Designing High-Velocity Organizations in Healthcare with Dr. Steve Spear

Why This Episode Matters

Healthcare organizations often tolerate ambiguity, workarounds, and recurring operational problems until they produce serious harm. Dr. Steve Spear explains how leaders can apply the same disciplined thinking used in clinical diagnosis to the systems in which care is delivered—making problems visible early, investigating them rigorously, and building problem-solving capability throughout the organization.

Key Ideas Explored

• High-performing organizations compete through distributed problem-solving capability.
• Standards work best as testable hypotheses, not rigid commands.
• Ambiguity and workarounds allow small problems to become serious failures.
• Amplification, slowification, and simplification create the conditions for learning.
• Leadership means developing others’ ability to see, solve, and share problems.

Takeaways for Quality Leaders

• Go directly to the point of work and observe where staff experience friction or suffering.
• Create clear expectations that make deviations and emerging problems visible.
• Respond to reported problems with curiosity, presence, and practical support.
• Pause when work departs from expectations rather than pushing teams to work around it.
• Build capability in frontline leaders so improvement spreads without depending on a large central quality team.

Continue the Conversation

Steve Spear on LinkedIn or through the See To Solve website

Resources & Frameworks Referenced

• Decoding the DNA of the Toyota Production System
• Fixing Health Care from the Inside, Today
• The High-Velocity Edge
• Wiring the Winning Organization
• See to Solve

Leading Quality is a podcast for healthcare leaders committed to improving systems, culture, and outcomes.

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Connect with Jason Meadows on LinkedIn for more insights on healthcare quality and leadership.

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

Credits:

Host, Writer, and Executive Producer
Jason Meadows, MD

Produced by
Thrive Healthcare Improvement

Edited by
Milan Milosavljevic

Transcript

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Go To The Suffering

SPEAKER_00 0:00

Go to the suffering. Don't worry about these high-level aggregated distilled lagging metrics of qualities and efficiencies and this review and that report. Go to the clinical bedside and look at the things that make it difficult to be a nurse. She said, Man, I always thought of myself as a real problem solver, but I just realized I've been solving the same bleep bleep bleep bleep problem every bleep bleep bleep bleep day for the last bleep bleep bleep 20 years.

SPEAKER_01 0:27

Welcome

Welcome And Guest Context

SPEAKER_01 0:28

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.

unknown 0:46

Dr.

SPEAKER_01 0:47

Steve Speer is a senior lecturer at the MIT Sloan School of Management, where his work has focused for decades on a deceptively simple question. Why are some organizations able to achieve dramatically better performance than others, even when they operate with the same technology, the same constraints, and the same external pressures? That question led him into deep study of Toyota. The now famous Harvard Business Review article, Decoding the DNA of the Toyota Production System, emerged from his PhD work at MIT. Later, books including The High Velocity Edge and Wiring the Winning Organization, the latter being co-authored with Gene Kim, added to an already extensive body of writing and thinking on quality across industries. His writing has also been repeatedly recognized in the quality and operational excellence world, including Shingo Honors and the ASQ Crosby Medal, most recently for Wiring the Winning Organization. In this conversation, we focus on what healthcare can learn from his body of work. Steve argues that the real lesson behind the success of high-velocity organizations is the disciplined behavior behind the results. Designing work so that problems can be seen, responding to those problems quickly, learning from them, and building those capabilities throughout the organization. A key insight he shares in more detail is that healthcare already teaches clinicians how to diagnose, treat, and follow up on biological systems, but often fails to apply the same discipline to the systems of work around patients. We talk about ambiguity, workarounds, speaking up, leadership presence, and why running toward the point of pain is not extra work for healthcare leaders. It is the work. I expect many listeners will already be familiar with Steve's work, because he is one of the most important thinkers in quality improvement across industries. For those who are not, I hope this conversation serves as an introduction that makes you want to learn more. And for those who have encountered his ideas before, I hope revisiting and expanding them here will add real depth to how you think about improvement, leadership, and the design of work. I know it did for me. Steve Speer. Welcome to the show.

SPEAKER_00 3:05

Oh, thanks for having me. Really appreciate this.

The Performance Gap That Started It

SPEAKER_01 3:09

So, Steve, really been looking forward to our conversation. Thanks for joining me. Really excited to go through your work and how that's evolved over the years. I wonder if you can start with giving me a bit of background to your academic training and how you uh got into your first publication or your first big publication based on your dissertation in 1999?

SPEAKER_00 3:30

Yeah, great. Um so uh the common theme of my work, which now runs about three decades, believe it or not, is uh trying to understand the gap. The gap between what some organizations are able to uh achieve, you know, sort of actual, in terms of their ability to generate and deliver value into society uh with rewards to the variety of stakeholders that depend on their efforts, and what's actually possible and that gap. And what motivated me to try and understand the source of that gap was uh, you know, I came to a professional age in the uh 1980s when uh Japan was posing an existential threat to American manufacturers and American industry more generally. And uh what was well documented was that uh on any given day, with uh less effort, less time, much greater agility, reliability, et cetera, some of these firms, not all of them, this was not just a national cultural thing. This was very particular to individual firms, but firms like Mitsubishi, Sony, uh Toyota, Honda to a very large extent, that on any given day, their ability to generate and deliver value into society was way off the charts of what was uh possible by their American counterparts. And I was one of you know the many huge uh cadre who were trying to figure out what was it that was going on inside these very particular uh Japanese firms that they had such an enormous advantage and created this enormous gap in performance between themselves and their counterparts, who everything else, and it sort of, you know, everything was the same but for outcome. Same rules and regulations, same foundational science and technology, uh competing in the same markets, on and on. Everything was the same, but for outcomes. There was this enormous gap between, in the same competitive environment, what most were able to achieve and what these few were able to achieve. So that was the instigation for the work I've done.

SPEAKER_01 5:18

And so then that takes us into your studies at MIT and in your PhD, which you know I understand was largely focused on the work at Toyota. Can you walk me through a little bit how you know how that came to be and what you tell me a little bit about that work.

SPEAKER_00 5:35

Yeah, so when I got to MIT, um I was really quite fortunate by timing. Uh the uh Sloan School of Management, both where I was a student then and now on the faculty, it had oriented around the mission of beating Japan. So, you know, if we're gonna and it made sense at the time, right? Because uh we were not just the Sloan School, we were the Sloan School of Management at MIT. And if uh Japan was winning on its ability to manage technology, manage, you know, all the way from the upstream um uh discovery of new technologies, design of products and systems, their delivery into uh the marketplace, what better place to think about the management of technology than MIT? And it became the core mission of uh the school, and it became the mission of the students who were there at the time. And so that was around the time when MIT was generating some of the seminal work like The Machine That Changed the World, which started to establish the enormity of the gap in performance between what was typical, what was actual for most, and what was uh shown to be the potential by the rare ones. And um, I got caught up in that thing. And right at that time, there was some inklings of the real source of competitive advantage of um some of these stellar firms, like I mentioned before, Toyota, Sony, Mitsubishi, Honda, to a large extent also. There was at the time the dominant theory of competitive strategy was one of uh differentiation, that somehow, you know, and this was the five forces notion of Michael Porter, that somehow you could build a castle, build a moat around that, pull up the drawbridge, and by that keep your uh customer base trapped, and where you could exert uh power and pressure on them, and you could keep your uh intruders, competitors, substitutes, at bay. And if you could build that a very static, defendable position, you were in good shape. But here's the thing you start looking at the uh the exemplars in Japan, they couldn't do that. The auto industry at the time was the world's largest, and it was the world's most competitive. And so, how is Toyota doing this? Because there was no castle, no moat, no drawbridge. Uh, similarly with Sony, electronics, consumer electronics, wildly competitive. So, not because of that, Sony was not in a position to build a castle, dig a moat, pull up the drawbridge. And yet they had these enormous differences. It was a refutation of the five forces model as the source or the sole source, anyway, of competitive advantage. So, anyway, that was what was so exciting. There was something else out there. And the something else out there had to be the management systems themselves. Something about how these enterprises were being managed versus everybody else. It was the management system that was the source, not the positioning within an industry or the type of industry. Anyway, jumping forward, I had this uh you know really good fortune when I landed at Harvard to do my dissertation uh under the mentorship of Kent Bowen, who was uh already retired as a uh faculty member at MIT. It was his

