Wednesday, December 9, 2009

Golfing With Friends

With his permission I am posting a short essay written by my esteemed colleague Dr. Jon Stanger. I asked him to reflect on his experience at our last Kaizen report out.

I deeply respect Jon's perspective and hope you enjoy his comments as much as I did.


The following is his response:

Golfing With Friends
Jon Stanger

(Dr. Stanger is clinical and organizational ethics consultant at CCRMC. He is a member of the hospital Operations Team. His passions include family, medicine, literature, moral philosophy, and – recently – golf.)

We’ve all heard the expression, “A bad day on the golf course beats a good day at work.” Who’s going to argue? It’s not so much that I disagree but, in the wisdom of my maturity (i.e. as I get older), increasingly I find that experience has an irksome way of challenging categorical pronouncements. Here’s the deal. Somehow, one day last week I canceled a golfing date with good friends to attend a meeting at the hospital – and came out feeling, well, OK about it. This requires some explanation.

I successfully resisted golf for years. Even though advancing age and receding cartilage made it a natural for this erstwhile sportsman, I thought Mark Twain pretty much had it right when he described a day on the links as “a good walk spoiled.” Anyone with that much time on his hands needs to get a life. Besides, it’s not a real sport, is it? And “the physician golfing” calls to mind all the wrong associations – of plaid pants, power politics, and privilege – for this affirmed county doc.

About a year ago, trusted friends lured me onto the fairways for my first time. Start-up can be a painful experience for the novice. We can all remember our first times, right? Talk about performance anxiety. It takes a special mix of courage and humility to step up to that first tee, a gallery of aficionados on the clubhouse veranda feigning indifference while in fact watching you … judging you … smirking at you behind a foamy veil of Bud Light. That drive off the first tee is one of those rare certainties in life. You can be pretty much certain that it will be every bit as humiliating as you had imagined. Then, safely down the fairway at last, the searing pain of ego laceration gives way to a dull throb of frustration. This is when you realize the marketing genius behind the exorbitant green fees you just paid. Only such substantial investment, combined with primordial arrogance, keeps you from taking the shortest path from the fairway bunker directly back to the parking lot.

I have to believe that none but the delirious and demented would make it past the clubhouse turn of that first round were it not for a mysterious seduction that takes hold around the sixth or seventh holes. Stirring poetry has been (or should be) written about the power of that moment when the golfer, looking up from the Swoosh™ for the first time, finds herself painted onto a canvas of natural beauty and transcends preoccupation with her own situated particularity to embrace oneness with the cosmic universal. [Note: Italics here are employed to denote the author’s erudite use of technical philosophical terminology.] And there is something more I never anticipated – some alchemy of four friends, now comfortably distant from adolescent preoccupations with “winning,” sharing the disappointment of the slice into the woods along with the joy of the forty-foot chip that improbably finds the hole.

Certainly, golf has the challenge of personal improvement, and old-fashioned competitive drive has its place, but for me the appeal of golf is ineluctably social – friends come together for these few hours in a common pursuit, supporting each other, calling one another to the twin virtues of humility and courage as circumstances and individual dispositions require. We are in this together. We have learned together from the misadventures and triumphs of the last hole. Now the next tee is waiting, and beyond that another before we take our turn on the veranda to sip our beers and critique the next foursome. Stories will be squared, sins will be forgiven, hope renewed, fellowship affirmed, and a tee time booked for next week.

Where was I? Oh yes, last week I had a golfing date scheduled with good friends. Unfortunately, a conflict had arisen with work. On this same day there was to be a “reporting out” of a “kaizen event” that had been under way over the past week. I was not so isolated in my semi-retirement as to have no inkling what this involved. Kaizen is all the rage within hospital management circles these days, and my work in the field of organizational ethics requires that I have some basic understanding of these sorts of things. I had read the required texts, attended a few lectures.

The word “kaizen” is from the Japanese, meaning “improvement.” In common usage today it refers to a philosophy and practice of continuous improvement in the workplace. Pioneered in the Toyota production line, kaizen has gained popularity in a wide range of manufacturing, business, and, more recently, healthcare settings. A “kaizen event,” then, is a weeklong multi-disciplinary effort focused on improvement in a particular area of service. Surgical care had been the focus for this week’s event.

