Why Healthcare Improvement Gets Stuck in the Sidecar with Ken Segel

Why This Episode Matters

Healthcare has made real gains in quality and safety, but Ken Segel argues that too much improvement work still lives as projects, dashboards, or specialist-led initiatives rather than as part of how organizations are run every day. This episode examines what it takes to move from episodic improvement to habitual excellence: a clinical operating system where safety, flow, problem solving, leadership, and accountability are built into daily work.

Key Ideas Explored

•  The Pittsburgh Regional Healthcare Initiative and the early proof that zero harm could be pursued across competing hospitals 
•  Why safety, quality, patient experience, access, and cost are all connected through the flow of care 
•  The clinical operating system: the work system, the problem-solving system, and the leadership system 
•  Why quality and safety experts should advise operating leaders rather than own the work from the sidecar 
•  The shift from rear-view mirror problem solving to real-time learning while information is still fresh 

Takeaways for Quality Leaders

•  Look at whether improvement work is central to operations or still peripheral to how care is actually managed. 
•  Treat quality and safety as operating responsibilities, not just specialist functions or compliance activities. 
•  Go to where the work happens and observe how care flows, how problems surface, and how leaders respond. 
•  Build problem solving into daily management rather than relying only on retrospective reviews and dashboards. 
•  Use discipline to free clinical expertise, not constrain it. 

Continue the Conversation

Ken Segel on LinkedIn

Ken Segel at Value Capture

The Habitual Excellence Podcast

Resources & Frameworks Referenced

•  Pittsburgh Regional Healthcare Initiative 
•  Value Capture 
•  Value Capture Canada 
•  Toyota Production System 
•  Decoding the DNA of the Toyota Production System (The Four Rules in Use) 
•  Shingo Institute 
•  Prisma Health Pulse

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

If you found this episode valuable, follow the show, rate and review the podcast, or share it with a colleague working to improve care.

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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From Projects To Daily Operations

SPEAKER_01 0:00

Healthcare traditionally still gravitates a little bit toward a specialist and project-based approach. We still have so many places where the quality team is separate from the safety team and separate from the patient experience. But it takes going to the front line and watching care flow for about 20 minutes for us to help leaders realize they're all the same thing. We have to think of safety as the responsibility of the operating leaders.

SPEAKER_00 0:30

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. Ken Siegel is the Chief Relationship Officer at Value Capture and one of the co-founders of both Value Capture and the Pittsburgh Regional Healthcare Initiative. Over the last 25 years, his work has focused on helping healthcare organizations move toward zero harm and build the leadership and operating systems needed to make excellence more habitual.

Meet Ken Siegel And Zero Harm

SPEAKER_00 1:11

At PRHI, he was part of early regional work that helped drive major reductions in central line and catheter-associated infections across competing hospitals in the Pittsburgh area. At Value Capture, he has continued that work with health systems across North America. Our conversation today is about what happens when healthcare improvement moves beyond projects and specialist-led efforts and becomes part of how the organization is actually run every day. Ken describes the clinical operating system as the connection between the work system, the problem-solving system, and the leadership system.

SPEAKER_01 2:41

Pleasure to be with you and learn with you.

SPEAKER_00 2:44

Beautiful.

SPEAKER_01 2:58

Yeah, so so sort of the most direct path is the last 25 years where I was a co-founder of uh something called the Pittsburgh Regional Healthcare Initiative in western Pennsylvania in the US, where we were brought some of the first ideas of zero harm being possible and then the modern methods to achieve it, and drove down our regional uh CLABSy and CODI rates by more than two-thirds, and had the CDC and others validated academically. And at that point, there were other gains as well on the clinical side. Uh, but we we sort of noticed a phenomenon where the health system partners were achieving great things, but they were still running um the efforts as projects. And we could see that the principles of uh sort of habitual excellence that we call them, high reliability, others, etc., could really inform in a much deeper way how the whole organization's run. And so we created a firm called Value Capture, and now they capture at Value Capture Canada, to, with the mission of a vision of health care without harm, weight, or waste, to try to work with health systems around North America who were the leaders sort of wanted this embedded excellence and how they ran the place. And it's been a quite humbling 20 years uh being a co-founder of Value Capture as well, with an eminent figure, Paul O'Neill Sr., who was a Titanic figure in the safety movement worldwide across industries, but including healthcare, and then my partners, uh Paul O'Neill, Jeff Webster. About a year ago, I transitioned the CEO role, which I had had for 11 years, to our first next generation leader, Shanna Padgett, who is terrific, grew up from the lab bench in the hospitals to the C-suite and great advisor. And I've had the privilege since then of being our chief relationship officer, uh, which means I get to connect with people, connect deeply with ideas, engage in significant thought leadership because our mission is sort of to advance the field and make healthcare safer for everyone. And it's just a pleasure to connect with you and know, Jason, that we have some overlaps back through your MSK heritage and to hear the great sensitivity and depth with which you are exploring these topics and helping people sort of get to the root and get to the power of them and figure our way through this with real humility. So it's it's a pleasure to be with you.

SPEAKER_00 5:32

Very kind of you to uh to join me, and then the pleasure is

How PRHI United Competing Hospitals

SPEAKER_00 5:36

all mine. Um, I'd love to dig just a little more, if we could, into the the PRHI background, only because that's something that, you know, once I learned of that in your background, I said, oh, this is something I've read a lot about. And it might be immediately, you know, that acronym might be immediately familiar to people in our audience, but for those uh for whom it isn't, this is one of the, you know, one of the kind of the most important uh I think times and and places in in healthcare. So maybe you can just tell me a little more about how it was founded and you know what came out of it.

