On ‘death and dying’ and organisational change

‘Buy-in’ is a term commonly used when talking about change in the workplace. We want everyone to buy in to the change.  Often, supervisors and managers appear completely perplexed when people do not simply buy in or change their ways when told to.  Numerous books have spoken about ‘managing change’ and ‘obtaining (the elusive) buy-in’.

The lean methodology addresses some crucial aspects of ‘obtaining buy-in’,  including involving the people performing the task in the change process, empowering people to experiment with new ways, and coaching employees in problem-solving techniques.

There is a significant human factor that, if ignored, hampers sustainability of change: emotions.  In the work environment, where change is underway, these are labelled different names such as resistance, anger, or passive aggressiveness.  In this blog we will call this emotion grief.

We become emotionally attached to our routines, and our way of doing things.  And even though we might logically know that it’s not the best way to perform a task, we experience a feeling of safety and a sense of belonging within our routines.

In organisations with strict hierarchies and bureaucracies with red tape such as hospitals, those that have been around for a long time find and establish the loop holes which enable workers to get the job done based on longstanding networks and local knowledge.  Long-serving staff may view a suggested change to the way they do a well-established process as a threat. Exposing the loop holes can lead to feelings of vulnerability, frustration and anxiety about getting into trouble with management; especially within the ‘blame culture’ typically found in these bureaucracies.

Elizabeth Kubler-Ross, a psychiatrist who studied near-death situations and the emotions involved,   identified five stages of grief as a pattern of adjustment: denial, anger, bargaining, depression, and acceptance.  Each person will pass through these stages at their own rate and in their own way.  The task of a grief counsellor is to provide support during these phases.

A criticism of the model is that Kubler-Ross did not adequately take into consideration the role that the personal environment plays.  Certain environments make grieving easier.  And not everyone experiences grief in the same way, as some people are more resilient and adapt with little grieving.   Charles Corr, a social psychologist and a critic of Kubler-Ross’s work stated that grief and resilience are influenced by patient empowerment.  The more empowered the patient, the faster and better they adapt to the end of life situation. He highlighted two important aspects from Kubler-Ross’ work that I think are also true for organisational change: 1. that each person will react in their own way to the challenges that confront them, and 2. that one cannot become an effective supporter or carer unless one has learnt to actively listen to the person grieving.

How do we create an environment where employees feel empowered during the ‘death of the old ways’?  This question is particularly difficult to answer in the beginning of a lean journey, where management (and the organisation) are using traditional methods, the ‘blame culture’ is still firmly established and people have no success stories to demonstrate that the changes are in fact improvements.

I’d like to suggest though that we can better support employees during organisational transitions by preparing people for change, supporting their emotions during change and making it ok to grieve.

Grief is personal and subjective.  We can’t measure grief by comparing it to other people’s grief or phase of adjustment. We need to create an environment in which it’s safe to express emotions without judgement, where concerns are not simply dismissed, challenges ignored and what-if scenarios discarded. Emotions and feelings should not be denied when implementing change, otherwise staff will feel oppressed and devalued.

As such, I am making a case that the direct line manager is not the most appropriate person to provide emotional support during large-scale change initiatives.  The line manager is emotionally invested in the change and going through their own grief and adjustment, especially if they are confronted with challenging their beliefs on how to manage and problem-solve within their unit. They are grieving themselves.

So who should provide support then?  Could Human Resources become more involved? Is this perhaps a role for HR departments, with an understanding in lean thinking?  I’m not sure.  What I am sure of, though, is that whoever provides emotional support needs to be like a grief counsellor:  slightly removed from the actual incidence, with little emotional investment in the operational processes and ways.

Kubler-Ross: Phases of grief in organisations

Denial:  This is often expressed through statements such as, ‘We don’t have any problems in our department.’  or, ‘If only Department XYZ worked harder, faster or better, then our results would improve.’