I confess to having cultivated a degree of skepticism toward this whole kaizen thing. From an ethics perspective, medicine is, or should be, the most teleological of disciplines. This means that the health professional must have a single-minded devotion to the end or purpose or “telos” of providing quality care for the vulnerable patient. To my view, many of the sins of medicine today can be laid at the feet of those who would betray this orthodoxy for the false idol of marketplace economics. Should we really be looking to Toyota Corporation for enlightenment? In this all-too-competitive world of health care qua market commodity, where efficiency has become the salient virtue, the last thing we need is for our administrators, let alone our clinicians, to be flitting across the continent from conference to conference genuflecting at the altar of business school dogma.

I knew that our organization was in the midst of just such a conversion. My reservations notwithstanding, the spread of this heresy within our hospitals and clinics is plainly evident in the new hallway vernacular of kaizen novitiates. “Lean”, “hansei”, “5 Whys”, “value stream mapping”, TPS, CQI, TCAB, TWI … Do you speak Kaizen? Do you have your Six Sigma black belt?

This was not the first time that the conference room had been invaded for a kaizen event. I had stolen glimpses of friends, colleagues, and fellow employees – physicians, nurses, clerks, administrators, housekeepers, pharmacists – all gathered together, cooing and pecking like a flock of pigeons in the park on a spring afternoon, before winging off to the wards at the behest of some unseen external threat. Surely, I was missing something. This had none of the feel of the muscular command and control management that we needed in these tough times. I mean who was in charge here? Who was calling the shots? Who was making the tough decisions? Just when we most needed an eagle, we had a flock of pigeons.

It was time I learned a little more about this whole undertaking. I was just plain curious, and the word itself – kaizen – seemed to suggest a spiritual imperative that could be ignored only at risk of soul damage. I also felt some responsibility, as organizational ethics consultant and a member of the operations team, to better understand the kaizen phenomenon. Besides, the morning broke cold and drizzly, so I called my buddies to say that I couldn’t make it for our golfing date.

I found a spot standing against a wall in the back of the conference room near the exit, ready for a quiet getaway. What followed was quite unlike any hospital meeting I had experienced, and I am a veteran of thousands. The executive sponsor gave a one-minute – really, one minute – welcoming statement of support for the activities of the past week. The balance of the session consisted of fifteen individual reports from various participants in the event. Each report was brief, perhaps two to three minutes long, and each told a story. Some of the reports addressed seemingly minor, though not unimportant, issues. “The FAX to Nowhere”, for instance, told of how a simple hardware cable connection lay at the root of a longstanding delay in getting post-op medications from the pharmacy. Other reports dealt with major systems issues such as reduction of surgical suite “turnover time” and elimination of a long waiting list for routine surgical cases.

The narrative structure of the reports was unmistakable: the protagonist of each story is the patient and the story is told from the perspective of the patient’s experience; a problem area or “conflict” is identified; paths to potential resolution of the conflict are tried; and the outcomes, good and not so good, are described. It may be that this narrative structure was unintentional on the part of the kaizen participants, but the effects are important nonetheless. Narrative ethics is one of the most exciting and productive areas of inquiry in the fields of both clinical and organizational ethics today. At the heart of this model are the observations that we humans are meaning-seeking and meaning-forming creatures, and that story is our most effective and engaging means of communicating meaning. Just as four duffers come to understand the day’s events on the golf course in terms of the stories they rehearse on the veranda, we shape and share the meanings attached to our professional work through narrative.

The narrative frame for our discussions of problems within the hospital, then, goes a long way toward determining the solutions we will imagine. It really is important that the stories told by the kaizen folks keep the patient’s point of view center stage and that frontline hospital workers are given roles as active agents for change within these stories. All too often the narratives we have customarily told under the rubric of performance improvement have been told from the perspective of the hospital, or the county budget, or the clinical department, or the employee. And all too often the casting call for agents of change has been limited to the pool of “stars” within the administrative and clinical hierarchy.

I was told that, during the week of this kaizen event, roughly one hundred empirical trials (“small tests of change”) had been implemented and that seventy-five of these were “successful.” To one who cut his teeth on a system in which a single change could take months to wend its way through the web of departmental and committee structures, often only to become terminally stuck, this seemed frankly unbelievable. The “trick” seemed to lie in a radical understanding of what is meant by “success” and a somewhat disarming comfort with giving new ideas a try. For the kaizen participants, success is always tentative. A change is not proven once and for all, engraved in the policies and procedures manual, and revisited again five years hence. There is no pretense to Ultimate Truth here. Rather, a new procedure is “standard” only until such time as an alternative approach is shown to be an improvement in meeting the ultimate goal of providing quality care for the patient.

