Think Like a Scientist: Why Great Healthcare Leaders Don’t Pretend to Have the Answer

Why This Episode Matters

Healthcare organizations invest enormous effort in quality improvement projects, yet many struggle to achieve durable change. Too often, improvement is treated as something that happens at the frontline, while leadership behaviors, management systems, and organizational culture remain untouched.

In this episode, Dr. Lee Erickson reflects on decades of hands-on improvement work to explain why real progress depends less on tools and more on how leaders think, learn, and show up. The conversation challenges familiar assumptions about accountability, expertise, and authority and offers a grounded alternative rooted in scientific thinking, transparency, and coaching.

Key Ideas Explored

• Why improvement fails when leaders don’t change how they manage
• Thinking like a scientist as a leadership skill, not just a clinical one
• How daily management systems surface problems early — without blame
• Why spread depends on culture, trust, and peer-to-peer learning
• The limits of outcome targets without process understanding
• Building networks of change agents instead of relying on heroic leaders

Takeaways for Quality Leaders

• If you want front-line behavior to change, leadership behavior must change first
• Don’t demand answers before experiments — design systems that allow learning
• Use data to create transparency and motivation, not fear or punishment
• Build truly interdisciplinary teams for complex problems like flow and discharge
• Treat spread as a relational process, not a rollout plan
• Replace command-and-control with coaching and problem-solving support
• Invest in developing people who can think, test, and teach others

Continue the Conversation

Connect with Dr. Lee Erickson on LinkedIn or through her organization Adaptient to continue the dialogue.
This episode is especially useful for executives, physician leaders, and quality professionals trying to move beyond project-based improvement toward lasting cultural change.
If this conversation resonated, consider sharing it with a colleague or leaving a thoughtful review.

Resources & Frameworks Referenced

• Lean and Toyota Production System principles
• A3 problem-solving methodology
• Plan–Do–Study–Act (PDSA) cycles
• Lean Daily Management Systems
• Interdisciplinary improvement teams
• Helen Bevan’s work on change agents and spread (including the School for Change Agents)
• Incident Command System lessons from the COVID-19 response

New episodes published every other Thursday at 7AM Eastern Time.

Chapters

• 0:00 Why Frontline Fixes Fail
• 0:32 Meet Dr. Lee Erickson
• 2:40 The Lightbulb Moment: Lean That Works
• 10:36 Transparency, Targets, And Trust
• 17:39 Building A Daily Management System
• 24:20 AFib Breakthrough From Daily Huddles
• 31:58 How Real Change Spreads
• 38:18 The Sloan Kettering Discharge Redesign
• 49:06 Cross-Functional Teams And Safety
• 55:24 Why Culture And Incentives Block Progress

Transcript

SPEAKER_02: 0:00

The problem that I saw everywhere I went is we are trying to fix safety and quality and even efficiency and workflow in healthcare only at the frontline without making any changes in the way we manage an organization. It will not work. You can't ask frontline people to change the way they do their work if we, the leaders, continue to manage them exactly the way we've always done it.

SPEAKER_01: 0:32

Welcome to Leading Quality, the podcast spotlighting the people moving healthcare forward from the front lines to the C suite. I'm your host, Jason Meadows.

SPEAKER_00: 0:50

Today's conversation is with someone I've had the privilege to know not just as a national leader in quality improvement, but as a colleague and mentor.

unknown: 0:58

Dr.

SPEAKER_00: 0:58

Lee Erickson is a physician leader who came to improvement work the way many clinicians do. Skeptical at first, busy with what she calls real work, and unconvinced that quality methods could truly change daily practice. What changed for her wasn't a mandate or a buzzword, but a moment when she saw scientific thinking applied to systems and watched it radically improve care, flow, and working conditions for patients and staff alike. Over the course of her career, Lee has led some of the most meaningful improvement efforts I've personally seen. From building lean daily management systems to redesigning hospital discharge processes at scale to showing what's possible when leaders stop managing by command and control and start leading like scientists. During our time working together at Memorial Sloan Kettering, I saw firsthand how she combines deep perspicacity with genuine humility. Recognizing as a scientist that she doesn't have all the answers, while still lighting a clear path for others to achieve great things and let their talents shine. In this conversation, we explore why so many improvement efforts stall, why frontline change fails without leadership change, and why coaching, psychological safety, and scientific thinking are leadership skills, not optional extras. We also talk about culture, spread, and what it really takes to build organizations that can learn and improve over time. Lee brings rare clarity, honesty, and humanity to this work. And I'm excited to share her perspective with you.

unknown: 2:33

Dr.

SPEAKER_00: 2:33

Lee Erickson, welcome to the show.

SPEAKER_02: 2:36

Thanks, Jason. I'm really looking forward to our conversation.

SPEAKER_01: 2:39

Yeah, me as well. To start us off, I'd like to maybe get you to take me back to early in your career and just how you became first interested in healthcare quality improvement work.