Anger: In organisations this is expressed as passive-aggressive behaviour rather than actual aggressive outbursts.  If the not-so-obvious symptoms of this phase are not managed, the change will not be sustainable.  It’s important to support people through all the phases; however the anger phase is probably the hardest to diagnose as its symptoms may be subtle. Behaviour or symptoms of the phase include obstruction, lateral violence and bullying of others.  Other symptoms may include threatening to resign or requesting a move to another department.

Bargaining: If anger is the hardest phase to diagnose and support, then bargaining is the tipping point for change. The following remarks may be heard in this phase: ‘This is additional work, so I will make the change if you increase my salary’, ‘This is not in my job description so we need more time/resources/payment and then we will be able to follow through with this’ or ‘If this way doesn’t work, then I will leave and go work somewhere else’.  These employee responses should be carefully managed if the organisation would like to move past a point of consistent bargaining or negotiation towards sustainable change and behavioural acceptance.

Depression:  People might appear to be sulking, sullen and unhappy at work.  An important ‘sub-stage’ of depression is testing: testing the new ways and acknowledging that the new ways are not  all bad, but the employee is still not ready to openly accept it.  This is when people come to the realisation that perhaps it is not as bad as they thought.

Acceptance:  This is the‘buy-in’ you were hoping for from the start, or acceptance of the change.


Lean organisations should strive towards resilience, a state that is at the other end of the spectrum to grief, because people feel safe, supported and are able to adapt within their environment.  This desired state of resilience takes time to attain.

The phases of grieving must be diagnosed, addressed and managed.  If this is not done appropriately it will have long-term adverse effects, including bullying or consistent bargaining to perform tasks.

Until organisations reach the point of resilience, they need to plan emotional support into the improvement process.  This emotional support should not be seen as an extension of the direct line manager’s task.  Rather it should be outside of the functional unit. This is of the utmost importance in organisations starting a large-scale lean transformation.


The stages

A match made in healthcare improvement heaven

I’ve been collaborating with the Lean Institute Africa for the past six months and the collaboration has now been formalised.  As such, Lean Institute Africa will be posting some of my blogs on the news section of their webpage.

A bit of background about Lean Institute Africa (LIA): they were formed in 2008 as a non-profit organisation in South Africa.  LIA uses applied research approaches to implement the lean management philosophy.  Prof Norman Faull, LIA chairman describes lean as a management process for creating thinking people and eliminating waste.

One of the aspects of the lean philosophy that speaks to me is the concept of gemba (going to the problem or place of work and seeing).  From a lean perspective, problems are not addressed from a boardroom, intellectual discussion or based on opinion.  Rather, in-depth knowledge about a problem is gained in an empirical way, at the actual place of work, involving the actual people performing the task.   The actual ’workers’ are coached to think about the problem and solve it in a scientific way of experimentation until the most appropriate solution is found.

If you want to build a ship, don’t drum up the men to gather wood, divide the work and give orders.  Instead teach them to yearn for the vast and endless sea.  Antoine de Saint-Exupery

If you search for patterns in my blogs you would’ve gathered that I strongly believe in continuous learning and I am constantly exposing myself to new experiences. Another thread that you might have identified is that I use narratives or stories to shape perceptions and I believe that stories are an underutilised resource for influencing culture when implementing, improving and innovating the workspace.  I’ve addressed this as a conference speaker on a few occasions. My passion for storytelling is well-suited to the standardised storytelling approach (A3 problem-solving), as used by lean methodology.

The Lean Institute Africa has increasingly been involved with public health sector improvement and as you may have gathered from my other blogs, this is something I am very passionate about.

You can read more about the important work that LIA does at http://www.lean.org.za/ and follow them on LinkedIn, Facebook and Twitter.cropped logo

“Now this is not the end, it is not even the beginning of the end.  But it’s perhaps the end of the beginning.”  Winston Churchill

More good news is that whilst writing this blog I was asked to participate in writing a few blogs for the Emergency Nurses Society of South Africa (ENSSA), so I’ll still be writing about emergency medicine, access to care and more clinical nursing topics.

