One-time correction must be ‘normalised' by sustainable processes, says Prof Norman Faull, based on his experiences in public healthcare in South Africa.
A day after Spain lifted the FIFA Soccer World Cup in July 2010, South Africans were walking tall — rightfully revelling in applause for a successfully organised global event. For Professor Norman Faull, Managing Director, Lean Institute Africa, a key initiative had just hit the ground.
Faull, a Professor of Business Administration (Operations) at the Graduate School of Business, University of Cape Town, and his team, bagged a project from the National Department of Health. The mandate included determining the suitability and effectiveness of the ‘lean approach' in addressing challenges in healthcare service delivery in South Africa. And, to train management teams in 18 identified Government hospitals in the country's neediest health districts in the lean approach.
In conversation with The New Manager post an address at a CII-VLFM (Visionary Leadership For Manufacturing) learning convention in Mumbai last week, Prof Faull explained the origin of the project, the challenges in a public sector task of this scale, the mistakes and learnings therein, and opportunities. Forty per cent of a manager's time must be spent visiting people adding value on the ground in a way that is supportive of continuous improvement, says Faull. Edited excerpts:
When a country becomes a democratic nation, it needs to work like one. Or in due course, people will make demands on the government. They will ask for the fruits of liberation and a fair, equal opportunity society as promised.
Unfortunately, there is a sense that our (South African) healthcare system fails people even more now than it did under apartheid. The education system has not improved significantly. There are large departments within the Government that are constantly assailed by stories of corruption. Some of that is being addressed now. But we're in the midst of recognising that we have a longer way to go than we thought.
Around 2000, as a result of what I saw in Zimbabwe, I decided that my active involvement in trying to promote process improvement needed to switch from the private to the public sector. My opportunities then were in healthcare, where my past students are now in management positions.
The ‘Lean Experiment'
There are several things that we would change should we go through this project again. Some of these factors are critical enough to determine success and sustainability.
Choice of project
Each hospital that was part of the programme was asked to choose three projects (issues) to tackle. The idea was that hospitals would identify inefficiencies better themselves. Of the 56 projects chosen, 17 were in waiting time reduction, 11 in stock availability and nine in patient file availability!
The project to lessen waiting time was amenable to our methodology, because you are looking for things where you can make a difference in a week or a day. Whereas, something like equipment repair, being a supply chain issue, would involve outside agencies. The same applies for ordering of stock items or spares for equipment. So in those cases, you can only demonstrate what they needed to do and identify what the likely improvements would be. Those projects also tended not to endure well because the changes would not become visible.
If we had to repeat the whole exercise, we would not give the hospitals a free choice of project. We would tell them which projects they are more likely to learn from.
This is not about fixing things. It's about teaching people how to fix things so that in time they can fix anything.
Choice of attendees, frequency
For each of the 18 hospitals, my proposal was that two people should have the opportunity to experience this five-day workshop three times each. Only when you see it thrice do you begin to realise that you use the same methodology, with the same mindset, each time. They would then become pretty confident about how those projects run and how to support their own staff with the projects. The proposal went unheeded.
We were required to go back for an evaluation a month to two after the workshop, to check if this had been a useful experiment, and if the hospitals would like to see it continue. People wanted to see it continue. The follow-up report strongly suggests that the choice of the project is significant in whether it is sustained, and so is selection of participants. The involvement of the top management of the hospital is also very important.
We had also recommended that it was not enough to just have managers on the programme. We wanted the people directly involved and adding value — the pharmacists, nurses, porters and the like. The NDH said they wanted only managers. We realised later that we were right. Without involving the people actually delivering the service, you cannot bring about change.
What was also very important was that the senior managers at the district and provincial levels had taken no real interest in the project. There was a big disconnect.
There's a particular problem in healthcare, in the way it is structured in South Africa. There are nine provinces, and the provinces run the hospitals and clinics and employ people with the provincial budget. The National Department of Health can change the legislation on smoking, but it can't improve something in a particular hospital — they don't have that direct line of control.
