Accountability and reliable promises, pt. 3

Part 3 in a 3-part series

In the first two parts of this series, we used the example of nurses filling foam canisters in hospitals (to increase the odds of hand washing that protects patients from infection) to demonstrate what it takes to build accountability in an organization. Accountability requires promises, which in turn require effective requests (or offers) and acceptance of those requests. If the goal is for everyone involved to follow a similar process, i.e. standardized work, then it’s important that they all explicitly promise to do this. But what do you do if a nurse isn’t following standardized work? According to Mark Graban, the first thing to do is to ask why. He proposes asking the following about a surgeon who fails to follow “universal protocol” before a surgical case, but the same applies to nurses who fail to refill canisters.

We can ask:

  • Is it a case where the person CAN’T do the work properly?
    • Do they not know how? This might be a systemic training problem. The individual can’t be held accountable for that.
    • Does the person not have the right resources? Maybe they WANT to do it right, but they just can’t. Leadership needs to help eliminate those barriers.
  • Is it a case where the person WON’T do the work properly?
    • Is the situation one where the person truly has a choice and they made a bad choice?

Accountability and reliable promises, pt. 2

Part 2 in a 3-part series

What does it mean to have accountability? As we observed in an earlier post, piggybacking off of Mark Graban, if a hospital manager expect nurses to be responsible for filling foam canisters to increase the odds of hand washing to protect patients, there needs to be an explicit promise between that manager and the nurses. Such a promise requires both a clear request (or offer) and an acceptance. Promise = Request + Acceptance.

Now, what can we say about the components of an effective request or offer? Let’s make explicit what was partly implicit in the above example. An effective request or offer consists of the following:

  • Clear conditions for satisfaction. There needs to be a shared understanding of what it means to restock a canister.
  • Clear timeframe or deadline. What days and what times of day will the nurse restock the canister—or at least check to see if it needs restocking?
  • A specific speaker. What do we mean by this? If a vague pronouncement comes out from “management” about who is responsible for restocking the canisters, there is not a specific speaker. The nurse doesn’t have anybody to respond to (by accepting, declining, counter-offering, or promising to promise). Another way that a speaker can be “missing” is if a manager holds uncommunicated expectations; they want the nurses to refill the canisters, and maybe even mention it in passing, but never actually make a request.
  • A specific listener. On the other hand, let’s say a particular manager makes the request but communicates it vaguely to a full team of nurses. Now, we have a specific speaker but not a specific listener.
  • A shared “background of obviousness.” This is a fancy way of saying that when the manager says “restock the canisters in the middle hallway”, both the manager and the nurse understand which canisters these are and which hallway is the middle hallway.

Accountability and reliable promises, pt. 1

Part 1 in a 3-part series

What do we mean by accountability? In a recent post, I suggested that it’s silly to hold someone responsible for fulfilling a promise when they never actually made a promise. After all, request + acceptance = promise.

Let’s connect this to an insightful take on the same question provided by Mark Graban of Lean Blog. He suggests that it’s unfair to hold accountable someone who isn’t responsible and quotes Deming’s advice to “fix the processes, not the people.”

Can we hold nurses and other staff accountable for not always following proper hand hygiene procedures when coming in and out of patient rooms?

Let’s say the foam canisters are empty outside a few rooms in a row (something I’ve seen recently). We can’t hold the nurses accountable. This is a system problem. “Writing up” or punishing the nurses would be counterproductive. We need to ask why the canisters are empty? Is there somebody to hold accountable for not restocking the canisters? Maybe not – what if it’s a bad process, where there’s no “standardized work” and no clear cut assignment of who refills the canisters (“everybody?”).