ABOUT THIS ARTICLE: This article was written by Skip Steward, Vice President and Chief Improvement Officer at Baptist Memorial Health Care headquartered in Memphis, TN. Skip will keynote the 2020 TWI & Kata Summit Europe, June 4-5, 2020 in Barcelona, Spain. Download a PDF copy of this article to distribute.
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Every enterprise has a Management System, whether the people inside know it or not. This Management System may have been intentionally conceived and deployed, or it may have developed ad hoc. For better or for worse, there is a Management System. Even if many of the system components are good, they will fail if not integrated properly in the overall Management System.
To understand what a Management System is or might be, first one must understand what a system is. At its most basic definition, a system is a whole that cannot be divided into independent parts. The human body, for example, is a system consisting of many interdependent subsystems like the circulatory system, the respiratory system, the digestive system, and so on. Any one of these parts cannot function and survive on its own. The body lives and thrives in the interactions of the subsystems. The parts of a system satisfy three conditions:
- Each of these parts affects the whole and is necessary.
- No individual part has an independent effect on the whole system. The way that each part affects the whole depends on what the other parts are doing. The parts are interdependent and connected.
- No subgroup of parts has an independent effect on the whole system. If parts of a system are grouped into subgroups or subsystems, they have the same properties as do the individual parts.
We know the properties that make up a system are the product of the interaction of the system’s parts, not the sum of those parts taken separately. In other words, the properties of the whole are derived from the interaction of the parts and not the actions of those individual parts.
The late Dr. Russell Ackoff, a pioneer and leader of systems thinking and management science throughout the second half of the last century said:
“Managers fail to diagnose the failures of the fads they adopt; they do not understand them. Most panaceas fail because they are applied anti-systemically. They need not be, but to do otherwise requires an understanding of systems and the ability to think systemically.”
I would argue that at a very high level your Management System should be made up of three dimensions. Imagine in your mind that you have a triangle and on each corner is one of three nodes representing these three dimensions. The three dimensions represented by the three nodes are Purpose – People – Process, which sum up the critical areas that need to be captured in the Management System. The results of your Management System come from the interactions of these three dimensions, not the sum of the dimensions taken separately. Within each dimension there are many subsystems and, of course, within these large dimensions there are many questions for any enterprise to answer to help understand if the parts and subsystems are connected or disconnected.
From the dimension of Purpose, one might initially question what the company’s long term strategic and philosophical purpose should be. What are the large strategic imperatives that must be achieved over the next one to three years? What are the large hypotheses that we believe will address those imperatives? How will we ensure proper alignment? How do we think about deployment? How often will we review? How do we think about studying our effort and then making adjustments when needed? There are many more questions that I am sure you could imagine to help connect the dots.
From the dimension of People, one might question how people are trained. How do we ensure people are engaged? How do we capture all their amazing ideas? What kind of culture do we want? How do we show respect and lead with humility? How do we deal with people issues when they arise? What do we want leadership to look like in our company? How do we treat people as individuals? There are so many questions, and it is always good to remember that everything we are trying to accomplish is done through People.
From the dimension of Process, one might be initially interested in a simple question — what is our Standard? Are we following the Standard? How much variation exists in the process? How do we think about improving the process? How do we think about problems or obstacles that are in our way moving forward? What was our last experiment? What did we expect to happen and learn from that experiment? What actually happened? What did we learn? These questions could become very detailed as we move up and down throughout the organization.