SPEAKER_02: 2:52

Yeah, in the beginning, I was not remotely interested in this. You know, I was one of those docs when you saw the quality department coming, I mean, like, I've got to go hide. I have real work to do, and the quality police are coming down the hall. But early on in my career, I was only a year or two out of residency, I got my arm twisted to be medical director of one of our department's larger community health center clinics. And it was a very dysfunctional clinic, overwhelmed with volume, not a lot of resources. It was in a county health system, so you know, we didn't have much margin. And problems in care delivery, operations, frustrations for everyone who worked there, for the patients as well, had just been allowed to fester for decades because nobody had the appetite or the know-how or the budget to fix things. And I quickly found out, um, even though I had a great mentor who talked me into taking the job who said he'd teach me how to do this, I found out that I had to do these god-awful things called PDSA projects twice a year because back then the joint commission required them, and this was a clinic on a hospital license, so we had to do them. And I didn't know it at the time, but I was working in a health system with a CEO who had fallen in love with Toyota and thought the Toyota production system and lean and systems engineering was going to be the solution for quality and safety and healthcare. And so not only did I have to do these improvement projects, you were using this whatever it was, PDSA methodology I'd never heard of, I had to do them on these big sheets of paper called A3s. And I'm like, oh, this is ridiculous. I have patients to take care of. Why are you bothering me with this? And I think I had been in the role for about three or four months, and we had to go to these quarterly quality improvement meetings as medical directors and listen to everybody's projects. And they were usually held in the evening when we all wanted to go home after seeing patients all day. So all the docs would sit in the back of the room with their paper charts, because this is pre-electronic health records, quietly finishing their notes during the presentations of projects and not paying any attention. And so I'm sitting in the back row, sitting next to one of our surgeons, and some nurses up front, you know, the lights are dimmed, and she's doing this PowerPoint, and nobody's listening to her. And in fact, the surgeon next to me was leaning back in his chair on the wall, quietly snoring like he had dozed off. And she gets to the end of her presentation and said, And now the ORs run on time about 95 to 97% of the time. And I hear his chair goomph, like slam down on the floor. And he sits up and he leans over to me and goes, What did she say? I said, I think she said the OR is running on time all the time now. He's like, What? That's not possible. And he like raises his hand, and the MC, who is my mentor, calls on him and goes, I'm I'm sorry, could you repeat that? And she says, Yeah, now the ORs run on time about 95, maybe 97% of the time. And there's this silence, and then he goes, No, I'm I'm sorry, I I missed most of your talk. Could you just tell me again how you did it? And Harry, my mentor, turned the lights on, said, All right, clearly this story has gotten your attention. Let's go through it again, step by step. And so she presented her A3 improvement project, using lean engineering principles, to look at the bottlenecks in the OR of this 1100-bed county hospital with a three-state burn unit, the busiest maternity department in the state, um, huge operating room volume. And if you were going to have an elective colosystectomy or, you know, some other planned surgery, you were not getting it on the day you were scheduled because all of the burns and trauma and emergencies and crass C-sections would bump you. And even then, you'd probably start your case several hours after you had intended to start it. And they took a look at it and really using scientific method and data, figured out where the bigger bottlenecks were, went to the board and said, we need to fix this and this. And here's the data that proves we're right. And they went, okay, and spent the money on some relatively simple renovations and a little bit of staffing shifts and solved it. And I remember sitting in the back of the room going, wait a minute, this crap works? Get out of here, really. And so a couple of colleagues in in the practice and I started trying to tackle something that made all of us cranky, and we fixed it. And we were all like, wait a minute, oh my God. And that was it. I was lost. You know, this is my career forevermore. Because when I realized I could use scientific thinking, which we all learn, you know, prepping for med school and then reinforcing med school, when I could use it to actually make life better at work, not just for the patients, because that's, you know, all of our altruistic goals, but really make it better so the docs could all go home on time for dinner and the nurses wouldn't be getting yelled at by angry patients who had been waiting for hours anymore. And all the other things that make working in healthcare in this day and age miserable, when you can get that friction out of it, oh my God, it's it's worth every ounce of energy you put into it. And that's sort of how I I got my start in it. It was not what I was planning to do. I was going to be a department chair and, you know, an academic clinician, sort of leader and educator. And I still did that, but I just did it about quality and safety instead of clinical stuff.

SPEAKER_01: 9:00

Aaron Powell I think for sharing that. I've heard you you shared this story with me before, but I you know I never realized in the number of people that I've heard share their their so-called light bulb moment, that yours was literally in a room that was dark and had the light bulb had to be turned on at the moment you were all having this collective realization. I just love that. Yeah.

SPEAKER_02: 9:21

Yeah, yeah. It was it was pretty funny. And I have to hand it to Harry, my mentor. He knew what he was doing. I think he'd planned the whole thing. Um, and he was trying to find a project that would surprise everybody and get them excited and engage them on purpose. Yeah. Smart guy.

SPEAKER_01: 9:39

Yeah. So tell me a little more about how it unfolded in the weeks or months or years immediately following that. You had this light bulb moment. You saw things as being so much more possible than before. How did things unfold after that?

