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Beyond Lean: Resilient Redesign

Posted by Tom Bigda-Peyton Clarissa Sawyer on Thursday November 28th, 2013

Beyond Lean: Resilient Redesign

Tom Bigda-Peyton and Clarissa Sawyer

November 2013

In a 2010 blog post, Stephen A. Ruffa (an aerospace engineer, a business researcher, and Shingo Prize winning author) cites a growing push to go beyond Lean, just as with earlier improvement movements like TQM and business process reengineering. He asks, “Is it time to move beyond ’lean’? Or is going lean most urgently needed right now?”  


He concludes that, although the reasons for this shift could be the tool-centric approach that has come to represent Lean, confusion over where to start, or that Lean has failed to deliver what was expected, the real problem is popular ways of implementing Lean.


We have also heard a similar questioning of Lean from clients and colleagues, even those with extensive experience in Lean methods. They say that Lean takes too long, is too complicated, and too expensive.


We agree with these assessments and have some of our own. The problem with Lean methods is they are based on assumptions that organizational knowledge is explicit, cognitive, disembodied, and possible to understand stripped from its context.


We come from a tradition of knowledge creation associated with Dewey (experiential learning), Lewin (action research), Argyris and Schon (action science, organizational learning, reflective practice), Lave (situated, incidental learning) and Gilligan and Lyons (narrative inquiry). We view knowledge as constructed, often tacit, embodied, involving cognition, emotion, and behavior, and situational. We also view organizations, especially in healthcare, as complex, adaptive systems (Rouse, 2006).


We have been testing a model of process improvement and redesign since the 1990’s that draws from these traditions and also draws from principles of Resilience Engineering, and High Reliability in organizations.


This model, which we call Resilient Redesign, achieves the positive results of Lean (people orientation, reducing variation in practice, and sustainability of results) while using a simple but powerful form of data collection that is adaptable to a wide variety of situations, that focuses on the conditions and context of everyday work in complex, rapidly changing work environments.

Resilient Redesign also enacts Hollnagel’s four principles of resilient system design: the ability to Respond, Monitor, Anticipate, and Learn. In practice, however, we have found that the process we actually use resembles LARM: Learn – Anticipate – Respond –


Resilient Redesign has been used successfully to create improvement in settings as diverse as Fidelity Investments, the Federal Aviation Administration, and healthcare delivery organizations in the US and Canada. The results so far are promising. The method is faster, doesn’t require a lot of in-depth analysis, and produces more durable operations improvement than tool-centric Lean approaches. Let’s take an example.


Partners in Transition: Reducing 30 Day Readmissions

We were invited to help a region in North Carolina with three hospitals serving a two county area make a breakthrough in reducing 30 day readmissions. We met with the SME’s for this project, two hospital discharge planners and the regional coordinator for Medicare and Medicaid (details on North Carolina’s model for transforming healthcare is here). Also joining us were colleagues from Care Share Health Alliance, which organizes networks of care for the uninsured and underinsured.  


The regional team had done a root cause analysis showing that the clinical causes of readmissions were chronic heart failure, COPD, sepsis, and pneumonia. However, there was wide variability in readmissions rates across the three hospitals and the team was having difficulty getting a handle on a root cause. However, when encouraged to describe who was at high risk of readmission, they quickly reported they were “Frail elderly, over 65, with lack of supports at home.”


We weren’t surprised by their difficulty in identifying a root cause. A common tendency we have observed among healthcare professionals is to frame problems according to clinical diagnoses. This is a way of diagnosing and solving problems that is a taken for granted in how they work. To help them reframe their understanding of the problem, and create deeper understanding that was more wholistic and appreciative, yet grounded in specific situations, we asked them to share some examples or stories.



We asked the two discharge planners the following questions:

—  Think of a time when you saw a typical patient readmitted to the hospital.

  • Who were they?
  • What was their situation and story?
  • What happened with their care?
  • What were consequences (both intended and unintended)?


Here are two stories they shared:


  • An 87 year old woman moved from Puerto Rico to be with her family. She did not speak English and was very independent. She was treated at the hospital for diabetes but then was back the following week. Neither she nor her family had understood or followed the directions for caring for her diabetes. It turned out the family member who was with her when she was treated in the hospital and served as interpreter was not the same family member with whom she was living. That family member did not speak English well. In addition, the family member we was actually caring for the patient did not receive diabetes support education.


  • A 55 year old truck driver with chronic heart failure was discharged from hospital with a prescription for 40 mg of Lasix in the morning and 40 mg at night. He forgot to take his evening dose and was readmitted to the hospital. It turned out he was used to taking one larger dose a day and forgot to take a pill twice per day.


