How working in oncology reshaped my concepts of failure and success
More than 20 years ago, when I was studying oncology, a patient of mine taught me valuable lessons about how to set expectations at a time when the natural response is to fixate on outcomes. She had incurable ovarian cancer and faced a heavy course of chemotherapy, with terrible side effects. But somehow the calendar was on our side. She, who was 65 at the time, asked me whether she would be well by Christmas, and I answered: “Yes, certainly”. I was not certain when I said it, but she made it. At the next session, she asked the same question, but this time about her grandson’s preschool graduation. And she made it again. Then came many other small victories, which, although not so clear to me, were very valuable to her in different ways. She benefited from each new drug that was launched.
A few years later, I was already working at IOV, and she sent me a farewell message: those had been the best years of her life, and she had lived every moment intensely, full of love and with the support of her family; she just wanted me to know that. I may have learned science in my academic and professional life, but I learned a great deal about purpose and negotiation, resilience and human relationships from this intelligent and passionate lady.
Today I see success in different ways. It is not just about fighting cancer; I consider success to be helping patients have a meaningful life, even without guarantees. Oncology is like a race. Sometimes it is a marathon; sometimes it is not. Sometimes, even when you set a reasonable level, things can go wrong, which can occasionally mean death from toxic side effects. A close friend of mine had recurrent breast cancer a few years ago, and I was very comfortable with the treatment. A well-tolerated drug would be used, and minimal toxicity was expected. And yet she died in the second week of chemotherapy, from a rare side effect reported in only 0.3% of cases, after a terrible week in an intensive care unit. Human life is delicate and transient, and believing that you are in “command and control” does not do justice to reality.
When I moved from clinical work to management, my passionate lessons from patients made me more relaxed, with slower progress and poor results as a leader. Change does not follow the same pace for everyone, just as understanding of what we are trying to do does not progress at the same rate for every individual. In one of our first A3s, we wanted to meet the “scheduled time” of appointments in a crowded public facility. We were trying to find ways to reduce delays, but we were not comfortable with the original idea, which would require a lot of pressure to arrive “on time”. For months, we failed to meet the deadline and ended up giving up. Each patient has a different story, with different expectations – trying to find a solution for each patient was very complex, expensive and did not add much value. Some patients are straightforward; others are not. Some like to share their family history; others do not. By asking patients about our failures, we found that most considered a 15-minute delay irrelevant, as long as the appointment had been meaningful. We discovered that we had not negotiated a good goal with our customers. So we began working with small batches and buffers for appointments, instead of takt time. Today, physicians work with minimal time constraints, and patients accept the occasional 10- to 15-minute delays, but they are never rushed out of the exam room. We never again tried to use takt time for appointments.
We learned something more from this. There are many great ideas that get translated into actions that actually run counter to them: someone is promoting or saying one thing, but the actions are going in exactly the opposite direction. Meeting patients’ “on-time appointment” expectations was heading in the wrong direction, and this kind of problem was more frequent than we imagined. We faced many problems in dealing with what we call “events that must never occur” (such as a wrong medication, a fall or a wrong procedure). We tell everyone that our problems are “problems with the process, not with people” and yet it took us years to reduce the disguised or direct punishment associated with these events. These punitive actions were, in fact, a terrible “contradiction”. Leaders were not tolerant of or resilient to errors or failures and generally did not give a second chance to those who failed: if you fail on your first attempt, someone will take your place in that activity (most of the time, the leader will micromanage the problem himself).
An “aha” moment for me has to do with seeing “errors” through different mental models. Brazilian culture, deeply influenced by the Christian religion, sees errors as a moral failing or a sin to be punished. However, the ancient Greeks, such as Aristotle, described an error as simply a poor attempt. From Aristotle’s point of view, you should try again and can improve with repetition; this has nothing to do with a moral failing, as there is no blame.
To reduce micromanagement (and especially a policy of disguised punishment), we decided to form “trios” at the gemba: a leader (coach), an A3 owner (trainee) and an observer to help “guide” and avoid the punishment trap on the leader’s part: thoughts like “I’ll have to do this myself” or “why don’t you try…”. It is a fun exercise at first, but it becomes serious with experience. IOV’s leaders are evolving and coaching themselves almost all the time in an open learning environment. Everyone now uses standard work to do gemba walks and reflection tools to align goals, creating a resilient and humble mindset. We can set high targets (and we ask them to always do so), but there is no problem in not reaching them on the first attempt; there is no blame.
This was probably our most successful initiative and became our “IOV leader’s handbook” in 2015. We developed a format to teach purpose, resilience, humility and alignment and supported it with lean tools connected through real projects. At that point, our performance was attracting attention and many visitors: we managed to double our capacity at four different facilities with the same resources, while improving safety and quality measures. But fighting cancer is more than chemotherapy or radiation – or science. Fighting cancer is more than just performing well in half of the system. Our mission to “Reduce the burden of cancer among all of us” could be fulfilled in a rather unlikely way. We began to cooperate and help the system understand mura, muda and muri, developing our people so that they help others develop. A nice win-win strategy.
We began sending our leaders to help other organizations improve their systems while developing new leadership capabilities, but with no guarantees – it was just training. At the hospital we had been working with for a few years, a patient with a breast nodule took 150 days from first appointment to chemotherapy; with the model line we created, this time fell to 75 days; surgical capacity increased by 20%, and chemotherapy and radiation capacity doubled with the same resources. Since 2017, we have supported another emergency hospital, which has 400 beds; they were able to reduce door-to-door time by 40 to 60% in the emergency department. Sepsis mortality was reduced by 30% with the “sepsis A3”, and overall mortality fell by 4.5%, meaning more than 180 lives were saved in 2019.
When I recently volunteered in a large and complex public health system (in my city, which has 700,000 inhabitants), I had that humble and resilient experience of the hallways from my first days: “command and control” is not possible in this system. We used the content of our leader’s handbook – we were among the leaders – some much more experienced than I, leading thousands of employees. We started 4 small, humble projects to learn about lean, dedicating 3 hours a week and “open gemba walks” at IOV (“come and go, see how it works with our local leaders”). Within a few months, they had created more than 15 other teams and projects, a two-tier grouping system to manage it, a training program, and leaders who do weekly gemba walks at some of their more than 60 facilities. Several processes were improved with minimal organizational effort. In one year, they saved more than R$ 5 million in logistics. Access to some specialists (urology, cardiology, orthopedics) fell from more than a year to 45 days. They doubled their blood sampling capacity and cut maintenance response time in half in several areas. The waiting time to see an oncologist is now about one week. The challenges for 2020 involve same-day appointments with a primary care physician in 50% of the system and 80% of elective surgery within 90 days.
What I learned about purpose and negotiation, resilience and human relationships from my patients became the backbone of our approach: a slower pace helps you ask better questions; there is no blame in failure; so do not signal your behavior through micromanagement; my colleague is the best person to help me develop. And yes, it is a marathon, with obstacles.
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Come and deepen your knowledge of the lean journey of Dr. Carlos Frederico and IOV at Lean Summit 2020, on September 2 and 3. Click here to learn more and secure your registration.