SPEAKER_02: 9:54

Yeah. One of the big things I remember, we ran into some reductions in force in that practice, you know, across the organization. Money was really tight. First thing healthcare does is fire people when money is tight, because labor is our biggest expense. And I was really mad. And I go stomping up to Harry's office, livid, like we're doing all this work, and now you're taking away two of my nurses and you know, these other FTEs that we really, really need. And he's I I have to. And he showed me the numbers. He sat down with me. At that point in my career, I didn't really know a whole lot about budgets and finance and reading profit and loss statements. And so he walked and walked me through them, showed it all to me. And as I'm looking at it, I see, oh, yeah, well, you were given a mandate from your boss, and this is the best way. I I get what you're doing. This actually makes sense to me. I don't like it. But I also saw, so wait a minute, if I can get our revenue up to here, do I get my nurses back? And he kind of went, um I I guess so. I was like, all right. So tell me, we need to get our clinic volume up to this, the RVUs, the revenue up to that. These are my targets. Yep. Can I go share these with the rest of the department? And he's like, wait, what? Because budgets are secret, right? You don't share your budgets with everybody. He's like, why? I'm like, I need to show them how many patients away we are from getting back to being adequately staffed so we can do the math and figure out what we need to do to improve flow in the clinic so that we can get the volume. And he was hesitant, but I talked him into it. And he's like, all right, all right, just you can't share salary data or anything really confidential, but you can show them the bigger numbers we've talked about. It's like, okay. So we have a huge staff meeting. I showed it to everybody. And I really remember being so surprised. Like the staff were like, wait, that's it. That's all we have to do. We can do that. And within a couple of months, we were in the black, actually, better than the targets that Harry and I had agreed on. And the day I got to come to a staff meeting and say, we're getting not two nursing FTEs back, but we're getting an extra one. So we get three. And we're getting our MA and our counselor from the social work department back. We're we're getting all of it and then some was really, really amazing. And for me, I think that was one of those moments where I realized there was power in transparency and data. And it's a great motivator. If you just show people the goal in a way that makes sense to them, they'll they'll exceed it. Because healthcare people are smart and competitive and ambitious and hardworking. Um, and so I got more and more interested in it. Um from that job, we moved, and serendipity would have it. I just happened to move into a department in another city where our department chair knew a lot about Toyota and lean and quality improvement. And nobody was talking about high reliability yet, but she had a real good gut instinct for safety practices. And she took me under her wing, said, You're gonna do our quality and safety curriculum as our new faculty member. You're gonna, I'm gonna send you to school. She sent me to study with Toyota. It was phenomenal. And then she had me start doing a physician executive program where I started learning about things like budgets and how to read and argue over profit and loss statements and how to understand staffing ratios and productivity reports and all the things you learn as a health system executive, so that we could use them to our advantage to get what we needed for the quality and safety work. She was a really great mentor, also. I mean, a lot of my career has been luck and good mentorship. So, you know, fast forward a little bit, and I find myself, and I think you've heard this story too before, Jason. I find myself as uh one of our hospital's chief quality officers slash chief medical officer and interim chair of our department. And that had two residency programs in it, and I had two little kids, and I was like, this is ridiculous. I can't do two jobs, which are really more like three jobs and have little kids at home and and stay sane. And so I talked to a lot of my mentors, partners, colleagues, spouse, and decided I didn't really like being department chair as much as I thought I would. I like fixing stuff way more. And so I let that sort of academic leadership role go and have never looked back. I I have loved what I've chosen ever since. It's been it's been a fun and interesting career path. Not at all planned. You know, it's just sort of a door presents itself, you crack it open, take a peek, and go, oh yeah, I'll go through here.

SPEAKER_01: 15:21

And so you talked about the the kind of the early wins with you know the operating room that inspired you, the clinic flow that got three rather than two nursing FTEs. And now you've liberated yourself from this chief of department role, uh, you're going full-time into quality improvement. What were some of the kind of the major change efforts? Was there a um uh was there kind of one example that you felt like it was really validating lean as a uh as a meaningful way to have durable impact?

SPEAKER_02: 15:50

Oh yeah. Um so this this hospital where I was the chief quality officer, yeah, and my mentor Marion put me there. Um they have a lot to thank her for. We had been experimenting a little bit with some lean things, you know, having Kaizen events, teaching people about designing processes without waste, you know, some of the sort of more superficial stuff. And we were seeing that it was useful. And again, serendipity, you know, this was in Pittsburgh. And at the time, southwestern Pennsylvania was this weird little crucible of lean in American healthcare. So we had the advantage of a number of nonprofit organizations that were trying to help healthcare learn to do things more safely using the Toyota production system. So we brought in a small boutique, uh I don't even want to call them consulting firm, because they were really an academic department at an engineering school to help us. And they helped us implement a lean daily management system. We around the same time needed to replace our CEO at that hospital. And so we intentionally went looking for a CEO that understood the Toyota production system and daily management systems and found one and decided to make that community hospital in our system our learning lab. And so we did a full-on lean integrated daily management system. It was really cool. And when I left that job, I knew I was leaving something really special, and I've been kicking myself ever since because I've never gotten it back. Um but we started with the executive team, um, created a balanced scorecard, started disseminating across the organization. But at the same time, we were also opening up a brand new service line at the hospital. We were opening a cardiothoracic surgery program. We didn't have one before. And we had a member of our board of directors who ran his businesses using the Toyota Daily Management System. And so we decided we would open this new service line. It had new buildings, new critical care rooms, new ORs, all new staff hires. I mean, it's a greenfield, brand new from the bottom up, brand new service, that we were going to build it from the ground up using lean principles. So some of the architectural design was informed by it. The way we hired people was informed by it. Um, they began with the balance scorecard and daily huddles and improvement methodologies from the get-go, like before we even opened doors to real patients. Um and it was fascinating. And so that one brand new service became the learning lab to spread it across the hospital. As we were rolling out a new new unit, they would come and watch the cardiothoracic team do their thing with lean, and then they'd go open the same kind of program in their unit or their department. Um it was really cool. I I don't know if I've told you this story. I probably have. That cardiothoracic surgical group was having a daily huddle one morning, and I've just, as luck would have it, I was there, and we did our huddles very tightly scripted because we stuck to the 15-minute standing rule. Like if if it was 14 minutes and 59 seconds and you weren't done talking, we'd cut you off at 15, because that was the rule. One of the nurses, when the leader of the huddle said, Anna, have we had any quality problems in the last 24 hours? She goes, Yes, Mr. So and so had apib post op last night. And the surgeon, medical director goes, I that's a known complication. Everybody gets that. It's no big deal. And she looks in the room, goes, But, but Mike. Isn't that a problem? No, it's just a non-complication. We get that all the time. She's like, Yeah, but we don't want him to have a fib, right? So it's a clinical problem. And Mike kind of blinked and went, Oh, oh, I see your point. So they started doing PDSA cycles on every post-op patient that got AFib. And because it's a whole scientific method and trial and error and observation and data crunching, they started to figure out all the things that contribute to post-op AFib and started redesigning their post-op care processes to get rid of them. And a year and a half later, their post-op AFibrates were so low. When they went to the STS annual meeting, the Society of Toracic Surgeons annual meeting and presented their data, people said they were fudging the data and not telling the truth because everybody knew it was impossible to have AFibrates that low. And I was, again, kind of like, this is not just about flow or operational excellence or efficiency. This is about clinical care. And fundamentally, it's just about thinking like a scientist about everything. You know? That was a really special place to see that kind of management system implementation, the speed with which an organization can pivot or can respond to a challenge or how quickly you see a problem instead of finding out at the end of the quarter when some report is published. You know about it within hours of it happening when you use these integrated management systems. It was really fascinating to be there. We've all experienced it a little bit with the pandemic, because if you think about it, the incident command system methodology, which is frequent briefings and huddles every day, is a daily integrated management system. And I keep saying to people ever since COVID, what if we could work like that all the time, but without the panic? Wouldn't it be awesome? Because the things you can accomplish, I mean, the things we did in the pandemic, we could not have done without that kind of integrated management. Think of what we could do when we weren't distracted by a global emergency if we still worked this way.