Behavior Beats Tools At Toyota

SPEAKER_00 8:36

second career, was becoming uh a faculty member at Harvard, already a emeritus professor at MIT. We had this chance for me to embed karate kids fashion inside Toyota, which was one of these world-class standouts. And I went in there curious. I don't think I had very well-formed preconceived notions. One, I didn't have that many preconceived notions. Whatever I did, they were wrong. Having embedded in Toyota and this experience of very karate kid wax on, wax off, what I realized, I was never being coached in math, like a new operations research algorithm to control a flow of material through machines. I was never being coached in anything particularly technical. I was being coached in behavior, fundamentally being coached in behavior. And the behavior was to have more rigor, more discipline, more speed on solving, seeing and solving problems. That was the realization. And when I wrote my dissertation, it became my first article, decoding the DNA of the Toyota production system. The realization there was Toyota is competing on problem solving. And I think the tagline we put in that first article was that what people don't realize is Toyota has used this notion of standards, which most people think in terms of command and control. And instead, they use standards as hypotheses. That every time you go to do your work, before you do your work, you make a declaration as to what actions you expect will have what outcomes, scientific method, and then when you do your work, you um have ways to see whether your hypothesis is not refuted, your work is going as expected, or it is refuted. And rather than that being a failure, that's a trigger to stop, pause, recognize that you have a problem that's investigatable, and come to a better understanding. And so that was the big insight coming out of that research is that for all the other attentions around all these lean tools of uh 5S and standard work and this thing and that thing, fundamentally, it was a management system built around cultivating enterprise-wide problem-solving skill.

SPEAKER_01 10:44

Across your writing, you distinguish between the visible tools of the Toyota production system and the underlying management behaviors that make those tools effective. In decoding the DNA of the Toyota production system, you described four rules governing how work is specified, connected, sequenced, and improved through the scientific method. What did those rules reveal about how Toyota actually develops problem-solving capability?

SPEAKER_00 11:12

There was this evolution. And um i in my dissertation, I had five rules in use. And then we realized, well, wait a second, they kind of compress when we write the article. But fundamentally, and this really is around the point about competing on the uh intelligence, the problem-solving creativity distributed through the enterprise. There was this continuous evolution of how you explain that, and things started to crystallize on this problem-solving dynamic in 2005.

Four Capabilities For Reliable Care

SPEAKER_00 11:38

I wrote an article called Fixing Healthcare from the Inside Today. And that article was informed by experiences we had primarily in Pittsburgh with some great collaborators here in the Boston area, Beth Israel, Deaconess, Mass General, et cetera. Great examples elsewhere, uh Virginia Mason, uh, Thetacare. But it was the crystallization of how do you compete on the distributed creative problem-solving potential through the enterprise. We said, well, the first thing is if uh you're competing on intelligence by converting everything into an experiment and converting everyone into a scientist, then what you have to do is design your work that you can see problems right away. And it's this combination in that when we talk about the rigor of the scientific method of having a hypothesis with a refutation, so we put it back in industrial terms, that you have a pre-specified standard, a recipe, a script of um what you think you will do and what you think will happen with a quote unquote test built-in or a built-in test to reveal that you were wrong. So that became capability one. And then capability two was that when you discover your hypothesis has been refuted, what you don't do is keep plowing forward. What you do instead is uh swarm the problem. And you know, in good uh medical practice, swarm the problem, do an examination. In industrial terms, you might call that um grasp the current condition, but do an examination, do a diagnosis as to why the problem occurred, what was the what actually happened that refuted your hypothesis about action and outcome, uh develop uh a corrective action, a treatment plan, implement that, and then see how the next experimental cycle goes. So that became capability two. One was design your work so you can see problems through this pre-specification plus built-in tests. When you see a problem, swarm the problem and investigate it with rigor, whether you call it clinical rigor, like in your terms or the scientific method, when you've had a discovery, and a discovery can include the existence of a problem, right? Because that's that's a realization. You up to that moment you thought your hypothesis was unrefuted, and now you've discovered it is refuted, right? So third capability became when you've had a discovery by seeing and attempting to solve a problem, have mechanisms to share what you've discovered so that uh the local discovery is available systemically and in a shareable, sustainable fashion. And then the last capability, and this is really uh a key insight in the uh 2005 article, which then gets generalized in the high velocity edge, the book, is that all these behaviors for a variety of reasons are counterintuitive and countercultural. Doing work so that you're constantly calling attention to things that aren't working, pausing what you're doing when you're falling behind because you've had a problem rather than trying to work even harder, sharing what you've discovered by your own personal failure, all of that is countercultural in any organization. And so uh the fourth capability we identified in that 2005 article and then expanded on in the high velocity edge is that leadership has to practice these capabilities so they can model them, coach these capabilities, develop these capabilities, cultivate these capabilities so these capabilities are available enterprise-wide for deployment and use.

SPEAKER_01 14:57

To

Mrs Grant And Workaround Culture

SPEAKER_01 14:58

make this as kind of as connected as possible to healthcare examples we can understand, I'm wondering if we can talk just for a second about Mrs. Grant. And Mrs. Grant is someone you've used in uh in a few different pieces you've written. This is a famous example, obviously, with a name anonymized of an insulin rather than heparin administration. I wonder if you can walk us through a little bit of that kind of through the lens of the work that you've done and why this is both understandable to healthcare people and really, really important to fix in disciplined ways.

