Midcourse lessons from SPIRIT

Here are some comments made after today's BIDMC SPIRIT training session (see some of the participants above). We are now winding down on training the first 600 people. As you can see, people quickly get to the core issues, problems, and opportunities. This is about where we expected to be at this point in the process. After all, we are introducing new concepts of empowerment, problem identification, and problem solving -- and sometimes people are confused or nervous. The suggestions from these trainees are exceedingly helpful. But look, too, at the last comment: Key messages are starting to come through. Then, see a bit of my analysis after the comments.

We noticed when logging our issue that you see “SPIRIT problems.” We think it would be better to look at “SPIRIT opportunities.” One idea we had was to change the language.

On the issue of what are appropriate call outs, several of us were talking earlier today that there seems to be some confusion out there about what it’s OK to call out and who can do it. At the beginning, it seemed that it could be about anything and everything and the staff would be empowered … then there seemed to be a reassessment and it became in some areas there are some things you can call out and some you can’t … that you have to go through the manager and the body language suggests whether this is going to go forward or not … and I think there are varied answers to these things depending on who’s speaking from the help chain.

How to fix this? I think just a reaffirmation of the goals and key principles to the entire leadership team, so that it is not interpreted in various ways by various leaders. In some places, staff aren’t allowed to touch the log without talking to the manager. We know we are trying to find our way and it’s early.

Talking about the “chain of command” has a connotation of fear in some places. Where we were, these were perhaps more junior nurses than in the PACU and they didn’t want to identify anything as a problem … it seemed they were fearful. For us, residents, it can be hard to call something out. We need an environment where all are equal and our insights are encouraged.

We’ve trained all the managers and supervisors and not the front line in this way because that would be overwhelming but perhaps we could do an in-service DVD that just lays out the key principles that this is all about. Staff are reading about this on the web, they are hearing things second hand, but if you (Paul Levy) could deliver the message it might help with the consistency of the message as well.

A big thing is … just because it happens all the time doesn’t mean it should. We see all of these problems. 10 minutes here. 20 minutes here. People think they are little. But they add up quickly. For those of us who are out there, they add up quickly to patients’ lives. 1 life. 2 lives. They may seem small but they aren’t. They matter. People need to understand that.

We started our journey toward eliminating hunting and fetching for every BIDMC staff member 8 weeks ago. We are consciously following the path trod by other large organizations in other fields (Toyota, Alcoa, US Navy submarine corps) that seem to do what their peers do to far superior results, in terms of staff satisfaction, quality, and business performance. The core of our approach is empowering everyone at BIDMC to call out when they hit a glitch in their work (see the problem) and participate in understanding the problem and developing solutions. We are learning how to provide the right level of help to them right away (swarm the problem), then how to share improvement stories transparently throughout the hospital.

Overall, we stand about where I expected, but some of the particular challenges we have are interesting.

We have plenty of evidence that it is right to involve each employee more deeply in problem solving, every day. Story after story has surfaced about how the people who do the work have pointed to the solution that could work – and is more likely to endure. Just last week, the housekeepers and unit staff in an ICU developed a solution to a chronic shortage of pillows needed to prop up their patients that has been driving them crazy for years.

We also are seeing the value of immediately investigating specific instances of problems, while the details are fresh. Using the observed details of what just actually happened keep us on the right track in a way that far-off committee meetings of folks who may not actually do the tasks being discussed may not.

And while we are still in the infancy of learning how to share effectively, people are picking up not only specific solutions from the SPIRIT log, but also insights on how to solve problems.

And people are paying attention. The SPIRIT log is often viewed more than 1,000 times a day, and my reports from SPIRIT here on this blog are being tracked by people around the world eager to learn with us.

So that is good, but we are still far from where we want to be in the breadth and quality of problem solving that will really make life as good as it could be for our staff. That’s what we expected at this stage of things, but it underlines how much work we have to do. What are the challenges on which we should focus at this starting stage?

First, the quantity of hunting and fetching investigation and solution attempts we are seeing is not even a small fraction of the challenges we know staff face on a daily basis. This is not a numbers game, but we do want to see much more high quality problem solving occur. Every person at BIDMC has something to offer (and gain) to understand this dynamic in their own areas, but here are some of the forces at work.

(1) It’s clear that in many places, it doesn’t feel “safe” for staff and managers to have problems in our areas being called and worked in the transparent light of SPIRIT. This sense is critical to overcome. When people feel more comfortable to bring opportunities to the surface and work them in plain sight, we will make the most rapid progress. It is the areas where I am not seeing any SPIRIT call outs that I worry about the most at this point.

(2) Some of us are so used to working around problems that we don’t even recognize that there is an opportunity to make the work easier. Some managers are countering this by actually walking next to staff as they do their work and helping them see what may be a “work around” and where there is opportunity. That works and can be helpful in these initial stages.

(3) Many people don’t really believe their boss wants to hear about their next hunting and fetching episode “in real time.” People have been implicitly rewarded in the past for solving impediments by brute force, and they think their leaders may not welcome reports of a “small” problem. After all, the managers are busy, too. We need to reaffirm that the responsibility rests with supervisors to actively encourage those who look to them for leadership to begin calling out opportunities to them in person. Of course, we won’t be able to work on every problem in real time until we get a lot better and faster at this, but we need to start.

(4) Some people don’t yet know how to “call out” in the most productive way. We need specific reports of specific problems, without blame. We need people to stick to the facts. And we need reports made in person to the immediate supervisor, not entered directly on the log unless no one is available to help.

Second, I see lots of opportunity to deepen our solutions, so that we are not only solving the immediate problem, but also applying the lessons to similar situations. For example, if CT radiology residents didn’t have an easy way to realize they were sometimes presenting their technologists with protocols that conflicted with the original physician orders (a “connection” problem), how many similar situations exist across our clinical services? We plan to begin pushing on these issues as we progress.

Third, though we are pleased with the orientation and training we have provided to almost 600 managers, staff have told us that they need more direct exposure to the SPIRIT principles and tools. We will expand efforts in this area shortly.