Like our Premier — who attended Harvard University for a week — I too spent a week in1989 “studying at Harvard” with a group of healthcare reform radicals led by an unknown professor/physician named Don Berwick – who went on to become the acknowledged healthcare quality guru on our planet.
Berwick and his team were breaking new ground way back then. They came armed with dozens of “tools”, “frameworks” and “quality processes” borrowed from Deming’s work with Japanese manufacturers. Unfortunately, the first generation of healthcare quality learners all seemed to go out and start consulting companies that sold fancy TQM Workshops with CQI Tool Boxes — instead of being focused on what Berwick actually taught us: which was “a different way of thinking”.
The repeating pattern we have experienced over the past two decades is that the healthcare sector has been borrowing ideas and processes from the manufacturing sector wholesale — and implementing them as “flavour-of-the-month” solutions.
Most self-respecting hospital CEOs back in the ‘90’s went out and hired a Director of TQM/CQI and ran “expert-led”, “bums-in-seats” seminars for front-line workers — where everyone learned why they could not do their job without a pareto diagram and a fish-bone diagram.
Sadly, the idea of education and skills development for the front-line care providers turned into a scam because most people did not understand that what Berwick, Deming, Shwerhart and Juran taught was that the quality improvement movement was about a different way of thinking, it wasn’t about the tools. The tools were a process that ought to enable people to see the “same/old” issues with fresh lenses.
For two days later this month, Berwick is bringing together the faculty and students from 25 years ago to participate in a 25th anniversary quality conference called Improving Skills For Tomorrow’s Healthcare: The Experts Perspective (April 30th – May 1st).
In the advance video promotion for this gathering back at Harvard, Berwick points out that “a lot has changed in the 25 years since the Institute for Health Improvement founders built on the work of Deming, and applied the science of improvement to the healthcare sector”.
IHI trained 10,000 people as QI leaders in the first ten years of its existence. This work has spread over the past ten years and has been systemized as quality improvement curriculums – often on a state-wide basis — targeted to hospital middle managers who are then responsible for engaging their front-line workers using these improvement tools.
Groups like the OHA have also cashed in on this lucrative “bums-in-seats” educational workshop business — by teaching green and black belts for lean thinking, along with other courses. From the private sector, the Studer Group has created a powerful quality training program which a number of Canadian hospitals have used to create real improvements.
But most of the training packages around today are still stuck in “old-school” quality tool training. Rather than being pragmatic, they tend to have a strong academic bent that leaves front-line staff cold. Why? Because left-brain manufacturing processes that promise to “save money” does not really motivate care providers.
Today, Berwick acknowledges that back in the early days of IHI, and the beginning of the TQM/CQI movement, we (believe it or not) did not even think about the one diagnostic tool that today fundamentally changes the whole equation: the patient!
Interesting how “old school quality” didn’t see the patient as a potential source for solutions — or even for meaningful measurement.
“We also didn’t understand ‘systems’ back then”, says Berwick. “We didn’t understand hospitals as systems, or local community services as a ‘system of services’ that somehow ought to fit synergistically together.”
Since the early days of borrowing manufacturing quality tools and processes, we’ve learned a great deal about the behaviour of human systems that people like Margaret Wheatley, Herbert Wong, Barry Oshry, and Dee Hock refer to as “complex, adaptive systems”. But we no longer do 1980’s-type “bums-in-seats” academic theory training. We’ve learned from these limitations, discovered the power of collective intelligence, and moved on.
The Health Council of Canada’s new report, “Which Way To Quality?” traces the Canadian version of the TQM/CQI craze in the early 2000s with the Canadian Adverse Events Report in 2004, and demonstrates our progress in each province since that time.
Today, in Saskatchewan, for example, they are using Hoshin Kanri, a lean-based approach to planning — with some right-brain components — that involves identifying a common vision, setting goals, tracking progress towards those goals, and changing direction as required. This is the “learning-by-doing” model borrowed from the manufacturing sector that has had some success in places like the Virginia Mason Health System in Seattle.
“Using a ‘top-down’ and ‘bottom-up’ approach, Hoshin Kanri incorporates feedback from people working at all levels of the healthcare delivery system. However, best practices tells us that each organization, and each cluster of organizations (in a LHIN, or Health Link) require a customized approach that reflects the unique idiosyncrasies of the complex human system that needs to move forward.
We certainly won’t successfully transform our healthcare system by pushing everyone in the province into a classroom to learn how to use manufacturing tools for quality that have achieved some success in another healthcare system in some far-off place.
