An Example of Improvement - Involving people in redesigning their environment


Don Winton

An Example of Improvement

-------Begin Snip-------
From: "Anton O. Tolman, Ph.D." <[email protected]>
To: [email protected]
Date: Mon, 26 Apr 1999 09:23:20 MST
Subject: An Example of Improvement

Bob (of SOPKRules) recently wrote:

> ANTON recently posted an excellent example of involving people in redesigning
> their environment.
> My question to ANTON is:
> Did your people go about the redesign of providing Adolescent care by any
> particular methodology? What was the approach?

This is a good question. I would respond by saying that we implemented the Deming philosophy with an emphasis on the "unknown" elements of the SoPK rather than the measured elements, although we did make use (or rather, *I* as manager made use) of some SPC tools. It generally went like this:

1) When I took over ASU, they were in almost a constant crisis or "putting out fires" mode. They were angry at administration, feeling that administration was not supportive of their need for increased staff. They felt staff was needed because there was a high rate of property destruction and staff injuries on the unit due to high rates of seclusion and restraint to contain violent patients. There was very little sense of teamwork, although the staff did have a sense of "us vs them" and were cohesive in that sense.

2) One of the first efforts I began was to "wean them" from my presence. I was only a part-time manager and continued previous duties as well as picking up the ASU. Increasing their sense of empowerment as a clinical team was vital not only to their growth and development, but to my own ability to successfully manage the team. I began by expressing the Deming philosophy, talking about the importance of people doing the work making improvements and decisions, and that my role was primarily administrative, not clinical (even though I am a clinician).

3) Once that process began, I followed through on it by referring BACK to the team any issues that were primarily clinical. Initially, as they asked for my help, I would go to the unit and meet with them. Later, I phased that out, using primarily telephone contacts to determine the situation. I would ask questions to decide if the issue was primarily clinical or administrative. If it was clinical, I would basically say to them, "That sounds like a clinical issue. You are the team. Decide what is in the best interest of treatment and interventions and then follow-through. If you run into snags obtaining resources or information, let me know and I will help you out with those elements." And then I would leave the unit.

You might imagine that at first, this engendered some intense reactions on the part of the staff. I think at first they believed I was uncaring about them or that I was representing this "distant administration" that they were so angry about. I was accused several times of not doing my job and of not supporting them. However, when issues came up that were administrative, I fully supported the unit, I encouraged the staff's participation in decision- making rather than just telling them what I had decided, etc. I shared budget information with them and involved them in discussions about how to improve the unit, and kept them informed of management decisions at senior levels.

4) I started a "group therapy time" which we called the Process Team Meeting. We met once a week and I made a commitment to be there. The meeting was to learn how to talk about charged issues with each other so that we could learn to support each other, build cohesion, and deal with anger and resentment between shifts or disciplines. In the early stages, we asked the hospital chaplain to participate and assist us so that we had an objective outside observer to comment on the situation. He did a fine job and eventually we felt we were doing well enough that we thanked him for his support and began to run the group ourselves.

In order to prevent this post from being too long, I will finish up the story in a following post. I will point out at the end of part 1, that in implementing this "approach", that the use of the Deming philosophy was evident and deliberate with an emphasis not only statistical analysis, but upon people, interactions, understanding systems, etc. I will talk more about that in Part 2.

This is the 2nd part of a message responding to Bob's question about the approach used to achieve improvements on an adolescent inpatient psychiatric unit.

I will add to my previous post by saying that I had determined that the critical elements necessary for the unit to be successful were to first establish the team as a confident decision-making body for clinical care, second, to improve the cohesion and functioning of the team interpersonally which presumably would result in decreased turnover and increased staff retention, third, to design an improved treatment environment and cohesive philosophy or approach to care, and fourth, to document improvements in clinical outcomes resulting from the previous elements. My first post described some of the efforts to achieve #1 and #2 above.

continuing with the previous numbering:

5) Once the Team was feeling more confident of my support, they began to call me much less often; I continued to attend the weekly process meetings and to meet with the team when it was requested. We implemented an in-service program to meet the staff's needs for improved clinical understanding of clients, but our turnover rate was still very high making this an ongoing drain on our time and resources. We began to implement a version of a "pre-admission process" on the unit similar to what was being done on adult units. The goal of this process was to have an impact to potentially redirect inappropriate admissions to the unit, to be able to better manage the influx of patients coming in and to prepare the staff to provide better care by receiving increased information from our suppliers.

