Debunking the Program-of-the-Month Myth

“This is what you and I were talking about four years ago—before the Kaizen Curmudgeon blog even existed: ‘Jaded Julie announces to everyone within earshot, “I’ve seen them all—Total Quality Management, Quality Circles, Baldrige, ISO 9000. We tried them, spent a lot of money, management lost interest, and they went away. They were all just the program of the month, like this new Lean stuff. It will go away too.” '

“To which I responded, ‘No, Jaded Julie, you’re wrong (mostly). Lean is not the program of the month, and it has worked too well to simply ‘go away.’ Here are the facts:

· All of the programs that you listed came from a common origin, W. Edwards Deming’s principles of driving out fear, employee empowerment, studying and improving processes, and reducing waste.

· The programs had many elements in common, such as people working together in teams.

· Over time, the programs evolved, became more sophisticated, and were given new names.

· Programs came and went because they were mismanaged. On this point you were correct, Julie: Management often lost interest before the programs could pay off.’ “

“You’re right, Curmudge. I was too quick to criticize; I’ve learned a lot in the past four years. Lean has been working well for us, and it has become widely used in health care organizations. But what are some of the other current programs? When I encounter them in my reading, I want to know what the author is talking about. However, it’s my guess that success doesn’t depend so much on the program itself but on how vigorously it is implemented.”

“Let’s start with an old name, Gemba Kaizen . Although this is the predecessor of Lean, the name is a trademark and is not used very much. Among the principles of Gemba Kaizen are management’s role in upholding standardization, focusing on the process, analyzing process data, establishing and implementing countermeasures, following PDCA cycles, revising standards, and policy deployment.”

“That sounds a lot like Lean. Because it is Lean’s predecessor, that should be no surprise. Lean has also strengthened the emphasis on housekeeping (5S), process analysis using value stream mapping, and A3 problem solving.”

“Most of what we have discussed can also be found in Six Sigma, where their project elements include Define-Measure-Analyze-Improve-Control. In addition, there is emphasis on process control, statistical design and analysis of experiments, and training of project leadership (black belt and green belt).”

“I assume, Curmudge, that you are going to mention the Institute for Healthcare Improvement’s (IHI) Model for Improvement.”

“IHI is sort of like a supermarket; if you need something, they are likely to have it. In this case, IHI can provide a lot of guidance as well as tools for improving a process. Principal elements in their Model for Improvement include: Forming the Team, Setting the Aim, Establishing Measures, Selecting Changes, Testing Changes using plan-do-study-act cycles, Implementing Changes, and Spreading Changes. A newer IHI tool is their Improvement Map .”

“Although the Improvement Map is free of charge, Curmudge, I understand that its use requires installation of Microsoft Silverlight software.”

“Here’s an improvement program—also fairly new—that comes from The Dartmouth Institute for Health Policy and Clinical Practice. It’s called Clinical Microsystems. To me, it looks like a highly structured, Lean-like approach to process improvement with preprinted documentation. The microsystem is ‘your unit,’ and it is defined as ‘the place where patients, families, and care teams meet.’ For people in the unit, job #1 is to provide care, and job #2 is to improve care. Steps on their Improvement Ramp include: Assessment of the unit, Theme (identified in the assessment), Global and Specific Aims (specific numeric goals), Ideas for Change, and then Plan-Do-Study-Act cycles. The organization provides so-called Greenbooks for applying these steps to specific units within a hospital (Inpatient Units, Emergency Department, etc.).”

“As you suggested, Curmudge, these programs—the old as well as the new—have a lot of features in common. So tell me, how does the newcomer decide which of these she will propose to her organization?”

“Jaded Julie, although we favor Lean and call it the Affinity Performance Excellence System, one does not need to be a purist. Pick and choose what might work best in your organization or unit. And feel free to supplement from the works of Quint Studer (Hardwiring Excellence) and James C. Hunter (Servant Leadership).”

“When we wrote much of this four years ago, we were contemplating changing my name to Enthusiastic Emily. Whatever came of that?”

“Jaded Julie, it will never happen. Your name has become a household word, or at least a hospital-wide word. You will no longer be jaded when I am no longer a curmudgeon.”

Afghanistan ER--Firefight

“Hey, Curmudge. We haven’t heard from Mack recently. Is the war in Afghanistan over?”

“Don’t I wish, Julie? Mack was in the States for a mid-deployment leave, but he’s back over there now. He copied me on this note to a friend:

‘Hi Rich,
It's been a decent week here. We had a ground assault mission three days ago; was nice because it was only one day. We left at 0400, got back at 19, in time for hot chow. The purpose was to hunt for bunkers and weapons/explosive caches. We found a lot of stuff and blew it all up. In the afternoon we got into a rather large firefight. The Taliban were actually hitting with more than their usual accuracy, meaning they were hitting the grape rows in front of us. We fired a ton of ammo, not really sure if we hit anyone, but certainly stopped their shooting. What the enemy usually does is fire on us for a short period of time, then simply break contact and disappear in the grape rows. They usually shoot from buildings like houses or grape huts but not for long. If they did we would get a bead on them and destroy them. They are usually not very accurate; their plan is to get us to pursue and lead us through fields where they have planted IEDs. We don't usually go for that anymore. The best part of this day was that no one stepped on an IED or got hurt. I'm all scuffed up from crawling over 5-foot high walls, etc. and destroyed a set of ACU pants. I'm certainly the oldest one out here, at age 49. Most everyone is in their 20s.
Mack’”

“It probably doesn’t make Mack feel any better to remember that he was an infantry platoon leader (prior to med school) before some of the younger soldiers were born.”

