The French filmmaker Jean Renoir said, “the foundation of all civilization is loitering,” expressing the view that transformative value is created when people have time to step back and imagine a better way. Most businesses today seem to take a contrary position. Organizations in health care and beyond have spent a generation attacking slack, removing inefficiencies within processes and budgets. The narrow operating margins of health systems have led many to turn to companies such as Toyota or General Electric (GE) to learn about lean or Six Sigma techniques.
Subsequently, frontline clinicians are easy targets for attacks on slack. They are among the most expensive personnel within health systems and their productivity drives profitability. Working at the top of one’s license is set as a goal — reflecting the view that anything that can be delegated to a less expensive resource should be, and that everyone should be adding directly measurable peak value at all times.
A problem in translating lessons derived from general management experience is that even when conceptually appealing, they rarely meet medicine’s evidentiary standards defined by randomized trials or carefully controlled observations with homogenous populations, standardized interventions, and explicit outcomes. Instead, management lessons often take the form of stories – and perhaps only those selected to support a particular point.
Most of these stories point to the importance of efficiency and productivity in health care. In this post, however, we select other stories that might provide a contrary lesson and theory that may be just as compelling as the theory that argues for lean. After all, even as many health care organizations put their faith in lean, one of the theory’s flag bearers, GE, lost two thirds of its market capitalization and some anti-lean approaches began to show promise.
Slowing Things Down
Physicians used to be taught that beta blockers, which reduce heart rate, were contraindicated in heart failure, but now we know that slowing things down can improve cardiac output. It sounds counterintuitive, but carving time to experiment out of employees’ schedules has likewise been shown to increase output. Google, for example, implemented a policy allowing employees to spend 20 percent of their time experimenting on projects outside the primary responsibility of their jobs.
When Google measured this program in 2005, they found it had generated 50 percent of new product releases. Over $10 billion in annual revenue can be traced to Google’s 20 percent time experiments. Similarly, when Intuit launched innovation programs in the mid-2000s, the company allocated time for employees to pursue projects based on their personal insights and passions, using a program modeled on Google’s. Intuit saw a 6x annual increase in ideas becoming new product releases, climbed Forbes’ list of the world’s most innovative companies, and went on to deliver shareholder returns more than four times greater than the S&P 500.
This approach of creating slack can be traced back to the 1920s, when an engineer at 3M disobeyed orders to stop working on a project deemed to have little potential by senior management; the engineer proceeded to invent masking tape. 3M consequently institutionalized the freedom to pursue passion-driven projects with its 15 percent rule. More recently, researchers at the University of Manchester won the Nobel Prize in Physics for experiments with Graphene, a one atom thick lattice of carbon atoms with remarkable strength and conductive properties — experiments performed during slack time they maintained in their lab despite pressures to produce similar to those faced in academic medical centers.
Beyond a long list of examples like those above, conceptual logic also supports the need to introduce experimental time for frontline staff. The conceptual argument asserts that if you want people to reimagine their world, they need time to reflect. In health care, we give up even more than most professions when we do not allow slack.
Health care is a mission-driven industry, where personal passion often attracts providers to the field. We leave value on the table and put engagement at risk if we do not provide outlets for that passion and enable clinicians to try new ways of solving problems they deem worthy, within appropriate guardrails of safety. Because implementing improvements in clinical care requires clinician engagement, uninvolved clinicians can become obstacles.
The converse is also true: when you allow people to pursue passion-based projects, they persist to overcome the stream of obstacles and objections that invariably stand in the way of change. This pays dividends: When people have internal motivation to persevere, their actions are more likely to continue to the point of generating data which, in turn, illustrate for others a project’s feasibility and potential value. An organization’s leaders allocating time for people to act on their insights catalyzes this dynamic.
For an industry such as health care trying to move to evidence-based management, there is also strong support for allowing time for experimentation. An analysis of the association between seven management techniques and productivity in 307 firms revealed that while empowerment of individuals was associated with productivity improvements, other approaches including those focused on efficiency were not. Author Dan Pink has written extensively about evidence showing the importance of tapping intrinsic motivation to produce surprising outcomes: from academic research institutions to small technology companies, organizations creating freedom from traditional time and metric constraints generate repeatable innovation success.
Clay Christensen found that 93 percent of innovation successes start in the wrong direction. PayPal, for example, began as a service to beam money across PalmPilots, and YouTube launched as a video dating service. The essential lesson is that ideas have no inherent value. They develop value once innovators make them tangible, try them, and typically, redirect them. If 93 percent of innovations with potential start in the wrong direction, leaders seeing presentations of initial ideas have little chance of picking winners by making a few big bets.
In fact, companies that grant experimental time often find that big wins come not from those initiatives prioritized and funded by the companies’ leaders, but instead from projects driven by a passionate employee with frontline insight able to produce sufficient validation to merit further investment. Repeatable success is achievable when leadership enables many fast, low-cost bets, and then scales investment in the few where critical assumptions are validated.
Many Forms of Slack
So if slack is essential, but has a cost, who gets cut some slack? Not everyone in an industry with thin margins and revenue threats can be afforded such time. Nor is every context appropriate. Slack in the operating room is waste. But enabling a clinician to set aside time to pursue a mission-relevant passion is something else.
This freedom can come in many forms, such as rotating protected time for a percentage of physicians and nurses or a defined number of internal grants in the form of time for experimentation. Such grants could be awarded to employees based on explicit criteria ranging from the demonstration of early evidence to winners of idea tournaments. These are not the big blocks of time required for randomized trials of comprehensive solutions, but the smaller amounts of time required to rapidly validate key assumptions at reduced scale – enabling teams to gather early evidence in days instead of months.
Time can also be allocated in discrete chunks, such as a two-day sprint or a one-month exploration similar to Facebook’s hack-a-month. Adding slack to foster innovation in health care does not mean reducing discipline, negating evidence-based process standardization or reducing focus on outcomes. It means investing systematically in professionals’ insights to test novel approaches to important problems.
When setting budgets for any organization that plans to be around for the long term, leaders must include time for experimentation by clinical frontline staff. It is easy but shortsighted to see that time as an expensive luxury, or to sacrifice it for immediate needs. As health systems face cuts from all sides, latitude to test new health care delivery approaches is all the more important. The most forward thinking leaders appreciate the importance of experimentation, have a convincing story for those who see slack only as waste, and budget clinician time as a disciplined, strategic investment.