Lean Management for Physicians: Isolating the True Problems

For those of you who don’t read this blog regularly, I am doing a series on Lean Management for Physicians. I am currently taking a course on Lean Management (aka the Toyota Production System) through my employer. As part of the course, we are supposed to come up with a performance improvement project. I had a whole list of things that I thought needed fixing and selected one that was high impact and problematic enough to warrant my energy and time. Plus, although this is a Lean no-no, I already had the problem solved in my brain.

While I was in my data-collecting stage, a curious thing happened. The problem, which occurred for me personally several times per day, stopped happening. I wasn’t sure if this was an effect of something being watched improving simply because of the observation. Our nursing staff was similarly puzzled and assured me that, yes, it was indeed a frequent problem. I checked with our front desk staff. They also endorsed the problem but had noticed that it hadn’t been happening lately. Puzzled, I tried to figure out how this problem solved itself.

 As it turns out, there was an upstream process that was fixed that had a downstream effect on the problem I was trying to solve. I had no idea of how the upstream problem, which I also recognized, impacted so many other areas of office function. The good news is that the problem that plagued me is gone. The bad news is that I need another improvement project.

When I was making a decision to leave academic medicine for full-time clinical practice, I had a lot of ideas about what the problem was. It was the frequent call, difficult residents, changing work-duty-hour requirements, the challenge of juggling research, teaching, administrative work, and clinical medicine. However, there was a lingering doubt. What if what I thought was the problem wasn’t the actual problem? What if I made huge life changes and didn’t solve anything? 

Fortunately, my job change did solve many of the challenges I faced in achieving work-life balance. However, I often solve the wrong problem. This happens with my patients, with my kids, and with myself.

Sometimes, I am absolutely convinced that I know why a patient’s blood pressure or blood sugar are poorly controlled only to take a moment and take a breath and actually ask my patient.  It’s not uncommon for me to find that my supposition was wrong. What I thought was the barrier is not it at all.

With my kids, I can leap to conclusions as well. It takes a humble and patient parent (which I’m not always) to backtrack and ask the question that should’ve been the first thing out of my mouth. Why? 

With myself, I blame a lot of things on my rising levels of stress and frustration.  However, when I stop and think about it, I often realize that whatever is aggravating me at that moment is not the real problem - whether that’s a patient, a colleague, or a demand. Instead, there are other decisions I’ve made that have created the circumstances that allow my stress and frustration to blossom.

 So, one of the first lessons I’ve learned is one that we all learn over and over again, often the hard way.  Before you start fixing something, make sure you know what’s really broken.