Tools for Leaders

Regaining Focus - Keep it Simple

Regaining Focus - Keep it Simple

The Junkyard: Artifacts of Lost Focus

I recently talked to a colleague about her experience with the shifting sands of continuous improvement in healthcare. She walked me through the programmatic junkyard cluttered by the past 14 years of leadership thought. It was right to think that service can be a differentiator. It was right to focus on quality, and, oh yea, safety. It was right to look around at trends in healthcare management and hop on the lean bandwagon, then the six sigma one, then the lean sigma one. The biggest problem, said she, was that they kept losing focus. Each initiative would start out with energy and verve. But, soon, what looked promising, was quickly seen as a flash-in-the-pan.

Repackaging the Same Thing Makes it Fuzzy

I’m teaching a course called Operational Excellence in Healthcare at a local university. Every year I have to prepare by doing a literature scan and each time I do that I find great sources that echo my colleague’s sentiments.

This year, I found this 2009 article, published in International Journal for Quality in Healthcare by Kieran Walshe . A key finding by Walshe is that we keep repackaging the same thing and get limited results.

Over the last two decades, we have seen the successive rise and fall of a number of concepts, ideas or methods in healthcare quality improvement (QI). Paradoxically, the content of many of these QI methodologies is very similar, though their presentation often seeks to differentiate or distinguish them. Kieran Walshe

1)Even operational excellence is simply repackaging total quality. I’ve argued such in the past. We have to get focused if we want the movement to succeed. Walshe goes on to say:

The repeated presentation of an essentially similar set of QI ideas and methods under different names and terminologies is a process of ‘pseudoinnovation’, which may be driven by both the incentives for QI methodology developers and the demands and expectations of those responsible for QI in healthcare organizations. We argue that this process has important disbenefits because QI programmes need sustained and long-term investment and support in order to bring about significant improvements. The repeated redesign of QI programmes may have damaged or limited their effectiveness in many healthcare organizations.

His point is well-taken: by constantly re-packaging, and buying the next, new shiny thing that comes along (promising the same benefit), we do a disservice to the idea of sustained and thus continuous improvement. So, what advice can I give to regain focus? Keep it simple.

From Fuzzy to Focus: Simplicity

Regardless of what you call it, simplicity will help you gain or regain focus. Here are three ways to navigate to simplicity.

Have a single, compelling, common aim that always pricks your value system.When you think of lean or six sigma or even early attempts at TQM, you know that having a target condition is essential to solving problems. Without a standard, it’s impossible to improve. The result in the early days was to set up metrics willy nilly. By willy nilly, I mean we’d set up global metrics that seemed right based on the external pressures instead of aiming at something compelling. Or, we’d set sub-optimized metrics that were myopic and parochial. Use a single, compelling, common aim that pricks values to create sets of aligned metrics. Ask yourself this: if we hit all of our targets would we lurch forward to our compelling aim? If hitting some of your targets would have you careening off-aim, look how you are defining improved performance.

Avoid the Perfection Trap where you end up going too deep without respecting learning by experimenting. My colleague described something called “Communication Boards” as a thing she could see in the junkyard. While the boards were a well-intentioned tactic, equally well-intentioned folks worked hard at getting them “right”. Even in my own practice, I’ve had to coach leaders who tended to be individual-performance driven to back down from seeking perfection. In a classic case of losing the forest for the trees, people who seek perfection lose focus on forward progress by focusing on jots and tittles. Forever, continuous improvement has been based on trial and error. Shewhart via Deming gave us a nifty learning aid: the pdCA cycle and we know that it’s all pdCA. When we try to perfect one thing, we neglect perfecting the things connected to it. I can have a perfect visual scorecard, but have weak problem solving “feeding” it. Better to try and fail and learn the system-ness of continuous improvement (thank you, Dr. Deming) than to perfect one component of the system. Simplify things by navigating to pdCA not perfection.

