By Erin DuPree, M.D., Chief Medical Officer and Vice President, The Joint Commission Center for Transforming Health care
The knowledge needed for improvement is seldom found in the conference room.
Some of you may be familiar with the term “gemba,” while for others it may be new. Gemba is the Japanese term for “the real place.” So, going to the gemba is going to the place where value is created, where the real work is taking place. It stems from the Japanese mindset that when there is a problem, one should get as close to it as possible and learn BEFORE proposing a solution.
Problems are visible. For detectives, gemba is the crime scene. In manufacturing, it is the factory floor. In health care, it is wherever there is patient interaction. In hospitals, the real place can be on the units or in the operating room.
This gets me back to the conference room. How often have we as leaders in health care tried to solve a problem in a meeting when the real knowledge and real experts were at the bedside, delivering care? Too often in health care we jump to solutions. After all, we were trained to know the answer. When leading improvement, though, we must resist the impulse to ‘solve’ the problem right away. In practice, this results in short office meetings, with the brunt of the work being done in a gemba walk, on a hospital unit, for instance.
Health care leaders can achieve multiple objectives when going to the gemba. The main objective is to obtain a comprehensive understanding of the process through a series of interviews in the relevant place. In health care, this is often on the floors, in the operating rooms, doctor’s offices and labs. Sometimes, it brings us to the patient’s home. We are tempted to overlook this critical step in improvement, especially if we are rushed, think that we already know the answer, have preconceived ideas of the primary issues, or get consumed in large volumes of data. By going to the unit, observing and talking with care providers involved in the actual process at the actual place, one can obtain actual data, which is critical for improvement. The best improvement ideas often come from going to the gemba. Importantly, it also helps to build trust between management and front-line care providers -- a critical element in a safety culture.
The way to “go to gemba” was perhaps best expressed by Toyota Chairman Fujio Cho when he said, "Go see, ask why, show respect.”
When taking a gemba walk, see if processes are designed to enable people to work toward achieving organizational purpose. Is leadership working to align people and process to achieve purpose? Be prepared to accept the differences in the process -- between what is and what it should be, much less what the organization wants it to be. You might find that the policy that you sweated over is found to be fictional because workarounds have been developed and training was inadequate.
Although it is the second element of Cho’s mantra, "why" is not actually the first question we want to ask at the gemba. First ask “what,” then “why,” then “what if” ... and, lastly, “why not.”
Finally, show respect. When visiting any gemba, through showing respect for the workers we also show respect for patients and the organization. Look for evidence of disconnects between stated objectives, perhaps those expressed in the organization's vision statements, versus what we actually observed at the gemba. Also look for signs of disrespect, such as overburdened nurses. Certainly as health care leaders, we respect people because we believe it's the right thing to do and simply because it makes good business sense. Respect means doing what we can to make things better for the people delivering care, which starts by not making things worse. The first rule of gemba walking is “Do no harm!”
So, next time you are in a meeting and find the group is trying to diagnose and prescribe a solution from the conference room, get up and go to the gemba. Confirm what is actually happening, as it is happening. It is one of the most important principles and practices of leadership.