‘Just Do It!’ Still Won’t Do It

Even good ideas must be subject to critical thinking

Published: Wednesday, January 29, 2014 - 17:58

I remember all too well the “quality circles will solve everything” craze during the 1980s, which died a miserable death. During this time I was exposed to Joseph Juran’s wisdom about quality circles from his outstanding Juran on Quality Improvement video series from the 1970s. He was adamant: They must be separate from an organization’s formal quality improvement efforts and used only to solve everyday, localized, frontline problems—the 80 percent of the processes causing 20 percent of the problems.

For quality circles to be effective, they must be built into a mature, overall organizational improvement process that is actively working on the majority of problems, those 80 percent that are caused by only 20 percent of the processes.

A hot topic at the moment, especially in healthcare, is rapid cycle PDSA (plan-do-study-act). In many cases, I’m seeing it presented as a “Go on... just do it!” process for everyman to test good ideas in his routine work as a way to work around sluggish management.

The rallying cry is: “What can we do now? By next week? By Tuesday? By tomorrow?”

Here’s rapid cycle PDSA in a nutshell:
• Test on a really small scale. For example, start with one patient or one clinician at one afternoon clinic, and increase the numbers as you refine the ideas.
• Test the proposed change with people who believe in the improvement. Don’t try to convert people into accepting the change at this stage.
• Implement the idea only when you’re confident you have considered and tested all the possible ways of achieving the change.

Note: The implicit “plan” of PDSA seems to be, “Come up with a good idea to test, then plan the test.” Sounds so easy, at least on paper or at a conference.

Is this just a modern-day variation of quality circles? Good people with good ideas doing their best? As Deming growled many times, “They already are... and that’s the problem!” He also said, “For every problem, there is a solution: simple, obvious... and wrong!”

Reviewing two of my respected colleague Mark Hamel’s observations from a previous newsletter:
• Human systems don’t naturally gravitate to discipline and rigor.
• Most folks are deficient in critical thinking, at least initially.

The fine print?

I researched a bit on rapid cycle PDSA and found some resources to help one “plan”—see examples No. 1 and No. 2. If, after reading them, you feel a tad overwhelmed, join the club! This is not easy. To see it done right, I highly recommend the superb reference, The Improvement Guide, from which example No. 1 was, shall we say, borrowed. Example No. 2 sees the process as one big PDSA, which is erroneous, as is considering it the same as PDCA (plan-do-check-act).

Today? Tomorrow? Next Tuesday? Next week? In an environment where leaders are not instilling discipline, prompting critical thinking, or facilitating daily kaizen? Any “good idea” needs to be subjected to the discipline of critical thinking in dialogue with people who have deep knowledge of improvement—and beyond a bunch of tools.

As I’ve said repeatedly, the most important problems are the ones of which no one is aware. Many “good ideas” could be naively applied to the more obvious, superficial symptoms of these deeper, hidden problems. In addition, one must inevitably deal with resistance (and unintended human variation) every step of the way while testing the idea and then trying to implement it... based on a very limited, ad hoc “planned” data collection.

Respect the process

In improvement, there’s a lot of talk about respect for people. As if that wasn’t hard enough, there needs to be yet another important recipient of our deserved respect: the concept of “process.”

More practical wisdom from Mark Hamel:

“Every process, standardized or not, should be respected at least to the extent that we must grasp what it is (admittedly difficult if it is not standardized) and the reason for its very existence. How many times have folks eliminated or changed a process without understanding what problem it was trying to solve in the first place, only to find that their rash ‘improvement’ was counterproductive?

“Basic respect is extended to people because of their inherent human dignity. A standardized process has a certain inherent value in that it provides, if nothing else, a starting point for improvement. Think back to your last time you (improved and) standardized a previously nonstandardized process. Hard work, but it established a critical foundation for the next kaizen activity.”

Implicit in lean is the idea that there’s no kaizen without standard work. Initially, the proper use of standardized processes readily reveals abnormalities, which is the feedstock for problem solving. Hamel continues:

“Standardized processes, until improved yet again, represent the best way for the organization to do things easier, better, faster, and cheaper. Why wouldn’t we respect that? A standardized process represents, if established properly, the genuine PDCA and SDCA (standardize-do-check-act) efforts of a number of folks. We need to respect their hard work, courage, and creativity.”

Why?

“PDSA. It’s difficult to respect what you don’t understand,” Hamel notes. “Good old-fashioned PDSA requires the improvement practitioner to grasp the situation. The plan portion of PDSA directs us to understand and compare what is happening against what should be happening, and what we know vs. what we don’t know. In other words, we shouldn’t willfully further process ignorance.

“SDCA. SDCA is about ensuring, via an audit, that standardized work is being adhered to and is sufficient. This assumes an organizationwide discipline to follow the standardized work, a leadership obligation to reinforce adherence, and in the event of lack of adherence, determine the reason why and help to develop and deploy an appropriate countermeasure. Sometimes lack of adherence is driven by one or more of the following: the process is insufficient, a better way has been adopted (and should be reflected in updated standardized work), insufficient training, or willful disobedience.

“Patience. Standardized work needs to be lived with for some measure of time before changes should be experimented with or instituted. I’ve witnessed folks immediately dismissing standardized work, which was SDCA’d in an identical process from another location, as insufficient when compared to their organic, nonstandardized work—and then desiring to change it or just plain ignore it.”

The basic principles aren’t so basic, are they?

About The Author

Davis Balestracci

Davis Balestracci is a past chair of ASQ’s statistics division. He has synthesized W. Edwards Deming’s philosophy as Deming intended—as an approach to leadership—in the second edition of Data Sanity (Medical Group Management Association, 2015), with a foreword by Donald Berwick, M.D. Shipped free or as an ebook, Data Sanity offers a new way of thinking using a common organizational language based in process and understanding variation (data sanity), applied to everyday data and management. It also integrates Balestracci’s 20 years of studying organizational psychology into an “improvement as built in” approach as opposed to most current “quality as bolt-on” programs. Balestracci would love to wake up your conferences with his dynamic style and entertaining insights into the places where process, statistics, organizational culture, and quality meet.