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Lean principles have been advocated as effective methods for the improvement of services. Toyota, widely credited with perfecting lean, operates lean under Continuous Improvement and Respect for People (RfP). The theories and tools that have been developed to facilitate this process have effectively delivered service transformation on many occasions. Despite these successes, the elder statesmen of lean improvement acknowledge that it is vulnerable to staff resistance.
Respect for People
Named as a second pillar in lean transformation, RfP, is the rarely discussed human relations side. HR is a topic to make many managers cringe and to which many modern organisations pay lip-service. It is often epitomised by a complex and highly detailed HR policy that is designed to outline which rights an employee is entitled to and what support the organisation is obliged to provide. In many cases it is used to protect both the company and the employee from unreasonable demands made by the other.
In contrast, RfP is not an exhaustive list of actions that can be pointed to or highlighted under this title. It is more of an ethos or an umbrella term under which actions can be judged. This may seem vague but it represents a less exclusive and more flexible way to manage staff. This approach seeks to avoid the mistake made by many authors of detailing an exhaustive list of tools or practices. Such a list is then taken as being all-encompassing by readers who follow it dogmatically, They ultimately miss the core message that the tools are contextual but the ethos ubiquitous. Should the organisation fail to develop a dynamic, lean culture, the techniques are lamented and the term lean is demonised.
In an attempt to avoid this trap we are seeking to outline three broad encompassing themes to act as guidance. Within these themes there are specific tools that have been described by multiple authors as being integral to the effective implementation of RfP.
Measurement and accountability
‘What is measured improves’ ?Peter F Drucker
Measurement and management are fundamentally linked in both business and healthcare. Without measurement it is practically impossible to manage a treatment, a service or a business. An effective manager has to set clear achievable targets for ALL members of staff that are fair and reflective of effort and allow staff to see how they contribute to the success of the organisation. The development of these measurements cannot be arbitrary and requires a clear understanding of the desired outcomes. It is therefore, integral for each manager to understand which value represents Performance or is a Key Performance Indicator (KPI).
Within lean’s Japanese heritage this understanding is gained through a requirement for the manager to ‘visit the Gemba’ (the workplace). This allows managers to truly appreciate the act of adding value and a comprehension of how strategy translates to the front-line. Furthermore, it allows them to understand which measure to apply that is achievable and fair. In clinical practice this allows managers to appreciate the demands on their staff and empathise with the obstacles faced by clinicians.
This may appear to place responsibility for delivery solely at the feet of the manager, but paramount to the effectiveness of these measures is that staff be held accountable for the outcomes. If accountability is not practiced then the manager is deficient and the measurement is ineffective.
Communication
‘An individual without information cannot take responsibility, and an individual who is given information cannot help but take responsibility.’
Jan Carlzon
In the communication age the medium by which an employer engages with their staff can be in many forms from verbal and visual to email and webcasts. The chosen medium is largely irrelevant so long as it is tailored to both the individual and the nature of the information to be communicated. What is important is that it effectively disseminates the content and context of the information in a form so that it can be comprehended.
The second feature of an effective communication process requires the reinforcement of the message using either repetition or preferably a second medium. A message is made more ‘sticky’ by engaging different regions in the audience’s brain simultaneously.
Finally the communication has to be bilateral as managers who are uninformed are worse than useless. In many cases this can mean using a proxy observer or authority figure to engage with staff. This also provides a clear channel through which staff can communicate with management. The effect of this engagement should be to listen in an effective way with clear channels of two-way communication allowing a constructive dialogue.
The first requirement in this theory is that the manager has a strategy and is capable of articulating how it takes the business forward. In optometry the manager must be able to take tough decisions on the direction of the business.
Satisfaction
‘Of course motivation is not permanent. But then, neither is bathing; but it is something you ?should do on a regular basis.’
Zig Zigler
The third theme in this interpretation of RfP is based on the need for staff to be fulfilled by their work. This has been proven in multiple worldwide studies but in many organisations has not affected staff relations. Some managers argue that treating individuals with respect and empathy and trying to motivate through satisfaction is in some way soft. Many fall back on coercive forms of control like bonuses or disciplinary punishments in the hope that fear will sufficiently motivate.
Some organisations that appreciate the need for satisfaction develop complex policies referencing the hierarchy of needs developed by Abraham Maslow. This theory is widely known and referenced in many corporate brochures but it is not always skillfully implemented. It has its critics because it is extremely linear, using prescribed steps as hoops through which a manager can throw their staff. This ‘standard’ in all cases and especially for professionals may be problematic as what satisfies on one level might be dissatisfying on another. Despite the problems with complexity, the use of any theory-driven approach to HR demonstrates that a clinic is appreciative of the fact that change is difficult and must be managed.
In contrast to Maslow, one of the benefits of RfP is that it appreciates change can be a many-headed monster and so satisfaction can be represented by different things for different people. Lean organisations seek to address this complexity through including all staff at all points within the change processes. They are at the heart of data collection analysis and the formulation of change plans. An improvement event called a ‘Kaizen Blitz’ is used where staff examine their own work with their colleagues, formulating new practices in tandem with managers. All these tasks are designed to respect the individual as a person and not just as an employee allowing them to embed their own personal and collective goals within the newly developed practices.
In spite of this flexiblity, RfP and lean are not perfect as they are often initiated by managerial decree and a feeling of alienation and victimisation can still be felt. Frontline staff might be respected but an external decision to enact change will cause anxiety and can scupper improvement before it starts. Even by closely following all the tenets of lean, some improvement projects can still fail.
Conclusion
There are three areas on which healthcare managers can focus to encourage, empower and enfranchise their staff in practice. The article outlines the ethos of RfP and including them in change decisions. Measurement, Communication and Satisfaction are three headings under which this could be enacted, but ultimately it is most important that respect is applied.
New practices having an impact in mainstream healthcare are based on evidence from decades of successful projects worldwide that bring improved quality and reduced costs. We have outlined some of the tools and practices that we use in improvement projects within optics. They offer a better understanding of customer pathways and allow a better appreciation of what changes are necessary. ?
? Gareth Paterson is a management consultant at cMedicas. www.cMedicas.com