Early adopters may not be the best building block for focused change; rather, move as a team. This idea may take some time to sink in. I’m a fan of transformation thinking. I know in my heart that I should do something with my early adopters. Some would advocate pointing to them and saying, “See, this is what I mean! Look at how positive this is!” Thinking that the example is convincing, we’d expect others to just follow. The problem with this line of thinking and the reason that it adds to lost focus, is that like the Perfection Trap, we lose a sense of the whole. Drawing on what I learned as a young Naval officer learning infantry tactics (that’s a long story), a team that is moving as a team packs a bigger punch than one moving as a set of individuals. Early adopters tend to run out in front and it is right to harness their energy. But it’s equally wrong to let them outstrip the team and get too far out in front. A strung out team can lose people, picked off one-by-one by the flaming arrows of fuzziness in purpose, direction, and distraction. To stay focused keep it simple: move as a team.

Leader: Do This to Focus

Each time I start a new engagement, I try to begin with an assessment. I start the assessment by wandering around looking for artifacts. Some are active, in use and healthy. Though, I have to confess that I mostly find these in pockets and lacking system-ness. Most of what I find has been neglected and collecting dust. Junk in the programmatic junkyard, evidence of another short-lived movement.

Leader: get rid of the junk, go back to the basics and keep it simple to keep it focused. Simplicity begets focus. Focus begets results.

Next time I’ll take on Regaining Focus Part Two: System-ness through Integration.  Until then, pursue #better and stay excellent.



1. Kieran Walshe; Pseudoinnovation: the development and spread of healthcare quality improvement methodologies, International Journal for Quality in Health Care, Volume 21, Issue 3, 1 June 2009, Pages 153–159,
It’s the Process not the Person

It’s the Process not the Person

We Don’t Wake Up Scheming to Make Defects at Work (Most of Us)

My mentor, Rodger Lewis, drilled this one into my head from our first meeting.  While we love to blame people for outcomes, the truth is that the process is the culprit.  Most of us don’t wake up in the morning and think, “How can I cause a problem at work today?”  We don’t brush our teeth and ponder ways to create defects. In fact, most of us go to work thinking, maybe even hoping, that nothing goes wrong.  But, for some reason, we act like – therefore at least at that moment, we believe that – people are planning to do wrong at work.

We don’t wake up scheming evil at work.  Just our problem employees do.


I often find myself quoting another great friend and colleague, Dr. Rick Kunkle, a retired emergency medicine physician and healthcare executive.  Rick (“Doc”) Kunkle says, “The process is perfectly designed to give you precisely the result you are getting.”  When a defect surfaces, the process produces it.

Some will argue in favor of human error, to which I’d just reply, “Your process allowed the error.”

Med Error or Human Error: Process or Person?

I was working with a nursing manager a few years ago. She had 60 plus direct reports. As her organization hoisted lean on her without preparing her mind and heart, she saw it as a heavy burden. When problems surfaced on her team, she quickly ran herself ragged working offensively to contain them.  She was just doing what had been successful for her: firefighting.   When she couldn’t contain them all, she slipped back into her default defensive mode: blaming. First, she’d blame her leaders for forcing her to change, and then she’d blame her team.  One day, a serious medication error alerted the unit to the potential harm they were doing to their patients.  Instead of blaming people, she took a team with her to solve the problem. As she went from the point of recognition (the patient got the wrong med) to the point of cause (when the nurse was pouring the med), she realized that in the spirit of not harming anyone else, any one of her team could have made the same error.

Why?  Because the process allowed the error to be made.

Fatigue, distractions, confusing med names, similar patient names all create the potential for errors.

Waking up in the morning and devising evil plans to fail?  Not so much.

The distractions at the point of cause were many.  Their med dispensing unit had been located in the midst of their nursing station – the hub of all things on the unit – because power and internet cabling was readily available there.  They were thinking cost savings over safety.  It made sense to the nursing manager because so much of the nurse’s work away from the patients was done there at the hub.  They were putting productivity before safety.  When they observed nurses being interrupted endlessly whiling pouring meds, they knew they had put that step in the process, pouring critically controlled meds, in the wrong place.

As a new containment, the nurses would don fluorescent orange and yellow safety vests – the kind you’d see in a factory or on the highway – when they poured meds in the busy area.  It was a visual signal to not interrupt me when I’m pouring these meds.

Re-Thinking How We Think: it’s the process not the person

So, how does a wise leader correct his or her defensive thinking?

