Engaging Front Line Staff with Kaizen

Business901 Podcast Transcription
Implementing Lean Marketing Systems

Engaging Front-Line Staff with Kaizen
Guests were Joe Swartz and Mark Graban

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Copyright Business901


Healthcare Kaizen focuses on the principles methods of daily
continuous improvement, or “Kaizen,” for healthcare
professionals and organizations. In 1989, Dr. Donald M. Berwick,
founder of the Institute for Healthcare Improvement and former
administrator of the Centers for Medicare & Medicaid Services,
endorsed the principles of Kaizen in the New England Journal of
Medicine, describing it as "the continuous search for opportunities
for all processes to get better." This book shows how to make this
goal a reality.
About the Authors:

Mark Graban is an author, consultant, and speaker in the field of
lean healthcare. He is the author of Lean Hospitals. Mark has
worked as a consultant and coach to healthcare organizations
throughout North America and Europe. He was formerly a senior
fellow with the Lean Enterprise Institute and continues to serve
as a faculty member.

Joseph E. Swartz is the Director of Business Transformation for
Franciscan St. Francis Health of Indianapolis, IN. He has been
leading continuous improvement efforts for 18 years, including 7
years in healthcare, and has led more than 200 Lean and Six
Sigma improvement projects.


Transcription of Podcast

Joe Dager: Welcome everyone. This is Joe Dager, the host of
the Business901 podcast. With me today is Joseph Swartz. He
has been leading continuous improvement efforts for 10 years,
including seven years in healthcare, and has led more than 200
Lean Six Sigma improvement projects. He is currently the
director of business transformation for Franciscan St. Francis
Health in Indianapolis, Indiana.
Along with him is Mark Graban, who is the author of "Lean
Hospitals" and has worked as a consultant and coach to
healthcare organizations throughout the world.
Mark serves as a faculty member at the Lean Enterprise Institute
and is also the Chief Improvement Officer for KaiNexus; a startup
software company that helps healthcare organizations manages
continuous improvement efforts.
Mark writes the immensely popular "Lean Blog," which not only
focuses on healthcare but touches upon all things Lean.
I would like to welcome the both of you and could I just start with
how the two of you became connected for your new book,
"Healthcare Kaizen"?
Mark Graban: Sure. Thanks, Joe. I'll address that and then Joe
can tell, I guess, his side of the story. It turns out we have a
shared connection with Norman Bodak, who people might know
for all the trips that Norman has made to Japan, and all the books
that he's written about Kaizen and continuous improvement. Back
in 2005, when I barely knew Norman, I was getting into
healthcare, and somehow we got connected. Norman said, "Hey,
I know this guy Joe Swartz, who is also moving from
manufacturing to healthcare. I think you two should talk."


I know Joe, and I traded emails. I don't know if we talked on the
phone. We might have. Then, a couple of years later, we crossed
paths at one of the Society for Health Systems' annual
conferences.
Joe was presenting on Kaizen, and you could see all the great
stuff they were doing at Franciscan St. Francis Health. We got
talking and kind of started brainstorming and the long, short
story; we decided it would be a very good collaboration to do the
book together.

Joe: What was the good part of having a co-author? Because
you've authored, a book on your own before, Mark, but what was
a good part?
Mark: Joe has written and co-authored books before, and he can
tell you about that. It turned out to be a good collaboration
because, for better or for worse, my experience has been flitting
around as a consultant with lots of different organizations and
introducing people to Lean and Kaizen in lots of different places.
Joe brings such a depth of experience that's so impressive, of
these five-plus years of really driving this change deeply in one
organization. Those different examples and experiences, I think,
came together really well into a great story in the book. Joe can
tell you more.
Joe: Joe, what other books did you work on?
Joseph Swartz: I wrote a book with my father called "Seeing
David in the Stone." It's about how to find and seize great
opportunities. Then, I was a contributing author to another book
on leadership. A book's such a huge project, that it's a challenge
to pull off individually. I've partnered with all the last ones, and I
found it very advantageous.
I think partnering with Mark was a coup on my part.


