Building Continuous Improvement Systems that Last
Monday, November 11 2019
In my roles at Northwestern and Purdue Universities I get to work with leaders and staff at all levels that are knee-deep in strategy, process, decision-making, and technology challenges. They work in healthcare, life sciences, financial services, retail, software, manufacturing, and many other industries across the US and the world.
One thing I always ask about is PDCA.
This ubiquitous method – plan, do, check, act - is like a law of physics when it comes to improvement. You cannot avoid it because it is so basic; however, because it is so basic it can be hard to get right, just like physics.
PDCA is about planning an improvement, implementing, checking to see if it works, and making adjustments that tune it up or lock it down. You tune it up by doing another complete cycle of the same PDCA logic – plan how you want to tune it up, implement the tune up, see if the tune up works or not, and so on. You continue this iterative process until you have what you need and it sticks.
It is hard to imagine making an improvement without going through those steps in some fashion. Indeed, it is impossible. We even learn that way as individuals. How did you learn to ride a bike or read (or do almost anything)? You had an idea of what you wanted to try, you tried it, got some feedback, and adjusted until you figured things out or decided to give up.
The tough part is getting specific about how to do each of the steps and making the cycle a matter of habit across your organization to get a continuous learning culture happening. Additionally, there are many choices for how to get specific.
Check out the list of tools discussed for the steps in PDSA (similar to PDCA only the “C” for check is replaced by to “S” for study) published by the Minnesota Department of Health. Also, you can take a deeper dive into details of improvement Science created by the Institute for Healthcare Improvement that includes:
“Dedication to rapid testing (PDSA cycles), prediction and learning from tests.”
Some approaches have become very popular in healthcare. For example, a national survey conducted by the Center for Lean Engagement and Research (University of California in Berkley) found that 53% of US hospitals (n =1,222) use FOCUS-PDCA as part of their approach to transformational performance improvement. The FOCUS stands for Find a process problem, Organize a team, Clarify the current knowledge, Understand causes of variation, and Select process improvements.
There are many more options and approaches to PDCA. In general though, concerning the steps, you want to have a measurable goal, define a standard way to do the work in an improved way, collect data reliably and cheaply, get to root cause, make sound inferences, and iterate (repeat the steps) quickly.
That sounds nice, but as the references above prove, things can get complex. Questions about metrics, types of charts, sample sizes, team makeup, and many other factors pop-up and complexity kills progress.
Fortunately, in everyday life we can muddle through the complexity. Think about learning how to ride a bicycle. Often you start with a tricycle and then moved up to a two-wheeler with training wheels. In the best case there is someone to walk along side of you, helping to maintain balance once the training wheels came off. Don’t forget to include a dose of cuts and bruises. We learn from staged experiences and a willingness to try.
The key is to start (on a tricycle) making it almost impossible to fail or fall over and once you master that, make things more complex in stages. It turns out that is an excellent way to master almost any complex skill. Improvement experts call it deliberate practice and there is plenty of literature ( including some best sellers) that suggest it is the development process used to achieve world class performance in a wide number of domains.
Deliberate practice can be difficult to use in the messy and busy world of work. Ideally, you have a structured task and an excellent coach that can assess performance and tirelessly increase the bar to push you forward with just the right mix of struggle and success.
Some organizations that master PDCA, making it a culture-wide habit of continuous improvement and learning have done so using a form of deliberate practice. That is, they start off with super simple tools and logic for the PDCA steps (tricycle), drill on those until they reach the limits of use, then up the game to slightly more complex tools, data collection methods, and logic (training wheels) and so on until they reach the highest level of performance where their system/coach can take them.
This is simple to say but hard to do. Unfortunately, some organizations are in too much of a hurry to start with the super simple stuff and move up in progressive steps. They may have some temporary success but without doing the deliberate organizational learning there is no foundation to hold up and accumulate improvement wins as stable performances.
At Northwestern, I have had a chance to learn from many organizations that managed to develop PDCA mastery along this path. At Purdue Healthcare Advisors, I have worked with colleagues over the last four years to field test a toolkit and learning method for others that want to take a similar approach.