SPEAKER_01: 22:22

Absolutely. I I remember uh a recent conversation with uh Dr. Hillary Babcock, who was uh CQO at BJC in St. Louis and and was like infection prevention and then kind of shifted over to CQO. And she describes it the same way, like the intensity of focus we had over a single unified global problem. If we could extract that secret sauce and kind of redeploy on all of our ordinary day-to-day problems post-pandemic, we would be, we'd be so much better off. I'm wondering you you set up this cardiothoracic surgery um center and you you set up the whole service line and then had to establish this this culture from the ground up of a daily management system. What did you learn after that about spread? Because this was your testing lab.

SPEAKER_02: 23:11

Yeah, spread is interesting. It isn't easy because you can never overestimate how much culture is going to try to drag your spread backwards. The other thing that I think I've realized more and more with each passing year is you know, go back to your basic theory about adult learning. And actually, I don't even think it's adult learning, it's just the way humans learn. We don't learn by being told, we don't learn by being shown, we learn by doing. And so for that hospital, we had a tremendous advantage in opening that new service line from the ground up this way, because everybody who was hired into it, we just said, this is the way we work. And they're like, okay, there was no culture to eat us alive because it was all new. But then we would choose who was going next very carefully. You know, it was a combination of who had a critical problem that needed to be solved, because we wanted to get to those fast, but also who was culturally ready or had a few champions with cultural authority, you know, that people would listen to them, that we could bring into our thoracic surgery service line and show them. So we would find a couple early adopters in the next area we wanted to spread to and have them come spend a couple of days in the cardiothoracic surgery team. You know, the docs would shadow the surgeons, the nurses would shadow the nurses and each other and just kind of learn. And we'd say, look, you're you're not here to learn about cardiothoracic surgery patients. You're here to watch how they are doing their work, not the clinical care itself, but how they talk to each other, how they store their supplies, how they surface problems and things like that. And it worked very, very well. It's not always easygoing, though. I remember one experience we were working on one of our nursing floors that was getting ready to roll it out. And one of the first things you can do in a hospital setting, actually in clinics too, are some 5S projects, you know, the things to help you manage your inventory. They're always a good way to start because they make the staff so happy when things are suddenly organized and nothing is expired and nothing is broken and it's all clean and ready to use and it stays that way. They're like, oh my God, this is amazing. So we would often 5S a place before we roll the huddles and everything else out. Or we would start the huddle system, but all they would talk about at huddle in the beginning was their stuff and like how is the 5S improvement work going? And I had this nurse manager on this floor who just didn't want to do it. I mean, she was fighting me tooth and nail, couldn't, didn't want to run the huddle, thought, I mean, it was just too awful. And she finally is like really mad at me, but leave this this isn't gonna work. We don't have any room for our supplies. I'm like, all right, well, let's go walk your unit together and show me what you've got. And the hallways in this hospital had these big alcoves at one end of them for like storing your EKG machines and a wheelchair or whatever. What they had become over the years was giant junk piles that you could leave there because they weren't obstructing the hallway. So the joint commission didn't care what you had in the giant junk pile as long as it was not 18 inches too close to the ceiling, right?

SPEAKER_01: 26:53

As long as it was an organized junk pile.

SPEAKER_02: 26:54

Yeah, yeah. And I said to her, What's all this stuff? Like, why can't we clear this stuff out? And you can do the 5S for the EKG machines and the other equipment right here. No, no, no, we can't move any of that stuff. Well, what is it? I I'm not sure. Well, let's go through it. And and there's like all the stuff that's broken. She's like, Oh, I didn't even know that was there. Well, let's throw it out. I can't throw it out. And there's this big machine like taking up a third one of the corners. And like, so what's this? I have no idea. Neither of us knew what it was. I don't even remember what it was. Some ancient broken machine that nobody uses from the 1970s that had been there forever collecting dust under this plastic cover. And I was like, well, just Mary, just throw it away. Like get facilities to come up and take it out to the loading dock on trash it. I can't do that. Why not? Well, they won't let me. Who's they? Administration. Mary, I'm administration. No, no, no, I don't want to get in trouble. I had to go get Gary, our CEO, to come up and give her permission to throw it out. At which point, she burst into tears because she was so anxious about getting in trouble for making change that even our CEO had trouble calming her down. And we were like, who is she afraid of? Like, he's the ultimate voice. She doesn't even know who the board members are. You know, it was really interesting. And so spread takes a lot of personal touch. You can't just delegate it to some training department because those culture moments, you can't predict when they're going to happen. And if you're not there and available, you'll miss them and the spread will fail. So it's it is very political. It is a lot of shaking hands, kissing babies, reassuring people, and then getting them to tell the story. So after we cleared that alcove out and they finished their 5S of the unit, she ended up having one of the best huddles in the house. And we used to go get her to come and tell the story about bursting into tears in front of the CEO because he said she could throw that junk away to the next unit that was going. And so the other thing for spread is get your last go live to tell stories to the next. One-to-one, peer-to-peer. It means a lot. Have you have you followed the work of Helen Bevan?

