What is the Process Improvement Mindset?

The process improvement mindset is a critical foundation to being effective at improvement and driving changes in processes.  I’ve said this many times and yet, what is the process improvement mindset?  I’ve taught classes in Lean and Lean Six Sigma for many years and there is always a section on “Lean Thinking”.  Is that the same as the process improvement mindset? Yes and No, exactly the type of answer you would expect to hear from a consultant.  Lean thinking describes the fundamental concepts of Lean, so it is not necessarily about thinking at all.  Usually in the Lean Thinking section there is a discussion about the process of Lean – Identify the Value stream, Pull, Single piece flow/reduce batch sizes and that is part of the thinking, but is this “mindset”?  How do we identify opportunities for improvement if we’re in a Lean model or if we are simply managing?  The obvious answer is opportunities are where the problems are, and the problems are easy to identify.  But problems are not easy to identify.  Unless a problem completely breaks the process, it may not come to light and I often see people solving problems without regard to process and ending up no better off or worse than when they started.  I often think of a situation I encountered in Detroit.  I visited a Hospital Emergency Department and they described their process regarding X-Ray results.  When the speed of getting results is critical, as it often is in the Emergency Department, the Radiologist performs a “wet read” (a term from the days when x-rays were on film and the Radiologist read it while the film as still wet).  A wet read means the radiologist prioritizes the image above others and reads it quickly and in this case faxed a result to the ED.  I thought as this was described to me that it sounded like the process I’d seen in many other ED’s and I asked “so the results come in on this fax machine on the desk here?”  “No”, the nurse replied, “that fax machine is broken.”  Me – “then where do the results come to?”.  The nurse, “they come to the fax machine in the office – go through those doors, down the hall, turn right and half way down that hall is the office with the fax machine where the results are sent to”.  Me – “So, let me make sure I understand – the critical results are sent to a fax machine down the hall and around the corner?”  Nurse, “Yes”.  The nurse is looking at me as if I’m a bit of a dummy – which often happens when I try to understand a process.  So, I ask, “How do you know when there are results in the fax machine that need to be evaluated and used for treatment?”.  “Periodically, when we have time, we run down the hall and check”.  From this nurse’s point of view, this was business as usual.  From my point of view, critical results are waiting in the fax machine for long periods of time while physicians can’t treat, and patients are waiting, and nurses and techs are running up and down the hall.  The staff did not see this process as a problem because it had not broken the process. They got x-ray results and used them to treat patients.  Hopefully, you are thinking this seems like a problem and an opportunity for improvement. Let me stress that in no way is this meant to criticize this particular nurse or the staff of this ED.  The expression “we can’t see the forest for the trees” is often played out in the work setting.  To the staff the situation was normal, it was the best fix they could come up with and for some staff it had been done that way since they arrived, so it was “the way things were done”.  I offer this story as an example of how something that is viewed with a process improvement mindset seems an opportunity to the observer, but not to the staff.  

The fundamental aspect of a process improvement mindset is questioning the way things are done.  If the fundamental aspect of the process improvement mindset is questioning, what do we question?  I’ve often heard “question everything”, but that seems exhausting. So, what do we question?  Question the critical or important processes.  For an ED, getting results from Lab and Radiology are critical processes. They impact the throughput or flow and they impact the patient experience.  Does this situation cause excessive travel and encourage waiting and delays? If so, then this is an opportunity.  Any time someone describes doing a part of a critical process “when we have time”, there is probably an opportunity for improvement.  The ED I described was experiencing excessive waiting and patients leaving without being seem, so examining processes that slowed the flow and increased waiting was a good first step towards improvement.  We begin by questioning critical processes, but what do we look for?  One of the simplest ways to uncover potential opportunities comes from the Lean framework. We look for 8 Wastes (defects, overproduction, waiting, extra processing, transportation, inventory, motion, employee underutilization).  I tend to focus initially on 4 of the 8 wastes.  I look at any critical process in terms of waiting, inventory, transportation and motion.  I find these are easier to see and where I find these, I also typically find other wastes. In my X-ray example, we saw the waste of waiting (patient and physicians waiting for results) and the waste of motion (having to go find the x-ray results).  Anytime we see one or more of the 8 wastes, we should consider an opportunity for improvement.  When a process exhibits variation, there is probably an opportunity to improve.  In my previous example sometimes, we got x-ray results quickly (if we happen to walk down the hall to the office right when they arrived) and sometimes the resulted waited for a long period of time until someone checked on them.  This inconsistency (variation) should alert us to an opportunity.  

So, what is the process improvement mindset?  It is characterized first by an openness to change.  I have to abandon the idea that change means I did something wrong and adopt an attitude that all processes will evolve and helping them evolve is good. Second, I have to view a chain of events as a process.  Things don’t happen randomly.  A process may be consistent or inconsistent, but it is still a process by which thing are accomplished.  Third, it involves questioning any process that displays waiting, inventory or transportation or any situation where we see staff hunting for resources, skilled staff doing work that lesser skilled or lower licensed folks could do, or we see work producing items that can’t be used in a timely fashion (over production). We define a problem as a situation in which the actual result and the expected result are different.  In order to understand we have a problem; we must know what the expected result should be.  Part of the process improvement mindset is having these expectations and to This article constantly compare our actual result to them.  Nothing is a problem to the individual with no expectations.  Some people exhibit a process improvement mindset naturally, while for others this is a learned behavior.

Why do I need a process improvement mindset?  Without one everything becomes routine and  we never see the forest for the trees.  We miss the opportunities to improve until a problem becomes so onerous that the system breaks and then not only do must we solve the problem, but we have all the breakage to deal with as well. Without a good process improvement mindset, the solutions or countermeasure implemented may not actually fix the problem.  This can set off more problems and a downward spiral in term of performance and sometimes resulting, in the healthcare business, in injury or even death.