First, take every leadership thought captive to the principle: it’s not the person, it’s the process.  As much as your heart wants to believe that John Doe is an idiot or, worse, an evil person planning to make defects on purpose, let common sense prevail.  Sure, John Doe’s personality may make him hard to manage, but the process delivered precisely what it was designed to do.

Second, begin to practice error proofing.  There are four levels of error proofing: elimination, prevention, detection and loss control. Eventually, the nurse manager I mentioned was able to move the medication dispensing unit.  Her containment worked as a form of prevention, but by moving the dispenser to a quiet, non-traveled area, she eliminated distractions coming from the unit nursing station.  Yes, the nurse pouring a med still was responding to call signals and pager calls, but at least the manager had eliminated some of the distractions.  To her credit, the nurse manager rounded the pdCA cycle and began to work on solving the next med error distraction problem: group pages that didn’t require a nurse to stop pouring a med.

Lastly, lead your team into this new mindset.  It’s so easy to get caught up blaming someone else.  For some reason, we believe that we are better if we can compare ourselves to others failures.  Truth and transparency prove otherwise.  Remember how our nurse manager realized that anyone could have created the med error with the process as it was? Lead your team into humility by practicing humility as you lead them.

Rodger and Doc knew the principle and lived it: it IS the process NOT the person.  The sooner we believe that the sooner we find our way to sustainable gains and a safer place for our patients and our team.


A Model for Thinking about Your Team’s Movement

A Model for Thinking about Your Team’s Movement

We’ve been teaching through this model for the past decade, but I’d like to introduce you to an update to it, debuting this fall (coming to a client near you). This diagram represents the new and improved Adams Strategy Team Continuum model, one of several thinking patterns that my team and I have developed over the years.

 ASG team continuum


First, a bit of background.  In 1993 I was introduced to a book that I continue to use even today.  The Team Handbook, First Edition by Peter Scholtes initiated a basic understanding of team development for me as a very young Process Improvement Project facilitator in the Navy Quality Leadership program at the Naval Station Newport, Rhode Island. One of the biggest takeaways for me was Scholtes’ “Four Stages of Team Growth.1)” Many of us remember Scholtes’ description of Forming, Storming, Norming and Performing. Who can’t relate to the feeling of starting anew with a fresh set of people, shimmying to understand their places in the vast scheme of the team’s mission?

Later, somewhere around 2005, my mentor, Rodger Lewis, introduced me to his version of the stages of team growth: tentative, emotional, attainable and masterful. He had been working with the Rotax division of Bombardier Recreational Products, and I found the last two words – attainable and masterful – clunky and abrupt.   Rodger had also added three C’s that I immediately labeled “catalysts” to move from one stage to the next.   From Tentative to Emotional, the team needed communication.   From Emotional to Attainable, the team needed consensus.  From Attainable to Masterful, the team had to develop consistency. The BRP team in Austria had used the T.E.A.M. model in some training and had drawn an arrow from left to right under the words.  Besides the clunky language, possibly attributable to “wooden” German to English translation, the linear nature of the design and the flow of the three Cs also didn’t sit right with me.  Perhaps an homage to Scholtes, Lewis’ pattern seemed to be a good parallel.

Shortly after that, I doodled my first adaptation to the model on a flip chart during a training session I was doing.  The simple adjustment changed the design profoundly and forever: I added an arrowhead pointing left to the left of the line.  The arrows on both ends of the line depicted movement both forward and backward.  My point was that while these words could describe the stages of team growth, the reality is that teams are on a continuum, always moving forward or backward, never static.  In fact, we all know that the best teams can slide the whole way back to “tentative” in a matter of minutes depending on the effect of the changes around them.  From that point forward, we called this model the Team Continuum instead of the stages of team growth.

After years of wrestling with the C-words as catalysts and the clunkiness of the team acronym, I have finally decided to unveil our new and improved Team Continuum (feel free to kick the tires).

I’ve left Tentative and Emotional and Communication unchanged. These three always seemed to make the most sense to me and required little explanation.  When we teach through communication as a catalyst, we emphasize the need to navigate to facts, getting to a full grasp of the situation.  On the road to understanding the facts, teams encounter strong opinions shaped by previous experiences; these differing views and even the facts can prick values causing emotions to surface. As emotions surface and begin to bump into one another, conflict is inevitable.  The duration and lasting effect of that conflict are something a leader can control.