Sorting to the point of discomfort

Have you ever joined a queue not knowing whether you are in the right queue because there is no signage….whilst simultaneously fighting the urge to jump in and sort and simplify the workspace?  You see many papers, duplications, thousands of notices, just not the one telling you whether you are in the right queue. And so, the signs that are there are rendered useless. You are surrounded by noticeboards with notices going back several years and unused equipment taking up space. I could go on, but I am confident you can relate and are picturing your own experience of such a frustratingly disorganised moment in your mind.

queue 2

By sorting out the workspace both the customer and employee will feel happier and know what to expect.  The sorted workspace is not cluttered and it is easy to see where to go and what to do.

We also have moments when we are disorganised in our personal lives and from time to time we need to take action to remedy this. A while ago I joined a ‘simplify your (personal) life’ challenge.  On the first day you are required to throw out one item. On the second day you throw out two items. On the third day, three items and so on, and you continue to do this for a month.  At the end of the 30 day challenge you will have thrown out 465 items.  That sounds easy, right? Well, yes it was….for the first few days when I was throwing out the items that I was comfortable getting rid of. But when I had thrown out the obvious items, but still had to complete the ‘simply your life’ challenge (and therefore I had to find many more items to discard) I became uncomfortable.

I was forced to ask myself critical questions like, ‘do I really need something that I’ve had for 20 years and not yet used?’  ‘Do I need the things that I kept for “just in case”?’  Possibly the toughest decision I faced was whether or not to throw out books.  I have a lot of books. I love books. But, I had to ask myself ‘did I enjoy reading every single one of them?’  ‘Did I find value in every single book?’ By the time I’d finished my sorting exercise, I had given books to the library, paint, paper and pens to a local school, clothes to one charity and kitchen utensils to another charity.  Once this was complete I had a great sense of achievement, but it took hard work to get there.

messy bookcase sorted bookcaseSorting brings order to your work and personal life

So here is what I’ve learned

It’s easy to sort and simplify on the surface, but we usually stop before it becomes uncomfortable.  Yet, as soon as you cross that level of discomfort it becomes a liberating habit.  At both work and home we accumulate stuff, even if we are not hoarders.  So we need to consciously make time to clear out, sort out, and tidy up.

If organisations can push team members to sort beyond the comfort level, a new sense of pride and space for new things is created. It creates flow. Sorting is a decision-making process and team members have to decide what is needed and what is not needed. Regular, routine sorting stimulates critical thinking about different ways to perform a task, equipment that might need to be replaced, or moved closer to a work space, whether there are unnecessary duplicates, etc.  (In other words it helps us to identify not-so-obvious wastes).

Regularly creating flow and simplicity in life creates space for better planning, and may identify new improvement projects.

Organisational wish lists and budget motivations can be toxic; they create a culture that says ‘we have to purchase more’ and add more equipment every year. Moreover, most organisations are not good about enforcing strategies to throw out the old and introduce the new.  In the end we keep the old, the broken and the new. Perhaps organisations should develop the courage and common sense to buy only that which is required. Or, we need to sort more efficiently.

The last and hardest lesson is that there is attachment and reluctance to let go of certain items.  We need a strategy to make peace with letting go.  This is where making sorting and sifting a daily habit is helpful.  When we continuously strive to sort, tidy and get rid of unwanted items it becomes a habit, not a rare, overwhelming and stressful event.


Sorting does not need to be overwhelming if it becomes part of the routine

You don’t have to get rid of 465 items to begin feeling the positive impact of sorting, but I would challenge you to get sorting as a routine, and allow flow into your life and work!

Florence Nightingale’s other legacy: innovator in descriptive statistics

“To understand God’s thoughts we must study statistics for these are the measure of his purpose” Florence Nightingale

The lady with the lamp….Florence Nightingale is best remembered as the pioneer of modern nursing. What is less known about Florence is that she was deeply committed to the field of statistical analysis in health care.   So much so that Florence was in 1859 elected the first female member of the Royal Statistical Society.  Florence was an innovator in the field of descriptive statistics and she was part of a transformation that showed how social phenomena could be objectively measured and subjected to mathematical interpretation.