SPEAKER_01: 29:27

Yeah, I have. Well, we'll get to it later, but the you, I think, were the one when we were both at Sloan who recommended the school for change agents. So that was my first exposure. Yeah.

SPEAKER_02: 29:37

That's right. We did our school for change agents at Kettering. Yeah. Helen has a really nice model for spread where she gets the groups that are going to go next observe the groups that are changing right now.

unknown: 29:53

Yeah.

SPEAKER_02: 29:53

And just watch them. And then when the go next group starts, the people who just finished coach the go next group. And the next one down the line is watching. And it's been a really successful model for that NHS. And so I've tried to borrow from that over the years as well.

SPEAKER_01: 30:14

That's great. And uh yeah, a lot of more questions I can I can think to ask there. I am wondering as we kind of so shifting gears into another phase in your career, you know, one of the most striking examples that I'm personally aware of is your work when you were uh deputy physician in chief for operations at Memorial Sloan Kettering Cancer Center. And that was during the time that you and I both worked there, and our time overlapped. Fortunately, that was how we ended up meeting. And ultimately, you know, the big headline number is that we've saved two hours uh on average for for all the discharges across about 23,000 discharges, which meaning you know 46,000 hours uh per year. Can you walk us through how that actually happened?

SPEAKER_02: 31:01

Yeah. So MSK was in this really difficult place where we had more demand for inpatient than we had beds. Quite a bit. And we had a huge mismatch in two curves that are really critical for inpatient flow. One was the admission curve, like when during the 24-hour cycle of a day the admissions start getting orders dropped and need their beds, and the discharge curve. And there was a huge gap. Like our missions admission curve started to climb at about 9 30 in the morning, but the discharge curve didn't start to climb until about 3 p.m. And so we would have these hours in the middle of the day with all of these borders jamming up everything. You know, the urgent care was backed up, the OR was backed up, PACU was backed up, it was really unsafe and very painful for everybody. But a discharge, one of the things you learn from process improvement, particularly using Toyota's approach, but it's it's also true in uh if you're a Six Sigma enthusiast or you know, most methodologies, is there's a real cardinal rule that must be followed. You cannot redesign work without the people who do that work. So one of the first things we did was build interdisciplinary improvement teams to work on discharge. And we thought very carefully about every function that touches a discharge. Each team had to have somebody from that function on it. So there's the physicians, the physicians in training, the nurses, the physical therapists, the case managers, the pharmacists, the people who clean the rooms, the people who assign the beds. I mean, there's so many disciplines that touch a discharge. Um, security guards, the people who direct traffic in the parking lot and out front in front of the hospital. I mean, there's so many pieces to it. We got them all together. We trained them all in some basic process improvement principles and methodology, some basic fundamental principles of work design, and then let them go at it with data. And if they would come to us and say, Well, we're gonna implement this, my answer was usually no, you're not. You're gonna test it first. And if you can prove that it works, I will back you all the way to implementing it. Um, and so we did dozens and dozens and dozens of experiments. Different floors would experiment on different things, and if we found one that worked, we spread it to the other floors. Because all of these streams trained together, they knew each other, they started sharing ideas. Um one of the biggest success moments for me was I don't know if you remember, was it M18 was our sort of surgical step-down floor? I think it was M18.

SPEAKER_01: 34:03

Sounds right.

SPEAKER_02: 34:04

They got a phone call from the Pac U one day and said, What are you guys doing up there? And Andrew, their nurse leader, was like, Well, what are you talking about? He goes, Two of your nurses just came downstairs asking us for the next post op so they could take them upstairs because they're ready. It's only 10 a.m. What do you mean you're ready for somebody to come out of pack you? That never happens. You know, it was just like they were so delighted with themselves. And most of the floors, overall, I think we moved the average discharge time when we started was a little after 5 p.m. And we moved it down to about one in the afternoon, which had a huge impact. I think overall, when we did the math, it was worth about 25 inpatient beds, just the amount of time saved, being able to move people upstairs quicker because we were moving people out quicker. It dropped length of stay. It patients were happier. I mean, one of the bigger ones was the discharge lounge, which I originally was opposed to. The team had come to me and said, Well, Lee, we've been reading about discharge lounges. And I was like, no, a discharge lounge is a workaround for a broken discharge process. Like, if you could get the discharges on demand and into the cars when they go home, you don't need the lounge. And we had a day where I think we hit 140% of census and like everything hit gridlock. Like, you know, on gridlock days in Manhattan when nobody can drive anywhere because all the intersections are jammed up. So they came to me, we had an emergency huddle. What are we going to do? They were like, Well, can we try the discharge lounge? I'm like, what do you mean? It goes, Well, we have space downstairs. Admission said we could borrow it for the afternoon. Let's just try it. I'm like, okay, fine. Let me know, you know, what you need from me. We'll meet again at three in the afternoon. And so we got together at three and I said to them, so did you figure out what you need for the discharge lounge? You know, let me go administration, I will get you what you need. And they look at me and goes, I know, we already opened it. I was like, wait, what do you mean you already opened it? They just on their own, because they were getting so good at this try stuff out mindset. Just try it, see what sticks. We ended up spending a couple of hundred grand renovating space for discharge lounge. And I was wrong. They proved me right. It worked great. The patients loved it because they didn't have to park anymore. They could, the family could call the discharge lounge and say, like, I'm three blocks away, bring her out to the sidewalk, and we just put them in the car. Huge patient and family pleaser. And, you know, if they hadn't held me to my think like a scientist, try it, it's an experiment. If it doesn't work, it doesn't. And if it doesn't, we never would have done it. So they had me. It was great.

