Respect – the missing element.

By Marianne Jackson, MD.

Respect – the missing ingredient

Without it – we crumble.  The house falls down.

In leading Lean change in healthcare, it is easy for the emphasis to be placed on efficiency, low cost and high quality.  That’s the point, right?  But if that’s all students of Lean hear, they are missing the essential ingredient that forms the passion and the integrating glue of Lean which is Respect for People.  All people.

When we are working without standards, without training, resources, support, clear expectations, functional equipment,  and safe conditions, we are all experiencing disrespect.

When patients are required to wait, queue up repetitively, answer the same questions over and over, be subject to unnecessary tests and errors, be overcharged and underserved, they are the objects of disrespect.  No amount of effort at “patient satisfaction” will overcome disrespect.  We should send out patient respect surveys.

When the state pours money into an organization that wastes resources, talent, and squanders tax payers’ money, the State and citizens are being treated with disrespect.

The outcome is predictable – anger, frustration, fragmentation, failure to follow leadership and a desire to go one’s own way.  We see it in staff, physicians, law makers, and patients.

Respect for people.

Respect for staff. Lean is about making sure work is meaningful, safe, clear and connected.  Whether making a patient appointment, preparing a care plan, coding and billing or performing surgery, respect means knowing the importance of getting it right. Leadership values and measures accuracy over speed.  Respect for staff means management knows exactly what is required to do the work and how long and makes sure staffing is adequate to cover the need.   It means no longer pretending that the job can be done faster with fewer people without taking shortcuts that eliminate details or safety checks that were deemed important.

It means having sufficient training to perform the tasks so a person doesn’t need to feel inadequate.  It means having proper resources – whether that is an accurate directory of phone numbers, physicians who answer pages when they are needed, passwords and permissions to computer information, well stocked cabinets, printers with ink cartridges, desk space, quiet for concentration, or any of thousands of items  needed to proceed in providing patient services.

It means knowing your work is essential to the system whole.  The registrar needs to know who uses those forms and cards and folders and why.  The physicians need to know why all those signatures, check boxes and forms matter.  The nurses need to know who reads that documentation.  And if no one does, stop doing it.

Respect  for physicians means providing necessary information in a timely, accurate format.  And providing all the tools necessary always to do their work where they work.  No vaudeville act can succeed without the hat and cane.  Likewise, no physician can evaluate and discuss or implement treatments or comply with the myriad of regulations without all the tools all the time. It means respect for their time which is their most precious resource next to their knowledge. They have to have patients available and ready, and reliable staff who form the teams that comprise medicine today.  And just like any other staff member, they need functioning equipment, supplies, and training including orientation.

Respect for patients:

Of course it should mean not wasting their time, finances, and energy or subjecting them to unnecessary error.  Of course it should mean not pretending (pretending that we can cure if we can’t, pretending that the risks are what we wish rather than what they are, pretending that silence is better than truth)  But it also means including them in discussions, decisions and goal setting.  It means including them in structuring our clinics.  It means being willing to learn from them – not just have them learn from us.

I believe much  (though not all)  “misbehavior” in our healthcare environment, is the end result of a culture that lacks respect  or that hasn’t sufficiently communicated the necessity of respect for each other as the basis for the work itself.  When we don’t understand how our work connects to another’s or when we are isolated, unsupported, insufficiently trained, given inadequate resources, or lack of support, we misbehave.

We talk about the House of Lean standing on a foundation of Standard Processes that are continuously improved and having pillars of Quality and Efficiency leading to a roof of Low Cost, High Quality and Safety.  I maintain that the mortar holding all the bricks together is Respect.  We hardly see it on the charts.  We assume it but don’t emphasize it. But it has to be pervasive.  Without it, the house falls down.