I feel grateful and fortunate to have partnered with Mark;
because he brought a whole dimension to this that I couldn't have
anticipated. I had bits and pieces but he was instrumental in
bringing linking it all together. He really thought through the
structure of it very well, and that was hugely advantageous.
Then, he's a master marketer and a master in so many other
dimensions, so I'm so appreciative to be a part of that.
Joe: I think it's so interesting how you complement each other,
having that experience of five years at Franciscan St. Francis
Health, where you're really able to see things that people can't
see from the outside a lot of times. That is really remarkable to
add to Mark's expertise for the collaborative effort. Joe, did you
start with Franciscan St. Francis Health when they first started to
move towards Lean?
Joseph: Yes, I did. I was brought in with the initial team. I was
one of the team members. I went in as a contractor, and they
ended up hiring me. As far as the Kaizen, Mark and I were on a
similar journey in continuous improvement. We were discovering
similar stuff in healthcare -- a good idea to get back to the basics
and teach those basics, and teach people how to make simple
improvements and get their confidence with these improvements,
so they can make bigger and bigger and bigger improvements as
time goes along. It's really about developing people.
He was on the same track, and we would dialogue back and forth
about that.
Joe: I think it's really tough for a hospital, more specifically, to
be able to institute continuous improvement or institute Lean,
from my vantage point. There are so many shifts, so many
different staffing things, numerous shifts and types of personnel.
Can you mention how you go about, maybe, immersing people in
programs like this?


Mark: Well, from what I've seen, that's a challenge, the fact that
you've got lots of part-time people, you have people working
multiple shifts and part-time and weekends. There's a big
communication challenge, in terms of training and educating
people about what Kaizen is all about. Then, there're just the
challenges of the communication across different shifts as people
identify opportunities, as they're proposing countermeasures to
implement, as they're testing and trying to help spread those
changes. Communication is critical. I've seen a lot of things work.
Simple bulletin boards can help communicate across shifts.
You have an idea; you have a structure. Rather than doing the
suggestion box model -- I think suggestion boxes are a model of
the past -- having ideas out on a bulletin board allows people to
walk by and see what's going on, contribute notes and talk about
it.

Then, you have people using software. I've been involved in a
startup company called KaiNexus that was started by an
emergency-room doctor who worked night shifts. That was part
of his problem statement, "How do we communicate? There really
aren't managers around on the night shift. How do we make
change happen?"
Whether it's cards and bulletin boards or software, there're
creative things that people are doing to break down some of
those communication barriers.
Joe: Does the book introduce Kaizen at a pretty basic level for
everybody to understand?
Mark: It really does. We say it's change, but the word "Kaizen,"
if you break it down into its two Japanese root words, "kai"
means change and "zen" means good. It's not just change. It's
making sure it's change for the better, and that it's really an
improvement. That's one of the core fundamental things that we
wrote about. Not all changes are good. We need to make sure

that we're following a good, systematic but not overly
complicated Plan-Do-Study-Adjust cycle. It comes back to the
Deming cycle of not just doing things, but doing things as a test
with a hypothesis and making sure, "Did we really get the results
that we expected?"
A lot of times, that's where people get frustrated, when changes
get forced on them and there's never any reevaluation. We're not
really doing the full PDSA cycle. That's one of the fundamentals
that we've tried to address in the book.

Joe: I've always heard that most people will say of the PDSA
cycle, people do the "Plan" really well. Maybe even the "Do" part
well. It's the "Study" and the "Adjust" that they fail at?
Mark: Sometimes I wonder if we even do the "Plan" well, if you
include the "Plan" as understanding the current condition and
understanding root causes. A lot of times, it's just a "Do" cycle or
a Do-Do cycle.

Joe: One of the things you mentioned in the book, "It's often
said that people hate to change." You go on to say that the book
disproves this notion. Can you let me know the secret or let the
listeners know the secret, without buying the book?
Mark: There's a great expression -- it's often attributed either to
Peter Drucker or Peter Sholtes -- the expression is something
like, "People don't hate change. They hate being changed."
There's a world of difference between having change forced on
you versus getting to participate in that process. Generally,
people like their own ideas. Kaizen is really about that process of
engaging people to come up with ideas in a grassroots,
bottom-up way, if you will. One example I often use is let's say
that you and a bunch of coworkers are going to go out to lunch.
It's Wednesday and it's time for your group to go, and somebody
says, "I've decided we're all going to go and try a new restaurant.


It's this kind of fusion of Pan-British-Asian-Thai-Mongolian
cuisine. It sounds great."

