Review of Perfecting Patient Journeys

Perfecting Patient Journeys by Judy Worth, Tom Shuker, Beau Keyte, Karl Ohaus, Jim Luckman, David Verble, Kirk Paluska, Todd Nickel and Sam Watson is the latest in a series of practical workbooks from the Lean Enterprise Institute. Think of this as “Value Stream Mapping for Healthcare” which the book does well in explaining, extending the discussion into proper scoping of problems, consensus-building and other change management and project management aspects. The Foreword by Sam R. Watson, Senior VP for Patient Safety and Quality at Michigan Health & Hospital Association, leaves the reader wanting more from the book. On the current condition of unaffordable, inefficient and sometimes dangerous healthcare delivery, he writes:

Many now hope that technology can turn the tide in the transformation of healthcare. But beliefs and behaviors are the root of transformation, technology merely enables, facilitates and hastens change.

It was disappointing that this topic of culture, and specifically the deep assumptions and beliefs that drive our behavior, did not receive significant discussion in the book. The aim of value stream mapping is to make problems visible and create a path to a more connected process end-to-end, and the project is a method to bring about the change. A major reason transformations fail is that we try to change things and rules without changing how we think and feel. Value stream improvement is a technique, if not a technology, on which many Lean practitioners place significant hope. Over-reliance on VSM or any Lean method remains a risks, if significant and deliberate attention is not paid to making cultural beliefs and assumptions visible, explicit and the target of the PDCA cycle.
The book introduces “socialization” and uses this new Lean term liberally in place of “get buy-in” or “develop consensus”. It takes some getting used to (I am not yet socialized to the use of ‘socialization’). We can say socialization is low-key culture change arrived at through cross-functional kaizen events, empowering people to redesign their processes and problem solving through consensus building. In the real world, organizations face much more dire challenges with culture during a transformation than the instructions in this book will effectively address, but it provides a good start in the form of socialization / culture change built around value stream transformation projects. The various hints on socialization, codes of conduct and consensus-building are fairly standard change management and kaizen preparation guidelines, reworded and put into the hospital context. The instructions are sometimes too shallow, simply saying “Socialize your data collection measures and plan to the rest of the staff” without explaining how this is done or what are the typical pitfalls.
The topic of clarifying problems statements also begged for more detail in terms of examples of good and bad problem statements, what to include and what not to include in problem statements, how to make it succinct, the differences between highest-level problem statements and lowest level ones, how to cycle back to the problem statement if it becomes apparent while turning the PDCA cycle that the problem was not properly stated, etc. There are good standards for problem statements in the Lean literature, the Toyota Business Practice, including in courses offered by LEI but the book, and it would be good to see more cross-referencing and linking of these best practices within the LEI literature in the future. While promising to help the reader practice the 5 pitfalls of problem solving, the book still leaves plenty of room for practitioners to err when writing problem statements.
The authors to promise that by patiently working through the steps in the workbook, the five pitfalls of problem solving will be gradually addressed and the organization will become more effective. It is admirable that it is presented in this way, not as a simple checklist of dos and don’ts but as process of learning which will take time and practice. Since the title is Perfecting Patient Journeys, the 8 pages dedicated to what happens after the value stream improvement project seems inadequate. The authors know full well the enormous effort and never ending commitment it will take to “perfect” patient journey, as in Lean terms this means to “approach perfection but not ever attain it”. Ending the book without referring the reader who is a beginner to books on daily management such as Creating a Lean Culture by David Mann seems unhelpful at best.
For those somewhat seasoned in Lean and with any competence in value stream mapping, there is little gain from the mechanics of the process. For a complete beginner, the book provides enough of the basics to make Perfecting Patient Journeys a good starter book. On the whole, the book is a valuable addition to the library of any Lean practitioner, in healthcare or any people flow process such as food service, entertainment, hospitality and so forth. It is a good refresher for a practitioner needing guidelines in the broad framing and execution of a value stream transformation project.

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