These stories were much more human and evocative than “frail elderly, over 65, with lack of supports at home” with “chronic heart failure, COPD, sepsis, and pneumonia.” In addition, the stories revealed that readmissions included cohorts other than “frail elderly,” such as the truck driver, and in other stories, younger adults who had a variety of issues with access to housing, food, support caregivers, and transportation.


Next, we asked for some typical stories where the patient was NOT readmitted to the hospital, and then stories of “bright spots” (the best examples they had seen where patients were not readmitted). Here’s one:

  • A 42 year old woman was admitted to the hospital with morbid obesity. The nurses and discharge planners soon learned that she ate only fast food which was brought to her by her family, as she rarely left the house. The discharge planner asked her if she wanted to learn about other foods she could eat in order to bring her weight down. When she expressed interest, the discharge planner referred her to a nutritionist. When the discharge planner saw the same woman in the community several months later, she could not recognize her- the woman had lost 300 pounds. When she shared the story with the group, the same discharge planner called this the story of the “Woman Who Saved Her Life.”

By gathering three types of stories – typical examples of the problem, typical examples of the solution, and bright spots (best case) – new knowledge was generated about the nature of problem and evidence of possible solutions. Reflecting together on individual stories about patients allowed us to see patterns across the stories. As a result, what initially seemed to be a problem of frail elderly, over 65, with lack of supports at home and clinical conditions like chronic heart failure, COPD, sepsis, and pneumonia, was too narrow.


This led to population-based insights and possible solutions that went beyond individual clinical pathways. A population approach has more leverage in creating an improved and coordinated system of care. The regional team realized that they needed to widen the definition of the problem of 30 day readmissions to improving care for all (otherwise known as improving “all cause readmissions”).  


Another insight from sharing and reflecting on stories was that the social determinants of health such as lack of transportation, problems with co-pays, and difficulties with food, were at least as important as clinical care. The discharge planners decided they needed to identify the top three social determinants of health that seemed to trigger readmission.


Testing the Stories and Learning More: Stakeholder Retreat


After interviewing the SME’s and reflecting on the stories with them we held a 2 ½ hour retreat with the SME’s, Care Share Alliance staff, and a wider set of stakeholders, 45 people from the three hospitals in the region, physician practices, and eldercare, homecare, and social services organizations. This group was collectively called Partners in Transition.


After a brief welcome and update on the project, the same storytelling approach was used at the retreat. First, the discharge planners shared the two stories they had shared with us (the Puerto Rican Lady and the Truck Driver), then we asked for reactions and standouts. The main standout was “We got these cases right the second time; how can we get them right the first time?” This insight created group engagement around a common focus.

Next, the group participated in developing a Community Action Plan, with a set of activities organized into early wins, process and procedure changes, and wider system issues.  This step built strategies and structures that correspond to Anticipate, Respond and Monitor into the discoveries made in the Learn steps.

Community Action Plan


Early Wins

(0-3 months)

Process / Procedure Changes

(3-6 months)

Wider System Issues

(6-12 months)

  • Inpatient Services


  • Outpatient Services


  • Communicate re: high risk patients
  • Spread & solidify early wins (noticing, advocating for patients, working together as providers)


Clinical early wins:

  • Medicare
  • PACE
  • Care Paths (ESRD, Palliative Care)


  • Use Transfer Alert Form
  • Communicate that patient identified as in target group. (Use hospital screening form, with top questions to ask based on Patient Journey Map)
  • Point out current & anticipated barriers to provider so they don’t have to discover it on their own.
  • Provide required documentation- Orders, H&P, etc.
  • Prior Authorization if needed
  • Medications, current
  • Address social determinants of health
  • IT enablement
  • “Hard wire” the process throughout the network




Inclusion of a wider set of people to reflect on and make sense of the problem, prompted another reframing of the problem and solution -- to incorporate key clinical pathways, for instance, in palliative care and end stage renal disease, as initial prototypes for reducing all-cause readmissions. This engaged the clinicians in new ways and made compelling connections between medical and operational issues.


In addition to the Community Action Plan, a list of six Next Steps was generated, with actions under each step. These are:

  1. Work with the expanded Design Team to debrief the Core Team, hold a conference call in 6-8 weeks, and hold a meeting to discuss wider system Issues in 3 months.
  2. Outreach with physicians, IT, administrators, pharmacy/meds management
  3. Develop funding strategies to sustain the project
  4. Move things forward with meetings, conference calls
  5. Develop a Teamwork Vision: Circle of Care for Inpatient, Outpatient, Elder Services, Community Services
  6. Create a Process Vision – specific activities improve processes


Follow-up to the Retreat

We took the stories and reactions and used them to create a set of 17 Powerpoint slides that include Patient Journey Maps – a visual representation of the aggregated insights about readmissions gleaned from sharing and reflecting on the stories at the retreat. The maps include cues for Anticipating and Responding when there are patients are at high risk of readmission: “look out for this situation and follow the preferred decision path when you see it.” The maps are also guides for patient-centered process redesign and coordination of care. Finally, they enable a shift from individual patient stories to population-based problems and solutions.  Here’s one, below:


The slides also include the list of Next Steps, and a draft of a Universal Transfer Alert Form, with specific details that can be “clicked down” into, depending on the situation.