Well, everybody else in the group might pause and think, "I don't
even know what that is! I don't know if that sounds good or not."
People might resist that new restaurant, or they might cancel and
not want to go, but if we had a process where everybody had
input -- Kaizen's not just about voting on what do we do or what
don't we do -- but if you got to choose the restaurant, I think
generally people like going to new places when it's either their
decision or at least they have some input on it, as opposed to
being forced or dragged into it. I think that makes a world of
difference.
I don't know if my example's a silly one, but I think things like
that happen in the workplace sometimes. "I came up with a new
idea. Everyone else should love it." Well, it's almost; I think,
human nature for people to question and challenge other people's
ideas, and that's a good thing. We just need to make sure we
have mechanisms where people can actually have that
discussion, rather than being forced to adopt a new idea or a new
standard.
Joseph: We devoted a whole chapter (chapter 8) to discussing
ideas when it's not just you and your idea that you're going to do
and only you have to change when you involve other people who
also have to change, and we address that. In chapter 8, we call it
the Art of Kaizen.
Joe: What are some of the oddities in developing Kaizen in
healthcare?
Mark: You know, maybe it's an oddity in a very good way.
People in healthcare have such a passion for patients, and for the
work that they do. The intrinsic motivation that's there in
healthcare is very high, and it's something we can really tap into
compared with other industries. When we look at getting people

started early on, and Joe has a lot great examples about this too;
you're getting people engaged in Kaizen and helping them come
up with little things that either make their day go a little more
smoothly.
You identify some little improvement, something that bothers you
or gets in the way of doing what you need to do for patients, and
let's address that little thing.
Or let's come up with little things that make the patients'
experience better, let's improve patient safety, quality, and
outcomes. It's not that hard to get people excited about that.
That's where I think Kaizen is different than a lot of top-down
improvement or change initiatives that are driven in the name of
cost-cutting. T idea of cost-cutting, I don't know if it inspires
people in other industries, but I think particularly in healthcare,
the idea that, "Oh well we're going to go and save a lot of
money," that doesn't get people real excited.

And the great thing about Kaizen is that when you focus on all
these little things (and it's often hard to quantify) quality, staff
and patient satisfaction; you do all these things. You reduce
waiting time; that cost and financial improvement tends to
happen as an end result cumulated impact of all these different
changes.
So I think we can tap into that motivation, and I think compared
to my days in manufacturing that's a huge advantage in
healthcare, that we have that level of intrinsic motivation.
Joe: There's been a lot of Six Sigma or as some people call it,
Lean Six Sigma driven into healthcare and they go through
training cycles and develop green belts in healthcare. What's the
difference between Lean and Kaizen being at a healthcare facility
versus that Six Sigma mentality?


Joseph: We started lean Six Sigma here at St. Francis Health in
2006. We introduced Kaizen in 2007, a year later, and I think
after a year of implementing Lean Six Sigma we realized if we're
going to reach all 4,000 employees it's not going to be through
Lean Six Sigma. The problem was with Lean Six Sigma you
develop these project teams that have 12 to 18 people on
them - sometimes more sometimes less. They take numerous
months to execute and complete. So even if you have a few black
belts you're only going to impact 50-100 people in a year, you're
going to infect 50-100 people with continuous improvement and
how to do it.
We needed to infect 4,000 employees on how to make continuous
improvement happen. It would take us 20-some years to pull that
off. We knew we needed something beyond Lean Six Sigma.
I've seen some similar kind of stuff done in manufacturing with
Kaizen, where we could engage everyone in the
organization - teach them the basic simple tools of Lean and let
them make individual improvements and work in small teams,
and it was powerful and I knew we needed that for healthcare.
I think Mark was on the same journey. He saw that's something
we need in healthcare, and in order to engage all the employees
because we're under such pressure to change so rapidly in
healthcare on so many different fronts.
Mark: Even this idea as Joe puts it about getting everyone
involved in improvement; Six Sigma doesn't always bring that to
an organization. But we see in a lot of organizations where Lean
hasn't brought improvement to everybody either. We share some
of those examples in the book. For example, ThedaCare is really
well known for the first four years of their Lean work. It was all
week-long rapid-improvement events all the time. That was their
only model for improvement, and their only mode of change.