SPEAKER_00 15:32

All right, so the the Mrs. Grant reference goes back to a series of uh quote-unquote quality grant rounds that ran in Annals of Internal Medicine in the early 2000s. And this was around the time where the Institute of Medicine and others were drawing attention to the huge number of adverse events hospitalized patients were experiencing wrong side surgery, mismedication, and so on, nosocomial infection. And um, how these were system problems, system failures, not the failure of individuals to act in a professional caring fashion. And so there was a series of quality grand rounds. In the case of Mrs. Grant, it was one of several horror experiences. In her case, uh she was uh recovering from otherwise successful procedure, had a central line that needed to be um cleared to prevent uh any clotting, and the nurse inadvertently um used uh grabbed a vial of heparin rather than the vial of, I'm sorry, grabbed a vial of insulin that he and rather than the vial of heparin that he intended to use with adverse impact. And some of the other examples were the patient who uh was literally lost and fell through the cracks uh waiting for care in an emergency department. Uh, another patient who um there was confusion between the name of the patient, Mrs. Morris, and Mrs. Morrison, and she had an invasive procedure. No long-term harm, none, but nevertheless an invasive cardiac procedure. And so um, a colleague I was working with in Pittsburgh at the time, a guy named Mark Schmidhofer, this was under the auspices of the Pittsburgh Regional Healthcare Improvement Initiative. We looked at all these cases and said, well, they're really quite different by the uh the presentation of the problem. However, there's commonality to it. In every single case, people walked into doing their work with ambiguity about the situation, ambiguity about what to do and how to get it done. And then, and this gets back to this uh problem seeing problem-solving dynamic, that uh feeling the motivation or the pressure to meet the needs of patients. And and again, just as a side, Jason, when we see systems fail, when it's dramatized in Hollywood, we need a villain. You know, we need John Malkovich in the Deep Water Horizon uh movie to keep pushing forward. We need a villain. But in real life, we don't necessarily need villains, we need well-intentioned people who uh keep doing what they're doing, despite the indication that what they're doing is in an environment where there are problems that hadn't been anticipated. And so the uh title of the article that uh Dr. Schmidhofer, Mark Schmidhoefer, and I wrote was called Ambiguity and Workarounds as contributors to medical error. And in some regards, this was the antithesis of what I had observed at uh Toyota and the antithesis of what the uh great industrial company, Alcoa, had done in order to drive towards near-perfect workplace safety. What they were doing was uh being very rigorous on declaring what they thought would happen and what would uh result, and um responding very, very quickly to aberration and ambiguity and workarounds is just the opposite. It's not making a strong declaration of what's expected. And then when there's indication of difficulty, like confusion many, many, many other times on uh which medication is in what location on the medication chart, telling people to be more careful uh rather than stopping, pausing, and figuring out how do we remove the ambiguity. And just as an aside, there's a guy named David Bates, teaches in the uh the Harvard medical school system, and he had studied this thing, and um he had these ratios, and this is not exactly but an approximation. He said, for every calamity, you know, patient death or serious harm, he said there was 10 injuries which were recoverable, and of those, there were uh tenfold more close calls, and for those, there were tenfold slips and mistakes. You know, what's a slip and mistake? You pick up the wrong thing. So that's a ratio of a thousand to one. And and and David Bates gave us a way to sort of approximately quantify the problem of workaround culture. A thousand indications that something is wrong, and we don't actually respond to it until it's hit uh catastrophe level. Anyway, carrying this over to healthcare, ambiguity in workarounds. So uh Mark Schmidhofer and some of the other folks we worked in Pittsburgh, a guy named Rick Shannon, who was at Allegheny General at the time, said, wait a second, you know, what we do with clinicians is we actually have great clarity on what we think um healthy looks like. And uh we uh put a lot of time and attention when we have suspicion of a patient being unhealthy, of monitoring the patient. So we can see aberration between uh health and non-health very, very quickly. And the more concerned we are uh that the patient doesn't have homeostatic self-stabilization, not only do we add more monitoring, but we're quicker to respond. And you start thinking about the the progressions in healthcare from you know the patient who's just out and about and going for their regular uh annual exam to the patient who's being monitored with uh checking in with your doctor once a month, to the patient who's uh in an inpatient setting to a patient who's in intensive care, right? And and and as we go through that progression, we go through more detailed monitoring to trigger faster and faster response to the immediate problem, right? Um it's not just I'm not feeling well, but there's been a fluctuation in some uh uh chemistry or respiration, whatever else it is. So, anyway, folks like Schmidhoefer and Shannon had the realization, holy cow, on the one hand, when we're at the bedside, we're adamant about seeing and swarming problems the moment we see them. And when we take a step or two or three away from the bedside, we fall into this ambiguity workaround culture. And so for them, and this is the connection to healthcare, they said, wait a second, so how do we improve the quality and the reliability with which we deliver healthcare? It's not that we have to learn all these other things that they do with Toyota and industry and this thing and that thing. All we have to do is take exactly the same disciplines we learned as physicians, exactly the same disciplines our colleagues learned as nurses and pharmacists and technicians, and apply exactly the same intellectual and behavioral discipline, a step or two or three away from the bedside. And if we look at the system. Of work with the same acuity and energy that we do when we look at the biological system that's inside the patient, we'll get to a better place. And so, what's the punchline they did? So in Pittsburgh, they did crazy things like the elimination of central line infections, the elimination of ventilator-associated pneumonia, the elimination of patient falls, mismedication, wrong side surgery, all while increasing capacity and quality of care and reducing overburden on staff. And what's the punchline is? They did nothing different than what they normally did as professionals. They just expanded the aperture to see the systems in which they were embedded and not just the patient themselves.

SPEAKER_01 22:42

Yeah. And, you know, simple but probably not easy, as uh as has been said before.

SPEAKER_00 22:47

Yeah, Jason, just a quick response to the simple but hard. You know, that that's the thing. Um you start thinking about the word I kept using over and over again about uh the disciplines learn to be a good clinician and the applying that discipline to um looking at the system in which the clinical care is being expressed. The basic principles are simple. You know, whatever you do, find a way to um declare what you expect and see problems that uh refute your expectations. When you see that, have the discipline to swarm in the moment and not wait, have the discipline to investigate uh energetically, creatively, generatively, right? The principles are simple, but discipline for anything is hard. Just as an aside, when I asked the folks at Toyota many years ago, I said, Why are you so open to study? And they had a bunch of explanations. Well, we owe it back to the people from whom we learned. It's a way to prove that we're not really cheating, on and on. But after hours, when you said, Really, why are you so open? They said, You have no idea how hard it is to be this disciplined doing these very simple things, and teach other people in a caring way to be this disciplined to do the same caring things. They said, Who else is gonna work this hard? And that was a rhetorical question. Dan, that's why we're open. Who's gonna work this hard?

SPEAKER_01 24:09

So, I mean, one of the one of the really powerful ideas that you that you write about, and you write about it first in 99, and and it goes on in in your work, um, is this idea of specification of the work. And I think that that idea is worth talking about a little bit because when healthcare people hear specification or standardization, they think that they're going to be confined in their ability to be flexible and creative in an environment where they they know and experience has rightly taught them that creativity will be essential. Uh, I'm curious what you say to that.

SPEAKER_00 24:48

Yeah, great question. So, look, Shakespeare is uh famous for a lot of things, but one is the line that a rose by any other name will smell just as sweet. That might be true for roses. More generally, we know words matter. Words matter a lot. And how we label something immediately affects how we uh think of the thing we've just labeled. So I understand in healthcare, which has uh issues of regulation and payment and this thing and that thing, you use the word uh standard immediately is going to trigger, oh, someone outside the enterprise is going to impose requirements on me and then enforce them through compliance, command, and control. All right, I get that. Words matter. But you start thinking about what clinicians actually do. They prescribe. They prescribe. And um, where does the prescription arise from? Um it arises from taking a history, doing an examination, then based on the examination, recognizing there are symptoms which are abnormal, doing a rigorous diagnosis, differential diagnosis to come to some hypothesis about cause, then thinking through, given that hypothesis about cause, what actions, what treatments can we apply to uh offset the causes to alleviate the symptoms? And that's where we get a prescription. And whether the prescription is for a medication or procedure, whatever else it is, there's a prescription. And what is a prescription? It is basically a recipe, a standard, a score, a play. Um, it's a hypothesis. If we do these things, we expect to get these outcomes, these improved outcomes. But what's the other part of a prescription? Follow-up. Right? When you go visit a clinician, they say, here, I've prescribed these pills. Let's follow up in a week to see how you're feeling, right? That turns the prescription from command control to dynamic. It's the physician's best guess with you as a patient as to what will alleviate your symptoms. So you follow the prescription, you take the pills twice a day on an empty stomach with fluids. And then you go back to find out if the prescription worked. And if it did, great, keep at it. You know, keep at it. It's fantastic. However, it didn't, what does the doctor do? The doctor then comes back, the clinician then comes back and says, you know what? We didn't fully understand. Let's do a recycling of history, examination, diagnosis, modification of the treatment plan, leading to a modified prescription, which you then follow through. So in the Toyota world, what does standard mean to them? It means in the world of clinical care, it means prescription based on all that clinical rigor beforehand. So words do matter. And uh as an aside, when we started working in healthcare, very often we abandoned any terms that smacked of uh industrial parlance because of the misunderstanding of what it was those words meant in the rare exceptional cases, and rightly I think what they meant in all other cases. And we just started talking when we're in Pittsburgh and here at uh Beth Israel Deaconess and elsewhere, some great uh experiences uh with primary care practices at Mass General. We'd go in and we'd have a problematic situation and say, oh, let's examine the system. And then uh then we we'd examine and say, all right, well, what are the problems? You know, what are the symptoms? And that's how we would talk about what are the symptoms? People can't get appointments. All right, well, what's our diagnosis suggest about that? And we'd come up with a diagnosis. So, anyway, what really matters here is behavior. And we want to be careful that we uh use words that um people align with the behaviors we're trying to encourage.

