The Power of Ideas to Transform Healthcare

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The Power of Ideas to
Transform Healthcare
STEVE HOEFT • ROBERT W. PRYOR, MD

The Power of Ideas to

Transform Healthcare
Engagi ng St af f by Bu ild in g Da ily
L ean Manageme n t S yste ms

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Contents

Foreword..................................................................................................... xi
Acknowledgments.................................................................................... xv
1 Introduction..................................................................................1
What Can Lean Do for My Organization?...................................................6
Bob’s Background........................................................................................8
Steve’s Background......................................................................................9
2 Why Lean? Why Now?.................................................................11
The Healthcare Desert Oasis.....................................................................12
Healthcare Challenges Nationwide............................................................14
New Challengers: Non-Traditional Healthcare Providers......................17
Keeping Up with Change......................................................................20
S&W’s Particular Challenges......................................................................22
S&W’s Growth Era.................................................................................22
S&W’s Financial Model..........................................................................23
S&W’s Secret to Low Costs—Integrated Health Delivery.....................24
How S&W’s “Secret Sauce” Helps Improve Population Health............26
Rapid Growth and Pride........................................................................27
Confusing Leaders—Management Systems and Gurus Everywhere.......29
Systems Thinking: Big and Small..........................................................32
Lots of Operating Systems: Which One?...................................................33
A System That Ties Together Other Good Micro-Systems...................34
Bob’s Bold Statement.............................................................................35
Toyota Changed the Value Equation (aka Only One Way to Thrive)......38
The Promise...........................................................................................43
What Percentage of Your Creative Brainpower?.......................................44
Countering the Two Biggest Excuses........................................................45

v
vi ◾ Contents

3 Philosophy..................................................................................47
Toyota’s Philosophy....................................................................................48
Patient Centered.........................................................................................50
The Improvement Philosophy for Healthcare...........................................53
Bob Finds His People-Based Lean Philosophy.........................................54
Go, No-Go #1: CEO-Driven.......................................................................59
Go, No-Go #2: No Layoff Policy...............................................................59
It’s All about People...................................................................................61
The Goal: Building a Culture of Continuous Improvement.....................63
Investing in People.................................................................................64
Philosophy—Inclusiveness......................................................................... 67
The Toyota House......................................................................................70
The Toyota Way Principles........................................................................76
Toyota’s Patience—San Antonio............................................................79
All Staff Need to Develop “Eyes for Waste” (DOWNTIME).....................81
Lead Time and Value-Added Time............................................................84
The Customer Determines Value...............................................................86
Types of Work........................................................................................88
Scientific Method....................................................................................89
Lean Thinking Penetrates Every Part of the Organization: Baldrige
Framework.................................................................................................91
Tensions Are Natural in Every Transformation.........................................95
Standardize vs. Improve: Defending Standardized Work.....................96
(Forced) Standard Improvements vs. Team-Based Improvements.......99
Detailed Standard Work or General....................................................100
Do It This One Best Way vs. Figure Out Best for You (Rigid vs.
Flexible)................................................................................................100
SMART vs. Stretch Goals..................................................................... 102
Problem Solver vs. Problem Finder..................................................... 102
No Layoff Policy vs. Layoffs for Volume Imbalances..........................103
Not Big Enough vs. Too Big................................................................103
4 How S&W Did It—Applying TPS to Healthcare........................105
Step 1. Lean Training and Tools.............................................................. 111
Orientation and Two Hats................................................................... 114
Continuous Improvement Training...................................................... 116
Common Core Training and Applications for All Staff....................... 118
Advanced Development Tracks for Select Staff..................................122
Lean Steering Council..........................................................................124
 Contents ◾ vii