So, there I was, against the wall, listening to this rather remarkable string of testimonials and thinking – thinking about medicine … and golf. As an affirmed intellectual, I need to read books and listen to experts when approaching any new discipline. This compulsion has lead me to pour over several golf texts authored by past masters of the game and to waste more than a few hours watching “tips from the pros” on the golf channel. I’ve learned that there are moments in the game that call for daring and panache, but the best results usually result from a steady routine, incremental improvement, and playing the percentages. Error and misadventure are inevitable and even the best of players must wrestle with the chimera of perfection. But this reality cannot excuse an, “Oh well, stuff happens,” attitude. It demands instead a discipline of error identification and management, and a commitment to incremental improvement so as to reduce the likelihood of repeating mistakes. There are breakthrough moments in golf … and in delivery of medical services … but improvement is mostly incremental, measured from season to season, the result of a disciplined dialectic of praxis and critical reflection. [More sophisticated ethics vocabulary.]

I have to say, however, that what struck me most about the kaizen report had little to do with tangible improvements in services. The stated goal of SCIP (“Surgical Care Improvement Project”) is a 25% reduction in surgical complications for certain target areas by the year 2010. That is nothing to scoff at, even if a one-week trial can’t be long enough to know whether changes have truly improved care. (Except maybe for that FAX cable.) But what really grabbed my attention was something about the demeanor of the people in the room. Call it enthusiasm … or engagement. It’s not easily labeled or measured, but there was a tangible sense of empowerment, purpose, collegiality, and community the likes of which I hadn’t felt in any committee meeting in recent memory.

My pigeon metaphor was off target. These weren’t doves, indistinguishable in the flock, driven by rote instinct and fear of external threats. A comparison to dolphins might be more appropriate. I don’t know a lot about dolphins, but they’ve always struck me as intelligent, inquisitive creatures, engaged in actively exploring their environment, each celebrating the freedom of its individuality yet always true to its social nature. Like our marine brethren, the kaizen folks behaved like empowered individuals united by a shared purpose and bound to one another by mutual respect.

And as for leadership, forget that eagle, alone and majestic on his rocky crag. A kaizen vision of leadership requires a humbler sort of majesty, wise but down to earth. Think owl or even turkey. This is the leader as sponsor, process expert, cheerleader and champion of the telos, less directive and more willing to trust and nurture employees’ shared commitment to the purpose that called them to this work.

Speaking of cheerleaders, I will own that the kaizen report felt a little like … well, a little like a high school pep rally. There was some applause and, at one point, I actually witnessed a high-five. I can see the eyebrows of my weathered colleagues rising at even the suggestion of such mawkish proceedings. But have we really become so cynical as to discredit an honest expression of enthusiasm resulting from an experience of working closely with colleagues to make things better for our patients? The feeling in the room was infectious. I found myself a little self-conscious, but also inspired – inspired and proud to call this group of dedicated professionals my friends and colleagues. Perhaps this is part of what organizational development experts mean when they say that the kaizen process can be “humanizing.”

Much of ethics boils down to theories of human nature. I side with those philosophers who argue that we humans fundamentally crave two things – meaning and community. It follows that the “good life” entails fulfillment of our nature through work that has an identified purpose greater than our own self-interest – work undertaken with our fellows in a spirit of radical respect for one another. This formula holds true throughout the range of human activities, whether building cars or caring for the sick … or golfing.

I’m not sure that I can yet be counted amongst the kaizen faithful. I will retain a certain measure of what I consider prudent skepticism regarding management models imported from the business world. And as a colleague cautioned, “We shouldn’t be too quick to drink the Kool-Aid.” But I also don’t want my concerns to make me too timid about stepping up to that first tee. For some time now, we who work in hospitals and clinics have been too disconnected from the ideal of service that called us to our profession. We have been too disconnected from each other. I don’t know if kaizen and similar recent performance improvement initiatives are the answer. What I do know is that on that morning last week there was something positive going on in the hospital conference room. It was new, and different, and a little threatening. But actually – and now I’m speaking from my expertise as an organizational ethics consultant – in some ways it was a lot like golfing with friends.

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