7 Start Here: The Assessment – Becoming the Change: Leadership Behavior Strategies for Continuous Improvement in Healthcare

Start Here: The Assessment

How does an organization begin this kind of work, looking deeply at what drives its people and then asking individuals to change their behavior? How do we decide to take on new traits?

As with every systemic change, it should begin like an A3, with a statement of the problem and the current conditions. And this is the way we have found to document true current conditions: the assessment.

In this chapter, you will meet two very experienced practitioners and follow along as they perform organizational assessments to determine readiness for change. We begin this way to make it clear that there is no one right way to do it. Every organization is unique and responds to change—or the threat of change—differently. The assessment should bend a little to allow for local realities.

After having performed dozens of assessments, we offer a clear framework for what needs to be in an assessment and how the work of doing it should flow. Figure 7.1, later in this chapter, shows the outline we use in our Leadership Assessment. The assessment really should be done by an outsider, but this is not always possible. For organizations that do their own assessment, we invite you to use that outline to guide your investigation.


Let’s dive in. An assessment is just as simple and as complex as any other current-conditions statement. It is the second item on a standard A3. The objectives and personalities involved can make it seem enormous in scope, however, because what usually needs to be assessed is how the top brass is leading and managing the work of transformation.

How do we know that the assessment will be scrutinizing executive leadership as opposed to, say, frontline managers? Let’s look at the problem statement. In most health systems that have been trying to improve performance, the problem goes something like this:

   Improvements are not sustained over time.

   Areas of improvement remain isolated.

   There is little leadership involvement.

Boiled down, the problems are with organizational focus and lack of coordination, which are the responsibility of the C-suite. Executive leaders, therefore, must be involved from the beginning in a thorough, respectful assessment.

A leadership assessment can sound like we are inviting people to judge the effectiveness or likeability of individual leaders. We are not. The root cause of problems, after all, is almost always found in process, not people. We focus instead on evaluating leadership work processes and their behaviors within those processes. Are the desired behaviors already in place? Do the work processes support or undermine the right leadership behaviors?

In most cases, leaders will need to learn new ways to work and to begin acting their way into new behaviors. So, take care to depersonalize the word behaviors. The investigation is into work habits, not personalities.

Usually, the first task of an assessment is to go see the problem in its natural environment. Over the years, we have developed a good method for capturing the current state that we will show in this chapter. But it is not the only method, so let’s take a look at the experiences of a few people and organizations who have done this work.


For Carlos Scholz-Moreno—who has now led assessments on two large health systems—the problems were the same each time. “There were some terrific improvements in certain areas,” he says. “But the work was not spreading to other areas and we couldn’t sustain it.”

Carlos’s first assessment was at New York City Health + Hospitals, the largest municipal health system in the United States, where he was senior director of process improvement. The improvement team there had begun transformation efforts in 2008 with rapid improvement events and, after six years, had completed something like 1,000 events and could claim $343 million in combined savings and new revenue.1 But improvements too often fell apart, and continuous improvement thinking was isolated in a core group of problem solvers.

So, the improvement team decided to implement a daily management system, beginning in four areas that worked as model cells. Remember, this is a huge organization with 11 acute care hospitals and more than 70 community health centers serving 1.2 million patients annually, so this was a very small beginning for the daily management system.

In each area, people created visual management boards and engaged in daily huddles; area CEOs performed regular gemba walks. People were trained in scientific problem solving, and managers learned to audit standardized work. Patient satisfaction scores jumped significantly in each area using the daily management system techniques.

Once those four areas were stabilized in the new work methods, the improvement team spread the daily management system. By the end of 2013, the system was installed in 15 hospital units or clinics, and senior leaders made plans to have the system up and running in 244 sites by the end of 2015. They were counting on viral enthusiasm and learn-do-teach training to help it spread.

While improvement team members were making plans to spread the system, however, it became clear that those 15 sites were struggling. Improvements fell apart. The sites were not delivering results on strategic initiatives. The VP of process improvement, Joanna Omi, Carlos, and a team of PI leaders from throughout the organization put together a team and began an A3 with a problem statement that essentially said: We need to be able to respond to strategic priorities and we are struggling to meet the demands of the business.