“Julie, if Mack slows up the troops any—and he probably doesn’t, I’ll bet they are still glad to have ‘The Doc’ come along with them.”

Afghanistan ER

“Hi, Curmudge. I see that Mack copied you on a note to one of his medical colleagues.”

“Right, Jaded Julie. When you read the note, it will be evident that it could only be fully understood by another Army emergency medicine doc who had served in combat. When I asked Mack about some of the terms, he dictated a rather cursory glossary (below). Here’s the note:

‘Hi Ian,
Had a terrible air assault day before yesterday, very dangerous area. One person killed by IED. Also Local National blown up accidentally by our APOB while we were trying to breach through really dangerous IED seeded area. Even though they did the whole procedure to warn the locals and clear everyone out. It was after dark when we crossed after the explosion, the people up front found a guy on the road, huge facial wounds but alive and struggling. I put in a tibial IO, (I carry the mini-drill in my Aid Bag). Hit him with IV Ketamine (in spite of the head wound. I heard that increased ICP with Ketamine was not really borne out by literature. Also only thing I had to adequately sedate him for any extended time). Also used some Versed. Did a cric, balloon failed so exchanged it for new tube over a stylet. Ran 2 Hextends IO for the crappy radial pulse. The guys used their Tac lights on their M-4s for light. Set up hasty LZ and evacd him. Guy made it back to the Role III alive; they did labs, CT scan, everything. He had a brainstem bleed and a depressed skull fracture, so they withdrew care and he died. My two medics and I were covered with blood. Several of us fell into a creek trying to get back to the exfil LZ so had to wait for 3 hours in the freezing cold while wet. We were in PZ posture in the dark; the Chinook almost landed on us. Whole planeload had to dive off 6-foot embankment to keep from being dismembered by the bird, then crawl up the sides of the ditch and run for the helicopter. Still scratched and sore from that.
Anyway, that's my world for the last 3 days. Take care—Mack’”

“Gosh, Curmudge, every note from Mack further strengthens my belief that war is Hell.”

“I believe most everyone can get that impression without the glossary, but here it is anyway:

IED—improvised explosive device
APOB—chain of explosives fired several hundred yards ahead of advancing troops to explode IEDs
IO—intraosseous. An ‘IV’ into a bone instead of a vein.
Ketamine and Versed—anesthetics
ICP—intracranial pressure
Cric—cricothyroidotomy; an incision in the front of the neck to establish an airway
Hextend—colloidal plasma volume expander
Tac lights—very bright, focused, visible light source mounted on weapon
Role III—advanced medical care. A battalion aid station is Role I.
Exfil LZ—helicopter landing zone to extract troops at end of mission
PZ posture—troops lined up in Pickup Zone in order of entry into helicopter”

“The glossary improves my understanding, Curmudge, but it doesn’t assuage my feelings one bit.”

“As always, Julie, you’ve got that right.”

Afghanistan ER

“Hi, Jaded Julie. Mack copied me on his exchange of Christmas notes with his friends, Ernie and Susan. You might find them interesting. Here’s the note that Ernie and Susan sent to him:

‘Christmas Day is just about done where you are, and the grandchildren here are already winding down - all the Santa gifts are opened and being played with. But we wanted to wish you a very merry Christmas and lift you up with a prayer that 2011 will be a year of much more peace - for you in particular and for all of us in general.’”

“It sounds like a classical, peaceful American Christmas, Curmudge.”

“This is Mack’s response:

‘Dear Ernie and Susan,
Christmas has been pretty nice. Today was a nice, quiet day. Just got a cold so spent a few hours napping at the house. The whole camp has had it; I'm like the last one to get it. Just got back from screening a detainee tonight. Christmas Eve was a little more exciting. I was eating lunch when one of my medics ran in the chow hall and told me we had traumas coming. Apparently one of the good Afghanis in a nearby village was the victim of a Taliban motorcycle drive-by. Shot in the chest, head and leg. His cousin brought him to right outside our FOB, with the guy in the back of a minivan. Stokes, one of my medics, and I took the little ambulance and had a hair-raising ride to the gate. Blood everywhere. The van was outside the gate on the highway since they couldn't come in. We drove through the gate onto the highway, usually a no-no since the Ford has no armor (and we were in T-shirts!!) The Ford does have a siren loud enough to peel paint, however.

I had the Afghanis in the van lay the guy by the side of the road and I did a "cric", which is a surgical airway where I cut a hole in his throat and put in a breathing tube, right there on the road. Fortunately no snipers. We put the guy in our ambulance and took him back to the aid station. Unfortunately he died; had a pulse of something like 29 when we got him on the table, but I think we got some I/O points with the local population for trying.

