We live in an age of information. Technology not only accelerates the generation of information but lowers the barriers to access. When it comes to solving business problems, useful knowledge remains elusive. Every day one can find countless books, articles, conference presentations, webinars, and blogs showcasing success stories of business improvement using various methodologies. While I enjoy learning about other improvement projects, many stories left me unsatisfied with the depth of analysis and the amount of new knowledge.
This lack of depth can be problematic to practitioners seeking practical solutions to their problems. Instead of knowledge that can be learned, practiced, and reproduced, they often get good stories (e.g. marketing) or worse, misleading information that can cost their future. It is a modern-day challenge that I don’t have a good answer for. But critical thinking — asking questions — always helps.
To illustrate my point, let’s look at an example. Harvard Business Review early this year had an article “Why Process is U.S. Health Care’s Biggest Problem.” The authors shared their experience in applying improvement methodologies, particularly the Toyota Production System (TPS), to the patient care process. Many people think of TPS as a method to improve manufacturing operations. Applying TPS to address the US health care problem sounds intriguing. What questions would you ask while reading the article?
Framing the problem
The authors introduced the problem of the care-delivery process in terms of “not standardized,” “lack of reproducibility,” and “every caregiver does it his or her own way.” This can give the reader the impression that standardization is the solution. Whenever I see “not” or “lack of” or similar words in a problem statement, I immediately treat them as implied solutions. What are the root causes of the observed variation? What kind of analysis has been done to understand them? Presenting solutions disguised as problems limits our ability to see the real problem.
More than semantics
The authors continued their introduction by offering the solution: “Stable systems that are reproducible” and “A process must first be stabilized and then standardized.” What is a “stable” system or process? How is stability measured in a patient care process? Is stability a problem in their system? What did they do first to stabilize the process? None of these was presented.
Many terms in business improvement methodologies carry specific or even profound meanings. They are not buzzwords to be used casually. As Walter Shewhart and Edwards Deming taught us, a stable process lacks special (or assignable) cause variation, which is different from common cause (or random) variation. This distinction is one of the most foundational concepts in business improvement because it directs us to very different courses of action. Without knowing how these terms are operationally defined in the patient care process and seeing the analysis on sources of variation, readers learn nothing if not confused.
Elements of a system
The authors claim that “There are two types of improvement systems needed to create a well-designed care process.” But little is discussed about why the two are needed and how they work together.
An improvement methodology, such as TPS, includes numerous elements (e.g. principles and tools). It is only effective if the elements are used together in a cohesive way. The result is not the sum of a few arbitrarily chosen parts; a missing element could lead to a complete failure of the methodology. In addition, the elements have to be used in a well thought-out sequence applicable to the particular situation. This is not different from strategy development. One cannot simply pull elements from various disconnected strategies and hope that they work together.
What were the strategic choices available to the leaders? How did they decide which methodologies or elements of the methodologies to implement, and which not? Under what conditions would a radical redesign be necessary? Were the decisions to standardize or radically redesign the process strategic, convenient, or ad hoc? How do other core TPS elements, such as value and flow, fit in the big picture? Answers to any of these questions would greatly improve a reader’s knowledge.
Managing change
What do we standardize, and what not? To what extent do we standardize? These are two important, practical questions leaders have to answer because of commonly known resistance to standardization. How did the leaders manage change? For example, did they evaluate how the existing culture or social structure in the organization might support or hinder the standardization effort? As described in The Toyota Way by Jeffery Liker, an enabling (as opposed to coercive) social structure is essential to TPS. It empowers employees, supports organizational learning, and provides rules and procedures as tools as opposed to controlling them. The statement “Every nurse and doctor does not get to do it his or her own way. Standards are established about how the work is performed, and those standards are followed by all until a better way is determined collectively by the team” indicates more control than empowerment. This and several other similar statements leave readers wondering if standardization would ever work for them.
The above are but a few sample questions we could ask to gain useful knowledge from others. What is your experience? What would you recommend?
Very thoughtful article and great guide on the right questions to ask to get to the root of issues.
Thanks, Bill. Asking the right questions is hard to do. But with practice, we can get better.