Sausage Diagram and Project Identification—System-Wide Value

Stream Mapping...................................................................................126
Project Prioritization and Selection Matrix..........................................129
Maintaining the Matrix: How Detailed?..............................................134
Step 2. Major Lean Projects: Self-Sufficiency Plan..................................134
Leader Roles......................................................................................... 135
Self-Sufficiency Philosophy..................................................................139
Many, Many Projects............................................................................ 140
Setup Checklists................................................................................... 143
Tracking Return-on-Investment (ROI)................................................. 147
Lean Project Example—Chemo Infusion (VSM Workshop)...............148
Re-Casting a VSM Vision...................................................................... 150
Spreading Ideas from One Area to Another....................................... 152
Why Doing Only Lean Projects Will Not Work.................................. 155
Step 3. Align All Staff through Hoshin Kanri......................................... 158
All 13,000?............................................................................................160
Catchball and Contribution to the Leaders’ Goals—Different for
Everyone............................................................................................... 169
S&W’s Hoshin Forms........................................................................... 171
Linking Human Resource Backward-Looking Annual Reviews
with Forward-Looking Hoshin............................................................ 178
Strategy................................................................................................. 178
Advanced Practice Professionals (APPs).............................................. 179
S&W Strategy Development.................................................................182
Population Health.................................................................................184
Step 4. Daily Lean: Lean Management System-Building (LMS)..............186
Unleashing Ideas—The Iceberg...........................................................186
“Ultimate Arrogance”...........................................................................190
Four Parts of Lean Management System (LMS)...................................190
Part 1: Leader Standard Work.............................................................. 192
Part 2: Visual Controls......................................................................... 194
What Do You Put on a Huddle Board?...........................................196
Workers Need Input or In-Process Measures to Do
Experiments.................................................................................. 197
Must-Haves.......................................................................................200
Could-Haves/Should-Haves..............................................................200
Close-Up of a Hand-Tracked Measure.............................................200
Close-Up of All Three Sections of Huddle Board...........................201
viii ◾ Contents

Part 3: Daily Accountable Process.......................................................203

Huddles.............................................................................................203
Gemba Walks...................................................................................206
More Gemba Walks, More Time...................................................... 211
Daily Experiments............................................................................ 213
LMS Examples...................................................................................... 215
Nursing—Labor and Delivery (L&D)............................................... 215
Temple Memorial—Overall Patient Satisfaction Effort Using
Huddles............................................................................................. 218
Quotes from Nursing Leaders.......................................................... 218
Monthly LMS Huddle Success Stories.............................................. 219
Temple Environmental Services (EVS).............................................221
Everyone at Every Level Huddles—A Tier-3 Leader Huddle..........222
S&W’s Employee Engagement “Outlier”..............................................224
Summary of S&W’s Idea Generators.......................................................225
5 The Huddle System (LMS)—In Detail.......................................229
Keep It Simple: Two Guardrails to Guide All Daily Lean Ideas............230
Leadership, Gemba, and PDCA Cycles...................................................232
Small “l” Leadership First.....................................................................233
New Ways of Thinking........................................................................235
Slow Data Feedback to Team Means Slow PDCA Experiments.........238
Building LMS............................................................................................239
Lean Leadership (LMS) Course................................................................240
Required Courses?................................................................................244
More on Gemba Walks in the LMS Class............................................244
Idea Lists..................................................................................................246
Leader Standard Work.............................................................................247
Visual Controls.........................................................................................248
Chaining All Huddle Boards Together—No Weak or Missing
Links................................................................................................. 248
Three Tiers...........................................................................................249
Keep It Simple......................................................................................250
Execute!................................................................................................ 251
Daily Accountability Process (Huddles).................................................. 251
Part A: The Huddle..............................................................................253
Huddle Tips...................................................................................... 255
Part B: Leader Gemba Walks...............................................................256
Part C: Increased Floor Time for Leaders............................................260
 Contents ◾ ix