SPEAKER_01: 36:52

That's amazing. I remember actually experiencing that in real time. And all of a sudden, as a as a frontline clinician as well, is doing some of this improvement uh work. All of a sudden, hearing and and being able to recommend this discharge lounge for people who are, you know, met the criteria of being, you know, more ambulatory, et cetera. What what other few critical changes do you think made made the biggest difference in this huge transformation?

SPEAKER_02: 37:17

I think one of the biggest is breaking down those interdepartmental barriers. When you build uh truly cross-functional teams like this, people have to talk to each other. And if you think about the culture of healthcare in modern times, we don't talk to each other. We text message, we send messages in Epic, we page using, you know, text on pages. We don't know the names of the people that we're working with. I mean, I've I've been in operating rooms where the surgeons don't know the nurses' names that they're scrubbed in with. It's it's really weird. But when you build an interdisciplinary team, teach them a common language, a common methodology, common tools, give them permission to iterate and ideate and then get out of their way, it's kind of magical. And it doesn't take very long for me as a leader to notice the change. Because what happens is people stop coming to my office to try and leave their problem on my desk because they don't know who to reach out to. They don't know their colleagues in that other department. Instead, I go to them at Huddles and ask, what are you working on? What problems are you solving? And they tell me and I say, Do you need any help from me? Make oh no, no, no, no. I know the guy in pharmacy. I'm I'm gonna go meet with him after lunch today. It's like, huh, this is awesome. You know. It's sort of it's the shift from people looking at me like I have two heads growing out of my neck, saying, What do you mean you want me to leave my office and go downstairs down the hall and talk to a stranger to, oh yeah, I know Frank. I'll just I'll just call him. No problem. You know. It's it's magical.

SPEAKER_01: 39:10

It it it sounds magical. And certainly it felt it at the time. Uh again, I I remember, you know, the freedom with which we would be able to share with other improvement teams. So at a certain point, I ended up being one of those kind of local uh physician leaders um on M16 and the dialogue between floors when someone presented, you know, on something that they'd been working on and actually being able to learn from them or adapt, you know, even different floors have their own local context. So, you know, to what worked on the bone marrow transplant floor might not work on the GI oncology floor we were on, but you know, does some version of that work? And how do we we think about spreading it? Um and then as you're kind of alluding to the leadership behaviors to create that psychologically safe space to allow for experimentation, you know. In a safe, controlled way, really allowed things to uh to blossom. We haven't yet talked about your work in Boston, which I know came after that that chapter, but having worked in in Pennsylvania, um, New York City and Boston and beyond, what are some patterns that you see repeating themselves across organizations that are important for us to be thinking about?

SPEAKER_02: 40:23

Right. So now I get to go from being Lee the optimist to Lee the pessimist. Um I keep seeing the same problems over and over and over and over again. And it's like that definition of insanity, you know, like keep trying the same thing and expect different results. It's just astounding to me. Why are we still working on patient flow? Why are we still working on collabsies and cowdies? Like we know what we need to do. The problem that I saw everywhere I went is we are trying to fix safety and quality and even efficiency and workflow in healthcare only at the frontline without making any changes in the way we manage an organization and the way we run our industry, you know, the healthcare industry. And it will not work. You can't ask frontline people to change the way they do their work if we, the leaders, continue to manage them exactly the way we've always done it. Learning to lead in this way has been a fascinating journey for me. Um so I'm a doctor and I'm bossy and I like to tell people what to do. And they taught me to give orders when I was in residency and, you know, all that kind of top-down command and control leadership kind of stuff. It doesn't work when you're thinking like a scientist. Because thinking like a scientist, I can't tell people the answer because I may not actually know it without doing the experiment. So the role becomes much more like that of a coach. And my job as a leader is how can I help you test your idea? How can I help you figure out the solution to the problem you are trying to solve? There's a famous management article. I may have even given it to you at one point. Um, Who's Monkey?

SPEAKER_01: 42:26

Oh no, I haven't gotten that one.

SPEAKER_02: 42:28

As a leader, people will come into your office with their monkey on their back, their problem, and they try to leave the monkey on your desk and go away. And the gist of the article is a really good leader will make sure they leave your office with the monkey with directions to feed their own monkey. And the first time I read it, I was like, oh, this is hilarious. I'm gonna try very hard not to accept any monkeys. But then I realized it's way more than that because they're bringing the monkey to my office because they don't know how to take care of the monkey. I'm not gonna take care of it for them, but I do need to coach them and show them and help them learn how to take care of the monkey, help them learn to be scientists. We don't do that as executives in healthcare. We get taught how to tell people what to do. We get promoted because we're good at coming up with ideas that we tell people to do. We don't get promoted because we're brilliant coaches. And we don't have a culture, despite 25 years of the patient safety movement, we do not have a culture yet where it is okay to show dirty laundry, bad data, admit how unsafe we actually are without getting your head served to you on a platter at a board meeting or your CEO is gonna ream you out after you unveil the terrible outcomes in front of people he didn't want to see them or whatever. You know, we have I don't know why our egos are so fragile in healthcare. I mean, it's it just is what it is. It's a problem. We should fix it rather than beat ourselves up about it or hide it. But I saw it everywhere I went, this sort of command and control culture and this fear of acknowledging, I hate to say it, but we kind of suck. We're the most expensive healthcare system on the planet, and we rank almost dead last in terms of outcome compared to all of our industrialized countries. You know, and I know there was um that paper in 2016, and then the OIG published this twice, sort of estimates of harm in U.S. healthcare. I actually think the math is right. I do think we are probably the third leading cause of death in the country. It only takes about a quarter of a million deaths from errors in healthcare a year to be the third leading cause of death. If you think about it, that's not that hard to hit when we think about people dying from infections, from missed diagnoses, from complications of treatment. Had we been more on the ball, maybe we could have prevented all those other things. They add up really, really fast. But we're not talking about it. It's it should be a national emergency, but we're not. And I see it over and over and over again. It's really disheartening. Well, the good news is still though, healthcare people are ambitious and we're determined and we're really, really smart. And if here I'll go way out on a political limb here, if capitalism would get out of our way, I think we could fix this. Um when we're trying to run an industry that is about service to human beings, like a for-profit business, it just doesn't work. There is no easily measurable profit in patient safety work and quality work. It's soft money. You know, I I can't trace this back to a hard dollar a CFO will say they can add to the margin. They don't think cost avoidance really counts the way we do our accounting in capitalism. And it just it doesn't work. That pattern has to change. We have to change the way we think about our industry. We have to change the way we think about our jobs as leaders. Yeah, it's it's a tough nut to crack. I don't think it's impossible, but it's a big challenge.

