Can An Autonomous Environment Truly Exist Successfully?

Mark Graben, author of Lean Hospitals and the newly released, Healthcare Kaizen, examines Accountability versus Freedom and their effect on both the education and healthcare industries. Graben refers to an op-ed piece in a recent Wall Street Journal article by Deborah Kenny titled, Why Charter Schools Work.

The WSJ article discusses the structural philosophy of what makes up a successful work environment and how to create proper checks and balances of staff while allowing for creativity and independence. Graben quotes the article and expounds:

“Freedom without accountability is irresponsible. Like all professionals, educators need to be accountable for the results of their work. Yet accountability without freedom is unfair: How can teachers or principals be held responsible for results if they don’t control decisions about curriculum or teaching methods? Accountability and freedom do not guarantee that a school will provide an excellent education, but they are prerequisites.”

There are parallels to discussions about “standardized work” in healthcare. Physicians are taught to prize their autonomy… but is “freedom without accountability” just as irresponsible in healthcare? If a surgeon wants to do things a certain way, are there measures (such as infection rates and mortality) that indicate if they are doing a good job or not?

Graben further discusses the efficiency of gaging educator’s accountability as well as healthcare providers:

 “Accountability” is often a loaded phrase (when used by people looking to punish people who deliver bad results), as medicine (like education) is more of a team effort than anything. Can we hold a teacher or a doctor “accountable” in isolation when they are part of a system?

The article talks about how teachers enjoy having the freedom to decide how to teach, as long as goals are being met (measured, though, through standardized tests?). How effective is the measurement system in education? We don’t want teachers to have a lot of freedom in HOW they “teach to the test” since we’d hopefully aim higher than just teaching to the test.

How effective is the measurement system in healthcare? Where do we strike the balance between freedom and autonomy (for employee satisfaction) and the need to education students and treat patients (without harming them)?

From the article, about a charter school environment.

We give our teachers an enormous amount of autonomy, and that ignites their passion. They feel happier because they no longer have to endure the demoralizing impact of working with people who are lazy, who gossip and complain, or who don’t believe in the potential of the children. Autonomy inspires teachers to be more creative and feel more committed. As one of our reading teachers, Michelle Scuillo, put it: “My old school made me tired and depleted. I understood why so many smart people leave teaching. I have to admit that I stopped putting my best effort into my lessons. I was ready to change professions, which was devastating for me, because in my heart I wanted to be a teacher.”

People in healthcare are often already tired and depleted. Just as teachers get worn down by top-down standards and teaching methods (dictated by leaders or outside consultants), we don’t want to wear down people in healthcare with overbearing or inappropriate standards. Standardizing methods can lead to so many great results: better patient safety, better quality, shorter waiting times, lower costs… but we have to work toward more standardized processes in a way that isn’t demotivating or soul crushing.

Utilizing Kaizen or a system of constant striving for perfection, engages staff and administration to work together. Graben discusses this theme as a possible means to a successful management method.

The process of “kaizen” (continuous improvement) means that people get to explore and learn as they improve in a scientific way. That’s highly engaging.

One other piece of the puzzling in the successful charter schools seems to be the leadership style (at least as described in the piece):

“Our principal had observed Steve struggling but had also gotten to know him during faculty retreats and meetings, and saw that he embraced our values of accountability and hard work. The principal took Steve out for dinner and offered encouragement and practical pointers. “I’ll remember that conversation for perhaps the rest of my life,” Steve later recalled. He went on to become a top performer. Not only did 100% of his eighth-graders score proficient on the state math test, but 100% of those eighth-graders also passed the Algebra Regents exam, which is usually taken by students in high school.”

Instead of just punishing or browbeating the teacher, the principal took time to get to know the teacher… being a coach and an adviser. That seems like great leadership, to me.

To read more of this article or for more of Mark Graben’s thoughts on Kaizen and creating a successful accountability/freedom measuring stick please visit his blog at

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