Now it’s time to share the knowledge generated so far, both upstream and downstream from the discharge process, to build shared understanding, and for members of the Partners in Transition to begin trying out the activities developed in the Community Action Plan.



We began by interviewing a small group of subject matter experts (SME’s) closest to the problem of concern, ask them to share stories. We have found stories to be particularly effective way of accessing organizational knowledge. They reveal patterns of practice in organizational systems, and as Paterson and Chapman (2013) point out, when retelling/rethinking about events we are better able to categorize events, emotions, ideas, etc. and able to link our intended purpose with the actions that we carried out. This is what enabled the regional team to become unstuck in their framing of the problem and discover a more helpful, broader problem definition.


We asked for three kinds of stories – typical examples of the problem, typical examples of solutions to the problem, and bright spots (the best they’ve seen). We used the stories to define the parameters of the problem and form a sample that was viewed by the SME’s as representative of their experience. Since we view organizations as complex, adaptive systems, the examples are holons that representative the whole, though we also test their validity when we widen the inquiry to include other stakeholders in the system.


The next step is to share the results of the story sharing and reflection with a larger community of practice that included the SME’s and other stakeholders related to the problem for comment, feedback, and reaction. This step created consensus that the stories represented their collective experience. In addition, the stories became entry points for generating ideas for improvement.  


In addition, we helped the community of practice develop a Community Action Plan with three kinds of improvements: quick wins, process and procedure changes, and wider system issues. Sub-groups and action plans are formed, with periodic virtual and in-person meetings.


Finally, we applied a form of narrative analysis to the stories to identify patterns of practice, theories-in-use, and combined them with statistics, when possible. These Patient Journey Maps capture the insights from the community of practice, and provide the community with a way to share the insights with others.


If we had used a Lean approach, the process might have included doing value stream mapping or process redesign. But with limited resources, we needed a quick, yet evocative and rigorous way to engage key stakeholders, and gather knowledge about the problem that would lead to insights, new knowledge, and action. Story-based inquiry helped the community of practice learn from its collective experience and ground their abstract definition of the problem in specific examples that represented the system as a whole.


We invite you to share your comments on the Resilient Redesign approach used in this blog post:


  • Does this approach look resilient - why or why not?


  • What are the advantages and disadvantages relative to your experience of Lean process improvement?


  • What are the challenges to transfer and adoption of this kind of approach? How might they be addressed? 




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Thomas Bigda-Peyton is a consultant, researcher, and educator working across high-consequence industries such as aviation, healthcare, and workplace safety. As a practitioner-researcher for 25 years, and currently as President of Action Learning Systems in Boston, he has focused on widening and accelerating the pace of improvement in individual, organizational, and large-system change initiatives. Current programs include the We Don’t Compete on Safety Consortium (a development partnership between aviation and healthcare), the Health Transition Learning Partnership (an initiative designed to catalyze transformation in the Ontario healthcare system), and US 2025 (a program in the U.S. intended to dramatically reduce the cost of care in three states while making parallel improvements in quality, access to care, and patient safety). Tom holds a doctorate in Organizational Behavior and Intervention from the Harvard Graduate School of Education, where he worked with two pioneers in the field of organizational learning and system dynamics, Chris Argyris and Don Schon. He also holds Master’s and Bachelor’s degrees from Harvard. See Second Curve Systems 


Clarissa Sawyer Ed.D. is an Organizational Effectiveness Consultant with over 15 years of professional experience in designing and implementing action learning projects which help organizations, teams, and individuals use their own experiences to identify, extend, and reuse best practices. Previous to this she was an Organizational Effectiveness Consultant for the MITRE Corporation where she provided services in organizational assessment and diagnosis, team development, strategic planning, qualitative research, and off-site design and facilitation to MITRE’s Center for Information and Technology (corporate communications, knowledge services, and information technology), Human Resources, and Legal and Contracts departments. Clarissa has a doctorate from Harvard University in Administration, Planning and Social Policy, where she concentrated on leadership, and organizational behavior and intervention. Her dissertation examined the effective leadership strategies used by a first-time public university president during a period of financial crisis at the university. She also holds an Ed. M. from Harvard University and a B.A. in Adult Training and Development from the University of Massachusetts in Boston.  Second Curve Systems 



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