Front-line supervisors and middle managers play a critical role in successful Lean Healthcare transformations. Without them, the improvement efforts will not be sustained despite the best of intentions of the improvement team. Why? Because newly developed processes will deteriorate over time unless there is someone taking measures to maintain them. That responsibility must fall upon the shoulders of those consistently present on those units — the managers.
In organizations that successfully deploy and maintain their improvements, the manager’s most important job is to ensure that the newly designed work is performed as intended, now and in the future. The problem? Middle managers’ plates are already very full—possibly too full. Many things are competing for their time and attention. Adding new tasks to the manager’s plate will not work well unless we support them in developing the skills and finding the time to perform them.
I had the privilege of working with Steven Spear recently in a program engaging middle managers in quality. A question we received from the group was, “How can a manager (middle or senior) devote time to fixing broken processes?”
Steven Spear’s response was:
Let me reframe the question to: How can a manager not devote time to fixing broken processes given the enormous toll on patients and staff that ill executed work exacts?
For example, when we shadowed nurses in clinical settings, we found that 1/3 to 1/2 of their time was spent doing nursing work – assessment, treatment, follow-up, education.
The remaining 1/2 to 2/3 was spent doing the scut work of finding materials, supplies, people and information. Why?
The relentless burden of “operational failures”:
- Work directed at the wrong or an ambiguous target
- The wrong person in the wrong place at the wrong time
- Input arriving in form, content, location, or timing that required substantial re-work
- A flawed but well-meaning approach to a task
All this sucked time, energy and resources like a famished vampire at the blood bank.
By stepping back from the regular doing of work (and working around all the impediments) for even a few minutes per day to engage in:
- Work up – what went wrong?
- Assessment – why did it go wrong?
- Planning – what should we do differently?
- Implementation – try it!
- Follow up – how did it work?
Staff found that time was pouring back to them, like being downstream of an opened dam during spring thaw.
In sum, we naturally worry how to manage limited time given the time sucking processes in which we are embedded rather than working to liberate time so that we can do so much more value creation with so much less exertion.
The key to that liberation of time, people and resources is: See, solve, sustain and repeat without end.
The issue of manager overburden is very real and needs to be addressed if organizations are going to be successful in sustaining quality. Time management becomes very important. What if you were to perform process redesign (a kaizen event, rapid improvement event, A3, etc.) on the manager’s work itself? Observing and measuring time, task, and waste is likely to bear fruit, giving the manager the time to be redeployed to other work like observation, visual management, daily management and coaching. My favorite waste for managers comes in the form of countless meetings with little being accomplished for the effort. Instead, reallocate that time working on the broken processes in their areas of responsibility. Then they aren’t constantly putting out fires caused by poor reliability of ineffective processes. Over time, the critical middle manager becomes an integral part of the improvement team. They gain the ability to see, solve and sustain, as Spear describes.
A few questions to ask yourself:
- Do our Lean Healthcare efforts include the engagement of our middle managers in driving and supporting improvement?
- Are we supporting the middle managers in these efforts by taking tasks off their plate or redesigning their work to take the waste and frustrations out of their workflows such that they have the capacity to engage?
- Do our executive leaders realize that the support, development and coaching of middle managers in quality is their responsibility? If not them, then who?
If you are not able to answer yes to all of these questions then you have more work to do. Taking waste out of your managers work flows and giving them the skills to drive improvement are fundamental to success.
I wish you success in your lean healthcare efforts.
Dave oversees all of HPP’s clinical and Lean Healthcare engagements. He plays a lead role in new services development and HPP’s continuous adaptation to the healthcare industry’s ever-changing needs. Dave previously served at Exempla Lutheran Medical Center as their Chief Clinical and Quality Officer. Dave has been a frequent speaker on the subject of leadership effectiveness and Lean transformation for a number of healthcare organizations including Institute for Healthcare Improvement, The University of Rochester Medical Center, Yale-New Haven Health System, Tulane University Medical Center, Pittsburgh Regional Health Initiative, Institute for Clinical Systems Improvement, and the Voluntary Hospital Association. Dave has served on the Agency for Healthcare Research and Quality’s High Reliability Advisory Group, has an extensive background in hospital operations, health plan governance, physician organization governance and clinical practice in internal medicine.
Dave received his M.D. from the University of Colorado’s Health Sciences Center. He is a faculty member for the Belmont University Lean Healthcare Certificate Program.