The fact that I was supposed to be here (in India for the CII-VLFM summit) with seven colleagues and they aren't here is a characteristic of working with the public sector. It's difficult to actually get anything done.
An infectious management issue
In one major hospital, the project was on infection control in the casualty department. When the project team went to interview the cleaners, they ran away. The managers came back and said, ‘They are lazy, they are trying to avoid us.' All we knew was that they ran away.
We found afterwards from the cleaners that the only time the management ever wanted to speak to them was when they were in trouble. They also said it was close to lunch time – they didn't want to be in trouble just before lunch!
We investigated that situation. There were four cleaners. Each was supposed to have a trolley with two buckets, four mops colour coded to the stage of cleaning and, of course, the disinfectant. Between the four, they had one trolley, two buckets, four mops which were not colour coded and stores had told them there was no disinfectant.
Why blame the cleaners? This is a management issue. Managers in a dysfunctional system spend nearly all their time fire fighting. So they feel there is no time to observe the work to understand why the problem keeps recurring. It requires a one-time correction and a sustainable process.
Managers keep fighting fires and in the end believe that is their job. Then, they too begin to feel desperate and hugely de-motivated. And their boss only calls them when they are in trouble!
Almost all CEOs in the project went back to fire-fighting mode. They could not give attention to the project that had been initiated and were part of.
Managers must lend stability
After demonstrating that the tools work, the task is to change the system in a sustainable way. That's at the systems level and managers will have to handle that system. It's not an IT system — it's a people relationship system.
The manager must come and visit you, must understand what you are tackling, must talk to you about your difficulties in a way that respects your attempts to solve problems. That must be the routine role of managers. Forty per cent of a manager's time must be spent visiting people adding value on the ground in a way that is supportive of continuous improvement.
We talk very glibly of continuous improvement. But the necessary precursor to improvement is stabilisation so that people will consistently use the same method. If you improve the method, they will consistently use the improved method.
If there is only fire fighting and emergencies, and everything is an exception, then there is a mundane and make-shift method and no one's accountable. Everyone says, ‘I am trying my best. I have been working long hours. You can't criticise me'. It is managers and their behaviour that sustain the stability.
Why systems for common sense?
In a country where there's a very high level of HIV, you would ask, why doesn't everyone practice safe sex? Why doesn't everyone use a condom? Well, they don't.
I make it a more gentle challenge. ‘How often do we floss our teeth?' Not as often as we should. That is a basic hygiene practice that everybody should follow. But we don't – we're just not good at this. Therefore, systems.
PHARMACY PROJECT IMPLEMENTATION IMPACT
Reduction in waiting time
Feb 9, 2011, at 1430 hrs: Pharmacy closed after two hours overtime at 6.30 pm and asked 70 patients to return the next day.
Feb 10, 2011 at 1315 hrs: Visible reduction in patient queues.
Feb 10, 2011 at 1550 hrs: Negligible numbers in queue. No patients waiting post 1615 hrs.
LEARNINGS
Daily attention to 5S activities is associated with projects that grow and become better. Highly visionary stuff comes down to daily attention.
Support of the senior management. Middle management is important but senior management lifts it to become one of continuous improvement.
5S: Seiri (Sorting), Seiton (Setting in order), Seiso (Sweeping/Shining), Seiketsu (Standardising) and Shitsuke (Sustaining the system).
3-EYED BUDDHA
In the VLFM programme logo, the eye on the right is the one for measurement and control. It lends stability by checking if we are routinely doing things the way we agreed to. The left eye has the staircase, asking us whether we are looking for and doing improvements routinely. The third eye explores if there are opportunities for complete innovation.
The two eyes that are next to each other — one is boring bureaucracy, the other experimentation. Those two things have to live together. If you only have bureaucracy, people feel disempowered and unappreciated. If you only have experimentation, you capture the innovations, but you have instability and inconsistency. That partnership is really important — and it's a management system that nurtures this partnership.
GEMBA WALKS IN PRIVATE HOSPITALS
Both doctors who did follow up research with me are of Indian origin — Murali and Kaskar. Dr Murali ran an experiment. He started four improvement projects in a private sector hospital. He started them knowing they would work because we'd gone beyond that; he started them to understand how to sustain the improvement.
