Everything You Just Said Was Wrong
As a bit of a Star Wars fan, I was watching The Last Jedi a few days ago. Every time I watch it, I wait for one scene. Luke Skywalker is getting ready to fight Kylo Ren when Kylo Ren says, “The resistance is dead, the war is over, and when I kill you, I will have killed the last Jedi.” Luke replies, “Amazing, every word you just said was wrong.” This phrase reminds me of a situation I encountered repeatedly throughout my 40-plus-year career. As I worked on a process improvement project, whether it was workflow, patient throughput, patient wait time, etc., hospital executives, department managers, and other well-meaning healthcare folks often told me, “Just ask the front-line workers – they know what is wrong.” This makes me think of three things:
1. Why did I spend years in school getting an undergraduate and a master’s degree in industrial engineering if all I needed to do to solve problems was ask the front-line staff?
2. If it is that simple, why didn’t you ask the front-line staff and save me the trip?
3. Everything you just said was wrong.
I never said any of these three things, but I thought about them.
Before I go further, let me digress and provide some background. I am writing a series of essays on topics in process improvement that interest me or that I feel practitioners should think more about. I've spent most of my career working to improve processes and systems, primarily in healthcare. I’m a Registered Professional Engineer and a Certified Lean Six Sigma Master Black Belt. I've been an Industrial Engineer, a Management Engineer, and a Systems Consultant. For most of my career, I have led a team of process improvement specialists doing process and systems engineering.
As a teacher of Lean Six Sigma, I always discuss two related concepts. Going to the Gemba (or a Gemba walk) and the three basic rules of Lean, which are usually stated as:
1. Go See
2. Ask Why
3. Show Respect
In Lean, the Gemba, which is Japanese for the real place, is interpreted as the factory floor or the place where work is done. A Gemba walk allows leaders or, in my case, process improvement professionals to observe and learn the process. Leaders/process improvement professionals going to the Gemba are intended to aid in better interactions and communication and improve trust between leadership/process engineers and frontline workers. As an aside, because we are supposed to observe the process, this is not the time to discuss process issues, employee execution problems, or policy deviations. As a nod to my first healthcare boss and mentor, Paul Woo, back in the mid-1970s, long before I had heard of Lean or Six Sigma, I was taught as a young engineer that one of the first steps in any improvement effort was to put the “Mark 1 Eyeball” on the process. Mark 1 Eyeball is an old term for visually assessing a situation. Going to the Gemba is a chance to observe, engage in humble inquiry [1], and learn.
When I teach Lean Six Sigma, I express the second rule as “Understand Why.” I do this so the students don’t confuse understanding why a situation occurs, which is what I believe is meant in Rule 2, with simply asking front-line staff what is wrong.
Let’s circle back. “Just ask the front-line workers – they know what is wrong.” Why do I say that this statement is wrong?
1. Perspective—Typically, front-line workers don’t see the whole process; they see only their part of it. So, while they may see problems in their part of the process, they don’t know if that is a symptom caused by problems elsewhere or if “their” problem is the originating problem.
This is a simple example I encountered in one of my consulting assignments. An order would be brought to the front desk of a Radiology Department by a patient. The order was handwritten, and sometimes the handwriting was difficult to read/interpret. So, the front desk clerk faced a dilemma: contact the physician’s office and get clarification, which left the patient sitting in the waiting area for some time, getting upset or interpreting the handwriting, putting it into the system, and moving on, which is what happened frequently.
The Radiology tech would shoot the X-ray only to find out that it was wrong (maybe left when it should have been right, one view when it should have been two views, etc.). When you talked to the Radiology Tech, they expressed the problem as the physicians ordering the wrong test. From their perspective, that seemed wrong, but the actual problem was that the front desk incorrectly interpreted the order.
But really, the problem was the order was handwritten and difficult to read. So, just asking did not cause us to understand why there was a problem. When we talked to the Radiology tech and the front desk clerk, we started to understand, and when we looked at the order as it came from the physician's office, “Go See”, we understood more. We understood even better when we talked to some physicians and their office staff and reviewed their process for generating the order slips. Interestingly, when we talked to the physician office staff, they thought the Radiology department had problems executing the orders and could not understand why it was so difficult.
Only when we laid out the entire causal chain of events did the parties understand the problems and motivations that caused the problem. While this example is simple, any process involving multiple staff has multiple perspectives on problems that appear.
2. Normal human bias – People in a healthcare setting, and in some other settings as well, often don’t think in terms of process; they think in terms of people. I’ve done a lot of Emergency Department (ED) consulting, and often, when I ask physicians about problems, they say, “It is the nurses.” And if I ask the nurses, they say, “It is the physicians or the Radiology techs or Lab techs, etc.” I have never talked to a group of people who said, “We are the problem.”