If we stop to reflect, we realize that most things connect to something else in an enterprise. All of these elements, connected to each other, are also constantly changing. Understanding the relationships and interconnections of the elements of a system makes better decision-making possible and creates visibility for improvements. Systemic thinking encourages improvements which are made on the system as a whole rather than on individual components of the system (e.g. departments), which is often where ideas for change are initiated. A sign of a mature culture of excellence is the elimination of a silo mentality, replaced by an enterprise mindset. By looking at the big picture and having an enterprise mindset, people are aware that changes in one part of the organization invariably affect people in other areas. They communicate and collaborate with each other concerning the long-term enterprise-wide implications of each decision. Here, leaders are being intentional at trying to connect the dots. Below, the image comes from geometry and is related to what is called an “Icosahedron”. I am using it as a picture for our mind’s eye to show the complexity of systems in companies and the difficulty of connecting the dots. The triangle initially mentioned has grown. Once again let us remember the quote from George Box, “All models are wrong, some are useful.”
The triangle model mentioned earlier exists at a high level and is incomplete, as all models are. There are numerous examples of this in healthcare. Let’s look at an example where a goal was provided to a Radiology Department. When speaking to the director of that department, she said that her department had been provided a goal of a seventy-minute CT scan turnaround time. Since many patients in the ED get a CT scan, it makes sense to align the CT Department’s goal with the Emergency Department’s goal to reduce total length of stay to 120 minutes.
After taking a closer look at the goals of the ED and their activities, it was clear that it would be very difficult if not impossible for the Radiology Department to hit its goal without a value stream, or systemic, approach. There are also several unit-specific or silo processes outside of Radiology that affect this goal. The ED, the Laboratory, and Radiology must all work together, collaborating their individual processes into one patient value stream that meets the more systemic goal of creating greater value for customers. Even though the Radiology Director was able to eliminate a few minutes in her phase of care within the Radiology Testing Department, it was not enough to meet the goal of the system. For example, included in the 70 minutes to complete CT, there is a 42-minute period from the time the order is placed until the patient arrives in the CT department. Together, ED and Radiology must work together to collapse this time in order to meet the overall systemic goal of 120 minutes throughput time for patients using the Emergency Department. Furthermore, if labs are needed, all three departments must coordinate to ensure that all processes are done concurrently within the time limit. All the processes that take place from the time the ED physician places a CT order to the time the Radiologist signs his/her report must work together with an outward mindset to achieve this systemic goal of the organization.
The communication and collaboration with each department concerning the long-term enterprise goals don’t always align. Good team members, doing their very best job to make their own department the very best it can be, will not, by itself, be adequate. This reductionist approach can lead to local departmental optimization, but often at the price of sub-optimization of the entire system. Imagine how much more the Admissions, Radiology, Respiratory, Laboratory, and other departments could achieve if they all were working on the same ED Length-Of-Stay goal together, learning how each process affects the other?
To think systemically is very difficult, because it is counterintuitive. We have been told, and maybe even said ourselves throughout our careers, that if each department or individual does their very best, then as a whole we will do our very best. This is not necessarily true, because when you improve the performance of each part of a system separately you do not improve the system as a whole and are very likely to hurt it. This is counterintuitive to how many of us have been trained in college, graduate school, medical school, and in life.
Consider the physician for a moment. He or she is a very important component of the overall healthcare system. If the physician works diligently to optimize his or her own efficiency but does so at the expense of the patient’s experience or quality outcomes, than value is lost. The doctor’s attempt to gain personal efficiency resulted in the healthcare system failure to create greater value for customers. This same concept applies to all healthcare workers and healthcare professionals.
Simply put, when we think systemically, we must ensure we are connecting the dots. The better we understand the connection between the parts or subsystems, the better we can make changes that improve the system. Remember that the properties that make up a system are the product of the interaction of the system’s parts, not the sum of those parts taken separately. Therefore, if one is not getting the properties (or results) that they expected, then maybe everything is not connected appropriately.
We looked at the need to have several departments connected to achieve the overall Challenge (i.e. goal or objective) of an organization. Now let us look within a department. Recently I was speaking to a CEO of a hospital about his frustration with a specific department and its lack of improvement around a specific lagging metric. I asked him about the Challenge that they were striving to achieve and dug into why this was important and how it was connected to the overall strategic initiatives of that hospital. Eventually, he was able to answer the question, but when I pressed him if the folks doing the work understood the “Why” behind this big Challenge, he said, “Probably not.”