And then team members went to the daily management system model cells and focused on asking open-ended questions about the experience of people on the front line.

“We would ask things like, ‘What is valuable to you about the visual management board?’ And we would hear things like, ‘Nothing, really. You guys are the ones who care about the board.’ ” Carlos remembers.

“We would ask, ‘How about the huddle?’ And I can remember one nurse telling me, ‘The huddle? I show up because I have to. But I’ve been trying to get a refrigerator to store my vaccines for the past year. Can you help me with that?’ I realized they didn’t even really have a path for solving their most important problems,” Carlos recalls.

What was most disturbingly clear, Carlos remembers, is that the daily management system had become one more initiative—a whole series of things to do on top of everything else caregivers and their managers were expected to do in a day.

Together, Carlos and his team then reread Beyond Heroes and asked what they were doing wrong. It did not take long to see the pattern, he says.

“We basically had a manual for creating a daily management system—using RIEs, training the trainers to create the standards, etc.—and said, ‘Do this.’ We decided on the tool first and thought the tool would change behaviors. We had it completely backwards,” Carlos said. “When the right behaviors for executives and senior leaders aren’t displayed, new work might be sustained for a while because it is anchored in people’s will to improve. But that will fade away when not enough attention is paid.”

Instead of meeting in a daily huddle to review new data points on metrics chosen by others, people needed to come together every day to solve problems in pursuit of their principles: keep patients first, keep everyone safe, manage resources, keep learning, work together, and pursue excellence. If principles were driving the huddle, fixing problems 137like refrigeration for vaccines would always win out over reviewing metrics, Carlos reasoned.

So, Carlos and his team came up with a plan to flip the script, to have principles drive behaviors. (Joanna Omi retired during this work, and Carlos continued on as VP of process improvement.) They stopped working with their outside consultant and instead focused on creating support for addressing problems at the front line. They used working sessions in key areas to clearly define what mattered, resulting in systemwide principles and a list of expected behaviors for leaders, managers, and people at the front line.

Working through that A3 over 18 months—a project that included three weeklong rapid improvement events to create new systems—the team rebooted the daily management system in four key areas, including King’s County Behavioral Health in Brooklyn.2

Focused now on frontline problems, the team at Behavioral Health, assisted by Carlos’s PI team, used the daily management system to tackle issues such as reducing the amount of time a patient had to wait for an appointment. Over 16 months between 2016 and 2018—even while the hospital was moving from one electronic medical records system to another in what became a very disruptive process—people working in huddles and rapid improvement events stayed focused on the issue and reduced the time to the third next-available appointment from 28 days to 4.

Getting that number down to a reasonable four days had far-reaching implications because it turns out that providers had been worried about continuity of care for their patients. 138If a patient was about to leave the hospital but needed care every week, and a provider saw that the next available appointment was three weeks out, the physician often kept the patient hospitalized longer. This was expensive and caused more slowdowns in the system. Once a patient could be guaranteed an appointment within days, fears dissipated and patients were released earlier. Beds were cleared for new patients, and getting care for a new patient in crisis became more reliable.

Teams fixed a few other broken links between inpatient and outpatient care and reduced the number of overstays3 by 68 percent. This amounted to 59,200 fewer bed days over that 16 months and a savings of $2.9 million. At the same time, Behavioral Health’s 30-day readmission rate dropped from 9 percent to 6 percent.4


NYC Health + Hospitals is always undergoing reinvention. Top leadership is appointed by the mayor, and new administrations almost always brings in new people and ideas. As it was clear that another such shift was happening, Carlos left New York for a large multispecialty physician group in Northern California in 2018.

Before taking the job as director of strategic initiatives in the physician group—a collection of two hospitals and 10 clinics and multispecialty offices—Carlos looked carefully at where leadership wanted to go in their improvement journey and saw a familiar story.

“They were passionate about improvement, you could see that,” Carlos said of the leadership team. The group had been working with an outside consultant for eight years and implemented lots of improvements, but those improvements stayed in pockets and shrank over time. Nothing seemed to change on a fundamental level.

“They knew they were stuck and wanted to be unstuck. So they went looking for inspiration. They had gone to Seattle Children’s, to Autoliv,5 and they had come back with a few shiny objects—the concept of a house, visual boards, idea cards—but they were just tools,” Carlos says.

