Introduction: The Current State of Healthcare – Becoming the Change: Leadership Behavior Strategies for Continuous Improvement in Healthcare


The Current State of Healthcare

Healthcare is in the midst of a massive disruption. Financial structures are in tatters. Public trust is shaky. Every aspect of the way we care for people is up for reconsideration, and, if we take advantage of this moment, we can create a better system. Imagine the changes we are capable of: Avoidable mortality and hospital-acquired infections could plummet in the coming months, while patient satisfaction rates climb. Waste in the system can drop by double-digit percentage points.

Does this sound like a fantasy? A nationwide survey of healthcare organizations conducted by UC Berkeley in 2017 found that nearly 70 percent of healthcare systems were actively engaged in improvement initiatives such as lean thinking, organizational excellence, or Lean Six Sigma.1 Seventy percent.

Most health systems were still in the early stages of these initiatives. Those with more mature initiatives—including a daily management system, widespread education, and leadership involvement—were reporting substantial improvement. The more mature the effort, the better the results.

The tide is starting to turn. The question is, can healthcare providers keep at it, creating enough improvement momentum to make this vision of a quality revolution come true?

We want to be optimistic. After more than a decade of executive coaching, teaching improvement methods through our not-for-profit, peer-to-peer learning center, and being inside hospitals in 19 countries where we have had the privilege of seeing hundreds of healthcare improvement initiatives in practice, we can say there is reason for optimism. After all, 70 percent of hospitals in the United States are putting serious effort into making positive change.

But only 12.6 percent of those hospitals report having a mature initiative with a daily management system2 and leadership involvement. We know from long experience that a whole-health-system effort is necessary to create sustainable improvement. The majority of health systems, however, have efforts that are confined to one or two departments or clinics—usually the Emergency Department (ED), Surgery, or Labor and Delivery—and too many leaders seem content to keep improvement quarantined this way.

In those hospitals where the work is isolated, improvement is slowly crumbling all the time. Newly transformed departments are held together by occasional heroics and the sheer determination of people who have seen that the new way is better for patients.

Leaders, meanwhile, are in their offices and conference rooms, leading their organizations exactly as they led them before: full of answers and directives, yet disassociated from 3the work. What we have witnessed in hundreds of hospitals and health systems is that autocracy and improvement initiatives do not mix well. The signs of disengaged or autocratic leaders are improved departments—an exceptional cath lab, a NICU that exceeds everyone’s goals—that are allowed to exist as islands of excellence. Or it might be frontline improvement work across several departments that never affects the working habits or expectations of executives in charge. Those leaders might brag about improved metrics, but they do not invite change into their own offices.

This situation has created the biggest gap between intention and execution that we have seen in organizations struggling to transform. Most often, leaders are not even aware that they are the roadblocks to reform.

This book exists because we have seen organizations correct course and have their improvement efforts take off with renewed vigor. In every case, the solution involved people making the conscious decision to change their leadership styles, altering the way they work and how they talk to peers, direct reports, and people on the front line.

We have seen that when leaders embrace new behaviors that are firmly based in commonly shared principles such as humility and respect for every person, improvement initiatives thrive. When leadership teams deliberately change their communication styles in support of an improvement initiative, the effects are fast and profound. One health system in Great Britain went from being ranked in the bottom third of the national health system to achieving top-third ratings in 18 months. In South Africa, another organization reduced infant mortality by 75 percent and maternal mortality by 40 percent in a single year. And in 2019, the orthopedic ICU’s hospital-acquired infection rate dropped from 12 percent to 1 percent in nine months.

These are organizations run by leaders who know they cannot succeed by pushing new work processes at frontline caregivers. These are leaders who have embodied the transformation by adopting change at a personal level.

Through illustrations and outcomes data in this book, we can prove that this change in leadership behavior is necessary for improvement initiatives to survive and that leaders—executives, managers, and governance board members alike—therefore have direct impact on the health of patients.

Before we begin making our case for this change at a personal level, however, we need to examine the current condition of improvement efforts in healthcare. This is what we always do: examine what is before moving on to what should be.

It may be difficult for some to remember, but there was a time just before the turn of the century that Americans took it on faith that people in the United States enjoyed the best healthcare on the planet. Every advance in medicine, every foreign dignitary who came to the United States for complicated medical treatment, was proof of our standing in the world. Even as medical insurance prices skyrocketed and car manufacturers complained that employee health insurance cost more on a per-car basis than steel, we believed that, anyway, we were paying for the very best care.