SPEAKER_01 28:21

Yeah, absolutely. Yeah, sometimes I I found that healthcare people respond to the the gold standard lingo because that's you know, that is something that we use, but it's it's really it's tough. I think as soon as people kind of sense this, as you said, this idea of outside imposition of standards, it can be it can be really tough. I like how you framed that. I

Standards As Prescriptions With Follow-Up

SPEAKER_01 28:40

want to move forward into uh the high velocity edge, which you wrote uh I think first in 2008. Tell me a little bit about what the high velocity edge did. That was an evolution from the the 2005 article we referenced as well as their 1999 uh PhD thesis and HBR article.

SPEAKER_00 29:03

Right. So long and short, the high velocity edge took the ideas that came out of studying Toyota that got reinforced um with these uh efforts in trying to improve health care and show that these are general principles. So if you look at the structure of um my dissertation, it's almost entirely about uh Toyota. You look at the DNA article, which came out of that, of course, that's you know, the the uh decoding the DNA of the Toyota production system. Um 2005, we write this article, fixing healthcare from the inside today, and say, you know, this can really be summarized. You know, this competing on the enterprise's distributed problem solving capacity, this can be summarized as these four capabilities of doing everything so that you have a refutable hypothesis when you know you've been proven wrong, solve the problem with rigor, when you've discovered something through the problem solving, make it systemically available. And if you're a leader, your job is to develop those capabilities in others, right? So we have Toyota as the bulk, some indication this works in healthcare. So then I get to the high velocity edge and say, hey, you know what? This this is actually general principles. And so that book has other examples, you know, and in-depth case studies. Alcoa's pursuit of perfect workplace safety and the near achievement of it, cutting the rate of on-the-job uh injuries by 98%, Pratt and Whitney's conversion from a company really struggling to win um contracts for uh jet engines to a leader in its field, uh, the development of uh the naval reactor program and the introduction of uh nuclear propulsion onboard submarines from starting at zero knowledge about how to do that in 1948 to the uh USS Nautilus, quote unquote, underway under nuclear power, seven years later in 1955. Um, and then of course healthcare. So that book goes richer examples of Toyota, but then say this is a general set of principles. And then it begs the question why is this a general set of principles? Because as different as Alcoa is from naval reactors, Pratt and Whitney, the healthcare examples, Toyota, et cetera, et cetera, by the foundational science and technology that's being developed and delivered, and the foundational science and technology that is being used to deliver value to society, what's the commonality? It's the working of individuals trying to integrate their efforts into collective action towards common purpose and winning on their ability to bring their brain power into that collective action. And so that's the point of the high velocity edge that this is a universal situation that we face anytime we do work, be it in a hospital, be it in a clinic, be it in a factory design studio, on a construction site, it simply doesn't matter. The managerial challenge is um getting all this creativity aligned towards common purpose, and it turns out there's a way to do that, which is indifferent to the sector because across all sectors, the commonality is people trying to work together well.

SPEAKER_01 32:15

And so you've dealt with these four capabilities and you see that they work across industries, you've seen that work in healthcare. What can you tell me about the real-world application when people try in healthcare to apply these? Are there certain of the capabilities which are particularly difficult for healthcare people to get their heads around? What do we need to learn about these four capabilities?

SPEAKER_00 32:42

I the thing I'd offer, and this is whether it's the uh the four capabilities we detail in the high velocity edge or further elaboration on how you build systems so that you can express these four capabilities well, and that's really the topic of Wiring the Winning Organization, the most recent book on this, is um the the one thing I want any listener to think about is much better as possible. And no matter what their situation is now, whether they're in a situation where they already already feel like, oh, we're very good at what we do, or they're in a situation where they feel, wow, my colleagues and I uh really struggle to do what society expects of us, or they're a leader in a situation, and I use the term leader uh very loosely to mean anyone responsible for the conditions in which someone else works, where that leader says, we're not as effective as uh expected as needed. I think that I want to start with much better as possible. Absolutely much better as possible, and it's proven. You know, again, we go we go back to uh the early part of our conversation, what motivated me and the many, many others to look into this field, the uh the actuality for most people and the potential that others displayed. Huge gap, right? The actuality that some displayed and the um fantastic potential that they were able to achieve. So much better is possible. And so you should start with that sense of optimism and potential, that much better is possible. So, what's the hard part here? I think it's the hard part for a leader in any of these settings to um have the discipline that uh your clinical colleagues have to provide great care to patients, which requires one, a persistent presence. That you're uh not trying to assess the patient at a distance, you're not trying to assess the patient at a on a delay, you're not trying to assess the patient through some mumbo jumbo metrics, etc., which uh distill and aggregate and otherwise distort the reality of what's going on. So you have to have that discipline to kind of get into the nitty-critty. And the discipline that when something emerges, how do you respond to that? Do you respond as a leader and say, well, you know, there are different ways to respond as a leader. One is you don't respond at all. And what does that say? Uh, you know, I don't care, so you shouldn't care. And we we we see that with um poor clinical practice. You know, someone going to a doctor and say, I don't worry about it, right? Uh, we see that with um, you know, the step two, three, four away from the bedside where someone is struggling with a situation and some leader doesn't even show up to at least validate that it's a reasonable concern. So that's one way to respond, not a good way. Second way to respond, or you really shouldn't, is when you show up, you say, Oh man, are you complaining again? Yeah, I don't want to hear about your knee again. I don't want to hear about your difficulty finding medication again, I don't want to hear your difficulty about getting clarity on physician orders. Just you know, figure it out on your own, right? You know, limp along. And that's basically what the answer is. It's the uh the organizational equivalent of limp along. So, how do you respond as a leader is to show up and say, oh, you you you have a problem, tell me more about it. You have a problem now you've told me more about it, let's see if we can figure out why it's happening. You have a problem, uh, tell me more about it. Um, let's see if we can come up with a solution. There's one other thing, Jason. I just want to make sure we we end on a very start with a positive, end with a positive, right? So we start with a positive, much better is certainly possible. What sounds overwhelming is the simple but hard. It's this uh persistent presence of leaders. But here's the here's the good news. As a leader, if you're persistently present and showing other people how to behave in this uh see a problem, swarm a problem to solve it, and then share what you've discovered so it's systemically available, other people will realize oh, that's what we do. And you start going back to um you know your training as a clinician and as a young person. Yeah, you all needed mentors to show up and show what good clinical practice looked like and felt like. That lasted for some period. But eventually you said, oh, wait a second, I've seen the model, I've got the coaching, this is now what I do, right? And so that mentor no longer has to be persistently present at your work because you've internalized those values and those behaviors. And then as you've advanced in your career, what's happened is that if you've exercised exactly the same behavior with the same discipline, you've modeled for other people, your juniors. And they said, huh, what's that doctor doing? What's that nurse doing? What's that pharmacist doing? What's that technician doing? Huh? I guess that's the right way. And then you put your hand on their shoulder, you know, the the the crusty hand of the uh the seasoned veteran, right? And you coach them. And they say, oh, that's what it feels, this is what it looks like. Now I know what it feels like. And at some point you can take the hand off the shoulder, trusting that the person you mentor not only will behave the same way, but will teach others. And that's where you get this huge amplification, multiplication, exponential growth of these capabilities. And just as an aside, when we look at organizations where this has taken hold, it's actually a very small group of quote-unquote quality, safety, productivity experts. And the reason it's a small group versus in some organizations it's a huge department, is because fundamentally this is about the experts coaching behavior and then stepping away with the trust that the behavior they've coached is not only sustainable, but uh self-generating and replicable. And so you don't need a lot of people to do that because of the exponential growth effect.

Leadership That Builds Problem Solvers

SPEAKER_01 38:34

So that's interesting. I I want to lean into that just a little bit. You're saying that places where you've seen this succeed actually had a, if they had a quality and safety department, it was relatively a smaller group. Is that what you're saying?

SPEAKER_00 38:47

100%.

unknown 38:49

Interesting.

