The 3rd entry in this series on organizational transformation using lean comes again,under the rubric of Process:Transparency is one of the keys to improvement but there are critical core characteristics of implementation that can make or break success.
Admitting mistakes is not easy. Look at the problems Toyota is dealing with because of their lack of transparency. Healthcare is no better. 5 years ago I met with a colleague at a very prestigious U.S. healthcare organization. I was invited by the Chief Medical Officer to give a talk on transparency and to share the results of the Wisconsin Collaborative for Healthcare Quality which was one of the first public reporting initiatives in the country (www.wchq.org). Following the talk I met with a small number of senior executives from the organization and asked them what they thought about reporting their data like we had in Wisconsin. They told me they thought what we were doing was great but they could never participate in such a process because they wouldn’t look very good on some of the performance indicators and this would damage their image. The CEO and marketing department wouldn’t let them do it in other words.
Actual real time performance data reported in a public way drives improvement faster than any other action. We know because it’s happened at ThedaCare and all across Wisconsin.As performance has been publicly reported resources have focused on fixing problems. The first step though is the hardest. Commitment to sharing results with the world starts at the top and cannot be manipulated by marketing and communications departments. When workers see their true performance they strive to improve. Most never know how they are doing and so they believe they are doing a good job. In my internal medicine practice years ago I thought I was a great internist managing heart disease and treating high cholesterol patients. Then when I actually did a chart review and found only 25% of my heart patients were meeting the cholesterol targets I was humbled. That humbling is what drove improvement and standard work for managing heart patients in my clinic. The root causes were identified and a standard protocol was implemented for treatment that brought our results to 75% of patients meeting goal within 6 months.
Visual control of performance can get the front line staff involved. That cholesterol control is now posted at every clinic at ThedaCare by doctor team on a visual tracking center(see slide 27 posted in blog no.1 PowerPoint) which all staff (and patients) can see. In fact these results are reviewed daily at huddles by the team and posting is done by the staff themselves.
Visual tracking centers must be meaningful to front line workers. For example,posting ventilator associated pneumonia rates in an outpatient clinic is useless. The staff and physicians have no impact on this. But posting the number of heart patients who have met their cholesterol goal is engaging because it is a big part of the work the staff and physicians do in a clinic.
It’s more than just posting results. There needs to be action. When problems are identified they need to be solved immediately, so part of the tracking process involves identifying and solving problems in cholesterol management using a standard work problem solving tool. This tool called a pdsa (plan-do-study-act) template will be described in greater depth in subsequent blogs but sufficed to say it involves a front line staff or physician identifying a problem and using the scientific method which we all learned in high school to solve it.First,identify what the problem is, in other words write a problem a statement. Then, decide why the problem exists the back round concerning the problem. Decide what the goal for improvement is, then do a root cause analysis on the problem and then run some experiments to see if a different process improves the results. Check the new results and start the whole pdsa over if improvement is not achieved. This level of scrutiny should be taught to all staff and physicians(not a small task). However, until the front line workers know how to identify and solve a problem nothing will improve and transparency will be useless.
In summary, there are two key components to transparency related to whole system transformation; public reporting of results and reporting of performance(and defects) at the level where the work is being done. This has to start from a commitment at the top of the organization and must be focused at the level where front line doctors and staff are actually doing the work.
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