Nightingale realized that she had to make data come alive to effectively convey a message; one of her persistent messages was that health care facilities needed to improve. Nightingale held the belief that visual aids and graphs should be easy to understand.  She believed that Queen Victoria and parliament who were not accustomed to statistical data would not understand traditional statistical reports.  So Nightingale innovated and developed the polar area diagram; occasionally called the Nightingale rose diagram.  This was an innovation on the pie chart, invented by William Playfair in 1801.

She was the first person to use visual presentations to report the conditions of health facilities. Data that she presented visually to implement health care reform includes the illustration of seasonal sources of patient mortality in military field hospitals, graphs to report on the nature and magnitude of conditions of medical care in Crimean war, bar charts to show how soldiers living in barracks in England were dying at a faster rate than civilians in the cities around them because of sanitary conditions. She used the visual graphs to demonstrate how mortality could be decreased and after implementation of her recommendations how it was decreased.

“…for me this experience emphasized the great importance of correct hospital statistics as an essential element.” Florence Nightingale

Nightingale was the first to use systematic documentation of deaths in hospital, using the records to calculate death rates due to different causes.   She convinced the politicians of the role of statistics in government pointing out inconsistencies in data such as mortality rate measurements that needed standardisation.  She then took it one step further designing a hospital statistical form for hospitals to collect and generate consistent data.

“…of what use are statistics if we don’t know what to make of them?” Florence Nightingale

Data visualization is the modern branch of descriptive statistics. It involves the creation and study of the visual representation of data with the goal of communicating clearly and efficiently.   It can be used in health care improvement to indicate what should happen and what are happening.

It is not recorded whether nursing documentation existed before Florence used it to drive improvement of care in hospitals and I think that she was the first nurse to use nursing documentation. Her aim with keeping nursing documentation was to illustrate the implementation of doctors’ orders and to use nursing documentation data for statistics on hospital environment, patient safety and quality of nursing care.

It is as imperative now as it was then that nurses should use documentation to push for change and improvement. Nursing documentation should not only be limited to patient care it should extend to drive health care change in the hospital environment.

Health care practitioners are already experts at using visuals to present patient information by taking real time clinical measures of patients, presenting it on charts and then using it to make decisions, implement actions and measure effectiveness. For example vital signs charts, input and output charts, temperature charts, pressure area charts, medication charts.

“Not that the habit of correct observation will by itself make us useful nurses, but without it we will be useless.” Florence Nightingale

We also intuitively understand the importance of taking the right measure and an exact measure. We don’t report that the patient has an ok blood pressure or mild blood pressure.  We don’t expect “some” temperature or “slight” outputs.  We know that if we are to care for the patient to the best of our ability exact measures and trends are important when interpreting charts and vital signs.

“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.” Florence Nightingale

We need to follow Nightingales guidance and use visual data to improve health care as a greater whole.  Innovating on her concepts and using functional visuals to plan our actions better and at a glance know where the bottlenecks could direct our daily work.  Imagine how we would or could perform if we had this data available to us throughout the day.  I can just imagine the state of nirvana for most emergency nurses glancing at the information and knowing that the EC does not need to overflow with patients because the wards are discharging and there is space for our patients….mmmm…what a happy thought!


A little note: this blog was supposed to be on the visual management of data for improvement, I completely ventured off the topic when I started reading about Florence Nightingale. I’ve read her work on nursing before and visited her museum in the UK, and I’ve always been aware of her nursing accomplishments. Somehow I missed the significance of her other work! They reckon that she was the driving force behind most health related legislation in England for a period spanning more than 50 years, she was instrumental in developing nursing in other countries, health care reform in India, and I could go on and on.  It is mind blowing that one person could impact change on so many levels.  Such an inspiration!  And they reckon that there are more than 300 Nightingale biographies alone!