Leaders Must Keep Teams Moving up the Stairs................................263

Examples of Huddle Boards (Old and Newer).......................................266
Memorial ICUs......................................................................................266
Medical Intensive Care Unit (MICU)................................................ 267
Surgical/Trauma Intensive Care Unit (STICU).................................269
Cardiothoracic Intensive Care Unit (CTICU)...................................269
Temple HR Recruiting..........................................................................271
Taylor POS Collections.........................................................................272
Temple Orthopedic Clinic....................................................................272
Temple GI Procedures.........................................................................275
Taylor Lab.............................................................................................276
McLane Children’s Hospital Physical Therapy/Occupational
Therapy (PT/OT)..................................................................................277
McLane Children’s Hospital Imaging...................................................278
McLane Children’s Hospital Lab..........................................................278
Llano Nutrition Services.......................................................................279
Hillcrest Baptist Physical Therapy (Re-Evaluations)............................279
Temple Pulmonary Lab........................................................................280
Entering a Huddle: Senior Executives.....................................................281
Elevation System—The Strong Chain......................................................284
Colored-Card System to Track Elevated Ideas....................................284
Interventions to Accelerate Ideas............................................................288
Analysis.................................................................................................288
Interventions.........................................................................................292
A3 Waves..............................................................................................292
Results...................................................................................................293
Major Projects.......................................................................................294
Huddle Tracking System..........................................................................295
Handwritten Trackers...........................................................................299
Managing Two-Deep...............................................................................299
Spread...................................................................................................301
Communication....................................................................................301
Tracking Huddles Two-Deep...............................................................302
Huddle Board Audit System....................................................................302
Layered Audits......................................................................................306
Lean Tools S&W Uses in Huddles...........................................................309
Tools..................................................................................................... 310
Rebalance and Workshare in Huddles.................................................... 311
Rebalance Process................................................................................ 313
x ◾ Contents

Workshare in the Huddle..................................................................... 315

Same Day Appointments (SDA) Effort—Using Huddles......................... 318
6 Tips and Techniques................................................................. 319
Tip 1: To All Leaders: Have Patience!...................................................... 321
Tip 2: Make It Visual!...............................................................................323
Tip 3: Be Flexible.....................................................................................325
Tear ’em Down.....................................................................................327
Tip 4: Understand How Change Affects People.....................................327
Tip 5: What You Measure Is What You Get; So, Be Careful What
You Measure............................................................................................328
Tip 6: Put Some “Teeth” into Hoshin Goals...........................................328
Tip 7: Partner with a Lean Leader—Even in Another Industry............. 331
Tip 8: Steve’s Sensei Folder......................................................................332
Tip 9: Using Assessments or “Scores” to Grade One’s Progress............332
Overall Lean Maturity Score................................................................333
Lean Assessment by Tool or Principle with Radar Chart...................334
Baldrige (or Several Other) Framework...............................................336
Tip 10: Tip of the Week Emails and Intranet Fresh Articles..................338
Top Five Lists for Huddles...................................................................339
Top Five Reasons to Huddle............................................................339
Top Five Things We Huddle About (Focus Topics)........................340
Tip 11: Building the Internal Lean and LMS Toolkit...............................343
Tip 12: Using Videos to “Get the Message Out”.....................................345
Tip 13: Have a Bias for Action.................................................................345
(Story 1) Must Cut Inventory in Half—A Bias for Action....................345
(Story 2) Door Here!.............................................................................348
Tip 14: Stop Lean and Huddles during New or EMR Rollout?...............350
Tip 15: Stop Lean and Huddles during a Merger or Acquisition?...........350
Tip 16: Get Flow...................................................................................... 351
Tip 17: The ROI Trap and Role of Training............................................ 352
Tip 18: Kaizen or Kaikaku: Redirecting Labor........................................ 352
Flexing Staff to Other Sites..................................................................356
Appendix A: Forms.........................................................................361
Appendix B: Acronyms and Some Terms........................................ 375
About the Author.............................................................................401
Foreword

I first met Steve Hoeft in a phone conversation. He described the Lean

management system he had been involved in implementing at Scott &
White Healthcare, telling me they used the description of the Lean manage-
ment system in Creating a Lean Culture as a template, and with great effect.
“Come spend a few days with us, see what we’ve done, and give us your
feedback,” he said. I agreed to Gemba the Lean management implementa-
tion Hoeft had described. By the time I made the trip, Scott & White had
merged to become Baylor Scott & White Health (BSWH).
I’ve seen hundreds of applications of Lean management systems. No
two are alike, so it wasn’t surprising that the application I saw at BSWH,
described in the pages that follow, was not the same as others I had seen.
What was surprising was its effectiveness, exemplified by this hallmark:
The Scott & White system, at the time this book was written, counted 2000
implemented ideas for improvement from employees per week from their
16,000 employees, this in an environment that included recent budget and
staff cuts. That number is unheard of in my experience outside of a few
high-volume, low-variety automotive manufacturers, mainly Toyota and some
of its suppliers.
That level of employee engagement is for me the sine qua non of a suc-
cessful Lean implementation supported by a robust Lean management sys-
tem. You will find descriptions of many elements of both systems here. One
thing I’ve learned after repeatedly being surprised by Lean management
implementations described as “taken straight from the book” is this: There
are many ways to do it right. The “right” way is the one you have developed
yourself that works for you, as long as it adheres to a few principles start-
ing with focus on the process. But most applications, even very good ones,
do not produce the high level of front-line engagement reported clearly and
credibly in this book.