He was testing three hypotheses:
The Gemba walk — the manager would come and visit once a week where the project was taking place, ask questions and check if things are still as they should be. He would have a conversation about what's not working and why it isn't, and what could be done to improve things.
Improvement meeting — When the improvement has not been identified, the people who can make the improvement need to discuss what to do.
Visual controls — This would help the manager recognise whether things are working correctly or not (closely linked to the 5S system).
Two months after the implementation stage, all four projects were doing well.
5S emergency
One of the projects was on 5S in the resuscitation room within the emergency ward. They looked at everything and what was unnecessary was identified. They got rid of the clutter. As they did, they found that the gel for the electrodes was wrong — the gel used for ultra-sound machines was being for electro-cardiograph machines also. This could possibly cause burn to the skin of patients.
They then found that this was common in all the departments of the hospital. Then they decided, very deliberately, where the things they needed were to be kept. They made sure that these were clearly labelled.
The time taken to collect something was measured before and after the clear up. There was a significant statistical improvement in retrieval time.
Soon after, the victim of a shark attack was brought into the emergency ward. He was very critically injured — a leg had been bitten off. The patient had multiple injuries; the rescuers had flown him in a helicopter.
Dr Murali's comment was that at no stage during the treatment of this patient, did any person have to leave the resuscitation room to collect anything. By inference, therefore, the treatment happened in the best possible or quickest possible way. It was a simple cleaning up exercise. Sustaining it wasn't so simple though.
Sustainability is king
There was an absolutely classic phrase in Dr Murali's report. He said, ‘The implementation phase on this 5S project in the resuscitation room never actually finished'. That was because backsliding began immediately.
Having gone through the whole process of getting rid of the junk, making sure they had the right stuff, deciding where it needed to be kept, labelling it, people immediately started introducing things which were not necessary, or not putting stuff back, or putting it back in the wrong place.
The three sustaining activities launched at the beginning would not suffice.
The managers should be told: ‘If we want those improvements to continue, it's your behaviours which must become routine to support that.'
BUREAUCRACY AND CORRUPTION
All governments are concerned about corruption. They may have put checks and balances in place in the system. If they don't work, they put in more. They go on until the system is so complicated that you get three kinds of people:
Crooks: When they get a complicated system, they will find a way to defraud you. Because the controls are not simple anymore, they find their way through.
Majority: They want to follow the system. Their biggest fear is to be accused of not following the system and defrauding it. They are very careful in following bureaucratic procedure, and this causes huge delays.
Totally impatient: Frustrated by the bureaucratic system, this lot is completely focused on getting the job done. They attempt to cut through the whole system.
Case of the caring doc
In one of the hospitals, a caring doctor with a strong personality was in charge of the intensive care unit for premature babies.
She was a forceful character who wanted to deliver for these helpless patients. The project was on the repair of equipment critical to the life of these babies. We looked at why it was taking long to repair the equipment.
We saw the bureaucratic delays in the process. There was a specific piece of equipment that we studied. It had broken down four months earlier. It was so critical that it qualified for emergency repair so you could short cut many of the processes. So we wondered why it had not been repaired for four months. In the week that we were there, the technician arrived, and it took one hour to repair.
It had taken four months to bring about one hour of value-adding work. Because the person in charge had been so frustrated, she would get on the phone with the technician and demand that he come over. So the person came, the repair company would then send in its invoice, and the hospital clerk would say that there was no order number for the service. The doctor didn't get approval, so no paperwork was in place. The company would not be paid. The next time the doctor phoned, they would refuse to come over until the paperwork was done.
This seems like a simple issue to solve — then why is it all around us?
The VLFM Programme, part of a joint co-operation agreement between India and Japan (2006), aims at creating a critical mass of visionary leaders for the manufacturing sector. It is guided by Prof Shoji Shiba, and has played a role in producing innovations such as Godrej's ChotuKool refrigerators.
Keywords: Norman Faull, manager's job, CII-VLFM