Fixing Frustrations at the Front Lines
Fixing Frustrations at the Front Lines

Here is another in my series of vignettes about health care organizations that are reducing physician burnout, taken from our book Preventing Physician Burnout: Curing the Chaos and Returning Joy to Patient Care. Following my post on Sunday about burnout driver #3 – Insufficient Reward – I’m happy to share this example of Lean providing physicians an intrinsic reward to help prevent burnout.  Please enjoy reading how Dr. Jack Billi supports his physicians in fixing frustrations, with the intrinsic reward of the power to change things for the better.

Fixing Frustrations in an Academic Medical Center

University of Michigan Health System (UMHS), a large academic medical center located in Ann Arbor, employs about 25,000 workers. John E. “Jack” Billi, MD has been a general internist in a primary care clinic at UMHS for 38 years. A decade ago he was tapped to become a senior Lean deployment leader at the health system. A significant focus of his work has been helping front-line workers acquire the skills they need to find and fix the root causes of the problems they face every day.

Front-line workers and organizational leaders worked together in rapid improvement events (RIEs) to create the health system’s “Lean in Daily Work” model, which is a framework for operationalizing Lean at the front lines. To date, the model has been spread to more than 75 percent of the clinics at the medical center. It includes teaching and implementing the philosophy and components of Lean. The model creates a process and structure by which front-line workers (both clinical and non-clinical) identify current and potential problems—and voice their opinions about possible solutions. Managers provide needed support and resources to experiment with the proposed fix and ensure that the various tests of change don’t conflict with each other.

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To encourage physicians to engage fully in the work, Billi reminds them that they are already comfortable with the scientific method as it’s applied to patient care. Lean is the application of the same method to the processes of care. To engage physicians who are initially resistant to Lean, Billi ensures that the group addresses problems that affect physicians as well. He tells physicians, “Lean will turn you from victims of burnout to people who have the power to change things.”

Achieving Physician Engagement Via a Three-Part Process

In an interview Billi shared a three-part process he uses to engage physicians in Lean:
• Motive: Ensuring that physicians see improvement as part of their job and believe they can succeed in improvement initiatives.
• Means: Teaching physicians to analyze their work and use a scientific process to identify and fix workplace problems.
• Opportunity: Helping physicians see that investing the time to understand and fix work processes is valuable because it puts them in an empowered position from which they can improve processes and patient care. Ensuring that a system is in place that provides physicians with dedicated time to talk about improvements, such as closing the clinic for an hour weekly.

 Going Upstream to Find Root Cause

In an interview, Billi explained the importance of fixing workplace problems with an allegory. A group of clinicians is picnicking by a river when a body floats by. Several clinicians pull the person out of the flow and start CPR. A second body floats by and the clinicians pull out the second person and start resuscitation procedures. A third body, then a fourth and a fifth, float by. The clinicians are beginning to get overwhelmed trying to keep up with the continual flow of people needing help. Billi pointed out, “No one thinks to go upstream and find out what is causing the people to fall in the river in the first place.” He completed the story by drawing the analogy to broken workplace processes. “Physicians are flogged by the daily crush but they need to stop what they’re doing and go upstream to figure out the cause of these problems. Otherwise, they will be condemned to be victims of the broken processes forever.”

Showing Respect is an Intrinsic Reward

Billi has found that the most significant obstacle to physician engagement in Lean is their belief that organizational leaders don’t care about the daily circumstances at the front lines of care. “If senior leaders don’t feel their pain, physicians lose confidence. Leaders need to go to the front lines, see what’s going on, ask questions, and show respect.” Another important obstacle is becoming overwhelmed with the size and scope of a problem. He encourages physicians to break the issue into small, clear actionable problems, then start with one small problem. For example, instead of trying to tackle increasing access to care for all pediatric patients, focusing first on a more manageable target: reducing the length of time for a return visit in the pediatric hematology clinic. He also reminds physicians to expect failure for many of their initial tests of change, because finding effective solutions is often an iterative process.

Have you had success at:

  • Fixing frustrations in your workplace?
  • Going upstream to find the root cause of the problem?
  • Showing respect to the physicians in your organization?

If so, please share what works for you in the “Comments” link above.

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