12 healthcare books for Yuletide — Nos. 5 & 6
Reading suggestions for the healthcare nerd in your life
On 23 November 2004, Mrs Mary L McClinton died in a hospital in the state of Washington, USA. She was 69 and in good health.
The cause of her death was a mix up between different solutions in an operating theatre where she was fatally injected with Chlorhexidine, a powerfully toxic antiseptic.
Given what we learned in Black Box Thinking about the failure of healthcare to learn, we might expect that this would have been an opportunity to sweep the problem under the carpet, deny liability, blame the doctors or nurses and otherwise carry-on as if nothing had happened.
Instead, the reaction of the hospital was to admit liability and make a full disclosure. But they went beyond that.
Mrs McClinton’s untimely death was an activating event.
It turned an otherwise unremarkable hospital into a world leader in safety (it’s improvement institution even has a branch in the UK). VM, as it is known, has more awards and accreditations than should be humanly possible.
These two books tell you how they did it and (should you entertain the idea of doing at home) how to go about it.
But let me warn you. It’s not an easy path.
Title 5: A Leadership Journey in Healthcare: Virginia Mason’s Story
Author: Charles Kenney
Date of Publication: 2015
Amazon rating: 1,038 in Hospital Administration & Management
Title 6: Accelerating Health Care Transformation with Lean and Innovation
Author: Paul Plesk
Date of Publication: 2014
Amazon rating: 937 in Hospital Administration & Management
Why you should read it
To understand how really really hard it is to improve healthcare organisations.
Synopsis
The reason that I’ve listed these two books together is that they are two perspectives on the same story. Kenney’s book tells how the senior management of VM, under the extraordinary and visionary leaderships of Gary Kaplan - who recently retired after 22 years at the helm - took-on, assimilated and adapted the famous Toyota Quality Management System within their healthcare organisation.
For those nerdy enough to know something about making cars and trucks (factoid: Toyota started as a loom manufacturer), it’s clear that adapting manufacturing improvement techniques to healthcare is not a straightforward read-across. Hospital processes are subject to waaaay more variation and the levels of accountability and loyalty are vastly complicated. If you work for Toyota, your loyalty is to Toyota. If you’re doctor in a hospital, your loyalty is to … well, that’s complicated: your patient, your profession, your team, your consultant/attending? Only tangentially is is to your hospital.
Which Kaplan and his team found out early on. Their attempts to change the power dynamics and hierarchy in order to ensure that energy was focused on quality improvement were met with strong opposition. The book has good chapters on what it’s like to take-on vested and conservative interests, and win.
The most important lesson from the book is that ‘Respect for People’ underpins all quality. As a healthare leader, you have to treat the-people-who-treat-the-patients with the same respect as the patients themselves. Holding employees and staff in high regard is not a strong point in healthcare.
There are lovely examples of how this focus on people is exemplified in the Japanese system. Standing on a painted line on a factory floor, for instance, is considered disrespectful to the staff who painted it and kept it clean (which they do in order to keep areas demarcated and thereby keeping you safe). Respect and safety are linked as if in a Jungian collective unconscious. A world of respect this deep and profound is a world away from almost all healthcare institutions.
Kaplan was quoted last year in the BMJ as saying, pointedly:
… culture is a make-or-break factor in successful transformation. I couldn’t agree more. Creating an environment of respect and empowerment that spans the organisation — from the front-line to the C-suite — is vital to build sustainable capability. To achieve that culture change, leadership needs to be committed, present and consistent. Changing CEOs every few years can be crippling to culture
Culture eats strategy for breakfast. We know that from our own experience and instictively. The questions is … what do you actually do?
The answer comes in the second of these two books. Here Paul Plesk (“plea-sic”) describes the vital components that make up the the “how” in lean improvement. For that is what it is: Toyota’s Total Quality Management System - translated into the Virginia Mason Management System - is ‘lean’ writ large.
And lean is difficult. Manufacturers have had nearly half a century’s first-mover advantage over healthcare. Products that emerge from modern factories work as designed, first time, every time. No one unpacks an iPhone that has been wrongly manufactured. It just doesn’t happen.
But as we have discussed, healthcare is so far off that mistakes are made in more than 10% of hospital admissions. It is - in a very literal sense - frightening.
Plesk’s book is dense with examples and ideas. It is primarily about how to stimulate and support innovation by staff. It is about the techniques and prerequisites that are required in order to imagine change and implement change: learning, infrastructure, environment and training. His take-home message, however, is entirely the same as that of Kenney’s book. It all comes down to leadership.
I mentioned earlier that VM had a UK office. They partnered with the NHS for five years with five UK NHS providers. In 2022 they produced their final report. It’s interesting how little this report mirrors the successes that VM have had in their own sites. There have been some significant challenges - including a global pandemic, no less - during this time. Nonetheless there is little in the way of glowing testimonials to the transformational impact for which they undoubtedly hoped.
A consultancy or partnership model can only go so far. To really, really transform a healthcare organisation takes a long time. And is hard. Really, really hard.
It all comes down to leadership.
My rating
Readability: 6 & 4 / 10 (both these books are heavy going, Kenney’s is the more approachable)
Applicability: 9 / 10 (VM has seen it, done and has a shed-load of gongs to prove it.)
Giftability: 2 /10 (partly because two books will set you back three ponies at least)
PS: If you have been following-along, you may have noticed a hiatus since my last missive. My apologies. SARS-CoV-2 (picked up on a hospital visit) is to blame.