Lukasz M. Mazur, Ph.D.

As you might know, recently, a number of hospitals have responded to the challenge by using lean methods to help solve their quality and efficiency related problems. However, if a hospitals turn out to have a similar trajectory to manufacturing, the percentage of failed lean implementation efforts could run as high as 90%. One important reason for the high failure rate in lean implementation is that most organizations revert to old habits without successfully making the transformation to lean thinking and behaviors. Repeatedly, experts point to the failure to develop lean as an operating philosophy, as opposed to an application of tools. Perhaps, healthcare administrators and managers may be unprepared to provide their employees with the learning and experience necessary to develop a lean culture and mindset. What do you think?

Most of the learning occurring on the hospital floor can be defined as detection and correction of error, but without addressing the underlying values that drive action and govern behavior. This is called single-loop learning (SLL). In SLL, importance is placed on the efficiency and effectiveness of localized problem solving techniques, but not system-wide analysis to remove the root-causes of problem. The focus is on fixing what is wrong and moving on. Unfortunately, using such a model, healthcare professionals often suppress their negative feelings about emergent problems and continue to operate using comfortable, safe routines to achieve productivity standards. Literature shows that such behavior hinders individuals’ psychological safety to engage in team learning and negatively affects perceptions on organizational trust. 

So, how do hospitals contribute to SLL? In general, job complexity and productivity demands create double-bind conditions in which professionals must choose between abiding by failing policies and procedures, or resorting to workarounds that are adequate in the short term but not the long term. This choice is made more difficult and stressful by hospital administrators and managers who allow frontline professionals to justify workarounds because the existence of faulty systems interferes with good productivity. In this sense, workarounds are seen as a reasonable way to meet productivity objectives and are often considered to be of little threat to the healthcare professional, patient, or organization. Moreover, workarounds can even be seen as positive because they reduce costs, save time, and allow employees to stay on time with daily routines. Once justified and legitimized, workarounds become embedded in the culture as a group norm and are very difficult to monitor, control, or eliminate. Therefore, in the long term SLL can lead to disruptive behaviors and employee burnout.

Well, what should hospitals do? Perhaps, develop double-loop learners. Compared with SLL, double-loop learning (DLL)  is more reflective and considered. Where SLL tends to address problem symptoms, DLL leads to the identification and elimination of root causes of problems. To accomplish this, DLL requires an environment where problems can be examined in an open and honest manner, using valid information, with problem stakeholders being free to express opinions and recommend actions. In addition, effective DLL requires an internal commitment by those involved to investigate and remove root causes of problems. Healthcare professionals operating in this manner feel empowered to emphasize patient safety and operational performance as critical components of care, and often initiate problem solving with stakeholders through the use of acceptable language, behavior, and available data. 

But, how to develop double-loop learners? My research and detailed observations in hospitals lead me to offer some concluding recommendations for hospital leadership teams that are considering developing DLL. 

1. First, make sure you have appropriate human resources to mentor and develop double-loop learners. Specifically, err on the side of broader frontline participation in DLL, versus building a smaller team of experts that can drive localized improvements. The investment of time and effort to build a broad base of double-loop learners in the hospital is an indispensible part of the learning organization. Without it, the change initiative runs the risk of losing momentum after the initial level of excitement naturally fades.
2. Second, leadership must make the financial commitment to adjust staffing levels for areas that have employees working on projects requiring DLL (i.e., Kaizen events). Typically, the expenditures for supplemental staffing will come in advance of any associated savings from improvement projects. Therefore, leadership must trust that DLL will succeed over the long term, even though the expenses will often occur in advance of any realized cost savings.
3. Third, leadership must focus on the role they can play in fostering the informal spread of DLL. In any organization, there is a formal structure and an informal structure. The formal structure is captured through the organization chart and the clearly defined reporting relationships, roles, and responsibilities of all employees. Conversely, the informal structure of an organization is the ad hoc, evolving relationships of employees across the organization as they self-organize to get work done. While leadership cannot directly manage the informal social networks in their organizations, they can recognize that informal networks exist and strive to understand who are and can become the informal DLL leaders.

Finally, I wish to conclude by stating an observation that may be apparent but bears repeating. Double-loop learning is much more than a set of tools and methods. The challenge is not to teach employees the tools and methods. Rather, it is to go beyond this level of training and into a deeper learning cycle of applying tools and methods, making improvements, reflecting and internalizing the insights and lessons of lean improvement, and building personal commitment – in other words, developing double-loop learners. As hospitals become more proficient at this, we will continue to see more success stories.