We had a beautiful candlelight Christmas Eve service in the chapel (tent) last night. I played the piano for it like I do for most of the church services.

Today Major General Terry (RC South Commander) flew in to visit everyone for Christmas. We enjoyed meeting him very much.

Anyway, I'm guessing you guys had a pretty nice Christmas Eve service at church. Feel free to read this letter at Sunday School if you want, so they know we had a good Christmas as well. Stay in touch and God bless. -----Mack.’”

“Curmudge, the FOB (Forward Operating Base) must be a fortified island of relative safety amid a sea of anarchy. So why am I shuddering? Maybe if I put on a warmer sweater…”

Afghanistan ER

“Good morning, Jaded Julie. You may be interested in the news bulletin (below) that I saw on the Web yesterday:

‘Six American soldiers were killed and more than a dozen American and Afghan troops were wounded on Sunday morning when a van packed with explosives was detonated at a new jointly operated outpost in southern Afghanistan. The soldiers were inside a small mud-walled building near the village of Sangsar, north of the Arghandab River, when the bomber drove up to one of the walls and exploded his charge around 9 a.m. The explosion blasted a hole in the thick wall, causing the roof to collapse on the soldiers inside. Others quickly arrived and clawed and pulled at the waist-deep rubble to free the buried troops. The building had been occupied by the Americans and Afghans for only a few days, an American official said, and was beside a narrow road. It was not immediately clear how the van managed to get so close without being challenged or stopped.’”

“Doesn’t sound good, Curmudge. We’ve heard about mud-walled buildings before. Did you send a note to Mack asking about it?”

“I did, and here is his reply:

‘Yes, that suicide bomber was for us. It occurred on Sunday morning at a small outpost, happened to one of our platoons, one that I have been out with a number of times and been at the exact same type of outpost with. Good I wasn't killed in a blast, but frustrating that I wasn't close enough to do anything to help. I was sent out there quite quickly by the command, but when I got there, all the dead and worst injured had been already evacuated. They were just digging through the rubble; I took care of a couple of Afghan Army folks. I've been busy checking out the remaining folks here, also there is a huge emotional toll since 6 guys were killed like that. Been busy, up until 0200 last night just talking to distraught guys.
Jim Slone, my PA, has gone on leave, so I can't really leave the Aid Station on base to go on missions, since we have to have at least one care provider on hand.’”

“My feelings are a mixture of thankfulness and rage, Curmudge.”

“Mine also, Julie. Mack said that with winter coming on, the Taliban chiefs will sit at home by the fire in the security of Pakistan and send out the young jihadis to become martyrs. I guess he’s right.”

Afghanistan ER

“Here’s Mack’s latest note, Julie. I’ll read it to you:

‘We did have a huge Thanksgiving dinner. I literally ate too much. Our mission that you mentioned was successful in that we accomplished what we set out to do. We went into one of the worst Taliban areas, found improvised explosive and burned and blew it up. We also found a Taliban Aid Station and burned it down. The real sad thing was that the other platoon was moving and an Afghani soldier moved off the cleared path and stepped on an IED, blew both his legs off, also injured an interpreter. Some of our guys were carrying him to the helicopter and the enemy apparently had a buried remote-controlled IED ready. When the stretcher bearers passed over it, they blew it up, killing two of our guys, injuring several more, and of course killing the Afghan guy on the stretcher. I was six hundred meters away with the other platoon and couldn't go help them since all the ground between us was not cleared and likely seeded with plenty more explosive devices. It was extraordinarily frustrating to not be able to help. Everyone was furious and despondent at the end of an otherwise tactically very successful mission. Memorial service was yesterday.

We are in our new Aid Station, which was just completed. It is beautiful and three times as large as our old one in the old stone Afghan building. The new place is by the helicopter landing zone; can be windy at times. Also too close to the trash burn pit, and I am lobbying hard to get the burn pit moved. Anyway, after I got back from the mission I pretty much just slept all day while the medics moved everything from the old building (none of them were out on the mission like I was). It was sometimes exhausting out in the field, climbing over the stone walls in the grape fields with full packs, weapons, etc.’”

“Golly, Curmudge, it must be awfully depressing for the troops and for the folks back home at Fort Campbell for the battalion to be losing at least two soldiers per week to IEDs.”

“Julie, I seem to recall reading about medieval times when battles were stopped to allow the wounded to be removed from the field. I guess now we are fighting an even more primitive civilization.”

“Civilization? Aren’t these the guys who condemn women to death by stoning?”

Afghanistan ER

“Another note from Mack. It’s rather short:

‘Pretty busy over here; lost some guys to a suicide bomber in the field. These were guys I had just been on the same mission with for 6 days. Then I went back in to check up on things at the aid station. Next day, guys I was just walking with out there were blown to bits by a s_ _ _-a_ _ with an explosive vest. Also three injured. I can't stand the fact that I was with them; then the moment I leave to go back here to work, this thing happens. Memorial service tomorrow.’”

“Do you have any comments, Curmudge?”

“Nothing that isn’t profane, Julie.”