Week-long events are great - not every problem, not every
opportunity requires a formal team and three days or five days,
so like Joe was saying ThedaCare learned they weren't able to
teach people or touch people fast enough by only doing these
week-long events.
So they started layering what they called continuous daily
improvement or daily Kaizen on top of those events and there are
other examples in the book of people who have started with daily
Kaizen and then started doing week-long events once started
people learned the Kaizen model and PDSA model. I think, even if
you look at Toyota as an example, they'll teach that you shouldn't
choose one type of improvement or another. It's really all Kaizen.
It's all PDSA.
It's either relatively small things that you can address in a
relatively short timeframe, or it's something that requires a
weeklong event, or there's bigger systemic change that can't
even be done in just one week. These different modes of
improvement, even Six Sigma, it's all pretty compatible. They can
coexist.
Joe: You're really allowing Lean to grow organically, but how do
you share? We talked about the different culture that's at a
hospital. How do you spread that?
Mark: People in healthcare really prize and value this idea of
autonomy. "I get to do things my way," especially, doctors and
surgeons and, sometimes, with nurses and other healthcare
professionals. I think that just goes to show why the old,
top-down change model doesn't work in that environment. In
fact, there was somebody who commented on my blog this week,
a doctor from a hospital who said, "There's some sort of new
protocol that was just forced out on everybody from on high, and
not everybody agreed that this is the thing we should be doing
with patients."


The one thing he highlighted, he didn't understand the problem.
What problem is this addressing? It was a very low level of staff
engagement, and it certainly wasn't Kaizen; it wasn't anything
Lean. Some senior medical leader or administrative leader will
say, "OK. Well, we learned here's some best practice from some
other organization. Everyone needs to do it."
Well, usually that doesn't really translate to a lot of change.
People nod their heads. "Uh-huh, uh-huh." Then, they don't do it.
This Kaizen model sometimes is very time-consuming. You're
building consensus. You're trying to get people on the same page.
It doesn't mean that people magically agree, but when you go
through the steps of making sure you've identified and
communicated a problem, and you've talked about the root cause
and you've talked about, "Here's this countermeasure and here's
why we think it's going to work."
When you have that type of communication, as Joe mentioned,
and as we talk about in chapter eight of the book, you can do a
lot to engage people and bring people on board, when you
involve them in this type of improvement. A little of involvement
goes a long way. A lot of times, people just get bent out of shape,
"You never involve me. You never communicated."
It's understandable, why they balk or not want to be involved. I
think that's where the things that we have in the book and in this
Kaizen model, the softer side of Kaizen, if you will, I think there's
a lot to contribute to try to help people engage physicians and
staff members in a better way.
Joe: Can someone touch upon what the Kaizen Wall of Fame is
there?

Mark: One of the key steps in the Kaizen model is to document
and share what you've done. Not just to do a bunch of change,
but part of the study cycle is to do a little write-up, a

before-and-after with pictures, diagrams, and just show simply,
"Here's what we've done." You can post that on a bulletin board
in a department. You can post it out by the cafeteria, if it's an
idea that you want people across the hospital to see and learn
from and go choose to adopt.
Or, you have organizations that use software. That's one thing
that KaiNexus does. Joe's organization has some software that
they've built to do a similar thing. Joe, do you want to...you can
share a little about how share these Kaizen success stories,
maybe.
Joseph: We have a bulletin board in our cafeteria that we post
monthly, some of the really rare Kaizens. We also send them out
through our COO periodically through email. In individual
departments, department leaders have a bulletin board where
they post notable Kaizens that their staff has done. Mark's right.
The real power of Kaizen is in the doing, but it's also in the
sharing. Someone else sees an idea that someone else has done.
They're free to adopt it and implement it in their processes in
their unique way, and then it's their Kaizen. They can use our
database to record what they did, in the database, and it's
accessible by all 4,000 employees once it's in the database.
Joe: Is it just accepted that this works or...how is it controlled?
Does someone have veto power over some of these ideas? How
do you control a Kaizen or a cycle like that, to maintain control?
Mark: Well, I guess part of what we're trying to challenge is the
idea of control that managers and leaders need to be less
controlling of their employees and the change process. That
doesn't mean that leaders are completely hands-off or laissez
faire about things. As Joe mentioned earlier, the second step of
the Kaizen model is to discuss problems and discuss potential
changes. The role of a manager shifts from being the old
suggestion box model of some far off committee or manager just


