“We Cannot Afford to Hurry”

Three components to improving: Leadership, Instruction and Improvement

“We cannot afford to hurry, because we have no time to lose.” Words not written by me, but by Sr Mary Brigh of St Mary’s Hospital, Boston MA in 1944. She was reflecting on her experiences of quality improvement (QI) in her hospital.

When I started getting interested in QI in 2007, I learned about the masters: Dr W Edwards Deming and his mentor, Dr Walter Shewhart. I learned that Deming spread a scientific understanding of improvement, popularising the use of “Shewhart cycles”: Plan-Do-Study-Act (PDSA). You Plan a change, aimed at improvement; Do it, preferably on a small scale and reversibly; Study the results, and ask “what have we learned”; and then Act. There are three equally valid types of Act: adopt the change, because it’s great; abandon it, because it’s not; or do the cycle again under different environmental circumstances. All three tell you about the system. These – and other statistical and improvement tools – were part of a package taught by Deming in Japan to Toyota and other Japanese companies after World War Two. In turn, they form part of the package learned (and taught) by Dr Don Berwick of the Institute for Healthcare Improvement, the Associates in Process Improvement and Intermountain Healthcare. From them, the API Model for Improvement has become the default QI model for the UK Royal Colleges, the Health Foundation, the General Medical Council and NHS Improving Quality, among others.

So what?

Well, I’ve been learning in the last 12 months that all this isn’t enough.

It is possible to have all the improvement tools but not to make any headway with colleagues because they are disengaged. Similarly, if people do things “their way” (with the very best of intentions), we won’t have a standard baseline from which to improve. If we have “hurry” in healthcare, there will be consequences. Sr Mary Brigh articulated the consequences of “hurry”:

“One result is inefficient and inaccurate work. Another, and an equally serious result, is the development of a mental attitude of busyness. The hurried head nurse believes that she is too busy to welcome a new worker to her department, too busy to teach a new student or direct a maid, too busy to analyse and improve a procedure.”

Therefore in order to improve, we need good leadership; clear instruction; and (last of all) improvement techniques.

These three teachable skills for supervisors were developed in World War Two, not by Deming, but by the directors of “Training Within Industry”. They believed that a supervisor needed five things: knowledge of the job and knowledge of responsibilities (both industry / location specific); together with instruction, leadership and improvement (which could be taught).

From http://whatistwi.com:

Each ‘J’ course was taught in 10 hours - two hours per day for five days - so that each supervisor was taught close to the workplace and could apply what they learned.

During World War Two, the TWI courses were taught on a huge scale, to over a million supervisors in four years – predominantly Job Instruction and Job Relations. The effect was profound: in increasing output; decreasing waste; reducing training time; and improving staff morale. The courses were taught not just in factories, but in healthcare, agriculture and other service sectors.

The one course that the TWI Directors recommended for all supervisors from shop floor to board was Job Relations – teaching leadership. So what is required of a leader?

Under the reminder, “A supervisor gets results through people”, they recommend four important steps (with key points for each):

  1. Let each employee know how they’re is getting along. (Figure out and tell them what you expect. Point out ways to improve.)
  2. Give credit when due. (Recognise extra or unusual performance. Tell them while it’s fresh.)
  3. Tell an employee in advance about any changes that will affect him. (Tell them WHY if possible. Get them to accept the change.)
  4. Make best use of each person’s ability. (Look for ability not now being used. Never stand in an employee’s way.)

And a final reminder: “People must be treated as individuals”.

These notes apply for all those in a supervisory role, from chief executive to ward manager and senior healthcare assistant.

What I have learned is that improving is not simply about knowing the improvement tools. We require instruction and, above all, leadership (as described above) to achieve the best outcomes.

For sustainable improvement, we need to look at how we include these in the development of all staff in a supervisory role, from most senior to most junior, not simply as a trickle down, but as a deliberate effort to train staff. That may take time - it’s a culture change - but the TWI programme trained a million supervisors in four years, and there are under a million staff in the English NHS. It’s a tall order, but the alternative is the mental hurry that will hinder us: “we cannot afford to hurry, because we have no time to lose”.

Key Reference
Brigh, M. (1944). “”We Cannot Afford To Hurry”.” AJN The American Journal of Nursing 44(3): 223–225.

For more information on the TWI programme, go to the TWI Institute website.

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