xi
xii ◾ Foreword

What I saw in late 2014 at the legacy Scott & White hospitals and clinics
was the product of a Lean journey begun in 2008. Prompted by accelerat-
ing change particularly on the financial side of healthcare, CEO Bob Pryor
was looking for ways to get ahead of the curve. He caught a glimpse of
the future in a benchmark visit to a Toyota assembly plant with its highly
engaged production employees and the thousands of implemented ideas for
improvement they submitted annually.
Steve Hoeft is a teacher and coach with firsthand experience in Toyota’s
thinking and approach. Pryor knew the direction he wanted to go: sustained
high levels of employee engagement in improving S&W’s performance.
Together, they developed an approach to move in that direction. Either
would tell you they are far from done. However, the distance they have tra-
versed and the progress they have made stand as significant achievements,
chronicled in the pages that follow.
The hardest part of Lean is creating the conditions that engage the hearts
and minds of those who do the actual work—the nurses, MAs, techs, house-
keepers, providers, and other professionals—in an ongoing improvement
process in which “bottom-up” suggestions for improvement are a significant
component.
This book documents the path the authors created at Scott & White, now
up to the merged BSWH to continue. It started with a familiar approach:
creating metrics, defining targets, identifying gaps, and chartering projects to
deploy Lean applications to close significant gaps. Many projects were suc-
cessful, but problems were growing faster than projects could reduce them.
Concurrently, many leaders were trained in Lean approaches and tools, but
few knew what to do as leaders to engage those they led.
In response, the authors developed their own approach for the next
steps. It did not come from a book or a consultant. Instead, they created the
next steps based on Pryor’s goal of high engagement at every level in the
organization: Hoeft’s Lean expertise, their experience up to that point, and
the gaps they observed in leaders’ behaviors and staff disengagement. They
combined equal parts of three-tiered accountability meetings, employee idea
processes, layered audits, Gemba walks, leader standard work, and visuals
for each team in each tier displaying goals and gaps appropriate to the team
in five areas consistent across teams and tiers. It is a systematic approach,
and it is working.
I believe the single ingredient essential to this success was the example
that Pryor, the CEO, set for his team and everyone in a leadership posi-
tion at every level throughout the organization. This was not something
 Foreword ◾ xiii

he delegated. It was not the CEO “getting it,” or endorsing an approach

for others to take. It was—and is—something he personally demonstrates,
coaches others on, observes them performing, and gives feedback. It is as
simple (uncomplicated) but difficult (to achieve) as this: Pryor insists that
leaders learn to lead, first by asking front-line workers to share ideas for how
to reduce the gaps between their unit’s performance and its goals, visually
displayed where teams meet for their daily (or weekly) tier meetings. Then
leaders are asked to take steps to be sure those who shared their ideas can
tell whether their ideas were acted on, and if so with what results on the
performance gap.
Hoeft and his team developed tools, processes, and coaching for lead-
ers on the behaviors and practices that currently yield thousands of
implemented ideas. As you read this book, you may think this sounds
straightforward. But that does not mean it is easy. What Pryor has insisted
on and personally reinforced and what Hoeft and his team developed are
rare. They entail taking leaders through a process wherein they persuade
themselves of the value of sharing, with front-line staffers, their manage-
rial discretion to define problems worth working on. When that happens, it
holds the promise to improve the entire organization’s performance in ways
others will find difficult to duplicate.
The goal is worthy, the journey is worth making.

David Mann, Ph.D.