Not surprising, it all works on a brew of lean thinking and tools. Lean runs on rapid cycle improvements and uses data and visual management. It prizes root cause analysis and small improvements made by empowered teams that know the work. Lean offers a development method similar to deliberate practice (lean kata) and can scale from small changes in the procedures in a specific work area (flow cell) to re-engineering entire processes (value streams) and transforming an entire operating model (production system) using a small set of principles and tools. It is one of the most articulated and successful forms of organizational learning that we have on the books.
At Purdue Healthcare Advisors, we often start with Lean Daily Improvement or LDI for short. LDI has been engineered to provide any organization (even small and under-resourced ones) a way to build capacity for continuous improvement at the point of service using high-speed PDCA cycles.
Here is how it works:
To master PDCA through LDI, you collaborate with a coach and start with small meaningful problems at work or home. You will begin with activities that you must change and that you know how to change.
For example, you might want to start using portion reduction at meals to manage your weight. Or if you work at a clinic, you may have the need to implement a workflow to do foot screens on diabetic patients or provide nutritional counseling to younger patients with a high BMI.
In these cases, you know the cause of the problem and you know how to solve it. While some may be concerned that these changes are too small to be meaningful, our goal is to find a tricycle, one where we likely can’t fall over so we can safely and quickly learn to sit, peddle, and steer.
To run your PDCA on these types of challenges you need just two tools:
- Standard work (an ordered list of steps on how best to modify your workflow to solve the problem)
- A run chart graph to visually and publicly track a metric that tells you if you are reaching your goal with the standard work.
If the solution works straight out of the box, great, you achieve your goal and sustained it. If the standard work does not hit the goal, you need a couple more tools:
- A way to huddle quickly as a team, get to the root cause of the problem, determine how to address it (improve the standard work), record who is going to implement the fix (called a countermeasure), and when they will do it on a simple and publicly visible countermeasure form.
Moving up from standard work and a run chart to include huddling and countermeasures is a bit like going from a tricycle to a full-sized bike with training wheels. A big move, but it for many situations it may not give you all the skills needed to be an autonomous biker. For that you need tools to address the people and change management challenges that involved with PDCA including:
- A visual graph that shows who is attending the huddles (encourage participation) and a tool based on behavioral science for implementing evidence-based tactics to deal with the human factors of change (e.g. people not completing countermeasures or speaking the truth in huddles).
Dealing with change management and people versus just process and workflow issues requires more skill and likely longer support from an experienced coach.
The deliberate practice story continues. We also teach how to use a Pareto chart to detect when a bigger change event such as a rapid improvement event might be needed, how to link multiple LDI applications together to solve larger problems, and even address organizational strategies.
There are of lot of things we could add into this brew from the lean toolkit (e.g. A3 problem solving) but we have resisted doing so. The goal is to minimize complexity without losing effectiveness. It’s a bit like stripping a cargo plane down to a “flying gas can” to optimize payload delivery.
While LDI does not make use of unique tools in PDCA (except for the behavioral science tools) it does take a unique approach to capacity building. Starting simple and scaling up means you are doing many short PDCA cycles. These are high speed learning and improvement loops using lean tools.
Lean tools are conceptually simple, so the harder learning is in the doing. That is why having a coach that can guide you through deliberate practice is essential. Also, it’s important to remember that everyone is different.
For example, when we deliver LDI training and coaching, we share all the tools with participants. Out of the 400+ people that have been through our LDI program, nearly half do their first lean-driven application of PDCA using just standard work, a run chart, and an attendance form. They hit their goal right away and never need to complete a countermeasure or formulate and implement an advanced change tactic.
Starting with the simplest case, gaining your balance, and achieving a lasting improvement is exciting. It teaches you how to sit, peddle, and steer paving the way for additional skill building on a more complex challenge. By starting with a simple case, everyone in the organization can engage in LDI quickly and at a low cost.
The applications they focus on can be linked to common and important drivers and metrics in the organization. This insures the small continuous improvements accumulate into big and significant impacts over time. Furthermore, participants move on to tackle related improvement problems that involve running huddles, finding root causes, implementing countermeasures, and using change tactics to build their LDI skills until the training wheels come off.
LDI is one way to implement PDCA and create a continuous improvement system, even in time and resource constrained organizations. It has been engineered to produce small spreadable improvements that stick as well as help sustain improvements made by larger change events. As a bonus, it quickly builds a practical understand and skill (not just awareness) of lean thinking across your organization.
Tags: Process & Cost Improvement (LEAN)
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