And then in November 1999, the Institute of Medicine put out a report estimating that as many as 98,000 people per year were dying due to medical error.3 The report was seized on by the media. Soon, every research project that showed quality problems in healthcare—from outright negligence to inaccuracies in recording prescription information—was given headlines in newspapers, documentaries, and broadcast news. This was a necessary eye-opener for all of healthcare.

When studies from Dartmouth University’s Atlas Project then started to reveal the inequities in how medical resources are distributed and used in this country—and the enormous variables in cost for the same care from one town to the next—it underlined the fact that our healthcare system was broken.4

And it was not just the United States that had problems. European countries, African countries, and other countries in the Americas started openly discussing their healthcare quality issues, too. Whether the systems were market-driven or nationalized did not matter. It was not the source of funding; it was how care was delivered.


In the first decade of this century, many healthcare organizations around the country vowed to find a fix. None of us—physicians, nurses, administrators—wanted to work in a hospital where patient harm was acceptable. But how were we supposed to start fixing it? Those of us who recognized our problems also saw they were deeply rooted.

We looked for answers in new places, such as manufacturing companies that had been improving quality and reducing waste with ideas from the Toyota Production System. As the CEO (John) and president of hospitals (Kim) of a major not-for-profit, cradle-to-grave health system in Wisconsin, we learned about these methods up close as we embraced what was known as lean thinking. We led different pieces of the initiative, and we both saw wild successes.

Beginning in 2002, teams throughout our organization applied the tools and ideas we learned and reduced, for instance, our cardiac mortality to near zero. We reduced patient time in hospital beds, improved their health outcomes, and—just in the first three years—cut costs by $27 million. We passed those savings along and became the lowest-price healthcare provider in the state.5

We were not the only ones. By 2015, it was common to hear hospital leaders around the country talk about their newly “lean” emergency rooms with strikingly low patient wait times. Major health systems in Seattle, Boston, Denver, and New York were trumpeting their patient safety records, the elimination of certain hospital-acquired infections, and their patient satisfaction scores.

But there was a dark side to all this accomplishment. Teaching lean or Toyota methods to health systems had become a cottage industry. Lean consultants who sold their services to healthcare had a standard playbook. They came into hospitals looking for the obvious signs of waste, otherwise known as low-hanging fruit, and then taught a team of employees the necessary tools to correct the situation.

Then the consultant added up the savings, presented the findings to leadership—almost always showing that the savings were greater than the consulting bill—and booked more work. Certain kinds of “transformation” rushed through our industry like fads, such as those super-efficient EDs and faster door-to-balloon cardiac surgeries.6 A team would learn the tools and ideas to transform an area, write about their success in a journal or share it at a conference, and others would copy it. New work processes spread quickly.

What we did not really understand was how much we were losing with each iteration of a solution. The teams doing the first transformation work in an organization were taught the value and purpose of a customer-centric value stream. Team members deconstructed and constructed working processes and deeply understood the needs of people working in an area.

But then, that team’s solution was too often applied to new areas or different hospitals or clinics without transferring the knowledge. If people in the new area did not understand why work was organized in this way or have an opportunity to work through their own problems, they just felt imposed upon.

There was another problem, too. Even those initial improvement projects—where everyone was trained and fully engaged in the transformation—usually began to see erosion in improvement scores after a few months. Islands of excellence often appeared to plateau or sink over time. People at the front line and their immediate managers stressed over the seeming failures and were unsure how to lead through change. And these setbacks proved to be a bigger problem than they might be in other industries.

The front line of healthcare is made up of highly trained experts with an emotional stake in the outcome of their work. People live or die at our hands. We do not want to claim healthcare exceptionalism across the board, but there are qualitative differences between caring for humans and 8building machines. That first wave of consultants—who usually began their careers as manufacturing engineers—did not always understand this. Too many times people at the front line felt pushed around by engineers coming in and telling them how to do their work or what was important. And if the improvements fell apart, caregivers took it personally. They became less willing to put in time and effort on the next attempt.

Healthcare executives, meanwhile, were often told that if they just committed to a regular schedule of kaizen,7 celebrated the work, and knocked down barriers that got in a team’s way, their job as a lean leader was done.