It is often easier to blame a group of people for the problem than to think about what may be going wrong in the process. W. Edward Deming, the father of modern quality theory, said that you should not blame the worker; you should blame the process. A physician, for example, telling you the nurses are the problem does not help solve the problem. Also, in my experience, workers were rarely the problem. Hardly anyone in healthcare or anywhere else comes to work intending to have poor performance or execution of a task. However, their perception of the problem is always affected by their bias.
3. Experience – After four decades of process improvement, I’ve done hundreds of projects and talked to hundreds of frontline staff, and never once did a frontline staff member tell me everything that was wrong in a process. Certainly, each staff member I interviewed provided insight disguised as the problem. We use a collaborative approach to problem-solving with a multi-disciplinary team. In our first or second team meeting, the members share their perspectives on the problem, and generally, they are amazed at how different their perspectives are. If it was as easy as asking the staff what causes the problem, we could skip Define, Measure, and Analyze and go right to Improve and Control (or skip Plan and go right to Do, if you prefer). Combining the staff’s insights with the process improvement professional’s observations, value stream and process mapping, data, etc., we understand the problem and can begin brainstorming countermeasures.
I want to be clear that you should talk to the frontline workers in the process. First, this shows respect, and as I said above, each person offers insight into the situation and the problems. I believe the rules start with “Go See” for a reason. Often, unbiased outside observers will see problems in a process that the frontline staff doesn’t see. This is, in part, conditioning. If you learn a process, that is the process. Most people haven’t been taught or encouraged to question a process. If you’ve seen the process done differently somewhere else (and maybe better) and you raise questions, many, if not most, healthcare organizations are not enlightened enough to encourage improving the process.
My previous essay on the process improvement mindset addressed some of these concepts. In that essay, I tell a story about visiting a Hospital Emergency Department, and they described their process regarding X-ray results. When the speed of getting results is critical, as it often is in the Emergency Department, the Radiologist performs a “wet read” (a term from the days when x-rays were on film and the Radiologist read it while the film was still wet). A wet read means the radiologist prioritizes the image above others, reads it quickly, and, in this case, faxes a result to the ED.
As this was described to me, I thought it sounded like the process I’d seen in many other EDs, and I asked, “So the results come in on this fax machine on the desk here?” “No,” the nurse replied, “that fax machine is broken.” Me – “Then where do the results come to?”. The nurse said, “They come to the fax machine in the office – go through those doors, down the hall, turn right, and halfway down that hall is the office with the fax machine where the results are sent to.” Me – “So, let me make sure I understand – the critical results are sent to a fax machine down the hall and around the corner?” Nurse, “Yes.” The nurse is looking at me as if I’m a bit of a dummy – which often happens when I try to understand a process. So, I ask, “How do you know when there are results in the fax machine that need to be evaluated and used for treatment?”. “Periodically, when we have time, we run down the hall and check.”
From this nurse’s point of view, this was business as usual. From my point of view, critical results are waiting in the fax machine for long periods of time, physicians can’t treat their patients, patients are waiting, and nurses and aides are running up and down the hall. The staff did not perceive this as a problem because the process worked. They were getting X-ray results and using them to treat patients. But just getting work done is viewing it as a one-dimensional concept. We should always look at other dimensions, such as whether we are getting work done in a reasonable amount of time. Are we minimizing travel and effort from the staff? And are we minimizing avoidable suffering for the patient? Hopefully, you think this situation seems like a problem and an opportunity for improvement.
Let me stress, as always, that in no way is this meant to criticize this nurse or the staff of this ED. The expression “we can’t see the forest for the trees” often plays out in the work setting. To the staff, the situation was normal; it was the best fix they could come up with, and for some staff, it had been done that way since they arrived, so it was “the way things were done.” This story is an example of how something that is viewed by an outside observer with a process improvement mindset seems an opportunity (or problem) to the observer but not to the staff. The three rules of Lean (Go See, Understand Why, and Show Respect) apply to every situation.
In the future, when someone says, “Just ask the front-line workers—they know what is wrong.” You may picture yourself as a Jedi saying, “Amazing, every word you just said was wrong.” But don’t say it—show respect and then go help them fix their problems using Lean Six Sigma and Operational Excellence.
[1]Schein, Edgar H. and Schein Pater A. (2021) Humble Inquiry, Second Edition: The Gentle Art of Asking Instead of Telling, Berrett-Koehler Publishers, Inc.