The older I get, the more I realize that there is little forward progress without conflict of some kind. I studied Clausewitz’s On War a dog’s age ago and learned that friction was good for two things: 1) spotting where, in the fabric of disagreement, I need to more deeply analyze and 2) advancing the contention to move to an agreement of some sort.   Applying Clausewitz to our team continuum model, I realized that just acknowledging emotions wasn’t enough.  The real catalyst to getting an alignment is active conflict.   I often illustrate this idea using the metaphor of a car stuck in snow or ice – without the addition of friction, the wheels just spin.  Living in the North, I am way too familiar with this situation.  Without resistance, the wheels spin, and I often end up going a different direction than planned: my car and I are not “aligned.”

I should add a few lines here about how negatively we westerners view the act of conflicting. I’ve worked with teams who have inordinate potential that remains untapped and unlocked because they refuse to conflict. The roots of the word mean “to strike together.” It is this militant connotation that I think causes the most anxiety in our hearts.  What if, instead of two people striking one another, the model for conflict was two ideas striking against one another.   Healthy debate is good for a team.  There is wisdom from the writer of The Proverbs who posits that iron sharpens iron.  The effect of this active, deliberate, sharpening style of conflict bears good fruit.  Active conflict as a catalyst led me to the next improvement to the team continuum: changing “Attainable” to “Aligned.”

Attainable reads like a possibility instead of a true condition.  Aligned is an actual condition, one that we leaders strive for daily (crave daily?). The aligned team is still fragile.  We may agree at the moment to aim in the same direction, but aiming AND executing in the same direction – moving forward – requires Consensus.

The best way to understand the Consensus catalyst is by illustration.  The team has reached consensus when each member leaves a decision-making meeting in agreement and tells his team, “This is what WE are going to do…” instead of “This is what THEY decided to do…”  Consensus requires work: nipping, tucking, taking away, adding to and ending up with something that the entire team agrees with, wholeheartedly.

The consensus is what initiates the team into Moving Forward. Anyone who has hung out with us more than an hour or two has heard us coaching teams to “move as a team.”  The implication is that moving forward means altogether, no one left behind, no one racing ahead and all aiming the same direction.  The team that is moving forward has the potential to succeed.  I think this is what Lewis meant by “masterful.”  In his view, the team was full of mastery.  Mastery and application of it require will. When I changed Masterful to Moving Forward, my intent was to add this sense of will – the impulse that got the movement started and that, Lord-willing, will keep it moving. Until change occurs and by nature causes the team to slide back.

The leadership key – how to put the Team Continuum to use – lies in developing proficiency in the catalysts.   While sliding backward is inevitable, regaining forward movement is entirely dependent on the leader initiating and engaging the right catalyst.  As Scholtes aptly says, “Don’t panic.  With patience and effort, this assembly of independent individuals WILL grow into a team.2)” Patience, friends.






1. Scholtes, Peter R., Brian L. Joiner, and Barbara J. Streibel. “Chapter 6 Learning to Work Together.” The Team Handbook. Third ed. Edison: Oriel STAT A MATRIX, 2010. 6-4–8. Print.
2. Scholtes, Peter R., Brian L. Joiner, and Barbara J. Streibel. “Chapter 6 Learning to Work Together.” The Team Handbook. Third ed. Edison: Oriel STAT A MATRIX, 2010. 6-8. Print.
To Transform Culture Exercise Values | Three Things to Do It Today

To Transform Culture Exercise Values | Three Things to Do It Today


My kids are part of a generation of fitness fanatics: they spend hours daily in the gym. At first, I didn’t get it.  When I was a kid, I “lifted” because my coaches told me I had to.  I was in the gym during the season.  There were distinct “off-seasons,” which I used to downgrade my condition, not maintain it.  Maybe that’s why I ended up playing club sports in college.

Howard Shultz, colorful twice-CEO of Starbucks, conceived of the cool coffee house as America’s “third place:” there was home and work and Starbucks.

My kids’ third place is the gym, daily.