As Carlos explained, “They also saw that leaders in those organizations acted differently. They were interested; they just didn’t know how to change themselves.”

Fresh from his experience in New York, Carlos believed that the organization needed two things immediately: agreement on their principles and an assessment to create a shared definition of their current state. Carlos and the 24 members of the leadership team decided “not to reinvent the wheel” and quickly adopted the principles first written by the Shingo Institute.

Then they agreed to work through the assessment method we had been using with other organizations. It is a little more intricately woven than Carlos’s open-ended questions of his first assessment, so let us walk through it with the California team (with gratitude that they were willing to share their experiences).

We have organized the assessment into five essential areas of inquiry:

1.   Leadership involvement

2.   Executive team behaviors

3.   Organizational readiness

4.   Teamwork

5.   Respect for every individual

While questions within each category will vary based on the problems at hand, these categories have remained remarkably stable. We have found that these are the main drivers and predictors of organizational excellence.

1. Leadership Involvement

When we say leadership here, we are talking mostly about the system’s senior leaders, including the chief executive. Because so much of healthcare has been reorganized in the last decade into multihospital health systems, this can include multiple hospital CEOs.

We have found that the most important questions to ask in documenting current conditions in leadership begin simply:

   Do leaders leave their offices?

   Are they comfortable talking to people on the floor (clinics, units, etc.)?

   If so, how are they talking?

   Is the leader curious and asking questions or giving directions?

As a benchmark, we look at whether senior executives are spending at least 20 percent of their time teaching and coaching, involved in improvement activities, or engaging in standardized work, such as a weekly or monthly assessment of projects directly related to True North.

For every assessment category, we ask the leaders to rate themselves from one to five. Then we spend time at gemba looking for evidence and offer an outsider’s rating. For instance, an assessment category might be, “System leaders participate in four improvement activities per year as part of their management standard work and use questions that don’t indicate an expected response.”

A rating of one might indicate that the leader participated in one event. To earn a five, the leader would have to participate in four improvement teams per year and be 145coaching others in the practice of asking humble, open-ended questions.

The gap between how leaders rate themselves and how they are rated by outside observers is the starting point for a discussion about development. The goal of that discussion should be to create a plan—such as a personal A3 and, ultimately, an organizational transformation A3—to chart a course to close the gaps.

The California team did not have a CEO. Instead, the organization used a dyad in that position, consisting of the physician in chief and the medical group administrator for each location. The power-sharing model does not change the nature of the people who rose to leadership positions, however.

“Humility was hard,” says Robert Azevedo, MD, physician in chief of the outpatient medical groups. “I was trained to solve problems, and I was really good at it. Now, I had to ask, how am I going to change the way I have led for the last 20 years? I wasn’t sure I had the time or capacity for it.”

A friendly guy with seemingly boundless energy, Rob loved the ideas behind organizational excellence and genuinely wanted to spend more time at gemba, helping others solve problems. When he looked at why his organization was unable to sustain improvements and then at the five desired behaviors, it all made sense, he said. If they—if he—showed more humility, curiosity, perseverance, self-discipline, and willingness to change, Rob was pretty confident he would change for the better.

He also agreed with the assessment report that he and his partners needed to do a better job developing the problem-solving capabilities of their direct reports. So, Rob worked out a personal development A3 with Carlos and signed up for regular coaching. He dedicated time to reflect every week about his interactions with others.

One of his biggest obstacles, Rob discovered, was learning how to stop giving “the answer.”

“Let’s say that leaders in the ED wanted to do [an improvement project] around patient flow. In the past, I would feel the urge to get in there and help them define the scope. I would say, ‘You know, I spent a lot of time in the ED, so I think I know a little about flow.’ That’s how it would start,” Rob said.

“Then, when I started trying to say, ‘I don’t know,’ I would add things like, ‘Ultimately, you’re the ones doing the work. I will support you.’’

The words I don’t know would not quite come out.

So, he would try again, saying, “This looks great. I don’t understand it, but I am here to support you and I want to learn from you.”

Those three words might still be missing from his repertoire, Rob will acknowledge with a laugh, but people could see that his intention had changed. And that change, post assessment, was creating a new kind of dialogue.