SPEAKER_00 38:50

Within Toyota, for example, they have something called the Operations Management Consulting Division. It it sounds like, and in fact, they are. They are the guardians of the Crown Jewels of Toyota, which is its management system. It it's a few dozen people for uh uh a global enterprise. Why do they only need a few dozen people? Because they're not there to solve technical problems. They're there to teach behavior. And uh, when they teach that behavior, not only are they teaching the behavior of this is how you um behave in a rigorous fashion, but this is how you teach others. And we we we talk about this um in the High Velocity Edge. We have a chapter, chapter nine, Developed to Leadership. And what is the uh recurring message in that chapter is leadership's number one job is building these problem-call-solving capabilities to the people they affect directly, so that those people can build those problem-solving capabilities and the people they affect directly, and on and on and on. And that's where you get the exponential growth. We're currently, you know, the work we did in healthcare over and over again, the uh places that had wide, deep, and sustained success is where the leaders like the ones I mentioned before, Mark Schmidhofer, uh Rick Shannon, Gary Kaplan over in uh Virginia Mason back in the day, John Tucson at Data Care, they were not there to solve technical problems. They were there to build capability and teach other people how to build capability. And the work I'm currently doing, I'm doing a lot of work in support of the Navy's uh work around maintenance and modernization of attack submarines. And the uh the shipyard where I've been supporting, uh, this is up uh called the Portsmouth Naval Shipyard in Kid Remain, they've had a profound change in fortune in about a two-year period. And you say, well, what happened? No new money, no new tech, no new time, and a workload that one could argue has gone up, not down. What's changed? Leadership behavior. And what is the change in behavior? Leaders taking upon themselves the responsibility for modeling these capabilities at first so that others could acquire them, and then cultivating the cultivation of these capabilities throughout the enterprise. It's been fantastic.

SPEAKER_01 41:01

Wow. That's inspirational that it that it works across so many industries and that the results are so significant. You talk about leadership there and leading in a variety of, you know, at a variety of levels to a variety of people and having this exponential effect. I one thing that I think a healthcare audience will think as they're hearing about this incredible work is that healthcare feels unbelievably busy. The work that you describe in high-performing organizations ultimately promises, as you said, to reduce cost, time, space, effort, and resource use. But, and you'll correct me if I'm wrong on this, it often requires an upfront investment of attention, time, and leadership discipline. So I'm curious for a healthcare leader who feels that they're already drowning, how do you help them see that this is not extra work, but it is the work?

SPEAKER_00 41:59

Yeah. So for the healthcare leader who's already feeling swamped, and again, I'm very sympathetic to the rules, the regulations, the payment mechanisms, who wouldn't be swamped? For the leader in healthcare, what I encourage you is go back to your basics. Go back to your basics. And what is your basics as a healthcare leader? Uh, many of whom were trained as clinicians, go back to the basics of alleviate pain and suffering. Right? That's what you learned to do as a doctor, a nurse, a pharmacist, a technician, an administrator and support, all those. The reason you took the job you took is to alleviate pain and suffering in the patients who trusted their well-being to you. And then how did you do that? Again, through the these the this professional rigor, discipline that we described. So, how do you get to a better situation in healthcare where the colleagues for whom you're responsible every day find it quicker, easier, safer, easier, especially, to deliver better care to the patients who depend on you, run to the suffering. You know, go to the suffering. Don't worry about these high-level aggregated, distilled lagging metrics of uh qualities and efficiencies and this review and that report. Go to the clinical bedside and look at the things that make it difficult to be a nurse. We did this. Uh, when we first started this work, we shadowed nurses. And and nothing intrusive. We just said, look, we don't understand nursing work, true statement. Um, if you don't mind, can we just follow you around and just as you go through the day, explain to us what you're doing? Well, we found at best, you start thinking about what a nurse learns in nursing school in terms of history, examination, diagnosis, treatment planning, treatment, follow up, education, I think it's five or six things. Half the day at most was spent doing those things. Normally it was one third of the day. What was the other half to two thirds? Finding stuff. Where's the medication? I can't find it. Where's the doctor's orders? Can't find those things. Where's the various uh bandages and other supplies I need to either do a diagnosis, an examination, or a treatment? Can't find those things. Where's the book I need? The patient record. Can't find that thing. Oh, I'm going into the IT system to get a little bit of information. I'm in here for what feels like eons, like I'm sucked into the matrix, right? Go to the point of suffering. We have examples of this in the High Velocity Edge in the chapter about healthcare. We talk about a nurse named Gloria. She's the unit manager in pre-surgical nursing at a hospital in Pittsburgh. And Gloria finally had the realization, and I'm not going to quote the profatty, but she did use it. She said, Man, I always thought of myself as a real problem solver. But I just realized I've been solving the same bleep, bleep, bleep, bleep problem every bleep, bleep, bleep, bleep day for the last bleep, bleep, bleep 20 years. Direct quote almost, bleeped out. So what did Gloria do? She said, you know what? I'm going to do good nursing. But instead of applying my uh nursing eye onto the patients, because we have a nursing staff to do that, I'm going to apply my nursing eye onto the nurses for whom I'm responsible. And I'm going to look at the things that make their day difficult. And what made their day difficult? Not being able to find patient records. Well, we'll get some people. We'll solve that. Not being able to find materials that they needed for a pre-surgical prep. All right, I'll get with some people. We'll solve on that. Anyway, what happened in that situation? They liberated the equivalent of two FTE nurses by giving time back to nurses. And now, Jason, you start thinking about this. It's not just time, it's uninterrupted time. And we get back to our premise that we're competing on, we're trying to perform on our ability to engage the well-intentioned creativity of people in the enterprise. Time is one thing, but uninterrupted time, to be creative, that's a whole gift. Over at the VA in Pittsburgh, they found that start and end a shift was 45 minutes to do pass down one shift to the next. An hour and a half of a shift was dedicated just to figuring out what had happened on one shift to inform the next shift. And even then, the pass down was uh so unreliable that when a shift started, nurses basically restarted regenerating the information. So the uh the unit manager there said, I'm gonna run to the pain to alleviate the suffering. And they started studying this pass down and realized most of the stuff could be done on charts and forms and easy grids. A little bit of it, the nuance and tacit, the idiosyncratic information about patients that wasn't codable, that required conversation bedside. They got uh passed down from 45 minutes at start and end of shift to 15 minutes at the start of end of shift. So not only was it much less time, but was time well invested because it was bedside about what was happening to patient spirit right now that we can't code, we can't put into a record because we don't have a way to describe it, but I can show it to you. So, anyway, alleviation of suffering. You know, you take an hour per nurse per shift. Again, what do you do? You liberate um all that time unfragmented to nurses to do what they were trained to do, what they aspire to do, which actually deal with uh the suffering of their patients, provide care, comfort, and cure. So, anyway, to the leader, back to you know, the advice go back to basics, alleviate suffering. And use the same care, compassion, rigor that you used, that you learned as a a young student, and now apply it onto the system in which uh the people for whom you're responsible, the system in which they're embedded. And if you do that, uh it'll be easier for them to provide great care. It'll be much easier for you to manage the system which is now competing on and performing on the distributed creative caring intellect of the people for whom you're responsible, and it'll certainly be a much better situation for the patients who've trusted you with their well-being.

SPEAKER_01 47:51

Well said. And I uh I think that's a an easy thing for us to wrap our minds around is getting back to the basics of why we got into this and the basics that we that we learned in our training. So on that on that front, and and given the fact that we need to rely on our frontline staff to really tell us, you know, where the problems are, um, many hospitals I think say that they value speaking up. In your experience, what specific leader behaviors make the difference between an organization that merely says that they want people to speak up and one where problems actually surface early?