Some of this consistent daily ritual is social.  My kids see friends there, they laugh, joke and share life.  All the time, lifting weights.

All the time: strengthening their bodies.


I work almost exclusively with organizations attempting some form of cultural transformation.  I see a common error made by leaders: they think that transformation is a passive thing.  It can be over great lengths of time.  Think of the Easter egg that you are dying.  You keep yours in the dye for 20 minutes, and it comes out brilliantly colored.  The three-year-old with you dips ten eggs in the same dye in the same period and her’s are a dull, pastel, less brilliant version of yours.  (Don’t fret: I told her that they were amazing and beautiful!)

The transformation model that I  subscribe to is much more active. We work with leaders to create what Edgar Schein, the granddaddy of Organizational Culture, calls the “daily experience.”  If we behave right, daily, the culture changes. But how?  It helps if you know how.


Transformed culture is a rearranging of the parts into their optimal whole.  Organizational culture consists of actions and behaviors, mindsets and attitudes, and values. Organizational value systems are not independent.  They are interdependent.  They represent the overlap of the organization’s individual values.  And, they are both virtuous and not.

Strategic transformation aims at strengthing the virtuous values, the ones that advance the strategy.  For example, one of our operational excellence system “threads” is continuous improvement.  Each thread has associated good values.   The continuous improvement thread values are “focus on the customer” and “solving problems.”  We place high importance on these things.  The strategic intent – continuous improvement – advances as we strengthen those values.

So, for me, the key to transforming a culture is to exercise the values. Schein’s insight – the daily experience – helps us to operationalize the idea.  Why? Because the daily experience is what exercises the values.

Every day in your organization, daily routines exercises values: virtuous ones and the ones that aren’t. The values you hope for and the values you despise.

What’s a leader to do? Don’t dip your eggs and wait! Design your daily experience to exercise the right values.

I’ve watched my kids over the years.  They’ve gotten strong and fit.

If we exercise values, just like muscles, they get stronger and more defined, easier to see and more efficient.


Here are three things you can do today to exercise your virtuous values:

1.  Add a predetermined sequence your operational discussions.  An excellent example of this is when high-reliability organizations apply “safety first” as a value.  They start each discussion with a safety observation.  When this starts to hit habit stage, the change is remarkable.  If you want a problem-solving culture, initiate the day with asking about problems.  End the day with the same questions.

2.  Find the pervasive negative values and starve them.  Well-fed and exercised values are hard to defeat. Find what is feeding and exercising the negative values and cut those behaviors out right away.  You’ll  be tempted to cut out the people giving the negative vibe. Resist the temptation.  Cut out the parts of the daily experience that feed and exercise the negative. For example, we often encounter middle managers who are able firefighters.  They work around problems and keep things moving.  That daily experience of workarounds feeds values that go against actually solving problems. Stop promoting firefighters. Recruit, promote and retain team problem solvers.

3. Use your positive values as navigational aids. Your team gets lost every day at some point.  A fog settles in, and they lose track of the ever-important “why.” Your responsibility to your team is to keep them moving in the right direction.  Values help us take our bearings so we know where we are and where we should be heading. When you encounter that middle manager who is trying to work around the problem, navigate to the value.  Help him answer his personal “why.” Why are you working around the problem instead of finding its root cause?  Is this the right thing for us to do for our customer or the expedient thing?

Awhile ago, I suggested to one of my kids that he could take a day off from the gym based on his busy schedule for the day. He agreed.  Later that day, he rearranged his schedule to get to the gym.  Exercising is his daily experience.  He wasn’t just exercising his muscles; he was exercising his values. In the end, they both get stronger.




Regaining Focus Part Two: Three Ways to Systematize for Focus

Regaining Focus Part Two: Three Ways to Systematize for Focus

In part one of this two-part series, I started the argument that to regain focus, you needed to simplify. I mentioned colleague who described the programmatic junkyard of artifacts strewn about over the years as she and her team pursued various forms of continuous improvement. In this installment, I want to make the case that to systematize is to focus.

Deming was pretty clear on the contribution that the system makes, at least in the negative sense:

“I should estimate that in my experience most troubles and most possibilities for improvement add up to the proportions something like this: 94% belongs to the system (responsibility of management) and 6% special.”1)

If you are experiencing unfocused movement, your continuous improvement efforts may lack systematization. Great, so what is that?


