Chapter 16

Define the Guiding Principles and Management System Elements to Sustain the Excellence Journey

Real improvement comes from changing systems, not from change within systems.

—Donald Berwick

Most organizations struggle to sustain change in their organization. Experience informs the following five reasons as the key contributors to failed cultural transformation journeys:

1.Behaviors expected from employees are not clearly articulated.

2.A conducive environment for employees to demonstrate expected behaviors on a daily basis is not provided.

3.The new way of working is not integrated into the employees’ daily work.

4.The excellence journey is treated as a project/initiative.

5.Leadership’s commitment to the excellence journey falters when the organization is in financial difficulty.

Since the control and sustain phases in most business excellence philosophies or project implementation frameworks are typically the last phases, not enough attention is given to developing countermeasures for the above causes in the earlier phases of the journey or while building the foundation for change. In the last ten years, enough evidence has been collected through studying and learning from successful organizations that what differentiates a top-performing organization with others is their culture.

In Chapter 5, we learned about culture, its constituents, and the role of leadership in developing organizational culture. In Chapter 6, we learned about business excellence models and their constituents. This chapter combines the lessons from Chapters 5 and 6 to create the management system framework required for developing a culture that delivers the new results an organization needs to achieve.

But first, let me clarify some terminology that leaders and practitioners find confusing. Figure 16.1 shows the different excellence terminologies mapped out on the seven categories of the best-practice Malcolm Baldrige framework, used for awarding U.S. organizations in the business, healthcare, education, and nonprofit sectors for performance excellence.

Organizations that achieve the performance excellence status align and integrate their leadership, strategy, customers, measurement, analysis and knowledge management, workforce, and operations to produce the best overall results. An organization can have excellent processes and products, but if its strategy is wrong or its results are poor, the organization will not achieve performance excellence. Don’t confuse project results with organizational results. The key to performance/organizational excellence is combining and managing all aspects of value creation in the business together, and establishing an internal framework of standards and processes to achieve and sustain outstanding levels of performance that meets or exceeds the expectations of all the stakeholders. Achieving operational excellence requires the successful implementation of a business strategy.

Since Baldrige looks at all components of an organization with equal emphasis and focuses on how each part impacts and links with the others, it provides a true systems perspective. It is for this reason that I have used the categories of the Baldrige model to create the Kumar Management System© (Figure 16.2).

How the Kumar Management System Works

The customers are at the top of the management system model. The customers truly guide the leadership in setting the direction and establishing organizational goals and strategy that include their voices, experiences, needs, and expectations. The strategy informs the area of focus and the corresponding big dot measures for the organization. The big dot measures inform the processes (operations) that need to be improved to achieve the overall organization strategy. The next step is to make sure that the people have the right skills and education to work on these processes. The desired operational metrics inform the skill gap that needs to be bridged in the workforce for delivering best-in-class performance. In the category of measurement, information, and knowledge management, a business constantly feeds and analyzes data and compares the data with not only the inputs and desired outcomes expected from all other categories, but also with external influences and benchmarks. The feedback loop informs us how well we are doing. It allows us to take corrective actions on a continual basis and adjust our areas of focus for the organization as a whole. The PDSA improvement cycle continues indefinitely in pursuit of achieving organizational excellence and culture transformation (results).

The Kumar Management System comprises fourteen guiding principles (Figure 16.3) and twenty-two sustenance elements (Figure 16.4) to support an organization on their journey to excellence and culture transformation. These principles and sustenance elements of the Kumar Management System have been handpicked after careful consideration (Figure 16.5) and are based on two decades of industry experience, practical lessons from visiting several leading best-practice organizations, and also extensive research on best-practice frameworks and methodologies such as Shingo, Malcolm Baldrige, Lean, Six Sigma, Patient-Centered Care, and Performance Management, among others.

