Newly appointed CEO of the Lean Institute Africa (LIA), Rose Heathcote talks about the significance of applying ‘Lean Thinking’ to improve outcomes aligned with the purpose and strategy of healthcare organisations.

Tell us about your background and how your interest in ‘Lean Thinking’ developed.

I’m an Industrial Engineer and over the last 22 years I have filled a number of roles in different industries. My late father was an entrepreneur who ran a manufacturing business and he’d often take me along to the factory which exposed me to the realities of running a business, improving processes and developing people. My father had a strong mind for efficiency, reducing waste and finding better ways of making the products more cost effective without compromising on quality. He was also dedicated to developing people. Observing how my father ran the factory was probably what piqued my interest in industrial engineering and shaped my career path which has brought me to my current role of CEO at the LIA. I’ve worked across Africa, Middle East, India and the UK which opened my mind to the multiple ways that the “Lean Thinking” practice could be applied in different environments and cultures and these experiences are also how I know lean can have a marked impact on any business or organisation. Wherever there is a process, there is an opportunity to improve.

Tell us about how the LIA has been able to entrench lean principles into its own organisation.

I firmly believe that leaders should practice what they preach and that’s what we aspire to at the LIA. We’re constantly revisiting the LIA’s vision to provide direction to what we want to achieve. We proactively reflect on our own learnings and improvement strategies in order to achieve that vision, which is essentially about making a difference in organisational outcomes but also improving the quality of life of people in sub-Saharan Africa.

When I think about how the LIA has developed over the years it’s remarkable; we’ve grown in our own understanding and perspective of what lean is and what it could mean for developing countries. We’re a public benefit organisation and our journey over this time has taught us a few really key things. Firstly, what our leaders do really matters; the messages they send through the ranks and how they think and act makes a difference. Secondly, the systems developed directly impact improvement sustainability and when implemented effectively, ‘the system survives the person’. Finally, developing people into problem solvers who solve the right issues every day, in a scientific way, matters.

Lean is a way to enable your strategy; but the challenge is to take all those tools, techniques, approaches, ideas, etc., and bring it together into a fit-for-purpose, integrated system so that you can deliver a better service and products to your customers. It takes a lot of careful thought, time and patience to figure it out and what it means is that organisations need to be prepared to experiment with new ways of doing things so they can constantly learn and adjust.

Tell us a bit about the LIA’s work in healthcare to date.

Our work in healthcare began 15 years ago when Prof Norman Faull and a few of his MBA students started looking at healthcare improvement and how to apply lean principles to improve processes. This initiated the LIA’s work in healthcare. We hosted Takeyuki Furuhashi Best Practice workshops in 2008 which was a really interesting programme that triggered a further 18 hospital improvement projects with the Department of Health (DoH) in 2010 as well as in the private sector. In 2014 Lean Transformation programmes kicked off in Gauteng and Western Cape public hospitals which we are still regularly supporting today. The Gauteng Department of Health projects were really exciting because there were four hospitals collaborating and supporting each other to solve problems. Staff weren’t just trained, but they achieved tangible improvements in waiting times whilst being coached through the challenges which made a big difference. In 2015 the Health MEC funded a trip for some of the CEOs who participated in the project to visit ThedaCare with the LIA, now called Catalysis, in the US to see first-hand how Lean Thinking works there. The CEOs also met with Dr John Toussaint who took a personal interest in coaching some of them, free of charge. We’ve seen a marked change in the leadership styles of the CEOs undergoing coaching from Dr Toussaint and the LIA and the performance of the teams they lead. This is extremely encouraging.

In other examples on-the-ground, our work in Gauteng has resulted in drastically reduced patient waiting times at hospital pharmacies (up to 86% in one department!). A neonatal ward in one of the public sector hospitals that the LIA has been working with for a number of years have reduced neo-natal deaths by 80% from November 2017 to March 2018. The transformation has been incredible and shows the kind of impact that we want to see. Of course, sustainability remains an on-going challenge, and hence the focus on coaching, lean management system development and CEO leadership development.

Another example is a paediatric unit that had a problem with infections among infants. After applying lean they had a marked decline in infant infections and in this case, the cleaners themselves had become the frontline problem solvers. They were actually teaching the nurses and doctors the daily habits that needed to be instituted in order to reduce the infection rates. It’s wonderful to see this level of empowerment taking place where both the employees and patients are winning.

Since our work in healthcare began, the LIA as an organisation has learnt a lot and have made significant headway in healthcare improvement. One of the key lessons we learnt is that although one-time interventions sometimes work, true transformation requires long-term support and behavioural changes of the managers and leaders. As a result, we’re seeing tangible transformation not only in patient service but in the development of a lean leadership style that enables sustainable change.