2. Executive Behaviors

In this category, we ask whether hospital presidents, chief medical officers, chief nursing officers, and others at this level are spending at least 40 percent of their time in deliberate practice of teaching, coaching, and mentoring. This includes time at gemba, and also in various meetings. Are they providing assistance and coaching others to effectively solve their own problems, or are they providing solutions?6

Much of what we are looking for here is evidence that organizational principles are clearly stated and that those principles are driving the right behaviors. When executives are leading with humility, curiosity, and self-discipline, we will be able to see it in how they talk to others, but also in how they organize their time. Our most important questions here are:

   Are executives setting aside time to develop people, to participate in improvement activities, and to help create quality at the source?

   Are they open about their schedules and showing up to assist their teams?

   Do executives ask questions that indicate an expected response, or have they mastered the humble inquiry?

3. Organizational Improvement

Updated and relevant visual management boards are one of the clearest signs that an organization is committed to improvement. Uniform displays and pretty lettering are not important. What we look for is current data, displayed in a place where people huddle daily, related to improvement projects and problem solving for that area.

Is work organized into value streams? Do people understand value streams and patient flow, or do these concepts only belong to the PI team members? We know that organizational excellence is sinking deep into the DNA of a team when people—both managers and frontline staff—understand value streams and use them to describe issues.

Are people comfortable talking about problems? This is one of the biggest cues to organizational readiness we see. Stand in a huddle and watch. Do people wince when problems are exposed, perhaps awaiting shame and blame, or are they coming up with a way to dig in and investigate?

Are patients invited to join improvement teams?

4. Teamwork

Problem solving by cross-functional teams is the root of every effort toward organizational excellence. If teams of doctors, pharmacy technicians, executives, and maintenance people can work together naturally and effectively, it is a good indicator of cultural readiness.

The question is, how many employees are invited and encouraged to join such teams? Are the goals identified as team goals, or are goals handed down from executives or a central improvement office?

The culture of teamwork can also be witnessed in how well teams respond to coaching and mentoring from managers. Is there an atmosphere of mutual respect here? Does being on a team afford people the opportunity to learn and grow? Do teams share their achievements, best practices, and breakthroughs across the organization?

5. Respect for Every Individual

The first benchmark in this category is a simple answer for those who conduct regular employee morale surveys: Is the organization enjoying increased employee morale? If it is not increasing, do you know why?

Respecting people means offering everyone the ability to learn and grow through formal training and engaging in a daily management practice.

Respect is also shown in how actively leaders pursue a safe working environment. Do accidents and near misses require an investigation with an A3 or similar problem-solving method?

Finally, we encourage organizations to look hard at promotions. If an organization tends to promote from within instead of hiring from the outside, it is a good indication of a robust training and mentoring culture.

The California team’s most important realization came from answering the questions on leadership, which led them to create this problem statement: “Our leadership style creates confusion, opportunity for waste and prevents us from unleashing our staff’s creativity and efficiency.” And that is what led them to embrace coaching, and to deliberately learn and practice new behaviors.

There are many ways to assess the current condition of an organization, from the open-ended questions of Carlos’s work at New York City Health + Hospitals to the reflection-and-feedback system of scoring that he used with the California group. Our next illustration, which occurred in Michigan, was more like the assessment we use at Catalysis, but with its own twist.

See Figure 7.1 (next page) for a full assessment.

FIGURE 7.1 Organizational Leadership Self-Assessment Questionnaire


When Al Pilong Jr. was asked to lead Munson Healthcare in Traverse City, Michigan, into a more cohesive system, he wondered how he would convince the leaders of eight other hospitals to adopt new thinking. As the CEO of Munson Medical Center, Al knew the pressures of running a big hospital with high aspirations. When a series of mergers and acquisitions created the new Munson Healthcare system with nine hospitals and dozens of clinics throughout northern Michigan, Al was named COO of the system and charged with making a sum of the parts.

The other CEOs, he knew, were all smart and committed to improvement. Teams in every hospital had all been engaged in some form of organizational excellence, working through problems with structured scientific thinking and creating standardized work processes at the front line. But they were all going about the work differently and with varied

The new entity, Munson Healthcare, was looking for solid improvements from every hospital. That was the commonality Al used to focus the team.