voting "Yea" or "Nay" on suggestions instead of thinking of or
approving or rejecting Kaizen ideas. It's really more about
collaborating, coaching, and facilitating.
I know that sounds really swishy, soft, and fuzzy but this idea if
somebody has a "bad idea" that's impractical or too expensive, or
is going to have an impact on a different department.
Sometimes the manager's job is to raise that as an issue but not
then just saying, no, we can't do that. The manager can help
coach and guide to find something else that we can do that
addresses that issue in a better way or addresses that issue
without side effects. Sometimes people come up with ideas that
are well intended but sub optimizing.
One example that comes to mind, inpatient unit, there might be
delays in seeing new patients once they've been brought up to
the unit. Once I saw a Kaizen idea where one of the nurses said,
"Let's delay admissions from the emergency department until
we're done with shift change."
As a manager you may say that's one way of addressing it. But
think of the implications now, we're just forcing our problem back
on a different department. Making the patient wait in the
emergency department is not good for that patient. It's not good
for other patients in the way that it might back up the ED.
If the problem is we can't see patients promptly because we're
dealing with shift change, we need to come up with local process
improvements that would change the way we're doing handoff to
shift communications so that we can see the patient without just
forcing them back, keeping them in the ED longer.

Sometimes a manager has to play that role of challenging ideas
but doing so not in a way that turns people off. Because
sometimes people say, hey, I had an idea, and you said no so
forget Kaizen.

I'm not participating anymore. I mean, there's a real fine line and
gray area between challenging people and doing so in a
constructive way that doesn't turn them off.
Joseph: That was one of the concerns when we first rolled out
Kaizen. Some of our leaders had that very concern, uncontrolled
change. Really, there are checks and balances in the system like
Mark says. We first ask Kaizeneers that practice this to go discuss
the idea with anybody that the change will affect. Peer pressure is
pretty powerful. They can't just go out and do anything they
want. They'd have to check with their teammates and stuff.
Then, like Mark said the supervisor or the manager coach. Really
there's very few that get implemented that is really wild,
uncontrolled change.
Mark: This isn't just lots of people running around doing
random, unconnected things. There are these checks and
balances. If we're doing a test of change, if we've tried something
that maybe it wasn't as well thought out as maybe it should be
then we can learn from that.
So managers can make sure that people aren't doing things that
would likely hurt a patient or hurt a coworker. Sometimes I say,
well, I'm not sure if that's going to work, but it doesn't seem like
it will really cause any harm. Let's try it. Let's follow the PDSA
model and see what the results are because you might be
pleasantly surprised, or it may confirm your suspicion of well; I
thought that wasn't going to work. We tested and learned and
confirmed that it didn't work.
That's something that helps you do Kaizen better in the future.

Joe: I think those were great points because I can just
remember in my experience biting my tongue a couple times.
Gee, I'm glad I didn't say anything because it worked.


What can Lean learn from healthcare?

Mark: Lean is incredibly customer focused. The patient's focus in
healthcare is a powerful thing. I think this idea of extending that
back to manufacturing or other settings but not being fixated on
just our internal processes but really thinking about do we
understand what the customers need. One thing I've seen that
works great in healthcare, if you're doing a rapid improvement
event is to actually have a real patient come and participate in
that process because a lot of times it's tempting in healthcare.

If somebody on the team has been a patient at the hospital
where they work, or they've had a child who's been a patient
they'll say, I'll play the role of the patient.
But an insider who's also been a patient often knows way too
much about the organization. They don't have the wide-eyed
newness of an outsider. So having a real patient participate in a
team can be really helpful.

They'll tell you what they value and what irritates them. I think
maybe there's an opportunity, hopefully some people in
manufacturing are doing this that they actually have customers
come and participate in Kaizen improvement in a very direct way.
Joe: Can you tell me a little about the target audience of your
book, who should buy it and a quick summary of it?
Mark: Well, the book is published by Productivity Press. The
target audience -- we address this in the introduction. There's a
lot of material in the book that we think is helpful for people at
different levels, in different ways. We think senior leaders are
going to read the book in a certain way and jump through certain
chapters. Front-line staff and front-line managers, I think, are


going to read it in a different way and take out all of the
examples.