Those of us who were very interested in the work also went to gemba8 regularly, practiced asking open-ended questions, and learned how to coach people to solve their own problems. Even that was not enough.


In our Wisconsin health system, Kim saw the problems with sustaining improvement as a management gap. She put together a team and created a much-needed daily management system that worked with, instead of against, the team-based improvement work.9 John became CEO emeritus and founded an organization, Catalysis, to help others learn these methods. He created a kind of transformational road map10 and studied improvement systems around the globe, looking for answers from failures as well as successes. Kim joined Catalysis in 2014 and began to see the same problems as John.

What became most clear to us during this time was that CEOs and executive teams were disconnected from improvement work at the front line. Furthermore, their bosses—governing board members—were often not even aware that anything different was required of leaders in a lean organization. Executives were being judged by profit and loss statements. Managers were being judged by their ability to maintain control. And the frontline caregivers—who were too often introduced to lean thinking by consultants looking for redundancies in the process so that everyone could do more with less—were saying that lean was mean.

It turns out that lean was mean, largely because dramatic changes required by lean thinking were directed at some people instead of being adopted by all the people. Lean became so closely associated with mean in healthcare, the term lean became a liability.

Just to be clear: almost all of the improvement initiatives being used in healthcare in the aughts and teens of the twenty-first century stem from the same place, no matter the name. Whether it was called lean thinking or Lean Sigma or robust process improvement, it was all based in the twentieth-century ideas and teaching of statistician, professor, and management consultant W. Edwards Deming. Deming was 10the first person to identify the principles of a management philosophy guiding organizational excellence that was different from what American companies were practicing in the forties and fifties. Toyota, around the same time, established a set of guiding principles that became the Toyota Production System, which was translated back into North American English in the 1980s by James Womack and John Shook.

These initiatives focused on removing waste from processes, searching for problems instead of covering them up, using the plan-do-study-act (PDSA) cycle to address those problems, organizing work in value streams focused on the customer instead of internal needs, standardizing work, and using team-based problem solving.11

And that list, we finally came to realize, was a big part of the problem. Improvement work was consistently described this way: a set of tools, a way to look at resources, a restructuring of work processes. Improvement was made up of big external gestures that created redesigned hospital wings.

But what we have discovered is that the most important part of this work is internal. It is personal. Beginning with executives and board members, leaders in an organization that seek transformation must change how they behave toward other people. The way we think and ask about problems, how we define our roles, and how we gauge success are all up for renewal.

We know this is true because every time we examined an organization that was having trouble sustaining its improvement efforts, we found executives stuck in command-and-control style management. And every time we found an organization that was spreading its improvement work past the model cell12 and finding new solutions, there were leaders who displayed humility, curiosity, self-discipline, and other traits that were crucial to their effort. These leaders were not magical beings; they were usually not born this way. These were leaders who adopted these traits because that is what they decided was best for the organization.

As we searched for a way to organize our thinking around the best leadership behaviors we were seeing, we kept returning to the list of guiding principles written by the Shingo Institute at Utah State University:

   Respect every individual.

   Lead with humility.

   Seek perfection.

   Embrace scientific thinking.

   Focus on process.

   Assure quality at the source.

   Flow and pull value.

   Think systemically.

   Maintain constancy of purpose.

   Create value for the customer.

In that list, we found all the bedrock principles that the best organizations were using—consciously or not—to define the traits and behaviors that were required of leaders. Working with these organizations, many of whom will be profiled in these pages, we further defined these principle-driven traits: willingness to change, leading with humility, curiosity, perseverance, and self-discipline.

Nobody perfectly embodied these principles and traits all the time. One executive might be naturally humble, but really needed to work at displaying self-discipline to the team. Another leader was good at staying on-topic and was entirely reliable, but still wanted to blurt out “the answer” to a problem.

The leadership teams that were most successful at supporting improvement work decided together on the most important principles and traits to embody and then held each other responsible. They worked at improving their behaviors. When people stumbled, they could expect a gentle correction from team members.

Because we know now that revolutionary change requires both internal and external transformation, when we need to label our methodology, we usually talk about organizational excellence instead of lean. It is a bigger tent of a label, and it reflects our more holistic approach.

When asked to help a struggling organization, we now begin with a full system assessment—from the internal drivers and behaviors of the executive team to how problems are uncovered and solved at the front line. It turns out that all of this matters. Readers will be able to perform their own assessments in Chapter 7.