This department was using a scientific approach that had been successful in the past. The CEO even admitted that the team members had been engaged in the past but now seemed to be disengaged. Can you see where the high-level triangle system of Purpose – People – Process quickly became disconnected? I am sure the people felt disrespected, but we also miss getting what the entire person has to offer. We missed their creativity, successes, and failures. When they do not understand the Purpose or the “Why,” we might have their physical bodies but not their hearts and minds. Most importantly, these folks are closest to the actual work and have the greatest impact on the results.
Within our company, the improvement system, which exists within the overall Management System, is made up of several subsystems and, within those subsystems, each is embedded with the necessary tools to enable the successful outcome of the system. I often reflect on the improvement system and the connection of the subsystems and tools. I tend to be passionate about the connection. Some of those subsystems are elements like Strategic Deployment, Improvement & Coaching Kata, Training Within Industry (TWI) Job Instruction (JI), Job Relations (JR), and Job Methods (JM), Standards, Visual Workplace, etc. I fundamentally believe in these elements because I believe them to be based on principles. These principles are timeless and universal. These elements may not be a part of your improvement system or ultimately part of your management system, but remember we started off saying that every enterprise, whether the people inside know it or not, has a Management System. This Management System may have been intentionally conceived and deployed or it could have developed ad hoc. For better or for worse, there is a system, and even if many of its components are good, they will fail if not integrated properly in the overall Management System.
Systems drive behaviors in an organization. Behaviors observed in any organizations reflect that organization’s true culture. Earlier in this article I talked about the three dimensions of Purpose, People, and Process. If the behavior of people in an organization, relative to those three dimensions, are based on true, universal guiding principles, excellent results will follow. In other words, if how they treat each other, how they understand and align their purpose, and how they improve their processes, are based on timeless principles, their ideal behaviors will generate ideal results.
Chris Butterworth stated it well when he wrote, “To succeed, organizations must develop management systems that align work and behaviors with principles and direction in ways that are simple, comprehensive, actionable, and standardized. Organizations must get results, and creating value for customers is ultimately accomplished through the effective alignment of every value stream in an organization.”
There are many companies and good intentioned people promoting parts or subsystems but as leaders we must figure out how they connect within the overall Management System. We also must take the existing good parts or subsystems and ensure they are connected properly. Recently I had the privilege to coauthor the book Creating an Effective Management System: Integrating Policy Deployment, TWI, and Kata. If this subject interests you, we would be honored for you to pick up a copy (bit.ly/effectivems). Finally, I would like to encourage you to reflect on your Management System and simply ask yourself how your Management System is working.
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ABOUT THE AUTHOR
Skip Steward currently serves as Vice President and Chief Improvement Officer at Baptist Memorial Health Care headquartered in Memphis, TN where he develops, directs, and implements performance improvement activities identifying inefficiencies; implementing strategies to improve quality, service, and finances; and fostering a culture of continuous improvement and excellence.
ABOUT THE PUBLISHER
Lean Frontiers, Inc. hosts industry-leading, intensely-focused learning events for the lean community. These events take the form of Large Summits, Hands-on Workshops, and Online Courses. Everything we do is focused on involving EVERYONE in lean thinking and developing required SKILLS to sustain it.
- Involve Everyone: A successful, integrated lean enterprise must involve EVERYONE. Our learning events are geared toward those in Accounting, HR, IT, Product Development, Supply Chain, Sales & Marketing, and Executive Leadership.
- Develop Skills: Most lean organizations are missing core culture and behaviors that sustain lean. To address these gaps, we offer learning opportunities on skills including TWI (Training Within Industry) Job Instruction, Job Methods, and Job Relations, Toyota Kata, Lean Coaching, and Lean Leadership Development.
Learn More: www.leanfrontiers.com
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