52 JOURNAL OF HEALTHCARE RISK MANAGEMENT • VOLUME 29, NUMBER 1

© 2009 American Society for Healthcare Risk Management of the American Hospital AssociationPublished online in Wiley InterScience (www.interscience.wiley.com) • DOI: 10.1002/jhrm.20006

Book Review

Why some complex systems fail as others succeed

Steven Spear’s landmark 2005 Harvard Business Reviewarticle on adapting Toyota’s systems improvement processto other complex organizations, including healthcareorganizations (HCOs), forms the basis for Chasing theRabbit.(1)

Spear is a senior lecturer at Massachusetts Institute ofTechnology, senior fellow at the Institute for HealthcareImprovement, and an expert in systems improvement. InChasing the Rabbit, he examines entities such as Alcoa, theNaval Nuclear Reactor Program, and Virginia MasonMedical Center. He views each as understanding theimportance of applying the lessons Toyota learned inimproving its business model. Healthcare examples arefeatured in the individual chapters, as well as in a dedicat-ed chapter, “Creating High-Velocity Health-CareOrganizations.”

Real-world solutions

Spear has spent much of his career analyzing successfuland unsuccessful organizations. His descriptions of real-world process analysis and solution development areengagingly written and provide the underpinning forunderstanding his thesis.

A fascinating example is the continuing problem encoun-tered on automobile assembly lines of trying to match thebolt holes in the seats with the retainer nuts on the chassisso a worker can insert and tighten a bolt securing the seat.Often the holes didn’t line up, and time-consumingworkarounds were used to solve the problem each time itoccurred. This highlighted the danger that workaroundsmay obscure solutions that, if identified and implemented

when a problem occurs, could result in time-savingprocess improvements. As many healthcare professionalsknow, workarounds can contribute to medical error, andthis is a recurring issue highlighted in the book.

Chasing the Rabbit analyzes why some complex systemsfail as others succeed spectacularly. The author presentsfour “capabilities,” or stages of process improvement,that define the successful organization others aspire tobecome: the organization that is continually ahead of thecompetition.

Some companies just do it better, and Spear proceeds totell us how. The four capabilities, identified in Exhibit 1,are presented in depth, allowing readers to appreciatetheir applicability to different organizations.

While Spear offers examples of healthcare organizationsthat have used similar processes to improve operationsand excel in relation to their peers, the depth andbreadth of analysis in the HCO examples does not reachthe level that is available for manufacturers such asToyota or Alcoa. This is because these improvementprocesses have not yet matured in HCOs; nevertheless,the four capabilities provide a way to conceptualize theroad to improvement.

Ultimately Spear offers a disciplined look at process con-trol and improvement, with a focus on achieving thisthroughout an organization. He provides concrete exam-ples of how successful leaders manage these systems. Inaddition, he includes healthcare examples that start outsmall in scale but exert influence beyond the specificexample. This is a result of the skills developed in thepeople who implement the system and process changes.

Chasing the Rabbit: How Market Leaders Outdistance the Competition and How Great Companies Can Catch Up and Win

Steven SpearPublisher: McGraw-Hill, New York432 pages

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DOI: 10.1002/jhrm AMERICAN SOCIETY FOR HEALTHCARE RISK MANAGEMENT • VOLUME 29, NUMBER 1 53

One example, an analysis of the shortcomings in theeducational process for training medical students, givesus all reason to wonder why medical schools are notdoing a better job of developing these future healthcaresystem leaders.

For large, complex organizations like HCOs, the ever-present threat of lawsuits and med-ical professional liability litigationpresents a moderating influence onthe ability to share clinical improve-ment information across the organi-zation under any but the most con-trolled circumstances. This is amajor block to organizationalimprovement in healthcare, whichSpear and others acknowledge;hence, we must find ways to neu-tralize this consideration in order tomove HCOs to the next level ofexcellence.

For any organizational leader, man-ager, or team leader, Spear’s bookprovides a conceptual structure that has practical valuefor attacking problems when they arise. His use of thefour capabilities works when focused change is thedesired output. When this framework is implementedenterprise-wide, there is the prospect that the organiza-tion will become the leader that others chase.

Spear acknowledges that no single approach applies in allsituations, but he provides the tools to take an organiza-tion beyond day-to-day crisis response. Others are alsostruggling to find solutions to these problems. The inter-est in managing “positive deviance” in the workplacesprings from a similar concept of using the individual cre-ativity and successes of workers in managing processes as

examples for the rest of the organiza-tion to adopt. Spear goes beyondthis concept to provide a structure toensure that this improvementprocess is ingrained in the organiza-tion so that the response to externalstimuli is directed and leads to orga-nizational excellence. This requiresan organizational makeover so com-plete that the old ways of thinkingdisappear. Everyone within theorganization must be touched bythis process.

Key step: Sharing information

HCOs, to take full advantage ofthese tools, must find ways to share information abouttheir errors and the systems solutions devised for improve-ment. Without this key step, we can’t develop the man-agers and executives who can lead large, complex organi-zations to excel beyond the mediocre and distance thecompetition.

Ultimately what Spear

offers is a disciplined look

at process control and

improvement.

1. System design and operation mandates that leaders, managers, and staff understand the design and opera-

tion of the organization from the ground up.

2. Problem solving and improvement requires that all stakeholders respond to a crisis or challenge and,

through a process of “swarming,” conduct an analysis (root cause) determining the contributing factors and

devise corrective measures.

3. Knowledge sharing is essential in order for members of an organization to learn from its mistakes. The

details of the root cause analysis, improvement plan, and results must be shared throughout the organiza-

tion, across all of the organization’s business units and locations.

4. Developing high-velocity skills in others completes Spear’s blueprint for change, allowing organizations to

achieve excellence and maintain that capability into the future.

Exhibit 1:

Capabilities That Can Define Success

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Virginia Mason Medical Center’s restructuring toincorporate elements of the Toyota improvementprocess is an example to emulate. However, unless wecan neutralize the threat of litigation and the legal dis-covery process in medical professional liability cases,we will be doomed to handle improvement efforts insilos, and this will defeat any efforts to improve acrossthe organization.

Chasing the Rabbit is well worth reading, and its conceptscould help us climb out of the silos that prevent ourgrowth. Spear’s four capabilities coexist well with the con-cept of enterprise risk management because they provide a

path to integration of different interests throughout acomplex organization.

REFERENCE

1. Spear, SJ. Fixing healthcare from the inside today.Harvard Business Review. September 2005, 83(9):78–91.

Reviewed by Robert Stanyon, MS, RN, CPHRM, vice pres-ident of risk management at FOJP Service Corp., New York.

For more information, read Spear’s blog at http://chasingtherabbitbook.com.

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