Author of Creating a Lean Culture, 3rd ed.
Acknowledgments

What a difference a few years make! Steve’s Stories From My Sensei* was
released just over five years ago when he was still a traveling sensei working
for a nonprofit health research and consulting organization. Bob went from
grinding along as CMO, then added COO, then CEO, then back to CMO/
COO after a big merger with Baylor Health Care System.

For Bob:
One thing I must say at this point is that this is not a history book, even
though there are historical accounts written in this book. These accounts
serve to illustrate teaching points. This is a book about our journey. It
started by understanding the gaps in our present state and continues with
our desire to move to a future state. The present state is an ever-changing
landscape with some pathways well worn and others accomplished only
after forging a new way in a new land.
First, I would like to thank my friend, co-worker, and sensei Steve Hoeft.
He not only started me on my journey of understanding and practicing the
Toyota Production System, but also he was the driving force that made this
book happen.
There are numerous people within Baylor Scott & White Health who
helped make this possible. I thank the staff of Baylor Scott & White for their
patience in allowing us to take this journey. Through several years of learn-
ing and implementation, I can say that we are much better off having taken
this journey.

* Hoeft, Steve, Stories From My Sensei: Two Decades of Lessons Learned Implementing Toyota-Style
Systems, Productivity Press, New York, 2010.

xv
xvi ◾ Acknowledgments

I must thank Kerri Beckham who has kept me organized, mostly on time,
and appearing when and where I should for all of the various meetings that
I must attend. I also thank Alicia Dunn, my chief of staff. Without these two
wonderful women, I could not have accomplished half of what I did.
My senior leadership team at Scott & White is phenomenal. They walked
with us on this path and helped us go from a very rudimentary understand-
ing to where we are today. We are only starting this journey and we have a
long way to go. It is only through the hard work of the senior team that we
have gotten as far as we have.
I need to add a word of thanks to those who have reviewed this manu-
script and given valuable input. This, of course, includes the editors, the
quality department, the Operations Excellence department, and the STEEEP
Institute at Baylor Scott & White. Efficient care is part of the Baylor Scott &
White STEEEP Way and the Toyota Production System is at the heart of effi-
ciency. To that end, I would like to thank Joel Allison, chief executive officer
of Baylor Scott & White, and Dr. David Ballard, the leader of our STEEEP
Institute.
I need to thank my wife, Kay, who has stood by me through many dif-
ficult times in my medical and administrative careers, and has unwaveringly
supported me. Thanks to my children, Jami, Jarrod, and Jaxon, and to my
five grandchildren for making my life worthwhile.
Last, I must thank the chairman of the board, Drayton McLane. He is
indeed an inspiration to many and a trusted mentor for me.

For Steve:
There is no way to thank every person who contributed to the improvement
toolkit at Baylor Scott & White Health. Even today, it is still growing. Several
people were noteworthy contributors to the toolkit and this book.
First, Bob Pryor and the Scott & White Healthcare (S&W) leadership team
for actively experimenting, tinkering, and developing new applications in
healthcare that did not exist anywhere else. Bob’s persistence in building a
TPS framework and a culture of continuous improvement guided this effort
through its early, fragile years before momentum could be sustained.
Scott & White’s Pat Currie (chief operations officer), Glen Couchman
(chief medical officer), Cyndy Dunlap (chief nursing executive), and
the regional presidents led a war on waste that is still improving today.
Presidents Shahin Motakef, Glenn Robinson, Jason Jennings, Jay Fox (Kevin
 Acknowledgments ◾ xvii