Relentless leadership

Lead like a relentless but reflective bulldozer.   I’m off course referring to the LEAN Institute Africa’s 2014 summit theme.  I’ve summarized some of the summit’s consistent themes regarding the traits of such a leader.

The LEAN Africa’s Institute’s pamphlet for the 2014 summit defines the relentless leader as a purposeful leader, continually driving for improvement whilst simultaneously being compassionate. Thesaurus defines the word relentless as sustained, unremitting and unyieldingly severe.

Traits and ways of the relentless leader:

  • The relentless leader acknowledges participation.  The relentless LEAN leader realizes that people are more involved when they feel appreciated and acknowledged; therefor they find time and ways to encourage participation and experimentation.  The relentless leader not only knows that it’s about the people but also cares deeply about the people.
  • A relentless leader sets direction.  They do not simply introduce a toolbox.   They start by creating a shared vision and philosophy. The most applicable tools are adapted to suit organizational need and support the shared vision.
  • A relentless leader is persistent. There is no end to improvement.  The relentless leader makes LEAN stick; the relentless leader takes the organization beyond LEAN being a project, fad or process with an end date.
  • Relentless leaders are information conduits working consistently towards creating a corporate memory.  Relentless leader creates a focus on producing knowledge in the same way that one produces work.  Every problem is an opportunity to learn and generate knowledge.   The relentless leader ensures that there is no space for exclusivity and knowledge is shared across functional boundaries.  They know that functions may be specialised or specific to a work area; however the significance of knowledge is collective.
  • The relentless leader is a good listener and finds the problem before offering solutions.  In emergency medicine we teach that the most dramatic injury is not necessarily the most serious injury.  For example if a person has an obviously broken bone that you see as you approach and you immediately focus attention on that, you may miss that the person is not breathing and has no pulse.  So they will have pretty splint but also be pretty dead, because you didn’t address the real problem.  So don’t get side-tracked by the noise and always follow the same systematic approach. It’s the same with solving problems what appears to be an immediate problem and/or solution is most likely not addressing the root cause of the problem.
  • The relentless leader is visible at the workspace and makes gemba tangible.  Gemba is not simply going to the workspace to “see” the problem.  Gemba is going to the workplace and observing until your mind shuts up, applying all the senses.  It’s like meditation, you need to feel the workspace and observe the work cycle.
  • The relentless LEAN leader leads by example:  their office is neat, they use visual management tools, they can find data easily and they share knowledge.  They know that you can’t “delegate” LEAN or not have time for “LEAN” expecting that the team will then make the time, and buy into LEAN if it’s not visible from leadership.
  • The relentless leader is consistent. LEAN is not just for when things are going poorly.  It is habits that are formed by practising it every day.  These habits includes measuring performance, huddles, daily activities, workplace discipline, the relentless leader is consistently setting the pace and leading by example.
  • The relentless leader respects and values the team.  As such the relentless leader considers that when bringing about change for the first time, it’s scary and unknown.  They know that there will be resistance.  To add a little bit of my own spice, with regards to change I’ve been taught to apply the grief process as extensively described by Elizabeth Kuber-Ross to understand the initial resistance.  The relentless LEAN leader intuitively plans and allows for some adjustment and that there may initially be denial, maybe even anger because the workplace is changing.
  • The relentless leader measures performance.  The analogy presented was if you are a rugby fan and its 20 minutes into the second half when you first tune in on the tv.  What is the first thing that you look at?  The score.  Because that gives you an instant update of how the game is going.  The relentless leader knows that in order to know the score, the right score must be kept and displayed to the team.

I think that it’s the mission of the relentless leader that sets them apart. And I would like to add a quote by management guru Peter Drucker:  “The three most charismatic leaders in this (last) century inflicted more suffering on the human race than almost any trio in the history: Hitler, Staling and Mao.  What matters most are not the leader’s charisma, what matters is the leader’s mission. “