This is a continuation of last week’s Lean Healthcare Exchange. If you have not read the first part, click here to read The Blind Spot, Part I.
For starters, every coach needs a playbook. For healthcare, this is the standard work process we are trying to implement. This could be the future state developed by a Lean team, the new care bundle adopted in the ICU, the policy/procedure for patient hand-off, or others. The playbook provides the context for the coaching; the intent for how work should be performed in the organization. There is a cultural barrier in healthcare to this. Both physicians and nurses are trained in the professional practice model and are accustomed to determining their own solutions and work habits. We are wired for variation. This is all the more reason that coaching is necessary. Without it, we will be pulled back to our old habits. We need to coach to the “playbook” for as long as it takes for the new habit (standard work) to displace the old one (unnecessary variation). Over time, this will stabilize the work to the standards developed.
Another requirement of coaching is presence—such that you can observe directly. Just as a football coach must be on the field, coaches must be present in the workflow so that they can observe and see the real issues and spot the coaching moments. One can’t coach from the confines of the office or meeting room. How much time do executives and managers spend on the units away from their offices? Hint, it is likely a rhetorical question, in general they spend much less time on the floors then they need to in order to coach effectively. If you were to develop a work standard around management coaching (which must occur if you expect success), you are likely to be met with the response; “We have too much to do and don’t have time for this additional task.” Or even worse, you won’t be met with a response at all, just a silent incredulous stare. These managers have a good point. They are too busy and if you approach this with a layering-on of work, you’ll fail. Success requires redesign, not layering-on. You will need to take some current work off of their plates such that they have the capacity to do what you are asking. There are a number of approaches to do this that start with evaluating their current work for waste reduction opportunities. For the Lean practitioners reading this, go to the gemba (where the work is being done) and observe a nurse manager for the day. Look for the manifestations of the 8 wastes. Look for the searching, unnecessary motion, defects they must respond to, etc. Inquire about all those meetings he or she attends (waiting, transportation). Ask this difficult question about all those meetings; “What have been the measurable outcomes and accomplishments over the past year based on attending this meeting?” If the person struggles with an answer, you have an opportunity to redeploy time. You can even go so far as to facilitate a formal week rapid improvement event around the managers work flow to reduce waste, create time and develop a work standard. The manager’s work must be redesigned, not added to. Time must be found, not taken. It can be simple. One organization’s CEO challenged his executive team with cutting each of their meetings time by 30%. It worked. This gave them the time for their Safety Walk Rounds. Another organization noticed that the bed meetings were taking an inordinate amount of time, that people were not staying on task. The solution came when they took the chairs out of the room. Focus was easier to maintain and the meetings ended early. What ever approach you take, realize that the most important asset we have are our people and their time.
The third requirement is that of timeliness. The most effective coaching occurs at the moment the defect happens. The longer you wait, the less effective the interaction becomes. Two things happen when you wait: the path gets cold and the problem gets worse. People’s memories change over time, even over the course of 24 hours. Take the hand-washing example. If you wait 1 month for the “hand washing compliance report” to come out and go up to the staff person mentioned in the report to discuss the issue, they will not remember the incident at all, much less the reasons why it occurred. In addition, the person who did not wash their hands then had ample opportunity to spread the MRSA to the next patient or their family for that matter. If, on the other hand, the interaction occurs immediately, the act is fresh and the potential for damage can be mitigated or prevented altogether.
The fourth requirement is the standard work itself. Coaching is not intuitive. Variable approaches will be much less effective than a predictable standard approach. I’m sure the readers of this blog already know this point very well. That being the case, what should the work standards for coaching include? I’ve already mentioned the need to ask questions, the Socratic method, as well as the need to ask powerful questions that prompt the coachee to think deeply. Developing a group of questions that can be commonly used may be helpful. There are many tools and approaches around the practice of coaching that are in the literature. The important point is that a standard must be developed. In addition, the coaches must be trained and coached in the practice. Yes, coaching the coaches to coach.
The fifth requirement is that of follow-up. Unfortunately this one is commonly overlooked but it is critically important. Positive reinforcement is powerful. Asking people how they are doing in their development is a statement that the person and the practice are important. It also allows the coach to receive other feedback that can be used to improve the process. When a person is coached on an issue, the issue becomes front-of-mind. In addition, if the person is coached using questions, the person thinks about the issue and that does not stop with the interaction. They may be looking at the process more deeply and evaluating other opportunities for improvement. A lot can happen when one is engaged respectfully in an issue.
We don’t coach nearly enough in healthcare. It is easy to find excuses for this including the very common mantra “We don’t have time.” People don’t make the connection that the reason we don’t have time is because we don’t coach. Without coaching, processes remain variable, standard work is poorly implemented and poorly maintained. We then find ourselves spending time putting out fires due to the resulting chaos. The hamster wheel spins faster. This vicious cycle can be broken. It will require being open to approaches we may not initially be comfortable with. It will require changes in how we lead and manage. Looking at the state of healthcare in the U.S., that won’t be a bad thing.
Put me in coach.
This week’s blog was written by Dave Munch, M.D. and HPP Senior Vice President and Chief Clinical Officer