Creating Performance Excellence through Understanding and Developing Your People

6 Comment(s) | Posted | by 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.


  1. Monica Bailey's avatar
    Monica Bailey
    | Permalink
    This sounds good, but I suspect it will face great resistance. It is not human nature to want to examine "failures", particularly in a setting where such examination could be used in a lawsuit.
  2. Christina Lomax's avatar
    Christina Lomax
    | Permalink
    I completely agree with Monica. While DLL and examining the problems within our system would lead to greater productivity, it is difficult for people to acknowledge their weaknesses and where they went wrong. In order for this to be implemented successfully, it would take time and the leaders at a higher level need to embrace this system.
  3. Danielle Schramm's avatar
    Danielle Schramm
    | Permalink
    I think DLL is going to be critical to any organization hoping to embed the lean system in to its structure.

    The challenge of DLL is going to be financial as well as acceptability. The financial aspect is one that I would imagine, in the given economic environment, would be tough to sell. While that financial investment is critical to see DLL work, it seems like it would be difficult to convince a hospital, already struggling to maintain their level of care with ever-shrinking resources, to spend money like that.
  4. Ann Somers Wilton's avatar
    Ann Somers Wilton
    | Permalink
    As others have said, in theory, DLL is a valid plan for improvement. Difficulties will arise not only due to financial means and the fact that people don't like to bring attention to their mistakes, but also because the most difficult part of enacting a new approach in the work place is the challenge of changing people's behavior.

    Rob Sullivan, head of Duke's Center for Living, and a constant proponent of getting physicians to change their practices to include new prevention techniques, says the best way to do this is with "opinion leaders." When respected physician-leaders advocate for and modify their own practices, then others follow. Behavior change, led by well respected physicians will ultimately lead to culture change, which is necessary to over come the burden that people don't like to admit their mistakes. As alluded to in the article, to successfully implement DLL, opinion leaders must be identified and willing to participate.
  5. Molly M.'s avatar
    Molly M.
    | Permalink
    We tried to implement lean practices with a healthcare client at my last job, and it was very difficult because it takes some time for visible benefits to kick in - therefore we had low adoption despite frequent communication of why lean would be beneficial for the organization. In the interim it just looks like more work/training for already busy people.
  6. Bridget K.'s avatar
    Bridget K.
    | Permalink
    I like what Molly said: "In the interim it just looks like more work/training for already busy people." That's my gut reaction as well. However, that can be an excuse to impede progress of any kind.

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