Systems are made up of components, which are parts of the whole by definition. It’s a Latin word that means put together. Components are parts, so they each have a function that serves the whole. Systemized parts – components – won’t function properly apart from the system. Your heart is a pump, but a heart with no lungs doesn’t do much for me.

When you apply this thinking to a continuous improvement management system, you begin to realize that having a standard problem-solving method apart from having a way to prioritize problems gets suboptimal results. You solve problems, but they may not be the right problems. Solving the wrong problems degrades your organizational focus.

Complementary Components

For the components to yield optimal results, though, they have to be complementary: they should have good synergies and blend into one another. Having a problem-solving method that doesn’t mesh with your problem prioritization component just confuses.

I’ve worked with clients who have – in the past – put so much emphasis on what they were calling strategy deployment or hoshin planning, without having a component in their system to aim for the long term or to learn what their annual improvement portions were. They’d plan projects and rapid improvement events – tying up many people and a lot of resources – without knowing whether that specific improvement was needed. Instead of having a long-range plan for improvement and learning what to improve over daily, weekly, monthly and annual cycles, they’d stop once a year, speculate what would be needed the next year, then scramble everyone to do rapid improvement events. The only thing focused about rapid improvement events is the time and attention of the folks working on them…until they’re not working on the rapid improvement and they lose their focus to day-to-day problems that sap their energy.

If components don’t complement one another, they are more like tools in a toolbox. They are helpful at the moment, but like so many other continuous improvement concepts, we use them episodically and for a limited purpose. Limited, part-time, use isn’t focused.

Connected Complementary Components

A socket wrench and a crescent wrench may be complementary, but when they are rattling around in toolbox, waiting for someone to use them, they are hardly connected.

Complementary components have to be connected to gain focus. The walls of my house are incredibly useful, defining the space we live in and protecting from the elements. They provide pathways for wires, and pipes and they frame the windows that let in light and fresh air. I love walls. The roof of my house is useful, too. It keeps us dry and shaded.

At the core, my walls and my roof are entirely complementary. They both are made of the same materials, more or less. They both protect and define the space of our home.

Imagine, though, that my roof was laying in the yard beside my house, disconnected from the walls. It has the potential to protect my family, but because it isn’t connected, it doesn’t.

We can build components of systems that are very complementary, but not connected. Every component in a continuous improvement system obeys four rules: the pdCA cycle, defined responsibilities by role, visual management, and standardization. Each component is related and complements the other. But, when I connect them, the system comes to life to do what it’s designed to do. When I have a daily meeting and limit the conversation to problem-solving, it creates outputs that connect into other components: learning what’s important to solve, elevating problems that can’t be solved, and even learning how to help my team. Without problem-solving, a daily meeting is just another discussion, a transaction amongst thousands that create a cloud of ambiguity and sloppy execution.

Leader: Your Call to Action

Leader: systematized components define world-class operations. Think of a well-oiled machine humming along. Think of a team that’s playing championship ball or an orchestra that’s playing every note correctly. These are examples of many parts working as a whole, systematized components that align and focus your precious time and resources. If focusing better is what you need to reset or recenter your continuous improvement journey keep it simple and systematize.

Until next time, pursue #better and stay excellent my friends.



1. W. Edwards Deming Quotes. (2018). Quote by W. Edwards Deming. [online] Available at: [Accessed 12 Mar. 2018].
Stop the Chaos! Start Here: Replacing Your Non-Standardized Management System

Stop the Chaos! Start Here: Replacing Your Non-Standardized Management System


In one of my recent posts, I argued that an organization’s most significant process variability lies in your management system, not in your production processes.

My first argument seemed to resonate with many of you who agree that standardizing a management system – the system of navigation, logic, decision-making and action-taking pathways that govern how you do what you do to deliver to your customer – is a necessary and first step to stabilizing your organization.