SPEAKER_00 48:25

Yeah, you know, I I just got a I went to see my PCP recently and I got a survey in the mail. Tell us about Dr. Kelman, great guy. When you needed to see him, could you? Yes. When uh you got there, were you treated respectfully? Turns out yes. When um you were trying to explain your situation, did he listen attentively? Yes. Did he uh appear thoughtful in considering your situation? The answer was yes. Um when he started to discuss with you possible treatments for your situation, did you think he was thinking um holistically and thoughtfully and comprehensively about your situation? Yes. When um he arrived at a solution or prescription for your situation, did he explain it well? Yes. Did he engage you in how to carry forward with the uh prescription so that it could be most effective? Yes. Did he follow up after you were handed the prescription a day or two or three later to see how things were going? The answer was yes, right? All of those, 100% yes. So you start thinking about um, you know, what do you have to do as a leader? Again, go back to basics. Be like Dr. Kelman, right? When someone raises their hand and says, hey, uh, you know, uh, boss, unit manager, medical director, department head, president of uh of a of an institution or a system, we're having difficulty with this. How do you show up? And if you show up like Dr. Kelman and say, hey, what's the problem? Can you tell me? Give me some more details. Let's discuss it a little bit further. That's fantastic. Again, go back to basics, the things you learned as a young clinician or as a young administrator when you were probably an administrator in a unit, right? Uh show up with that presence, that uh attention, that sympathy, that empathy, that thoughtfulness, show up with that and you win. And you win all the time. And and Jason, this goes back to what we're saying about um both uh both of my books, The High Velocity Edge and Wiring the Winning Organization, is that fundamentally this is about creating situations in which people can apply their individual creativity, ingenuity towards good per good towards good purpose in concert with other people. This has nothing to do with making cars, designing cars, making aluminum, refurbishing attack submarines, or treating patients. This has to do with, as leaders, the conditions we create for the people for whom we're responsible, in order that our enterprise can achieve its mission in society. And and and again, look, you know, in healthcare, people pick their jobs because they start out sympathetic, empathetic, wanting to improve people's condition. It's that's the basics, just keep going back to that.

Amplify, Slowify, Simplify In Practice

SPEAKER_01 51:15

And so that's a perfect segue into a discussion of your most recent book, Wiring the Winning Organization, uh, which you co-wrote with Gene Kim. And in that book, you use the language of slowfication, simplification, and amplification. Can you give a a broad overview of what that language is about?

SPEAKER_00 51:36

Yeah, that's right. So um if you think about uh amplification, that that was really what I started discovering way back in the day when I embedded in Toyota. This idea that when you were surprised, positively or negatively, when you were surprised, raise your hand and call attention to the surprise. Because if you're the earlier you raise your hand, uh the smaller the problem is. To quote a guy I know from Naval Reactors, his tagline is see problems when they're small before they've had a chance to get big. Now there's a reason for that, right? Because when you see a small problem, not only is the problem and and again, this goes back to what are the basics in healthcare. If someone has a symptom, let's get on it early. Like I once had a paper cut. And you know, what do you do with a paper cut? You wash your hand, you you you you put some sort of uh cream on top and you bandage it. I didn't do that when it was a little problem. And then one day I wake up and I said, my I see my finger is it is red tip to tip, right? And I go to someone and say, What's going on here? He said, Well, you now have a big problem, right? You have an infection, you're going to the drugstore right now to get an antibiotic. And I said, What happened if I don't go right now? He says, Oh, then we go to the emergency department, we put you on an IV. Right? Anyway, you guys, back to basics. See problems when they're little before they have a chance to get big. Why? One, you get time, right? You get time. Because by the time it's big, it's now an urgent problem, it's not a minor problem. The other is you have simplicity when it's a little problem. The problem hasn't become, you know, it's just a paper cut that needs to heal. It's not a systemic uh infection that needs an IV. All right. So, anyway, back to the uh mechanisms we talk about in the high velocity edge. Amplification. Call attention to problems, good clinical practice, uh, when they're little before they have a chance to get big. Then what do you do? Hit the pause button. Hit the pause button. The problem is indication that the situation you're in is not the one you expected. It's abnormal. And this is not the time to just keep going by habit, by routine, by uh stimuli response, action reaction. This is to get out of all those things that give you great efficiency in action, all the all these habits and routines, but which really don't engage your creativity. What you have to do is hit the pause button and say, whoa, this is time to slow down and really figure out what's going on, examination, why is it going on, diagnosis, and can we improve on the situation? Improve on the situation. Can we treat it to make it better? Uh can we? We talked before, Jason, about some of the difficulties around amplification as a leader responding. Do I show up? How do I show up? Do I show up in a sympathetic way, like I mentioned Dr. Kelman? Or the leaders of Toyota? What's wrong? Why is it wrong? How can I help? Slovification, why is that hard? Because typically when we have a problem, we're falling behind. And when we fall behind, what what what's the uh the instinct? Oh, I've got to hurry to catch up. But the thing is, why'd you fall behind? Because you know how to fall behind. You don't know how to stay ahead. And so if that moment in falling behind, you try harder, what will you do? Fall further behind. It's like I did this, it was a stupid thing. A bunch of years ago, I was running in a road race and my ankle hurt. And I said, Oh, my ankle hurts. What should I do? You know, oh, I'm I'm running slower than my pace. I should run harder. That was exactly the wrong thing. What I should have done is stop. I ended up doing doing an Achilles injury on myself. Why was that? Because I didn't slowify. I didn't say, oh, wait, my ankle hurts. Maybe I should stop and figure out why it hurts and uh get my ankle um back into a healthy condition and run the next race. So I was out for like two years on this thing, and I'm still doing PT. Anyway, so what's the slovification? It's that it's hitting the pause button to engage the generative, creative part of our brains and not just keep moving forward despite the pressures to maintain operational tempo. So that's a slowfication, and then what's the simplification? There's two things. One is uh preemptive and one is the follow-up. Is that if we really are buying into this uh thesis, this strategy on competing on the creative power of human intellect, maybe augmented by artificial, I don't want to you know blow that past, but uh augmented by uh human intellect. Um I'm sorry, human intellect, augmented by maybe artificial intelligence machines. What we want to do is create, you know, sculpt the problem-solving space in a way that's conducive for the application of human intellect. And we're very good at little simple things that then architect into more complex things. We're very, very bad at understanding complex systems where everything is interconnected with everything else. And you see this again as a clinician. The human body is a very complex thing. How do you train a clinician? You um distill things out. We're gonna talk about the pulmonary system, we're gonna talk about the cardio cardiac, um, the cardiac system, we're gonna talk about the immune system, right? You start decomposing things, you take it even further and say, Well, why is the immune system behaving in this way? Um, you decompose it even further, right? And and it's through this simplification, and again, you know, with all all you know, all fairness, people have gone through the uh professional education in the healthcare professions, even when you decompose it's still hard. But the human body is impossible. When we start thinking about subsystems and how those subsystems operate and how they interact and then come together into the human being, the patient in the clinic in front of you, that's how we do it. So, anyway, where's the simplification? It's um the deliberateness to um when we have the latitude to construct a system, we construct it in this nested modular fashion so we can see the little pieces and then they come together rather than everything all at once. And uh when we have a problem and we're trying to generate a solution, do the same thing. Try to break it into small pieces and then gradually build the big pieces, put the little pieces back into bigger systems and mega systems and all da-da-da, and on and on. And in the the in the um wiring the winning organization, we have ample examples how audacious things were achieved, landing on the moon by breaking big problems, going to the moon and back safely into much smaller pieces. Uh, development of crazy products like the iPhone, taking that and breaking it into much smaller pieces. So that's where the simplicity comes in. And like I said, you know, how does this apply in uh for clinicians and healthcare? Back to basics, man, back to basics. This is what you learned as a as a as a young trainee. It's how to look at a very complex thing about uh like a patient and figure out how to break this into pieces and then reintegrate the piece thinking into the integrated whole.

SPEAKER_01 58:10

Yeah, I mean, what I'm what I'm hearing from you is something that I've noticed a lot since entering this world of quality improvement in healthcare, is that the the diagnostic thinking, you know, getting back to the basics of how we think about systems and their interconnectedness, we we somehow manage to learn that and learn it really well, and then learn to apply it only to the practice of medicine or the practice of nursing and forget that those skills are so transferable.

SPEAKER_00 58:40

It's the practice of life. It is the practice of life.

SPEAKER_01 58:43

It's the practice of life.