SPEAKER_01: 46:20

I wanted to lean in to something I heard you say there, that I think so much of what we do in communicating about quality improvement work and about anything in medicine is about how we can frame the message effectively. And what I heard you say was thinking like a scientist requires humility. I think that thinking like a scientist is really an easy sell for people who studied science and went into nursing or medicine or physical therapy or whatever healthcare discipline they come from. Thinking like a scientist is a really easy sell. And what you're saying is it's necessary to approach leadership with humility and with this, ultimately with this coaching kind of perspective, because you couldn't possibly know the answer of the the result of the experiment before you conduct the experiment. I think that's such a rich framing that I just wanted our audience to hear again as I as I was uh digesting it.

SPEAKER_02: 47:23

And if you think about it, it is not taught in business school. And these are the people who are running healthcare systems. I mean, yeah, there are more and more physicians and nurses in executive roles, but they're still relatively rare. They don't teach you to think like a scientist when you're getting your MBA, they teach you to think like a financial analyst, and it's very different. They want us to commit to the answer before we've tried the experiment. I mean, just look at how executive teams set incentive and bonus stuff. Well, you'll get your bonus if you can get the CLABsy rate down to this this year. And I would say, I don't know how long I can get it until I start experimenting. It's ridiculous. You know, this idea that the outcome metric is so much more legitimate than the process metric. Well, if you can't get the process metric right, you're never going to get the outcome. These are all like fundamental scientific principles that we don't teach in management theory. And we we need to start teaching it in management theory. And it's not our our executives' fault, it's what they were taught. And they need a tweak to their curriculum. You know, they why wouldn't we do scientific experiments for how to run an organization of human beings? Of course we should. That's really fundamentally what lean or six sigma process improvement work is about.

SPEAKER_01: 48:48

Yeah. I I want to shift to this current chapter, which I think is a big culmination of a lot of this incredible work that you've done in the company that you've now founded and that you lead as CEO, Adaptient. What can you tell me about Adaptient?

SPEAKER_02: 49:06

It's funny. I had thought about doing consulting work for many, many years, but I I like being an operator. I like doing things. And so I sort of said, I'm gonna, I'm gonna do one more job trying to do this transformation work as an operator. And, you know, post-pandemic, pandemic, and now the finance crisis and healthcare, it makes it very hard to be an operator. I would do it again, but I don't want to do it again for a CEO and a board and a team of executives that don't know how to think like scientists. So I thought long and hard, where would I find an executive team to join like that? I don't think there are any, maybe a half a dozen in the country. So that's not likely to happen. Maybe instead I would have more fun trying to teach them how to think like scientists. And so that's kind of how our company came to be. My partner, Sharon Hickman, is a systems and industrial engineer who's worked her whole career in healthcare. And we're having a ball, sort of a partnership as an engineer and a physician who knows this stuff. Working on projects at health systems. Um, we've done work with patient safety organizations, federally qualified health centers, teaching them what we know. And so we look at ourselves not really as consultants, but as teachers and coaches. You know, we'll bring us in, we'll teach you how to fish. We're not going to give you the fish and charge you$5 million for it. We'll teach you how to fish and then go away and you can fish. Um, that was the ethos for it. And it's it's really fun work. Really, really fun. Largely because when people ask for our help, they really want it. When you're trying to do this from inside an organization, people look at you like, what are you talking about, Lee? I don't want to do that. And you have to talk them into it. This way, they're already talked into it. You know, that's why they called us. And so it's that makes it a little more fun. Yeah. We also thought working in this way, we could reach more people than another C. Blanco role in another health system. I mean, you can have a huge impact. Don't get me wrong. And if some CEO who understands this is listening to the podcast and says, Oh my God, I want to do this in my hospital, yes, call me. Um, but uh for now, I'm really enjoying the favorite part of this work. My entire career has been the teaching part and the coaching part. And so that's what I get to do more or less full-time now, which is really lovely.

SPEAKER_01: 51:38

And so one of the things that I'm hoping for with this podcast is not only that we get to highlight, you know, the voices of leaders who have done amazing things like you have, but also to empower people kind of at every level, because we know that there is so much positive change that could start from kind of the smallest corner of the front line. For someone who is in the middle of a system and doesn't feel as powerful to lead change, kind of based on your experiences, uh, what was your best advice for someone like that?

