Regaining Focus - Keep it Simple

The Junkyard: Artifacts of Lost Focus

I recently talked to a colleague about her experience with the shifting sands of continuous improvement in healthcare. She walked me through the programmatic junkyard cluttered by the past 14 years of leadership thought. It was right to think that service can be a differentiator. It was right to focus on quality, and, oh yea, safety. It was right to look around at trends in healthcare management and hop on the lean bandwagon, then the six sigma one, then the lean sigma one. The biggest problem, said she, was that they kept losing focus. Each initiative would start out with energy and verve. But, soon, what looked promising, was quickly seen as a flash-in-the-pan.

Repackaging the Same Thing Makes it Fuzzy

I’m teaching a course called Operational Excellence in Healthcare at a local university. Every year I have to prepare by doing a literature scan and each time I do that I find great sources that echo my colleague’s sentiments.

This year, I found this 2009 article, published in International Journal for Quality in Healthcare by Kieran Walshe . A key finding by Walshe is that we keep repackaging the same thing and get limited results.

Over the last two decades, we have seen the successive rise and fall of a number of concepts, ideas or methods in healthcare quality improvement (QI). Paradoxically, the content of many of these QI methodologies is very similar, though their presentation often seeks to differentiate or distinguish them. Kieran Walshe

1)Even operational excellence is simply repackaging total quality. I’ve argued such in the past. We have to get focused if we want the movement to succeed. Walshe goes on to say:

The repeated presentation of an essentially similar set of QI ideas and methods under different names and terminologies is a process of ‘pseudoinnovation’, which may be driven by both the incentives for QI methodology developers and the demands and expectations of those responsible for QI in healthcare organizations. We argue that this process has important disbenefits because QI programmes need sustained and long-term investment and support in order to bring about significant improvements. The repeated redesign of QI programmes may have damaged or limited their effectiveness in many healthcare organizations.

His point is well-taken: by constantly re-packaging, and buying the next, new shiny thing that comes along (promising the same benefit), we do a disservice to the idea of sustained and thus continuous improvement. So, what advice can I give to regain focus? Keep it simple.

From Fuzzy to Focus: Simplicity

Regardless of what you call it, simplicity will help you gain or regain focus. Here are three ways to navigate to simplicity.

Have a single, compelling, common aim that always pricks your value system.When you think of lean or six sigma or even early attempts at TQM, you know that having a target condition is essential to solving problems. Without a standard, it’s impossible to improve. The result in the early days was to set up metrics willy nilly. By willy nilly, I mean we’d set up global metrics that seemed right based on the external pressures instead of aiming at something compelling. Or, we’d set sub-optimized metrics that were myopic and parochial. Use a single, compelling, common aim that pricks values to create sets of aligned metrics. Ask yourself this: if we hit all of our targets would we lurch forward to our compelling aim? If hitting some of your targets would have you careening off-aim, look how you are defining improved performance.

Avoid the Perfection Trap where you end up going too deep without respecting learning by experimenting. My colleague described something called “Communication Boards” as a thing she could see in the junkyard. While the boards were a well-intentioned tactic, equally well-intentioned folks worked hard at getting them “right”. Even in my own practice, I’ve had to coach leaders who tended to be individual-performance driven to back down from seeking perfection. In a classic case of losing the forest for the trees, people who seek perfection lose focus on forward progress by focusing on jots and tittles. Forever, continuous improvement has been based on trial and error. Shewhart via Deming gave us a nifty learning aid: the pdCA cycle and we know that it’s all pdCA. When we try to perfect one thing, we neglect perfecting the things connected to it. I can have a perfect visual scorecard, but have weak problem solving “feeding” it. Better to try and fail and learn the system-ness of continuous improvement (thank you, Dr. Deming) than to perfect one component of the system. Simplify things by navigating to pdCA not perfection.

Early adopters may not be the best building block for focused change; rather, move as a team. This idea may take some time to sink in. I’m a fan of transformation thinking. I know in my heart that I should do something with my early adopters. Some would advocate pointing to them and saying, “See, this is what I mean! Look at how positive this is!” Thinking that the example is convincing, we’d expect others to just follow. The problem with this line of thinking and the reason that it adds to lost focus, is that like the Perfection Trap, we lose a sense of the whole. Drawing on what I learned as a young Naval officer learning infantry tactics (that’s a long story), a team that is moving as a team packs a bigger punch than one moving as a set of individuals. Early adopters tend to run out in front and it is right to harness their energy. But it’s equally wrong to let them outstrip the team and get too far out in front. A strung out team can lose people, picked off one-by-one by the flaming arrows of fuzziness in purpose, direction, and distraction. To stay focused keep it simple: move as a team.

Leader: Do This to Focus

Each time I start a new engagement, I try to begin with an assessment. I start the assessment by wandering around looking for artifacts. Some are active, in use and healthy. Though, I have to confess that I mostly find these in pockets and lacking system-ness. Most of what I find has been neglected and collecting dust. Junk in the programmatic junkyard, evidence of another short-lived movement.

Leader: get rid of the junk, go back to the basics and keep it simple to keep it focused. Simplicity begets focus. Focus begets results.

Next time I’ll take on Regaining Focus Part Two: System-ness through Integration.  Until then, pursue #better and stay excellent.


1. Kieran Walshe; Pseudoinnovation: the development and spread of healthcare quality improvement methodologies, International Journal for Quality in Health Care, Volume 21, Issue 3, 1 June 2009, Pages 153–159,