SPEAKER_00 58:44

Again, because right, because no matter where we go in life, whether it's uh in the clinic or more broadly professionally or personally with our family, right? The one thing that's common to every one of those settings, as different as they are, is our hearts and our minds. And our hearts and our minds work in a particular way, right? And we can um we're very, very good at coming to a very particular situation where it immediately triggers uh sympathy, empathy. Like, oh, that that I understand. Your frustration with the missing medication, I can understand. Your frustration with the uh the knee that doesn't give you full mobility, I can understand that, right? So that's the thing we carry into every situation in our hearts and our minds, and our hearts and our minds are wired to work in a particular way. We respond to the particular. We're not very good at the general, we're not very good at the aggregate. We can understand the simple and then understand how the simple then comes together into the complex. We can't understand the complex. And so, you know, again, as uh professional training, whether it's in the skilled trades or engineering or the sciences or the healthcare uh professions, we learn to go to the point of affliction so we can connect emotionally and we can understand intellectually and then work our way back. And it's exactly the same for these systems of work. You go to the point of pain, you go to the point of work, you understand the experience there, and then work your way back.

SPEAKER_01 1:00:07

Yeah, so I'm wondering if you can give a concrete example, maybe in a bit of detail, about how this amplification, slovification, and simplification works. If you have a healthcare example, that's great. But but I think we could do a non-healthcare example too, if if that's more accessible.

SPEAKER_00 1:00:24

Yeah, let me start with a healthcare example and just prove the point that this works across. So um I mentioned a number of doctors I worked with in Pittsburgh many years ago. One, uh Rick Shannon. So if you start thinking about, uh I just want to draw the link here. Uh I wrote an article with uh Mark Schmidhofer. I mentioned this. This was the response to uh quality grant rounds and annals. And that was generalizing out of those particular examples, the Mrs. Grant, mismedication, the Mrs. Morris wrong patient thing, um, generalizing and say, how does systems fail? And they fail when we don't have clarity in our prescriptions, right? Ambiguity. And they fail when um we work around problems, we don't uh run to them, examine them, and treat them. All right, so that that article is about the failure mode. And I lead with that in the um the fixing health care article, and I lead with that idea of how do systems fail and high velocity edge. Now let me tie this over to another great colleague, uh, a guy named Rick Shannon. So Rick at the time was uh uh medical director in cardiac critical care at Allegheny General Hospital. Rick's gone on to uh other great things, University of Pennsylvania, University of Virginia, now he's in the Duke Health System. But at the time, what was the problem was central line infections. All right? Now you don't start thinking about that. That's a number. How many patients at what rate do we give central line infections? Oh, there's a number. And what do we care about the number? Well, it's the same number everybody else has, so I guess we're fine. What did Rick do first? He said, well, you know, that's actually a number, but it's a number which reflects suffering. So one day his colleagues walk into um work, and along the wall are pictures of patients. And you see this in hospitals a lot of time, you know, oh, here's the patient who gave uh birth to a child, here's the patient who uh we sexually successfully put into remission of terrible uh cancer. So the people will say, Hey Rick, who are these patients? He said, Oh, these are patients we all treated successfully. Uh this is great. You know, this person had an operation, this one had an infection. And he said, Oh, Rick, why are there pictures up? He said, Oh, well, yes, they got successful treatment for the reason they came into the hospital, but we killed them all. And they said, What? He said, Yeah, yeah. This is this is uh the woman who came in and had a successful procedure, but yeah, central line infection, and that's a picture of her daughter Sally, who her mother died at the age of three, so she'll have no memories of her mother. And this is uh Frank over here who came in for uh a procedure, and uh we gave him a central line infection, and uh he's now in a wheelchair. So before a Pittsburgh Steelers game, he will never be able to have a catch with a football with his son as their ritual to warm up for the game. And all right, so you know, this is what we talk about clinical practice. Rick's colleagues are like in shock because it's one thing to say we have a percentage of infection rate, but another to say we did this to little Sally who won't know her mom, or to this little fellow who will never have a catch with his paralyzed dad. And I said, Holy cow, Rick, how did that happen? And he said, here's the problem. We don't know. We just know the result, but we didn't study the situation in the moment. So then what does Rick do? He says, Here's what we're gonna do. And this is not exactly the words he used then because we didn't have the words, he said we're gonna amplify. He said, we have to give our patients central lines. It's just necessary because they're in a cardiac critical care unit, and occasionally we have to administer medication in such a fashion it gets into their system quickly, and we need a central line to do that. So here's the thing we're gonna start with defining what is the best possible way to administer and maintain a central line, and that was the subclavian versus femoral placement, and that it was uh the wound site was always managed, that was no sign of infection. He said, And then what are we gonna do next? Anytime, the first moment you feel that you're departing from having the perfect experience, either placing or maintaining a line, you raise your hand to amplify and call attention to it. And this is where the simple slovification simplification comes in. So, what's the first thing? Young resident has been uh doing a rotation through cardiac critical care. Patient needs a central line. Um, the the young resident hasn't been uh comfortably trained in how to do subclavian placement. So they're like, hmm, they trade-off now. I could try the subclavian placement, but it's difficult, I might injure the patient. Or the easier one, I could do the femoral, but risk infection. What's the normal behavior in that situation? Oh, I don't want to look stupid, I don't want to bother the fellow, I don't want to bother the attending, I guess I'll uh do one or the other. Both bad alternatives. But Rick has said, no, no, no, you don't do that anymore. You page me, we amplify. And so what does the resident do? He amplifies. So Rick comes over and says, you know what? The system failed you. And again, think about the language here. The system failed you, the resident, not the resident failed the system. How did it fail? One, it didn't provide you adequate training on how to do comfortably, successfully a subclavian placement. That's why you felt yourself in a dilemma. And what else did it how did it fail you? It didn't assert or recognize your inability to work night shift by yourself. You should have been on day shift learning this skill. So what came out of that? One, a much better uh training for anyone rotating through the unit on how to do a subclavian placement, and making sure that built into scheduling was whether someone had been validated, certified on subclavian placement or not. All right, that was one thing. Then there was another, which was um nurses saying, well, you know, ideally I would know whether this uh wound site is healthy or not. Um and normally what I would do is either my best guess, right? Again, dilemma, not a good choice, or I'd pull the bandage off with the chance of uh disrupting the wound site and and causing the patient uh Some difficulty and discomfort. So rather than choosing between those two inadequate alternatives, nurse raises her hand. And Rick comes over and says, Well, what's the problem? He says, I can't assess the wound site. So Rick says, All right, in the moment, we're going to have to do something so you can assess the wound site. But offline slowfication, what we're going to do is come up and figure out a different approach. And I found transparent bandages, simplification. So now when you walk by, you just do a glance and say, oh, look at that. The wound is healthy or not. I know what to do. Anyway, this went on and on and on. And eventually that unit drove the rate of central line infections to near zero. When you say, well, how'd you do that? What was the magic solution? The answer was there was none. It was just this combination of amplification in the moment I'm having a difficulty. The leader in the moment coming over and saying, What's the difficulty? Pause button, slowfication, simplification. Then can we come up with a simpler, more reliable way to uh achieve success and make uh failure less likely? Now, to that, and I'll just continue uh Rick's story a little bit. Once they realized that amplification, slowfication, simplification, again, they didn't have exactly those words, was the solution. Now it generated dozens and dozens of uh corrective action treatments to the placement maintenance of um central lines. They said, you know what, the same thing should work for a uh ventilator associated pneumonia. You know, what's ideal? What's the prescription? What's the standard? If you're having difficulty uh sustaining, achieving the ideal, just raise your hand, amplify, we'll come over. Boom, that goes to zero. Other things, other um adverse events go to zero. And anyway, that's the Rick story about um Allegheny General, but it's exactly the same pattern. Primary care, specialty care, um uh routine um things like uh cataract replacement, guy named Gary Shingleton in the uh mass general system, way down the cycle time to do uh um cataract replacement and also the complication rate, same thing. Amplification, slowfication, simplification.

