Roberto Priolo is editor at the Lean Global Network and Planet Lean
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Our editor recently spoke with the director of the largest hospital in the Netherlands and asked him about the Lean transformation he is leading there.
What kind of organization did you find when you took on the position of director of this hospital? What were your first 100 days like, so to speak?
I started two weeks before we received our first Covid patient. Of course, it was a hectic start, but once everything stabilized a bit, I decided to take a closer look at the state of affairs at Erasmus Medical Center. Those first weeks I conducted about 150 interviews with employees and constantly walked the gemba (=work floor) to really understand the situation. (It helps that I have been working in hospitals for 25 years).
During my research, I discovered several things.
First, I realized that our people were exhausted because of the recent move (the medical center had several locations in the city that were merged and moved into a new building). As part of the reorganization, all kinds of teams were integrated, but the fact that we had not followed a proper redesign process meant that many people were struggling during the transition. I felt that psychological safety was lacking in several areas.
I also discovered that we were doing wonderful things on the medical side - we are a very innovative organization - but not on the business side, because there was no operational management. This meant that we often struggled to stay on top of the work, to keep track of our activities, so we missed out on a lot of revenue opportunities. Another big problem for us was turnover. With the expansion of the hospital, the number of patients we treat has gone through the roof, resulting in stress: between 2018 and 2020, nearly 35% of our nurses left the organization.
From a cultural standpoint, I noticed that many managers were locked in their offices and didn't really understand what was going on at the gemba. On the gemba, I noticed that people found it difficult to admit when something was wrong, for fear of being reprimanded. Furthermore, while doctors and nurses worked together effectively in providing care to patients, they did not work together in problem solving. In other words, we were not a learning organization.
From day one, I saw many hard-working, enthusiastic people here at Erasmus MC, but also much potential for improvement. That's when Lean came into the picture.
What have you done to try to solve those problems?
Realizing that we needed to change the way of thinking of our people and create a system in which problem solving and continuous learning and continuous improvement become our livelihood, we partnered with the Lean Management Institute to get help in implementing a piece of business management and to get some stability in our processes. So from the very beginning, standardization was one of our main focuses.
Together with the Lean Management Institute, we devised a Lean strategy that included nine Lean waves for select leaders in the organization (the first cohort just completed their training). We understand the importance of changing their mindset so that they are more present at the gemba and help us steer the ship, so to speak.
At Erasmus MC, people are very enthusiastic about Lean (perhaps this says something about the pragmatic, hard-working attitude of Rotterdammers). Although they often want to jump to solutions, this is certainly fertile ground for a Lean transformation.
How do you select the people who participate in the Lean "waves"?
The waves are mainly aimed at middle management - specifically nurses, HR advisors (we plan to train 33 of them), quality managers and coordinators. I would like to see top management also participate in these development efforts, but we will have to wait a while, as we have a few senior leaders about to retire.
After the summer, we want to develop a plan to further involve the medical staff: they are already involved in the A3 discussions, especially the nurses, but we also want to involve the doctors. Fortunately, they are beginning to ask questions about the improvements taking place at the hospital: for now, we would rather make them curious than force them to participate in a training program.
We already see engagement growing and it is clear that more and more people are taking ownership of Lean , with a greater focus on patient needs. We continue to encourage managers to be more visible to their teams and to be coaches for them. We are seeing more visual management throughout the organization. Right now we are focused on spreading the Lean word and changing behaviors. After that, we will connect the dots.
What was the reasoning behind the reorganization and the merging of areas into larger departments? What are the lessons learned?
The reasoning was capacity management. From that point of view, it made sense to go in that direction, even though the change caused a bit of an identity crisis for some of our nurses in the beginning. When we merged the plastic surgery, orthopedics, dermatology and traumatology nurses into one team and one department, many of them no longer knew "who they were." That is no longer a problem(the work is largely the same) and cooperation between the specialties is now seamless.
How do patients experience the care they receive?
Our NPS is actually high, at 8.9, but I suspect that has something to do with people's expectations because we actually have so much to improve on!
Can you give us an example of a process improvement in progress?
We still send our patients letters to remind them of their appointments. However, due to privacy laws here in the Netherlands, we are not allowed to include the exact location and date of the appointment on the letter. Therefore, people also receive a message inviting them to look up the details of their appointment on a digital portal. This is cumbersome, and the problem is exacerbated by the fact that many of our patients are not comfortable with digital tools or do not speak Dutch to begin with. The result is that we lose an estimated 20% of patients! Those who do log in often arrive late for their appointments, and if they need to call us to reschedule, they have difficulty reaching us. So we have a lot of no-shows. And the worst part? By law, people who don't show up are fined €45! As you can imagine, complaints always follow. Surely there must be a better way to do this. I am happy to report that one of the leaders taking a Lean course is addressing this problem.
What does a learning organization look like in your eyes, and what are you doing to make Erasmus MC one?
To me, a learning organization is an environment where people are not afraid to identify problems, because from problems comes learning. I want to make Erasmus MC a safe environment for every employee. Our hospital has a traditional hierarchical structure, so people are often still afraid to make mistakes or speak out. We are trying to break down those walls.
Of course, that depends largely on the management team. Can they ensure that this is a safe environment for employees? I know that a Lean transformation can be overwhelming and it is common not to know where to start. Right now we are asking managers what are the top 3 problems their people are facing and what they think we can do to solve them. This is how we hope to get the learning going.
From an organizational perspective, can you tell me more about the problems Erasmus MC is experiencing and how you think Lean management can help address them?
Finding and retaining the right talent is certainly one of them. We cannot accept that people leave us after two or three years, given the investment we make to develop their skills. Lean management can of course help with this: it makes Erasmus MC a better place to work, it makes it easy for people to do their jobs and it ensures that they are constantly learning.
I think another issue is the healthcare system we have in this country, which makes hospitals compete with each other. This is ultimately not good for the patient. We need to move toward a model based on a regional network of cooperating hospitals. We need to find better ways to work together, and sharing Lean successes can help us get there. We have already started facilitating such conversations with other organizations in the region, and are even helping them conduct some Lean experiments of their own.
What is your role as a leader in supporting this Lean transformation?
I see myself as a facilitator. It is my responsibility to create a context in which the seeds we plant have the greatest possible chance of growing.
I make it very clear that this is not a "project" and that this way of thinking will be here to stay. I have a four-year term here, so I am constantly asking myself what I can do during that time to ensure that after I leave, the Lean journey continues. I know I need to make sure that the Lean culture becomes part of the DNA of this hospital so that everything we do is centered around the patient. It is clear to me that the solution is not some system, but people: we need to keep their enthusiasm going.
Of course, I also have to lead by example. How can I expect people to embrace Lean if I don't? That's why I spend as much time as possible on the gemba, asking questions and supporting people in their learning process. As a leader, it's important to show your face: as unnerving as it can be at first to have the boss around, this is ultimately what changes people's minds.
We still have a long way to go and a lot to learn (I've been working with Lean for ten years and I'm still learning new things every day). But I am confident in our approach: taking small steps and solving small problems will eventually make a difference.