Let’s talk more about leadership and managers in healthcare. What skills do they need to be equipped with to lead teams and contribute to redesigning the health system?

There are good managers that are dealing with broken processes and systems and as a result end up in a continuous cycle of crisis management instead of continuous improvement. Leaders are responsible for equipping and supporting managers to solve problems but also tackle more high-level problems and carry out the organisations strategy. It’s unrealistic to expect managers to perform at their best under these conditions.

One way to address this obstacle is to show managers how to develop their teams into better problem solvers. Over time this means that if we help managers help their team solve more problems in a scientific way, there will eventually be fewer small problems that escalate into huge ones. Essentially, what you find yourself doing is shifting from a reactive to a proactive approach that leaves managers to focus more on patient service instead of just keeping their heads above water every day.

Managers have a responsibility to develop people before products and services. So if top leaders are supporting managers to engage with their teams, build trust and teamwork, we will find ourselves in a system whereby someone working in patient administration will collaborate across borders with someone in the pharmacy to come up with a solution to address systemic problems. In time this breaks down the silos they find themselves trapped in and they get to experience true, cross-functional collaboration. It is also worth noting that this kind of leadership style from senior leaders isn’t about lawlessness and everyone doing what they want. Empowerment is not about just allowing people to over-night make autonomous decisions. This requires some key elements including: a willingness from the staff to take on these responsibilities; competency development to make them able; permission to do it; and accountability for their actions. Aligning the team, understanding the problems as a team and enabling innovation where before there would just be a broken system and people to blame for failures.

There are a few practical habits that managers need to adopt to start encouraging their staff to do their own problem solving. Things like regularly visiting the gemba (where the actual work takes place) to see and hear first-hand the challenges and offer support. Setting up a daily morning meeting around visual indicators to assess how their service ran the day before; what were the waiting times, how many of the rooms weren’t ready in time for consultations, what shortages they had, what went wrong, is there anything we can do about that so that tomorrow we can do it better, etc. Using those types of focused daily discussions to understand the problems and then finding ways to solve them as a team. In the beginning, it’s likely that managers will bump their heads with this because it sounds easier than it is in practice. Initially teams will be quiet, they might not want to participate at first or have any suggestions to make so it will be a challenge but if the leader or manager is consistent with these behaviours, it eventually kicks in and the problems start surfacing and reducing. It just takes time and patience.

How does lean help leaders and managers know how to prioritise problems?

Ultimately it starts with the organisation’s strategy, in other words understanding where the organisation needs to go and what they need to be good at. When this is clear, the opportunities for improvement become clearer too. But the challenge comes down to the fact that many organisations struggle to connect its strategy with what’s literally happening on the ground. So while they may have a bigger picture and ways to measure their progress, what’s actually happening operationally on a day-to-day basis is going to dictate whether they reach those goals and objectives or not.

Leaders need to frame these problems in such a way that staff, all the way through the ranks whether they be managers or frontline staff, agree on the important issues to be focused on. When staff see the problems through the same lens, and collectively agree on what to change, they start collaborating to improve in the areas that matter, together.

For example hospital CEOs from both the public and private sector might have the same organisational objectives: to provide quality care to patients in a way that can be measured both in impact to people’s lives and financially. But what does that mean on the ground? Are waiting times a hindrance to quality? Are resources used effectively? Are stock outs or mistakes in medicine dispensing negatively impacting patient care? Does poor communication between departments contribute to waste? Where are the pain points when trying to reduce infection rates? Is staff morale low and how does that impact on patient care?

These are common questions that can be drilled down into even further by the people who are delivering this service every day. How those get prioritised is a process of discussion between leadership and teams who are equipped and empowered to solve problems and take pride in the tangible changes they will start to see unfold. And this is essentially what lean is: helping organisation’s connect their strategy with the operations on the ground for improvement by developing people who solve problems every day. And in healthcare, that very often means improvement in spite of budget constraints, staff shortages and limited infrastructure.

You touched on financial constraints, what is the LIA’s strategy for introducing and implementing lean in more public health facilities?

Financial constraints in the public sector have always been a handbrake for the kind of work that we are doing but we also know that lean in healthcare works and can demonstrate as much. Doing nothing is not an option. We’re looking at ways (including private-public partnerships) that will allow us to expand our reach to more hospitals and clinics across South Africa and Africa.

We’re currently developing the Healthcare Lean Improvement programme which will incorporate capacity development, management system development and leadership coaching to embed a culture of lean in organisations that have the opportunity to make a real difference in people’s lives every day. We are passionate about what this means for us as a country and a continent and how it can contribute to some of the huge challenges we face in terms of disease burden and socio-economic disparities, to name a few. We are in the process of developing what the programme looks like and hope to share more about it in the near future but would invite interested parties and organisation to get in touch to discuss needs, resources and potential collaboration with us.

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