Based on the assessments, leadership teams then agree upon organizational principles, establish the most important traits and behaviors for their team, and decide how they will hold each other accountable.

The most common traits required for people at each level of an organization are illustrated in Chapters 3 through 7. Since all traits are based in an organization’s principles, it is impossible to say exactly which ones are required for every level of leadership in every health system. But there are strong 13commonalities from one organization to the next in what is required to support the work.

In general, top leaders need to get out of their offices. They need to listen rather than talk, to learn how to ask good questions, and to become vulnerable with others. All of this is necessary behavior for leaders who want to know what is happening in their organizations.

Leaders also need to standardize the way they do their work, enough to become more reliable to others. They need to support others, in success and in failure, and to effectively coach people as they learn to solve problems. Leaders who do this work, who learn to help others think through and make their own principle-based decisions, find they are not irreplaceable. Their leadership, however, is multiplied through influence.

In these chapters, you will hear from board members, executives, managers, and caregivers from all over the world who improved their organization’s patient care by examining and changing their own behavior. Many of these leaders were good clinicians with great people skills who were promoted into management and picked up a few bad habits because they simply never stopped to consider how their style of solving problems fit with their organization’s principles. Or, they are CFOs or human resources (HR) professionals who became true partners in the transformation because they learned to be vulnerable, to admit they did not know every answer.

This work also requires knowledge and use of a few practical tools, such as the Personal A3, a radar chart for tracking the user’s improvement in their traits and behaviors, and an organizational x matrix for strategy. We provide depth into the use of these tools in section two of this book, before taking a longer view in the final chapter on the future of real healthcare transformations. What is a transformation, though? It is not clear when the definition of transformation became so limited. In 2019, it seemed to mean that a few processes were changed in one or more departments in order to create better efficiency. This is not the transformation we are talking about. We are talking about culture change that begins from within and radiates outward.

Instead of peppering you with fishbone diagrams and spaghetti charts in this book, we are inviting you to read the stories of others’ work and examine your intentions, to deeply consider how other people feel after interacting with you, to question the type of outcomes you seek. This is how we begin to chart a more sustainable path to perfection.

1. Stephen M. Shortell, James C. Blodgett, Thomas G. Rundall, and Peter Kralovec, “Use of Lean and Related Transformational Performance Improvement Systems in Hospitals in the United States: Results from a National Survey,” The Joint Commission Journal on Quality and Patient Safety 44, no. 10 (October 2018): 574–582.

2. In its simplest definition, a daily management system uncovers frontline problems and potential problems in a daily series of one-on-one status exchanges and team huddles, creating a clear path to escalate problems up the chain of command when necessary, and provides leaders with ways to communicate strategy to all and ensure that mission-critical projects and concerns are addressed in the course of daily business.

3. L. T. Kohn, J. Corrigan, and M. S. Donaldson, eds., To Err Is Human: Building a Safer Health System (Washington, D.C.: National Academy Press, 2000).


5. John Toussaint and Roger A. Gerard, On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry (Lean Enterprise Institute: 2010).

6. Door-to-balloon time is a measure of how quickly an arriving cardiac patient made it from the front door to the cardiac catheterization lab for treatment.

7. Kaizen is from the Japanese symbols meaning change and good. It is translated as change for the better and often refers to a lean improvement project in which a cross-functional team studies and then improves an area or process in one week.

8. Gemba is a Japanese word popularized by the Toyota Production System; it means the place where real value is created. In a hospital, gemba is located wherever caregivers are directly helping patients.

9. Kim Barnas, Beyond Heroes: A Lean Management System for Healthcare (Theda­Care Center for Healthcare Value, 2014).

10. John Toussaint, Management on the Mend: The Healthcare Executive Guide to System Transformation (ThedaCare Center for Healthcare Value, 2015).

11. This is, essentially, a beefed-up version of the scientific method: developing a hypothesis based upon a study of current conditions, carrying out an experiment, analyzing the results of that experiment, and acting on that information with implementation of a new hypothesis.

12. A model cell pertains to any clinical or administrative department with identified business problems, such as throughput, quality, patient satisfaction, or cost, that are critical to the organization’s mission and future. This is where a cross-functional frontline team redesigns work processes, with active support from top management, to achieve big—50 to 100 percent—improvements.