A word of caution to readers: the elements of the management system are not tools. David Mann, in his book Creating a Lean Culture, states that a management system drives the culture of an organization by sustaining and extending the gains from implementing Lean improvements. Let me explain this through some practical examples. Visual management is a management system element. Examples of tools that support visual management include 5S, performance scorecard boards, and patient whiteboards. Likewise, the tools that supports Systems Thinking include the value stream map, systems map and an assets map; the tools such as the fishbone diagram, 5 Why analysis, A3 problem solving, challenge map, and KJ analysis support creativity and innovation; and the tools of staff conversation, customer/patient conversation, and process observation support the management system element of Go See Learn. While the tools are important, what is crucial is the need to ingrain management system elements into the fabric of daily operations to change the behavior of people, a key instrument in organizational transformation.

Validation of the Kumar Management System

The guiding principles and the sustenance elements of the Kumar Management System were validated at Hospital Heal while implementing their excellence journey of More Time to Care (Table 16.1 and Figure 16.6).

Patient and Family–Partnered Care Practices

Now let me elaborate the category of patients, share the patient and family–partnered care practices, and provide the roadmap that was developed and implemented at Hospital Heal. But before that, I would like to share my story of the journey to creating the roadmap and some revelations of what I experienced along the way.

To understand and learn more about the patient and family–centered care practices, I went on a learning mission along with two members of my team. We visited several hospitals in Canada and the United States that are recognized as leaders in practicing patient and family–centered care. We read a lot of best-practice literature on patient-centered care. We participated in leading conferences focused on patient-centered care to learn from the experiences of other healthcare providers and consumers. We spoke to some of the senior leaders and key personnel who are respected in this field to seek their guidance for developing a roadmap to implement patient and family–centered care at a hospital. We also sat as observers in some of the advisory council meetings.

While there was immense learning and exposure to practices and experiences of others who had tread this path before, I was amazed that we could not get a compelling answer that could direct me with confidence about where to start and what potential practices to include while designing a roadmap to patient and family–partnered care. I understand that every journey is different and you cannot copy-paste someone else’s journey to implement yours. However, I just hoped that I would have gotten a better response than “It depends.” The only common ground that most hospitals or individuals shared was to have a patient advisory committee.

So, the only option left was to design a roadmap based on the knowledge gained during our learning mission and relate it to the culture of the organization. After several weeks of deliberation and consultations within Hospital Heal, we designed a customized roadmap built on the four key concepts of patient and family–centered care, namely, dignity and respect, information sharing, participation, and collaboration. The roadmap consisted of eight guiding principles and twenty-two associated patient and family–centered care practices (Table 16.2).

The irony is that the practice of having a patient advisory committee, which was universally recommended, was not implemented. Instead, a conscious decision was made to build a pool of patient volunteers, leverage their knowledge, and involve them by matching the right experience with the improvement project instead of having a few select patient advocates providing input on every change initiative. This collaborative approach with patients and families positively impacted the quality of input in all projects and also their deliverables. For that reason, the practice was strategically termed as “partnered care” instead of “centered care” to reflect true collaboration with patients and families for improving their health outcome.

Twelve out of the twenty-two practices and their sequence of implementation at Hospital Heal is highlighted in Table 16.2. The intent of sharing the sequence is not to imply that your organization should follow the same, but to show what worked for Hospital Heal’s culture. These practices were initially tested in the pilot areas before being introduced across the organization. My endeavor is to provide senior executive leaders and organizational excellence practitioners with a starting point, a direction, a reference line, and an example of what a roadmap looks like based on my experiential learning, which is also supported by best-practice literature. I hope readers find the roadmap useful to initiate discussions with their teams and to create their own roadmap suitable to meet their organization’s needs.

Sensei Gyaan: An organization will fail to achieve the desired results of their transformational journey without integrating the management system elements into their daily operations. To change an organizational culture and ensure that the gains of implementation are locked in and sustained, it is imperative that the following two conditions be met:

1.Leadership sets the behavior expectations to live the organization values and provides an environment in which those behaviors can thrive.

2.Employees demonstrate a conscious change of behavior in their daily work.