Smith served as interim), Eric Looper, Dr. John Boyd, and Kim Langston are
Lean-thinking leaders. Clinic vice president Colleen Sundquist and George
Brown, a director, added much to the toolkit as they experimented with LMS
and committed to leading in a Lean way.
The Lean team—thanks a million! There are no better coaches and zeal-
ots than you in the battle to help develop all of our great employees into
waste-busters and problem-solvers.
The longest standing S&W Lean team member is Marji Henry, a great
people-focused training leader. She was chosen to start-up the fledgling
Lean effort. Thanks, Marji.
A trio of senior consultants saw the huge challenge in healthcare, joined
us at S&W, and now coach our growing system. Dave Scottow led compa-
nies, even serving as a CEO, before doing healthcare consulting. His bull-
dogged efforts make him first-in as an emergency responder—sort of a
“process doctor.” Dave helps coach S&W’s largest region. Dave’s work fold-
ers of well-organized huddle board pictures made the examples look good
throughout this book. Thank you, Dave.
The next thank you goes out to Dennis Raymer. Dennis is a friend and
colleague reaching back to Dr. Jeffrey Liker’s consulting firm Optiprise. He
embraced the challenge to bring TPS in all its glory to healthcare. Dennis
was described again recently as our best instructor. He simplified all of
Daily Lean into a few words and one quick drawing, and then watched
another lightbulb turn on. This was a few weeks after this student had been
formally trained in the classroom. Good coaching beats hours of training
every time. Thank you, Dennis.
Michael Baratz was made to coach leaders through their Lean journeys.
He was normally the first to make major changes in training materials or to
build a Lean system where none existed prior (tracking, layered audits, eleva-
tion system, etc.). Many innovations in this book started with him opera-
tionalizing the principles. Michael continuously improves the continuous
improvement system itself! Thank you, Michael.
Many other current team members added to the S&W Way including Dr.
Glenn Kuriger, Sundeep Boinpally, Aaron Liebig, Jarrod Pryor, Amy Stecker,
Nicole Hogan, Carlton Ligon, Todd McCann, and Stacey Simonton. Thanks
for building something special here at S&W—more Lean thinkers.
The world’s greatest senior executive assistant, Jana Huffstutler, spent
countless hours of her own time transcribing Bob’s and my recorded
thoughts. Her organizational abilities helped steer this book through the
many details. Thank you, Jana.
xviii ◾ Acknowledgments

Herb DeBarba led the Cancer Treatment Centers of America through their
Lean journey. We became friends after several of his staff took my university
course. Herb and his team mastered “A3 Waves,” and were nice enough to
show others and me how to conduct them as well.
Michael Sinocchi, executive editor at Productivity Press/Taylor & Francis
Group, was instrumental in leading us through delivery of this book. He
encouraged us throughout the process and offered great ideas.
Thanks to my kids, Megan, Erich, and Erin, for your encouragement and
inspiration. You have all grown up now, and I am proud of what you have
become. Follow Him.
One final acknowledgment is due. To my wife, Gena Hoeft—thank you
once again for losing me to the writing chair for many days when other nor-
mal people walk and talk. I owe you a non-distracted vacation. But, thank
you mainly for being a great wife and our kids’ mom. What would I do
without you?

A Message to Leaders and Facilitators

Outside of Healthcare
While this book was generally written for healthcare, the management sys-
tems described in detail here can and will work outside of healthcare envi-
ronments. In fact, Steve and others built on top of what they learned and
deployed in multiple industries and consulting careers. They are included in
this book.
If your organization is non-manufacturing, people- or business process-
oriented, the authors feel you will find a connection to the ways S&W tai-
lored the Toyota Production System (TPS) to work for them. Healthcare
processes are some of the hardest to systemize, standardize, and, quite
frankly, just manage. This should give leaders outside of healthcare hope—
and a challenge.
In some ways, a healthcare enterprise includes more high-tech, billing,
business, “engineered,” one-off, scheduling, information technology (IT),
transportation, supply chain, and people systems than many other indus-
tries. Outside of patient interfaces, healthcare’s support processes are similar
in many ways to these other industries.
The path S&W followed can benefit nearly any organization. Its flight
plan was not perfect by any means. Many TPS tools were adapted, some
 Acknowledgments ◾ xix

substantially. Key take-away: transforming and sustaining is not about Lean

or TPS tools. It was who learned them, who used them first, and how they
were sustained and spread throughout a fast-changing system.
And, it works. The principles and key learnings can be translated to
nearly any type of operation. The tools and systems can be adapted to your
industry and work processes. Just start. Commit to trying these concepts as a
system. Focus on the higher principles written here, and then ask, “How can
we adapt this way of thinking in our organization?”
Throughout this book, there will be call-outs and indented boxes to help
you focus on key points and important principles. Some of these will be
questions. When you reach one of these boxes, please stop and think.
The Japanese word Hansei means deep self-reflection.* So, do the Hansei.
Ponder a bit. Answer the questions yourself and then seek out other leaders
and staff members to see how they would answer. Involve your team mem-
bers. Your team time and discussions will provide even more tips and practi-
cal improvements on top of those contained in this book.
There is power in a single idea. Something changes when a staff member
brings up, tries out, and sees impact from a single idea. Multiply that times
every staff member, every day. Unleash ideas.

