I have a
job. In a
new country. In a
But it’s still me, luckily. And I bring the knowledge and tools that I
know and have used from other domains. I have often thought that the IT
industry was special. that projects in our environment was much more
complicated than in any other environment. That we had special
communication problems that only occurred here.
I’m now starting to change my mind. Of course I cannot talk
Specification by example with these people, but
there are many universal things that will help you: focus on lead times
and doing fewer things at the same time,
get people together in the same room, visualize your
problem to get a better and common understanding of it. Things like
In this post I’ll describe how we used three (Root cause analysis,
Impact mapping and Limit WIP) of the tools that I’ve picked up during
the latest years to help a struggling hospital director to get a solid
understanding and a plan for how to proceed.
The hospital director is a very young (28?) woman doctor who was
promoted because “we had no one else”. She has no management training
and was given a hospital that is in terrible condition, with a lack of
motivation among the staff, and a bleak economical future to say the
Not a very envious situation, but she has will power and really wants to
do something about this. I thought I’d try to help her get an action
plan in order, since like for many of us in this situation, she wanted
to do everything at one.
This is not a blog post that will end with "... and now they are the
richest hospital in Indonesia and the doctor has gone on to win the
Noble prize in management". There will be no victory dance.
We're not there.
I just wanted to show how we applied the ideas with these tools in a
very different domain from what it was first intended too.
### Root cause analysis
So, where do we start? At first I thougth that was a really hard
question to answer. There were so many problems. But then I came to
Root Cause Analysis
and how that from time to time
have led me to see how problems are related to each other.
One of the things that they (the hospital management group) often came
back to was that the BOR (Bed occupancy rate, number of patients in the
hospitals / number of available beds) was low. About 20-30% of their
capacity. So, even though I did know that they had A LOT of other
problems I suggested that we start with that. They were so bogged down
so they didn't mind: "Yeah, that's one of the things that we need to
As the exercise unfolded I came to realize that Root Cause Analysis not
is a problem *solving* tool - it's a problem *understanding* tool. More
on that soon.
I simply took a sticky and wrote "BOR is too low" on it and stuck right
in the middle of the board. And then we started upwards: "So what? Who
cares if our BOR is too low?". That got them going, I tell you. Before
long they had produced this:
I think it took about 1 hour and I did
only help them to stay on track in their discussions, trying to remember
to address all the branches we created.
We took a step back and looked at the tree we created and realized that
we now had a much better understanding on why we need to solve this
problem. It touched on some really basic and very important issues that
in turn was reinforcing our problem ("BOR is too low").
We then worked our way downward asking WHY-questions, as usual. Soon
this picture had emerged:
I was a bit disappointed at first, since I was hoping that we would find
a single real issue that we all came to realize: This, that's what we
need to address.
But we didn't. Instead it was a solid understanding of the problem
domain, the reason for that problem to occur and the consequences of
having the problem around.
### Impact mapping
I suggested a break, but that's not how Indonesians do it. They just
keep working. I have to try to help them with that.
Without any further ado we headed right into the next section:
My thinking here was that given our, now improved, understanding of the
problem we could start to formulate a plan for how to turn it around. So
we created a sticky called "*Increase BOR with 6 ppl / day*". I
When I came to Indonesia I reread
(yeah, fourth time now) and also ended up
talking a lot about getting a F1-question
. One of the anecdotes from Switch came
to mind and I suggested that we crisp up the goal a bit. So we said "*On
May 30th, 0900, we will have increased BOR with 6 ppl / day*". They then
change that into the real number (like 24 patients a day) which is even
With that sticky on the board I started to ask them *who*they thought
could help us reach this goal. This confused them, so I took the cover
of the Impact Mapping book as an example and talked about the racing
team and who could help them to win the F1-cup (I'm no F1-guy, but maybe
I should start following that...).
That example resonated with them and we got to work again.
I pretty much followed the same way I usually go about
impact maps, as described here.
I tried to stay in one area at the
time, first creating breath (all the *Who's* first) and then going to
the next level (*How*) per role. Then per *How* the *What's*. That
requires some discipline and a facilitator might be needed to not dive
to deep and go for the *What's* to early. This meeting was just another
reaffirmation of the knowledge.
It took quite some time but soon we had a impact map that looked like
Yeah, it was a bit messy. And I've had this experience quite often when
I create maps like these. These are my general tips:
- Get really big board
- Remember when you start to draw that it will be big and detailed in
- Move the What's to a separate paper or board when you start to talk
- When you document it. Use something simple, like a phone (these
photos is taken with my iPhone 5) and take both overview and
- Although there's awesome tools out there (looking at you
there's really nothing beating standing together in front of a
whiteboard. The tactileness and directness is something else. I, for
one, like it more.
- That said: do consider moving to a tool after the initial workshop.
As documentation for example. Search, navigation and a lot of other
features is very helpful to find stuff in your model.
### Limit Work In Progress
And with that we headed right into selecting a couple of actions. The
young doctor was super happy. She would try all of them (35+) and start
them tomorrow. The Lean-guy inside me cringed. Violently. I think it
I had to do yet another exercise with them, a simulation to teach them a
little bit about why you shouldn't do too many things at once. We ran
the "Learn to count" exercise that I've blogged about before
(and written about in
this free sample chapter from an excellent book
). I like
this exercise since you can run it with a single person and it's very
to-the-point and gets the message across.
The doctor picked it up fully. After that we did
a Dot vote
session to get the top 3 items to start
investigating. We wanted "bang for the buck" - biggest impact with least
effort. They got that too. But still, as we went around the board and
voted they were asking me for more dots... :P
Here we could of course have gone much more advanced and tried numbers
and weights, but this was good enough for now.
This is as far as I know. The doctor was very happy since she now got a
structured problem and an action plan, instead of an unstructured
problem and a lot of small activities. That felt really good.
I understood a great deal about what these tools are useful for. It's
maybe not the "get me a list of things to do" or "show me the root cause
so that I can fix it", but rather to give a complete picture and
overview. In a visual and direct manner. It problem and strategy
understanding that is the key point, I think. From that it's much
simpler to create a plan.
The tools I've picked up under many years in the IT sector worked just
fine here. Perfect in matter of fact. Maybe our problems isn't that
special after all.