For years, lean and six sigma thinkers have guided those making improvement to drive variability out at the process level and remove waste.  Recently, those in the “lean” community have come around to the idea that you need “lean” tools and a reinvented management system, one that involves keeping track of performance and aligning daily cadences with the pdCA cycle. Some even now argue for using a standard approach to team problem solving. For example, in a 2016 interview, John Toussaint MD, CEO, ThedaCare Center for Healthcare Value and CEO emeritus, ThedaCare, said this:

… just like with “traditional lean” we have seen a lot of tool-based approaches at first. Since those led nowhere, people hit a wall and started to call us to say, “lean doesn’t work,” when really they just hadn’t done it properly. You need to establish the principles that build the systems that change the behaviors, rather than simply rely on the lean toolbox. It’s all about the management system, which people are starting to understand a little better.

Gary Kaplan MD, CEO of the Virginia Mason Health System in Seattle similarly adds in a British Medical Journal | Quality and Safety article:

To successfully facilitate system transformation toward higher quality care at lower cost, Lean tools must be part of a comprehensive management system, within a supportive institutional culture, and with committed leadership.

Agreed:  we need to have tools and a management system (and integrated leadership culture).  However, I would (and have since I started doing this work in healthcare) reverse the order.  So, my second argument will probably rub some of you the wrong way: you have to standardize your management system and the leadership culture that uses it execute before you try to do any other improvement work, especially at the process level.  Here’s why:

1.   Workarounds Wreak Havoc and Cause Chaos. The standardized management system smooths the variability caused by team leaders who work around, rather than solve problems.  Working around a problem will perhaps give some temporary relief.  Carefully redesigning your management system, however, to “stop” to fix the problem – careful, I didn’t say stop your processes – will allow your team to apply both containment and countermeasures.  Deep lean thinkers and those who study Deming know that waste at the process level is a result of unevenness and overburdening, both of which originate in your management system. Workarounds create management process unevenness; let’s just call that chaos.

2.  Direction: Which Problems Need the Cross-Disciplinary Teams. As your problem-solving machine – your management system – spins up into action, problems that are unsolvable without study bubble up to the top, giving senior leaders direction for attacking your most significant systemic problems. They never set aside the problem-solving standard; they just add a few study steps to the front end to break these significant phenomena into smaller contributing problems.  A system of linked daily meetings  – a criticial component in a standardized, problem solving centric management system – creates the channels for that information to flow and find it’s home at the appropriate level in an organization, one that is best equipped to convene and resource solving complex problems.

3.  Human Change Takes the Most Time – Get Crackin’! Before they tackle complex issues, your leadership team needs to learn a new way of thinking about problems.  A unique and novel leadership culture has to emerge, one that changes mindsets by changing the daily experience around problems.  Heroes – once revered for their ability to swoop in and solve everyone’s problem (i.e., get a workaround in place, cause unevenness and never really solve a problem) – have to become a thing of the past, even frowned upon. Teams – the great human unit for winning – have to collaborate to solve problems, but everyone –  first – has to learn how to address them.  This very human endeavor requires time, leadership and much practice.  The day-after-day rhythm of pdCA – checking to see if we encountered a problem, acting (containing) and analyzing (finding the root cause), planning countermeasures, doing the actions to get the countermeasures in place –  cuts a new groove into your leadership team psyche and your team members’.  This social change is the more difficult transformation. Cutting a groove takes a sharp edge and some pressure.  Modifying a process is easy in comparison.  If you delay the human change, you just put off to tomorrow what is essential for today.  Better to get to work on the harder work as soon as possible.

Without centering all management activity and leadership thinking on the problems – the daily things that are eating your lunch –  you are merely crawling forward.  For many years those who follow what I call the Georgetown Pathway, put an all-out attack on the management system at the frontline of the battle plan and demand that leaders lead, keeping them accountable for execution.  Following what they learned from their Toyota mentors, who learned it from their mentor, Deming you must balance the human and the operational.  You must drive out variation to improve quality.  The quality of the output of your management machine depends on the quality of the management processes in your system.  At this point, the watchwords are patience and passion.  You are on the steepest climb, one that – even later – is at the highest risk for collapsing except for your constant, vigilant, pdCA.

Up next: Stopping (your management process) to fix the problem…




235 West Main St., no. 104
Ligonier, PA 15658

Mail to
P.O. Box 365
Ligonier, PA 15658-0365

Talk to us