6) In conjunction with the pre-admission process, we used flowcharts and system diagrams to illustrate and get a better idea of how to proceed. We also standardized our treatment planning process to improve it, and added a team facilitator to help move the discussions along. We again used process diagrams/flowcharts in outlining the standardized procedure and to encourage staff to improve the flow of information. We also changed halls to a new hall which had been recently refurbished and which, most important, provided most of the kids with a single room (a very SMALL room). This change in the environment was important in reducing aggressive behavior on its own. We also made an explicit decision to continue the furniture on the new hall to be pleasing to look at and comfortable, even if it was more "fragile" than the furniture we previously had. It was our belief that this new environment would actually encourage LESS property destruction; this belief seems to have been born out in the data.

7) We then began to redesign the milieu environment. I basically authorized a significant chunk of overtime for us to take a 3 day retreat with ALL clinical disciplines on the Team represented and all shifts represented. We left the hospital and met in the local community college downtown. The retreat was broken up with team-building exercises interspersed with discussion of clinical theory and design of a new program. During this retreat, we utilized Myron's "negative Ishikawa" technique to indicate all the worst elements of any program, and then used the normal Ishikawa process to identify the critical elements of a successful program to address those negative issues.

8) The Team then used the ideas from the Ishikawa diagrams to begin designing the nuts and bolts elements of the program (rules, reward systems, etc.). As you may imagine, this work continued long after the retreat was over. Once a week, for two hours, the clinical team continued to meet to hammer out the details of the new innovative RSVP (Rational Social Values Program); they were guided by the broad theory elements that we had agreed on during the retreat and had good participation from members of all disciplines on the unit. A date was set for implementation of the new program in December, 1997.

9) About this time, we noted that our staff retention was going up, but staff were still concerned and complaining about being "pulled" by central schedulers to cover gaps in scheduling on other units (who still suffer from fairly high turnover). In discussing this with the Team, I made several proposals to senior management to utilize creative scheduling (including a mix of 10 and 8 hour shifts), run by unit staff (the Unit Nurse Supervisor) NOT central schedulers, and utilizing Team members themselves to flex off time, to utilize comp time, and to have team members be accountable to each other for coming to work. After a couple rounds with the management group, this plan was approved; we *did* sweeten the pot by actually giving up at least 1 RN position and several aide positions for use on other halls (they were vacant at the time). If you remember my description of the unit when I first went over there, this was a MAJOR concession for the staff and indicated, more than anything else, their increased sense of confidence and pride in themselves.

10) Along with the design of the RSVP, and the self-scheduled unit, we designed a comprehensive staff training program in the RSVP to occur just prior (JIT) to the launch of the new program. Before I switched the unit to another manager in January, 1999, we had continued to have discussions about how to continuously improve the training provided to staff on the unit. About six months after the launch of the RSVP, I did a study of the outcome measures we had defined in our PDSA cycle as part of our planning. (We used the PDSA cycle explicitly as part of the entire improvement project). I've reported those results before, but there were significant administrative and clinical gains noted. The program has been very successful.

We have begun to get phone calls from persons wanting to know more about the program; when I left the unit, there were apparently rumors in the facility that I was leaving the hospital. One of the staff came up to me and touched my heart by saying, "Where are you going to? I will follow you there." When I left, I emphasized to them, and I believe this with all my heart, that the successes the unit has experienced are due to their own abilities and their own innovation and talents. I helped to provide a management structure in keeping with Deming's philosophy, and they did the rest.