* Lean Enterprise Institute Online Lean Lexicon, Hansei, Lean Enterprise Institute, Cambridge, MA.
http://www.lean.org/Common/LexiconTerm.cfm?TermId=223
Chapter 1

Introduction

Bob Pryor was told that he needed to be the physician leader in an

organization that was physician-led. But, what did that mean? Physician
leadership has been likened to “herding cats.” Also, in some physician
groups, their democratic process holds that a single dissenting vote is a
tie! Then, all changes being contemplated just stop.
His new role would be easier to define in a manufacturing company.
He knew what this meant in his prior roles. Bob had been the manag-
ing partner of a large group practice, start-up Medical Director of a new
Children’s Hospital, and then regional Chief Medical Officer of a large
healthcare system. But, to tell the truth, he didn’t really know what it
meant to be a leader of leaders. So, he did what most smart people do—
he went back to school to learn, and learn and learn...
After 30 years, Bob felt he had tried everything. In retrospect, it prob-
ably looked like one very long Plan–Do–Check–Act (PDCA) experiment.
He got some spotty results but eventually, changes slid right back to the
“old way” as his leaders turned their focus onto the next new crisis. In
fact, one 30-plus-year employee told him, “All I need to do is outlast you,
just like I have outlasted all the previous leaders. Nothing ever really
changes.”
There must be something missing in all the management fads he
learned thus far! He even went back for his MBA, and took barbs from
students calling him the “old dude.” Then, he started to adapt his own
way of thinking.

1
2 ◾ The Power of Ideas to Transform Healthcare

He was slowly developing a philosophy in his head that worked. Then,

rapid changes in health care—especially reimbursement systems—drove
him to try Lean production techniques. Could it be? Could something as
simple as empowering all staff to identify and remove waste be the trans-
formation methodology his organization desperately needed?

One theme that threads this book together is ideas. This single word weaves
together much of the fabric of The Power of Ideas to Transform Healthcare.
Another theme is “two hats.” As in, “Everyone hired at S&W Healthcare has
two hats. You are to do your job well. And, you are to improve your job—
every day.” Both are equally important.
Starting in early 2013, this mantra was modeled to every new employee
entering S&W’s renovated orientation process. This seemed to create another
inflection point on their journey to build a culture of continuous improvement
(CI). More on two hats in Chapter 4, Step 1.
Ideas and two hats for everyone. Put the two together and what do you
have? Chaos?! The authors believe there is great innovation and even job ful-
fillment on the edge of chaos, if changes are guided properly. You just need
to have the right guardrails. More on that in Chapter 5.
The new “currency” for 2015 and beyond will be ideas. This is what orga-
nizations will need more of to survive and thrive in the coming decades.
Not just ideas spinning around in someone’s head. It will be ideas that are
incubated, sought out, grown, guided, and encouraged.
Ideas on their own are not enough. You also need to build systems
by which great staff members can check to see if their ideas worked, and
elevate those out of their span of control. Leaders need to build these sys-
tems! In fact, it may be their most important job. Why? Because they control
the faucet for ideas. Leaders must ask for them. Moreover, leaders control
whether staff ideas “stick” and “spread!” The truth is that most supervisors
and leaders do not even ask for staff members’ ideas.
The authors first set out to write a book about a missing topic from
healthcare literature—building systems for Daily Lean and huddles in health-
care. The book became much more. First bigger, then wider, and then
(hopefully) deeper. Huddles cannot be taught or implemented apart from
the management systems that support and accelerate them. Thus, the most
significant concept in this book is not huddles. It is who builds the systems
around them, and why!