SPEAKER_01 1:08:08

That's great. And we'll we'll refer listeners to the the book for more details. Um you

Joy And Appreciation As The Signal

SPEAKER_01 1:08:13

know I'm really I'm grateful for this time, Steve, and and your you know, your work and your writing has been really influential on the way I think about these topics. I encourage our listeners to to seek out your writing to learn more. I'll often ask guests what five years from now would look like if their you know if their work current work uh achieves its kind of highest aspirations. But I'm curious, uh maybe a slight variation in that question for you, because healthcare has been maybe slower than it should be to adopt some of these really rich ideas that that you have brought into the field. Um what does the world look like five years from now if those ideas are better adopted? And how do we start doing that?

SPEAKER_00 1:08:59

Yeah, so uh we'll give you a question. What does the world look like uh if uh these ideas are adopted into wide practice? Before we do that, I just I just want to say for uh listeners, um, if they want more resources on this, it's great to pop the um the individual articles and book references. That's awesome. The other thing is um we realized that uh occasionally people need some coaching on how to behave this way. And uh I have some colleagues who've done this in other organizations and occasionally they need tools to make the connectivity between the person who's again in healthcare, what do you do for the patient where you have concerns? You have sensors, and those sensors uh immediately broadcast concern about uh reduced respiration, O2 saturation, et cetera, et cetera. So anyway, we created some tools in our site inside our firm called C2Solve, so that if people are more curious, have some curiosity both how do I practice these techniques and are there tools to support the uh expression of those techniques in practice, you know, go visit our website and you you can provide the link to that. Um we've got some cool case studies and demonstrations. As far as uh what does the world look like? Uh here's the thing is the situations we and our colleagues step into every day represent our best understanding about how to shape those situations for success. Right? Now we have to appreciate that our best understanding is just that it's our best understanding in the moment, but it's not perfect understanding. In fact, it's uh at best a very, very rough, poor understanding of what's possible. And the way we move from where we are to where we might be is uh by you know running to the pain, running to the point of work and seeing what's what's impeding our ability to uh create value and deliver to others in a way that's uh quicker, easier, safer for ourselves, more rewarding for ourselves. So, what does the world look like if people start picking up um these practices of uh designing work so you can amplify problems and swarm on them, actually hitting the pause button to slowify and try to figure out why problems are existing and how to uh prescribe treatment for them. And then those treatments are uh a simplified situation where it's easier to succeed and harder to lose, um, harder to fail. So I'll give you a quote. I mentioned we're doing uh work in support of uh maintenance and modernization on attack submarines. And for people to say, oh no, that's not my work, thank goodness. Uh repairing a submarine in this fashion is half a million labor days of work, half a million labor days of work. It spans uh skilled trades, um both skilled trades and engineering across dozens and dozens and dozens. People in healthcare are um concerned about rules and regulations. I get that. Bear in mind that these attack submarines have a nuclear power plant on board, so the the rules and regulations and the uh the inspection they're subject to is extraordinary. Um I would argue probably way more than in uh the typical healthcare setting. Um and the stakes are extraordinarily high too, because the work itself is inherently dangerous. And then you're doing this work on on behalf of a crew and the family of those sailors that when they get on board that ship and take it out to sea, they have full faith that the work you've done in the shipyard, the work you've done in the shipyard is done well. So when they can go do their missions and their patrols, they can do them safely and well. All right. That that that that is the so you know, for those in healthcare say, oh, our work is nothing like that of repairing an attack submarine. Let me just offer that the work you do is uh an expression of the promise you made to a patient and their families to do your best, to uh give them the most possible care, comfort, and cure possible. And when someone steps into a shipyard to do that work, they're stepping in and badging in each day, is making a promise to somebody that their loved one will uh board that warship in uh as best condition as possible. And we start off the wiring the winning organization. We say that that act of stepping into work, badging in, signing in, clocking, and whatever else it is, it's you're you it's that moment in which you express a promise to someone else that you give the best possible effort for them to have the best possible experience. So that's it. But anyway, Jason, back to the question, what does the future look like? So um, very senior leader of the United States Navy visits this shipyard periodically. And uh after his last visit, we have uh an exchange. He says, Am I missing something or are people happy to be there? And then you start thinking about whether it's in healthcare or elsewhere, when the systems in which we're embedded don't work, we're happy to do our work, but we're always frustrated. What are they going to do to me? What are they going to require? What have they done now? Right? It's always they, it's this amorphous they out there, which is acting um at best ignorantly and at worst maliciously. They are acting on us to make our experience worse. All right. So, anyways, it's the same, you can imagine in something, a big industrial operation subject to government uh management. You can imagine uh how people were walking into work all the time with the attitude of what are they going to do to us? And so, anyway, the senior officer says, you know, I I walked in there and I I I did I spent my day, and people seem happy to be in that shipyard. And he said, Well, you're right. Your impression impression was 100% right. And why is that? Because leadership have changed their behavior to run to the point of work, ask what is the difficulty, and then say, I'm gonna take your problem, I'm gonna figure out the cause of it, the diagnosis, we're gonna come up with a treatment for it so that later today, tomorrow, next week, when you step into a similar job, it'll be easier to succeed and harder to fail. And that, that uh certainty gives people joy. It gives people joy and a sense of appreciation. So, anyway, five years from now, what's the sign? What's the sign that these ideas have been picked up in an organization? You don't need the metrics, you don't need the reports, you don't need the surveys, just do the walkthrough. The people seem happy and joyful to be at work, and do they seem appreciated for the work they're doing? And if just those pulse checks of joy and appreciation trigger green thumbs up, things are working. And if those pulse checks trigger red thumbs down, you got work to do as a leader.

SPEAKER_01 1:15:15

What a hopeful note to end our conversation on, Steve. Um really appreciate you sharing, you know, this excellent summary of of the rich work that you've done over these decades now. Um for listeners who'd like to follow your work or connect, what's the best place for them to do that?

SPEAKER_00 1:15:32

Yeah, so uh again, and at risk of uh you know feeling like product placement, but it is. Um, you know, a lot of my materials are available or clickable through our uh firm, C2Solve. And uh you start there, and uh, we got some great case studies. There'll be links to the books, excerpts out of the books, out of the articles, and a good way to get in touch with us if you have uh more questions about what you as a leader can do to bring uh more joy to the work of your colleagues and uh more uh and better outcomes uh to uh the patients and their families who depend on you.

SPEAKER_01 1:16:04

Very good. And uh yeah, to amplify that signal, the uh our listeners can also go back if they haven't already to our recent episode with Maria Mencer, um, where she talks a lot more about C2Solve and and what it does. Thank you so much, Steve. Really opened my eyes a lot more today, as every time I read your work. Uh thank you so much for your time.

SPEAKER_00 1:16:24

Uh you know, and Jason, let me say a thank you to you. And then one is sort of the egotistical, oh, thanks for giving me attention. My self-esteem needs it, it's a bottomless void. And, you know, but but but more seriously, think about what you're doing. In in terms of uh training as a clinician, you got into this line of work again to uh you know provide provide care, comfort, cure to alleviate suffering. And what are you doing now? It's that third capability, knowledge sharing, taking other people's experiences, trying to do the same thing and lessons they've learned and making it uh broadly available through the system to both uh motivate, inspire, and inform others. So that that's a hugely valuable thing, which I think you're doing on your free time, right? You know, in this conversation we have, I know you pick this time because you're on vacation with your family, and you pick the time which deprives you of sleep, but doesn't disrupt their vacation time with you. So this is really a uh uh a very generous thing you do with these podcasts, so thank you for that.

SPEAKER_01 1:17:21

The pleasure has been all mine, but but thank you for that. I uh yeah, I do what I can. It's uh it's been a really fun thing to have this podcast, and uh, you know, it's great that some people are are listening. So, with that, I'll thank you again for your time, and Steve, we'll we'll talk again soon.

SPEAKER_00 1:17:36

Looking forward to it. Thank you.

SPEAKER_01 1:17:39

Thanks

Closing And Listener Call To Action

SPEAKER_01 1:17:40

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 was written and hosted by me, Jason Meadows, edited by Milan Milosavievich, and produced by Thrive Healthcare Improvement. See you next time.