I think that this example is a powerful example of the ability of the Deming method to produce significant and valuable improvement. You can also see the clear link to innovation in this example as well. I hope that providing this example has been of value to others on the DEN in thinking about how to apply the Deming philosophy in your own organizations.

Anton Tolman, PhD, CPHQ, Psychological Services Manager & Quality Management Coordinator, Wyoming State Hospital
P.O. Box 177, Evanston, WY 82931-0177
[email protected]
-------End Snip-------

I like it!

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Stephen Kuchar

Thank you for the snip. This is a very good testimonial of what we are to be about. I am a Quality Manager/Trainer, and I try to work with this type of a philosophy. Not always successful, but there are those that are enabled to be more dependent and have started to improve their processes because of it.
It is powerful to get feedback. My favorite is when you finish up writing work instructions that they gave you and you take them back to the team and ask them to do their job according to the work instructions. The operators come to you and say, "Wow, this is exactly what I do". They become empowered to do it again.
Stephen Kuchar


Don Winton

I have liked Dr. Tolman’s contributions to the DEN, and most are quite informative. I found this one was worth posting here for several reasons, given below.

I began by expressing the Deming philosophy, talking about the importance of people doing the work making improvements and decisions…
I have felt the backbone of a successful systems management method was the involvement of the people actually having to perform the tasks. He implemented this quite well as demonstrated.

That sounds like a clinical issue. You are the team. Decide what is in the best interest of treatment and interventions and then follow-through.
In this statement, he has implemented what I call the ‘teach them as though you taught them not’ method. He has empowered them to make decisions based on their knowledge and experience, although this was resented at first. But again, through demonstration and participation, the team began to began to function as a TEAM as demonstrated in Part 5. But, even then Dr. Tolman demonstrated his support for the group by actively participating in the weekly meetings.

In Part 7, his change in environment, the ‘negative Ishikawa’ technique and how it was implemented was also interesting. The environment change is something I also try to accomplish when beginning an implementation program. The first item I tackled at my current employer was, basically, clean up the place. I had a ½ working day set aside where everyone in the company (including management) was tasked with ‘housekeeping.’ That made a huge difference in morale and perception from employees. Now, there is one hour per week where housekeeping is the primary task, again of everyone.

In particular, his baby step approach should be observed. There is not one instance where he wanted to ‘shock’ the system. Just a guess, but I would think it took 1.5 to 2 years, based on some of the timetables he posted. That is the true beauty of systems management well done.

My favorite is when you finish up writing work instructions that they gave you and you take them back to the team and ask them to do their job according to the work instructions. The operators come to you and say, "Wow, this is exactly what I do".
One of mine, too.

They become empowered to do it again.
Every work instruction in my operation was written by and is owned by the employees who use them. It is such a success that whenever there are changes needed, they make them in draft form to the original without being prompted. Then ask me to release them in compliance with the system (change notices, etc.). I have not, at least not yet, had to prompt them to update their instructions. In fact, I am normally the one trying to keep up.

Oh, and BTW. Did anyone notice that ‘Total,’ ‘Quality’ or ‘TQM’ was not mentioned once in Dr. Tolman’s account?



Fully vaccinated are you?
Staff member
Did anyone notice that ‘Total,’ ‘Quality’ or ‘TQM’ was not mentioned once in Dr. Tolman’s account?
I'd like to see the word quality take a vacation.

How many times have you considered the role of ISO900x in 'quality'? One of the first things I learned when I was introduced to ISO9001 was that ISO9001 was (is?) not a factor in product quality but it is a basic foundation for a quality system. Who here read Catch 22 (seeing the movie doesn't count)?

Andy Bassett

Marc you are right

I do my upmost never to use the word quality, not least becuase you lose the attention of 90% of CEO's when it slips out of your mouth.

Interestingly even the European Forum for Quality management have renamed their model the Business Excellence Model.



Can anyone explain, or better still send me an example of how the Negative Ishikawa works.

Andy B
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