Keeping Wood Dry
My friend Warren Gaskill and I build a ‘lean-to’ last Saturday behind my garage. The lean-to replaced a wood pile covered by a tarp, held down by bricks.
The old way was OK for keeping the wood dry but not so good for seeing the status of the wood inventory or easily grabbing a few pieces for the fire. The tarp on wood also didn’t look very neat.
Our lean-to followed typical home-improvement projects: we developed the design, tested some options on paper, then implemented our plan. Given my skill in construction, we had to adjust the design as we built. Our first guesses at holes for the vertical cedar posts required extra digging to assure vertical and horizonal alignment. We also revised the method to slope the metal roofing panels, simplifying the support pieces. This week, I am thinking about how to maintain the lean-to. The plywood shelf is at risk from rain and snow; I think the shelf needs a moisture-resistant coating.
Changing Work: Five Key Action Words
Changing the wood storage system behind my garage illustrates the first three of five key action words I have learned to use to describe system changes.
Your initial system?
If I were in the business of making lean-to wood shelters, my project last Saturday would be my initial system!
In the health care projects I advise, teams are building or revising work that often cycles multiple times a day. The clinical and administrative units repeatedly deliver services that follow common paths. To improve performance, we advise teams to learn by doing. Focus on an initial work system that serves as a test site or ‘model cell’: one nursing unit, one care team, one clinic. Once a team has developed, tested and implemented one or more changes in the model cell, there’s a useful foundation to spread and scale those changes.
Integrated Health Care Example
In our current oral health project, community health centers are changing workflows to integrate dental and medical care for people with diabetes.
At one health center, the improvement team developed a change in the dental workflow. The dental assistant reviews the schedule for the day and flags patients who are overdue for hemoglobin A1c testing. The HbA1c test can be ‘preordered’ by the electronic record system; the dentist just needs to take the last step and authorize the order.
The team followed our advice and tested the change using the ‘rule of 1’. The team first tested the proposed procedure on one day, with one patient, and one dental dyad (one dentist with one dental assistant). The dental dyad carried out the task; the patient needed an A1c test and got it. Success!
A few more cycles convinced them that their change idea was feasible and helped the health center achieve their aim of integrated care for patients with diabetes. However, the testing only involved the initial system (the dental dyad) over a relatively short period of time this past spring. The improvement team now faces three challenges: how to implement the change so it becomes regular practice for the initial dyad, sustained week after week? The team wrote out a procedure to share. How to spread the change to all five dental dyads in the health center? They have presented the story of their change to the other dentists and asked them to try it themselves. How will they scale the change, adapting infrastructure like the electronic health record required to support implementation and spread? They revised the screen and fields available in the EHR to make it easier for any dental assistant and dentist to find critical information.
Can you see that the Model for Improvement with its embedded Plan-Do-Study-Act cycle applies to each action word?
Notes on Changes
For the past couple of years, I distinguished ‘sustain’ from ‘implement’ in my list of actions. My friend and colleague Kevin Nolan convinced me this week to include ‘sustain’ (or ‘maintain’) as a component of implement. Kevin’s advice reflects what he and his co-authors wrote in The Improvement Guide, 2nd edition, Chapter 8. Implementation should include your commitment to sustain your change. Kevin’s advice shortens my list of key words, too!
Size and Scope
For reference, here are two nouns that help me to describe a specific change. To build degree of belief that a change will work well, you usually need to increase the size of your test and expand the scope.