There are 120 plus examples from different organizations of real
Kaizen improvements. I think the internal Lean coaches, Lean
facilitators, are one of the other core audiences. How do they help
set up and establish a Kaizen program for the whole
organization?
We hope there's a little something for everybody. If they don't
read the whole book, there're at least chapters and things that
they can gain from the whole thing.
Joe: Joe, could you tell me a little about the examples
throughout the book?
Joseph: Sure. They're real. They're from our staff. We combed
through them and looked for the best, and those are the ones
that we post. We just took a bunch of the ones that got posted
over the years. Some of them, we've worked with the staff to
kind of refine, but the nice thing about it is that we've got a
whole cross-section from all kinds of different areas within the
hospital and all kinds of different Lean scenes, Lean disciplines. It
really hits across a wide area.
Joe: The book has; I think it says, over 200 color photographs in
it, which is just a huge number for any book that I've ever seen.
Mark: Well, we were fortunate that Productivity Press
collaborated, in terms of doing full-color printing, because there
are so many great pictures. We want it to teach by example, not
that people would go and copy those specific ideas, but just to
help illustrate examples of Kaizen and different types of
improvements. There might be cases where somebody might say,
"Oh, great. Look at that idea. We could adopt that tomorrow."
But that's not really the point. We want people to be inspired by
what they see in the book and go and make their own Kaizens.

In fact, on the book's website, hckaizen.com, there's a way
where -- some people have actually started doing this -- people
can submit their own Kaizen examples. We're posting those on
the web, to have a kind of living extension of the book where
people can help share -- like Joe mentioned -- not just within
their own organization but within the broader healthcare
community.

In the conclusion of the book, we pose it as an experiment to see,
"Can we share outside of our own organizations?" It's going to be
really interesting to see how that develops. That's one little
feature there, within the website, that's going to hopefully help
collect even more great examples.
Joe: If someone could only take one thing away from the book,
what would you want them to take away?
Mark: My thing would be, "Everybody can help improve.
Everybody, "We've mentioned Norm Bodak and I give credit to
Masaaki Imai, who says in his earlier works, "Kaizen is for
everybody, from the CEO to the janitor and all points in
between." In the book, we have examples from housekeeping
staff. We've got an example from Joe's COO. We almost got that
whole spectrum. The one message, I would say, is that no matter
what your education level, no matter what your job title, Kaizen
is about improving your own work.
Everybody who does any job is an expert in that job, and they
have a big role to play in improvement.
Joseph: I think we're all built with this innate ability or desire to
be creative. I think what Kaizen does is it asks every employee to
be creative. In that, I think it unleashes a lot of energy.
Everybody wants to contribute. Everybody wants to participate,
and they can do that in a creative way that advances the
organization. I think it creates and develops people that do that
on a daily basis.

Joe: How can someone purchase the book? You mentioned the
website.

Mark: There are links, if people go to hckaizen.com, or they can
find the book on Amazon. They can find it on
BarnesandNoble.com. They can go to productivitypress.com. We
don't know for certain, but we're told that the book will be
available in Kindle formats at or about the same time that the
paperback is available, here at the end of June. This is a version
of a Kindle book that is actually like the printed page, so it'll work
great on iPads, Kindle Fire, on Macs and PCs. It won't be readable
on the original e-Ink Kindle models, because there are so many
pictures and examples, but the book will be available in that
electronic format. It's almost a 400 page book, so it's easier to
carry around in your iPad.
Joe: I would like to thank the both of you, Mark and Joe, for the
opportunity to interview you. This podcast will be available at the
Business901 website and the Business901 iTunes store. Thanks
to both of you.
Mark: Thanks for interviewing us, Joe.
Joseph: Thank you, Joe.



Joseph T. Dager
Lean Marketing Systems
Ph: 260-438-0411 Fax: 260-818-2022
Email: jtdager@business901.com
Web/Blog: http://www.business901.com
Twitter: @business901

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Joe Dager is President of Business901, a progressive company providing
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assistance that is well versed in our principles. We have capabilities to
plug virtually any marketing function into your process immediately. As
proficiencies develop, Business901 moves into a coach’s role supporting the
process as needed. The goal of implementing a system is that the processes
will become a habit and not an event.

Business901 Podcast Opportunity Expert Status

Lean Marketing Lab


Engaging Front Line Staff with Kaizen

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