Out of Sight, Out of Mind: What We are Missing in the “Gemba”

My mother passed away recently.   As her children reminisced about her life, we recognized that one of the biggest gifts she had given us was her practical wisdom.  This wisdom came in the form of countless proverbs with which she would admonish or help us, some more well-known than others, such as, “don’t saddle the horses before the cart is ready,” “the night is a bad advisor,” “better late than never,” and, “bad news travels fast.”  Adding to these was the oft repeated reminder about the wisdom of the story, A Message to Garcia, when explaining why she set high expectations without giving clear instructions.

So it’s not surprising that I often find myself thinking of proverbs I learned from her in my daily life.  A proverb that summarizes for me what happens when healthcare leaders don’t spend time in the gemba (Japanese for “at the site”) is, “out of sight, out of mind.”

As it so happens, I’ve had to spend a lot of time recently inside three different healthcare facilities caring for a family member.  As a result, I have been immersed in the healthcare gemba, and cannot help but think that there are a number of things happening “at the site,” that operational leaders are unaware of.  I believe that if they were to spend only a fraction of the time I have spent in their places of service, they would see some of the same things I have seen, and as a result feel compelled to learn more, and perhaps even take action.

This is not to dismiss that there are areas in which it is clear great thought has been given to removing waste and designing processes that are patient and family-friendly, such as:

• Smooth admission to nursing units from the emergency department.
• Keeping the same nursing team with the patient from one day to the next during their stay to facilitate continuity of care.
• Team approach to care – one team overseeing care and coordinating other disciplines as needed to create one plan of care.
• Self-serve water and coffee station for families so they don’t have to interrupt staff when they need something, or have to leave the floor to get it.
• Nursing teams empowered to ask questions and make decisions.

But opportunities remain.  While leaders sit in offices and meeting rooms and dictate solutions, write policy, and design operating processes, their staff are heroically meeting the needs of patients and families on their own.  And they seem to have become so accustomed to the status quo that they do not see the need for change.  As examples I offer:

• Lack of readiness for patient admission due to orders not placed on a timely basis.
• Hunting and gathering for supplies.
• Disjointed care – patient moving from one department or specialty to the next without help to “connect the dots,” or coordinate care.
• Messy patient rooms.
• Nursing staff interrupted by phone calls while taking care of a patient.
• Small TVs installed so high on the wall that they are uncomfortable to watch.
• Slow response to beeping machines.
• Little information about patient plan of care or process to develop the plan.
• No weekend access to care other than through the emergency room.

I would suggest to all of you who are committed to delivering the highest quality service to your patients and their families to try some of the following, easy-to-do gemba visit activities to learn first-hand what they are experiencing and what they have to say.

• Sit in a patient service area to do your work. Listen to the conversations your staff are having with patients and families.
• Select one or two topics such as a recently implemented change and ask several patients, families, and staff members for their input.
• Spend time in the staff break room; they will tell you what is bugging them.
• Participate in an improvement event if your organization is using this methodology; stay for lunch and breaks.
• Walk around patient care areas on a regular basis and ask staff how they are doing when they have a free moment.  Get to know their names – ask them about their families.
• Talk to patients and their families; they would love to get to know you and know that you care by asking them about their experiences in your organization

You’ll be amazed what you learn.

PS – If you have had success with other gemba activities that we can share with others, email me at mkarlov@createvalue.org.