“In the first meetings with all the CEOs, we talked about how we drive results to get to our goals. They were open to trying new ideas because everyone was on the hook to show results in their hospital,” Al remembers. “For me, how we got to the results was just as important as getting those results, so we went through an iterative process, defining our True North and then identifying our principles and behaviors.”

When the team had finished that work, it was time to assess where they were in their journey. This was carried out in two parts:

1.   First, leaders rated themselves on issues such as whether their behaviors reflected Munson’s principles, whether leaders actively participated in improvement activities, and if there was evidence of standardized work for leaders.

2.   Then, two knowledgeable outsiders came in with a list of the same questions leaders had used to rate themselves. They spent a day in various hospitals and units, watching interactions and conducting interviews. Later, the team met again to confront the gaps between what they believed and what outsiders observed.

“For me, the results were a surprise. We weren’t as far along as I thought we should be,” Al says. “We had been doing lean, PDSA, and other approaches in all the hospitals. Every leader had their own idea about how to create improvement and we thought that would be all right. But in the assessment, we clearly saw the confusion and extra work we were causing due to the lack of standards.

“And the other big revelation was that we had too many initiatives happening at once. We kind of knew that we were suffering from overcommitment. But having evidence right in front of us was a big moment. We had to recognize that overburdening our people was not respectful.”

Using True North as a guide, the leadership team whittled down the list of initiatives and then each CEO created a personal A3 to track their growth.

When making a personal commitment to change, we all need some external form of responsibility to keep us on track. In leadership teams, we always suggest that the members are responsible to each other. And the team at Munson came up with a very smart way to do that, which they referred to as status exchanges.

Whenever they had regular planning and strategy meetings, they set a timer. They spent 30 to 40 minutes on operations, 15 minutes on strategy, and 15 minutes reporting on personal development.

Knowing that they would be expected to report on progress of their personal A3s made them more likely to look hard at where they were and where they intended to be.

“The hardest thing for me was to take time for the personal reflection that is required,” Al says. “I’m pretty hard driving and activity focused. But I owed it to my team to report on how I was doing. So I had to carve out 30 minutes every Friday—I put it on my calendar—to write in a journal about certain events during the week, how I handled situations, and how that behavior reflected our principles. That habit came in really handy, as far as remembering what happened and how I wanted to be. Finally, I could see change occur over time.”

Al used the idea of status exchanges as he taught his direct reports to use personal A3s, as well, thus ensuring that mentoring was part of his regular routine of meetings.

Without the original assessment that showed leaders where they needed to change in order to support organizational improvement, would Al have known that he owed it to his team to take time out for personal reflection? It probably would not have occurred to him. Al wanted to do well, but without the mirror of an assessment, it is difficult to know where to begin.

It is difficult for any of us to know where to begin change until we know where we are.

In the next section of this book, we describe some of the instruments we use to see where we are in greater detail. If learning by reading how-to is not useful for you, feel free to skip to the final section on work that is in development now.

All eyes are on the future of healthcare. This work will be crucial in the years ahead.

1. Kim Barnas, Beyond Heroes (ThedaCare Center for Healthcare Value, 2014), 155–156.

2. This had been the site of notorious quality-of-care issues in the past and was under Department of Justice oversight until early 2017 when a federal judge declared that NYCH+H had “exceeded expectations” in improved patient care at the site.

3. The best practice was for patients to spend no longer than 15 days hospitalized. Anything longer was judged an overstay.

4. Kim Barnas, “Part of the Solution: Management Systems in Healthcare,” Becker’s Hospital Review, August 2018, https://www.beckershospitalreview.com/hospital-management-administration/part-of-the-solution-management-systems-in-healthcare.html.

5. Autoliv is the world’s largest supplier of automotive safety equipment; leaders there learned the Toyota Production System from leaders at Toyota Motor Corp in the 1980s. Autoliv is known internationally as one of the best examples of enterprise excellence.

6. To rise to the level of deliberate practice, the executive needs to have clear intention, a thoughtful routine, and time to practice—preferably with a coach. In his assessment, Carlos chose not to include a hard number like 40 percent.