What is the Process Improvement Mindset?

The process improvement mindset is critical for effective improvement and driving process changes.  I’ve said this often, but what is the process improvement mindset?  I’ve taught classes in Lean and Lean Six Sigma for many years, and there is always a “Lean Thinking” section.  Is that the same as the process improvement mindset?  Yes and No is exactly the type of answer you would expect from a consultant.  Lean thinking describes the fundamental concepts of Lean, so it is not necessarily about thinking at all.  Usually, in the Lean Thinking section, there is a discussion about the process of Lean – Identifying the Value Stream, Pull, Single piece flow/reduce batch sizes, and that is part of the thinking but is this “mindset”?  How do we identify opportunities for improvement if we’re using a lean model or if we are managing?  The obvious answer is opportunities are where the problems are, and the problems are easy to identify.  But problems are not easy to identify.  Unless a problem completely breaks the process, it may not come to light, and I often see people solving problems without regard to the process and ending up no better off or worse than when they started.

I often think of a situation I encountered in Detroit.  I visited 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 looks 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 while physicians can’t treat, patients are waiting, and nurses and techs are running up and down the hall.  The staff did not see this process as a problem because it had not broken it.  They get X-ray results and use them to treat patients.  Hopefully, you think this seems like a problem and an opportunity for improvement.  Let me stress that in no way is this meant to criticize this particular 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”.  I offer this story as an example of how something viewed with a process improvement mindset seems an opportunity to the observer but not the staff. 

A process improvement mindset's fundamental aspect is questioning how things are done.  If the fundamental aspect of the process improvement mindset is questioning, what do we question?  I’ve often heard “question everything”, but that seems exhausting. So, what do we question?  Question the critical or important processes.  Getting results from lab and radiology is critical for an ED.  They impact the throughput or flow and the patient experience.  Does this situation cause excessive travel and encourage waiting and delays? If so, then this is an opportunity.  Whenever someone describes doing a part of a critical process “when we have time”, there is probably an opportunity for improvement.  The ED I described was experiencing excessive waiting and patients leaving without being seen, so examining processes that slowed the flow and increased waiting was a good first step toward improvement.  We begin by questioning critical processes, but what do we look for?  One of the simplest ways to uncover potential opportunities comes from the Lean framework.  We look for 8 Wastes (defects, overproduction, waiting, extra processing, transportation, inventory, motion, employee underutilization).  I tend to focus initially on 4 of the 8 wastes.  I look at any critical process regarding waiting, inventory, transportation, and motion.  I find these are easier to see, and where I find these, I also typically find other wastes.  In my X-ray example, we saw the waste of waiting (patients and physicians waiting for results) and the waste of motion (having to go find the X-ray results).  Anytime we see one or more of the 8 wastes, we should consider an opportunity for improvement.  When a process exhibits variation, there is probably an opportunity to improve.  In my previous example, sometimes, we got x-ray results quickly (if we happened to walk down the hall to the office right when they arrived), and sometimes, the results waited until someone checked on them.  This inconsistency (variation) should alert us to an opportunity. 

So, what is the process improvement mindset?  It is characterized first by an openness to change.  I must abandon the idea that change means I did something wrong and adopt an attitude that all processes will evolve and that helping them evolve is good.  Second, I have to view a chain of events as a process.  Things don’t happen randomly.  A process may be consistent or inconsistent, but it is still a process by which things are accomplished.  Third, it involves questioning any process that displays waiting, inventory, or transportation or any situation where we see staff hunting for resources, skilled staff doing work that lesser skilled or lower licensed folks could do, or we see work producing items that can’t be used in a timely fashion (overproduction).  We define a problem as a situation in which the actual and expected results differ.  To understand we have a problem; we must know the expected result.  Part of the process improvement mindset is having these expectations and constantly comparing our actual results to them.  Nothing is a problem to the individual with no expectations.  Some people naturally exhibit a process improvement mindset; for others, this is a learned behavior.

Why do I need a process improvement mindset?  Without one, everything becomes routine, and we never see the forest for the trees.  We miss opportunities to improve until a problem becomes so onerous that the system breaks, and then not only must we solve the problem, but we must also have all the breakage to deal with. The solutions or countermeasures implemented may not actually fix the problem without a good process improvement mindset.  This can set off more problems and a downward spiral in terms of performance, sometimes resulting in injury or even death in the healthcare business.