Successful health quality transformation will depend on local leadership, and the appropriate next step for each cluster — not centralized control with a “one-size-fits-all” approach to quality training.
While someone may have uncovered “the best Grade Eight Math Curriculum in the world”, if you are in Grade Three, or Grade Twelve, it is sub-optimal. Thankfully, Queen’s Park has abandoned their traditional belief in the “one-size-fits-all” philosophy of the past.
The Health Council of Canada reports that “many leaders talked about the need to change the healthcare culture to one in which people understand that quality improvement is ongoing and is part of their everyday work. Several stressed that it is important for leaders to set priorities and a clear direction for quality improvement initiatives to avoid change fatigue and burn out.”
One leader interviewed said “everybody is so busy doing what they are doing. No one seems aware that as a system, we’re not addressing what we need to be addressing. Culture change is required to get that discipline.”
The issue isn’t about the need to have the very same “tools” and curriculum. It’s actually about how we think. The fact is we’re ingrained in fragmentation — where we automatically always beak off the various pieces from the whole into isolated and incomplete parts.
The wonderful thing about the Health Links are that they are designed to look at the patient experience cross-functionally along the continuum-of-care. So instead of examining the experience silo by silo, participants are asked to address the “whole picture”, rather than the “sum of the individual parts.”
Art Frohwerk, the inventor of the Patient Experience Design Storyboarding Methodology being adopted by leading-edge healthcare organizations says “fragmentation causes us to lose context, optimize one part and sub-optimize others, and is the basis for the profound world of ‘missed connections’ in healthcare.” He says, “it is the missed connections that cause high-cost, poor results and bad human experiences – for both the patient, and the caregiver.”
Peter Senge explains that “from a very early age we are taught to break apart problems, to fragment the world. This apparently makes complex tasks and subjects more manageable, but we pay a hidden, enormous price. We can no longer see the consequences of our actions; we lose our intrinsic sense of connection to a larger whole.” When we try to “see the big picture”, we try to reassemble the fragments in our minds, to list and organize all the pieces.
But, as physicist David Bohm says, the task is futile — similar to trying to reassemble the fragments of a broken mirror to see a true reflection. Thus, after a while, he says, “we give up trying to see the whole altogether”. Today many people who work on healthcare can’t see “a system of care”, because there isn’t one. Health Links Teams will discover this when they ask patients and their families about their experience with the delivery system.
When we give up the illusion that the world is created of separate, unrelated forces, we can then build Learning Organizations — organizations where “people continually expand their capacity to create the results they truly desire; where new and expansive patterns of thinking are nurtured; where collective aspiration is set free; and, where people are continually learning how to learn together. “
In such organizations, people no longer compete with one another. There are no longer the traditional silo wars between departments or factions. People are working cooperatively and collaboratively together to integrate the component parts into a coordinated whole.
Integration is the opposite of fragmentation. Learning how to think in an integrated, holistic way involves a struggle to overcome our traditional, fragmented ways of thinking. Systems Thinking shows that small, well-focused actions in the right place can produce significant, enduring improvements. By contrast, traditional fragmented thinking focuses on symptomatic fixes — not underlying causes.
This doesn’t mean Quality Tool Training is bad. Of course it will do some good – as it did in the late ‘80’s, and throughout the 1990’s. But, hey we’ve learned a lot since then. We actually know the limitations of last generation’s tool-based QI training programs.
They tend to be more about teaching, than about learning.
They tend to be more top-down, than bottom-up. More didactic, than participative. More expert-led, than collective intelligence. More about politics/optics, than about fundamental transformational change. More about the process, than about achieving results.
Peter Senge says “in place of our traditional fragmented ways of thinking about the world, we can learn the skill of systems thinking – the ability to see the whole picture, of seeing interrelationships rather than things, and of seeing patterns of change rather than static fragmented snapshots.”
Adult learning methodologies suggest that each cluster of Health Link organizations need to evolve their own unique blend of what is already working for them locally right now – along with several new ideas that “fit” their unique circumstances.
In the ‘90’s, the leading-edge organizations that opted for “transformation” over “re-engineering” experienced performance surges – while 70% of re-engineering projects that were rolled-out top-down, failed. Lean thinking projects in healthcare achieve similar results.
So, unless we change how we think, we will always produce the “same/old” results. If the Health Links choose to evolve and adapt the new stuff, they could succeed. If they import old school expert-led theory-based tool training, they may flounder and fail to move beyond their fragmented silos.
Next week’s blog: “Health Coaches Innovative Program For True Patient-Centred Care”.
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