SPEAKER_02: 52:09

You know, it's actually advice from my father, who was a teacher his whole life, middle school, mostly, some high school, some elementary school, but mostly middle school. And, you know, I grew up in a family of change agents. You know, they weren't in healthcare, they were in education and politics, but they're definitely a family of change agents. And I remember asking my dad at one point, I think I was probably in senior in high school, maybe starting out in college, why wasn't he frustrated and disheartened? Like all the change he wanted to see in the world, it was so slow. And didn't he get frustrated and angry as a teacher, feeling like he couldn't influence change at a large scale? And he looked at me and said, What are you talking about? I'm influencing massive amounts of change as a teacher. I'm like, what do you mean? He goes, Look, I teach what, a couple of hundred kids every year? If I can get one or two in a good year, maybe six or seven of those kids, to begin to see the world differently, to think critically, to think about the possibilities for change and how they could implement change, then I've just converted a couple of people who in their lives are going to go out and convert some more people. And I figure by the time I retire, you know, after doing this for 30-something years, I'll have reached a lot of people. And that helps build towards the sea change. And I have always remembered that. Um, and then when I met Helen Bevan and she was talking about change agents and how to be a change agent and maintain your own resiliency and not get burned out, she talked about the importance of building networks of change agents so that we can support each other. And that's what you can do as somebody from any place in an organization, become the change you want to see, and you'll begin influencing the people around you to do the same. But also cultivate your network of change agents as you go along. So when you have a really bad week, you can call a couple of them and vent, and they'll hold you up and keep you going. When you have a great week, you can call some others and celebrate and they'll hold you up and keep you going. And that's how you change the world. You know, the big powerful sea black O's, chairs of boards, yes, they have a tremendous amount of influence, but fundamentally the things they do are shorter lived because when they step down and go away, it's gone. But developing other people, that lasts. And so do it wherever you are in an organization. Just become the change you want. And if you need support, give them my contact info, Jason. They can all call me, email me, put themselves on my calendar, join my network of change agents, join yours, you know, and we'll keep each other going.

SPEAKER_01: 55:09

Thank you so much for that. I I think that that has been uh a huge uh motivation for me in in starting this work, and and I uh appreciate the influence your father had on you and you've had on me in in the early days and still to this day in in the work that I'm doing here. And I appreciate that so much. Getting to the the work that you're doing right now, what um what does Adapting look like in five years or 10 years if it's achieving its highest aspirations?

SPEAKER_02: 55:40

Oh boy. That's a good question. My first thought was wait, five, ten years, I want to retire.

SPEAKER_01: 55:47

Yeah. That's why I kept the timeline flexible. It could be three years, it could be five.

SPEAKER_02: 55:54

I might not. I would love it if we've grown enough to really feel the impact of a network of change agents we're developing. You know, I don't necessarily need to be IHI's competition, not at all. What we really want to do, and sort of our mission, is to develop change agents, to nurture them and teach them to do what Sharon and I have learned to do over the years, what you have learned to do and are still learning to do. So that there's lots of people coming up behind me, because I do want to retire within the next decade, if not sooner. I need to know there's a group of people coming up behind me who can carry it on. Um and I think some of the ways Sharon and I teach this content and the ways we've learned to coach can be learned relatively quickly and spread fast. Um, she and I are both connectors intellectually. We're not the kind of people who focus down on one super specialized thing. That's why I'm a primary care doc, right? It's my nature. Um and our approach has been very much about connecting what we've learned as lean thinkers, Six Sigma, what she's learned as an engineer, what we've learned from the patient safety movement, what we've learned being executives in healthcare systems, connect it all into a more holistic model for thinking about our industry that you can use literally for anything. I mean, you know the A3 methodology. You can apply that methodology, because it's basically just a fifth-grade science experiment, to anything. You can apply it to finance, to management. I applied it to organizing my kids' coke closet when they were in elementary school and we lived in Pittsburgh and had terrible snowy winters. And I kept losing the mittens. You know, we did an A3 on that as a family, and now we always know where the mittens are. You can apply it to anything. And if we can just see that really begin to take hold and spread, um that that was that's success for adapting it. I I want to be somewhere totally random and have somebody show me something that I started, but they didn't get it from me.

SPEAKER_01: 58:18

Yeah. You've brought us back around to the optimistic note that we started on. And I want to thank you for that and for this uh this conversation. You alluded to people reaching out and connecting with you. If they wanted to do that after this conversation, what's the best way for them to do that?

SPEAKER_02: 58:34

Oh, it's actually pretty easy. If they just find us on the internet, adaptiant.com. You can email us from the website. You can put yourself on my calendar from the website for nothing. You know, just find an empty slot and you want to talk, or you have an idea you want to float, or you just need somebody to encourage you to keep trying on a hard day. Do it. You know, I the the connecting is the fun part of the work. And, you know, you and I haven't seen each other in a couple of years. It was so cool to see you doing this and see that you're still carrying the torch and doing this work. It's it's great.

SPEAKER_01: 59:16

Yeah, well, likewise, and we we uh we go farther together. So it's uh it's great to see, you know, what's Adaptian is now involved uh evolving into. I'll I'll make sure that we link in the show notes to the uh to the website so people can get in contact with you. Um I just want to thank you again for for a rich conversation about these incredible human-led, data-led, um, you know, big system impact things that you've done and continue to do. Um thanks so much for the conversation today.

SPEAKER_02: 59:44

Yeah, no, thanks so much. It's been a blast.

SPEAKER_01: 59:49

Thanks so much for listening to today's episode of Leading Quality. If you enjoyed the show, please take a moment to like, subscribe, and share it with someone who might find it useful. You can find all our episodes. At leadingquality.buzzsprout.com or in your favorite podcast app. The show is written and hosted by me, Jason Meadows, edited by Milan Milosavievich, and produced by Thrive Healthcare Improvement. See you next time.