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Lean Institute Africa Collaborator Blog: Charmaine Cunningham. I’m regularly asked whether my experience working on an oil rig triggered my interest in improvement and system strengthening. The answer is: ‘Absolutely,’ and this is how:

I was on an offshore site, where it took more than a year for medical supplies to arrive. Being an inquisitive person (also referred to as a pain that asks too many questions), I arrived on-board and started asking why the procurement process took so long. The standard reply was ‘this is how it is; we have tried everything and the situation cannot be remedied.’  I stubbornly insisted that there must be a better way, and one day they gave me carte blanche to find that better way.  Great! I did not need another invitation.

I started by mapping the process; only, at the time, I did not know it was a map, or a process. I thought that what I was doing was drawing a mind map to help me think about the problem more clearly.

The map demonstrated additional steps in the process, including drawn out approvals between the on-board medic, contracting company, pharmaceutical supplier and the client. Every change to pack size, dosage or alternative medication had to be approved by everyone, every single time.  From the initial supplier the packaged pharmaceuticals were shipped to another supplier in another country, where, when released from customs, the supplies were unpacked and re-labelled to meet local legislative requirements.  It was again packed, and shipped.  On arrival in Africa, it remained in customs for a minimum of six months.  When released, it would go to the client’s warehouse.  The warehouse was managed by a contracting agency; supplies had to go through a verification process taking up to six weeks. Finally it was dispatched offshore.

On arrival the seals of the boxes were broken and they contained rodent droppings and expired medication. We could not trust that cold chain was maintained during transit, making the use of fridge items, such as tetanus toxoid, unreliable.

The procurement process was extremely lengthy and the map was met with disbelief. I learnt an important lesson: facts, especially when presented as a picture, map or graph are a better way of pushing for change, than emotive complaints.

Until confronted with the facts we were placing band aids on the real problem. Actually not even that, we were ignorant of the problem.  Our attempt to ‘solve’ the problem by placing more orders did not solve anything. It was just the ‘easiest’ solution and increased expenses, such as the running costs of the clinic, cost to client and increasing the amount of expired stock on-board.

A related problem was that we were not ordering according to need. This resulted in relative shortages on certain medications and oversupply of others.  It’s like shopping without a shopping list: you always buy stuff that you don’t need and forget the things that are needed.

To make a long story short, by mapping the process, we were confronted by the facts and it was clear that we had to address supply chain issues. We could now make a plan and address it: within six months we implemented changes so that, from the point of ordering to the medication arriving on-board (intact and in-date), the waiting time was four weeks.  I could now focus on the medication shopping list and established average monthly usage to forecast future use and set minimum, maximum and reorder levels; thus addressing the relative shortages and oversupply.

Why it was successful
“To learn anything other than the stuff you find in books, you need to be able to experiment, to make mistakes, to accept feedback and to try again. It doesn’t matter whether you are learning to ride a bike or starting a new career, the cycle of experiment, feedback and new experiment is always there.”  Charles B. Handy

A crucial success factor to this experience was that I had a manager that created an enabling environment where I felt safe enough to experiment. And, perhaps I was lucky because the situation was seen as so hopeless that anything would’ve been an improvement.

What did the enabling environment look like?

  1. Trust. There was a mutual trust relationship.  Steven Covey has written two books about trust (Speed of Trust and Smart Trust) and he states that managers that trust their employees build capacity and confidence in their people.
  2. Listen.  The people on the floor know what needs to improve in their workspace and if their manager would just shut up and listen instead of offering solutions and quick fixes; problems could be solved in a sustainable way.
  3. Delegate and let it go.  Once it was decided that I could work on the problem, there was little interference and I was forced to take responsibility. Manager’s struggle to delegate and sometimes people on the floor struggle to take ownership.  A really clever manager will not take the ownership back; they will guide the person through a tough patch.
  4. Make it ok to experiment. Yes there will be some not-so successful experiments…that is part of the process.  One of our not so successful experiments was an attempt to hand carry vital supplies, which resulted in me being detained at the airport for a few hours.
  5. Set boundaries. Communicate and renegotiate the boundaries when needed. It gives freedom to experiment, within a certain frame (This was only done after I was detained).
  6. Acknowledge and reward people.  I received a special recognition award from the client. This propelled me to do more, read more and learn more. I think acknowledgement is so valuable and yet so easily forgotten.  There needs to be a concerted effort to notice contributions.

So was this LEAN, IHI, SIX SIGMA or whatever else? Define it now!
I am disillusioned by the quacks in the improvement field.  The quacks love the big words, the theories, and the tools.   They love making the concepts foreign to the people that they are supposed to be guiding.  They don’t seem to understand that the crux is not to define every action, step or prescribe solutions and tools for everything. Change and improvement is not about theorising which methodology is best.  I agree with Shakespeare on this one: “What’s in a name? That which we call a rose by any other name would smell as sweet”.

The big words and theories are not the essence. Complexity is failed simplicity (Edward Bono).  The bigger the words people use, the less they understand the essence (My opinion).

Unfortunately improvements are, at times, adopted as a programme or tool and forced upon people without realising that a certain amount of intuition, flexibility, an enabling environment and good management is needed. It’s not just about putting posters on a wall; it is a shift in culture.

Bringing it back to healthcare
Working on an oilrig triggered my interest in improvement and system strengthening. And yes, a great manager was instrumental to this.

Managers are products of their industry and their environment. So the culture of the oil and gas industry co- created the enabling environment. Culture is protected by the habits in the industry. In other words, hospitals and oilrigs (healthcare and the oil and gas industry) do not have a culture; they are a culture.

I don’t think that at the time I would’ve been able to experiment in healthcare and learn the lessons that I learnt. The structure definitely did not exist in any of the health facilities I’ve worked in and in many instances healthcare still needs to reframe the culture to one where people feel empowered to identify, explore and experiment on fixing problems in a way that it can remain fixed. This implies a huge shift in how healthcare is managed.

The good news is that recently the healthcare industry has woken up and there are various recent examples of improvement, innovative healthcare administration and leadership that can serve as examples. I hope to see this improvement continue, and continuously improve.

[Please note: I purposefully used the word manager and not leader.]

Written by Charmaine Cunningham, a Lean Institute Africa (LIA) Collaborator, currently collaborating with LIA on the Lean management development programme at Groote Schuur Hospital. This blog post was originally published on Charmaine Cunningham’s blog on 1 October 2014. Visit this link to sign up for future blog posts.