better healthcare.  The focus of this post is to explain what we mean by “guiding principles for excellence in healthcare.”  We will describe our current thinking behind these principles, and we invite you to share your thoughts as well.   We published a white paper in 2011, which provides some background about our journey to understand these principles.  A fuller description of guiding principles, some of the sources behind our thinking, as well as current examples of application can be found in this case study.  Much of what we have learned can be attributed to our work with partner organizations like the Lean Enterprise Institute, the Shingo Institute, the Institute for Enterprise Excellence, and others.  We believe we are just scratching the surface of what these principles mean for us.  We try to continue to learn and share what we are learning with others.

Why focus on principles?  The reason is because they are foundational to a lean transformation, and they need to be understood by senior management in any healthcare organization.  Most people gravitate to the lean tools and try to copy them, but they don’t know what to copy.  Some people are imitating the behaviors they see (like having huddle meetings, or using white boards, or gemba walks).  These activities are not wrong, but need to be understood in light of the principles behind the behaviors.

When people visit a great organization to learn what makes them perform so well, they see things such as tools, methods and other artifacts that are readily apparent.  These are “on the surface.”  An iceberg is a commonly used metaphor to explain this.  The visible part of the iceberg is small compared to what is under the surface, what you see is not all there is.

For instance, you might see visual management boards throughout the organization.  That’s the surface.   If you asked a few more questions and looked a little deeper, you would see (just under the surface) some of the processes behind the tools and methods.   Some people might call this the “standard work” or the current best process that we all agree to follow.

If you asked a few more questions and looked even deeper, you might discover a sub-system or a system, which is defined as “a set of interdependent components working together toward a common aim.”  The visual management board is one of the components of this system and so are the work instructions and standard work.  Perhaps there is a “visual management system” (or sub-system), which could be a part of a larger “lean management system.”

If you go deeper, you might discover the principles behind the systems.  These principles are the primary focus of this blog post, and a series of related posts that we will be adding over time.  If you go even deeper you would find the knowledge behind the principles (but that would be an entirely different blog post).

Principles are not the same as values.  We see a distinction between principles and values, which is summarized in the table below.

A common example of a principle is “gravity.”  Whether you are aware of it, or whether you believe in it, gravity affects us all and governs consequences of our actions.  Just take a step off of a tall building to understand the consequences of the principle of gravity.

The guiding principles for excellence in healthcare (and any enterprise) are in effect all the time.  These principles drive the consequences for organizations that use Baldrige as a guide, or Studer, or whatever the model might be.  The principles govern the consequences of everyone’s actions regardless of the model or approach.  The problem is that most of us are not aware of these principles.  We did not learn about these principles in our schools or in the businesses we worked.  We learned about and have been using a different set of principles – the principles of “common sense” and the prevailing style of management.  We need to unlearn the principles from the prevailing style of management and learn about principles for enterprise excellence.

What are some of the erroneous principles that currently drive our actions and behaviors?  First, let’s describe some of the prevailing management actions and behaviors – what you see “on the surface.”

W. Edwards Deming, PhD, described examples of faulty management actions in his books, seminars and consultations.  In his 1993 book, "The New Economics," he compared and contrasted the "prevailing style of management" (present practice) to better practice.  Under the prevailing style of management he described:

- Lack of constancy of purpose
- Short-term thinking
- Emphasis on immediate results
- Think about the present tense; no future tense
- Keep up the price of a company's stock.  Maintain dividends.
- Failure to optimize through time
- Make this quarter look good.  Ship everything on hand at the end of the month (or quarter).  Never mind its quality; mark it shipped.  Show it as accounts receivable.

Dr. John Toussaint wrote about the prevailing behaviors of healthcare managers in his books, On The Mend and Potent Medicine, and in his recent article “The Promise of Lean In Healthcare”, published in the Mayo Clinic Proceedings, and it has become a part of every presentation he makes.  Some attributes of what he calls “White Coat Leadership” (for clinicians and administrators) are:

- Exhibit an "all knowing" attitude
- Adopt an "in charge" posture
- Demonstrate autocratic tendencies
- Adopts a "buck stops here" approach
- Shows impatience
- Blames others
- Controls others

One of the principles behind these behaviors is “reductionist thinking.”  We see our organization as a collection of parts and we believe that by studying and managing the parts separately, we’ll get a well-run organization.  Our view of the organization looks like a typical organization chart.  Let’s use productivity management as an example.  The traditional (prevailing) approach is to give each department a target and tell them to stay within that productivity level.  We reward and recognize managers who manage their box well.  For example, we believe that a productive OR, plus a productive nursing unit, plus a productive laboratory will equal a productive organization.  In reality, we get the opposite.  This kind of approach drives unproductive and wasteful behaviors of maintaining silos, producing a lack of collaboration and cooperation.

The problem is that we don’t “think systemically,” which is one of the guiding principles.  When we view the organization as a system, we see how the parts are connected and interdependent.  We understand that for the organization to run well, the parts must (by definition) be sub-optimized.  Some departments will need to run at a loss, or be less productive (when measured separately).

This is just one example of one of the guiding principles we will be discussing in this series of blog posts.  This is our current thinking, but we will still learning.  What do you think?  We would like to hear your thoughts on this.