SPEAKER_01 6:10

Absolutely. I I will um I think everybody associated with it's quite proud of it and at the same time knows it it could be more. Um so you know, as as everything, there's a lot to learn from the good and the challenges, etc. So how it was created was there were um different forces in Western Pennsylvania under underway. In the healthcare sense, what was happening was, you know, in the American system and how we're funded, et cetera, there was an explosion of sort of consolidation and competition and and clinical relationships that had once been quite easy across uh institutions, et cetera, in a in a city and a region that's very proud of its medical care, were becoming sort of verboten or or strained because of sort of uh, you know, health systems sort of acting in very sort of immature competition with each other. And one of the things that this was doing was frustrating a lot of the clinical leadership that saw the virtues of working together and didn't really want to engage in sort of uh destructive competition. They were more interested in caring for patients and and you know, connecting with their colleagues and learning as they always had. And we were able to take advantage of that because the other thing that was happening was with the health system, and it was practically it was battles, you know, it was sort of wars going on. It worried the regional leaders that, you know, a great asset here and an asset to build on in western Pennsylvania could be sort of destroyed by competition. And, you know, could something more important come out and through collaboration strengthen the sector as a whole? And I was at a healthcare foundation as a senior program officer there, and the president of the foundation, Karen Feinstein at that time, Jewish Healthcare Foundation of Pittsburgh, organized an effort to sort of say what could we do that was important to unite the whole sector? And we found as her co-chair, Paul O'Neill Sr., who was at that time the CEO of Alcoa, and little did we thought he was just an important, you know, Titanic corporate chieftain in town. But little did we know he was perhaps the world's leading systems thinker and leader who had brought systems thinking around safety to the forefront and achieved the world's safest workplaces to be across 67 countries and one of the world's most dangerous industries. And so was a both a great uh framer of the issues in safety science, but also the leadership associated in the practicality of putting them in place. And we went through actually a year of organizing and learning from the best that was in healthcare thinking at this time, from Dr. Lucian Leap, from uh Dr. Dom Berwick, and others coming and helping us think through uh the physicians from the Northern New England Cardiovascular Disease Study Group and others to sort of inform an approach that might be successful. And at the same time, you know, Mr. O'Neill was helping us think through, and I think this is relevant to this day, approaches that sound good on paper, but sort of don't work in the real world, such as there are some that appeal a lot more to people with engineering types, but don't to others, etc. And out of that, we were able to forge sort of an agreement, and it was very difficult to get among all the not just the health systems, delivery systems, but the insurers, the attorney general of Pennsylvania, the big businesses in town, that we would pursue zero harm, eliminating Clabsey and Cotty, uh, as a way of learning to be excellent together and sharing openly and transparently our results, our process and outcome, and begin to work on things like um cardiovascular disease interventions and improving our rates of outcomes faster than others, um, our diabetic population's progress and health. And that's sort of that framing moment of that the leaders would stand by and support the stuff coming together was a bit seminal, but then we had to do it. And so what we did was to combine sort of the best of industrial safety, which is different to this day than healthcare's adaptations of it, together with the operational excellence side, so not just the safety side, but the operational excellence side of world leaders like Toyota, et cetera, together with the clinical scientists, you know, and there were some locally, and then of course the national, um, Intermountain Health, Dr. Brent James and others, et cetera, the best of those into an approach to move rapidly to attack these nosocomial infections, both you know, with the right sort of mass strategies, but also sort of building in the stability around the strategies and radical approaches that to this day are not practiced effectively in healthcare, such as real-time problem solving, not rear-view mirror problem solving, to produce you know, strikingly rapid gains across, you know, more than 40 competing hospitals. Politics was always present, though, and always threatening and you know, and and these kinds of things. So it was, but it was an important proof, I think. And and last year we were asked to consult a little bit with the Centers for Disease Control here in the States around their division that uh connects with hospitals. And one of the epidemiologists who worked with us at that time said, I think that really brought into it made it harder for people to resist the most significant safety efforts and made people realize zero really was possible. And, you know, that we should, if we're not there yet, we should be working hard toward it. So that that felt good. Our progress, I think, overall has been more limited, but it, you know, we're we are proud of the work that we did uh now 25 years ago to to show proof.

Why Projects Were Not Enough

SPEAKER_00 12:21

Thinking then, uh you mentioned that that going from PRHI, um, which I understand was a collection of a number of hospitals in western Pennsylvania, and shifting into value capture from there. What was that transition like and why did that happen?

SPEAKER_01 12:39

There was sort of a moment, and I I sort of alluded to politics rearing its head, where the leadership of University of Pittsburgh Medical Center at that time, which is you know, sort of the biggest institution in town and you know one of significant excellence on multiple in many ways, but the leadership there were quite aggressive previous leadership. And at a point where we had sort of lined the region up to be one of two finalists for some of the earliest, largest national value-based care operation uh experiments and funding to support it, the university decided that they did not want to be part of that effort and wanted to pursue sort of their own course overall. The transparency of it, the shared data, all of those things, they didn't want sort of a significant force in town tied to federal government, you know, high-priority stuff that sort of bound them with their competition in this way. And they were very straightforward about it, but they pulled out of that effort. And at that moment, those of us, as I said again, that had been seeing that even our greatest successes were still in most institutions being pursued as projects, said, look, there should be a group that continues to work with the region. And there is, the Pittsburgh Regional Healthcare Initiative still stands. I'm now an advisory board member, but a group of us who have a real passion for working with leaders who want to make this a whole system property and you know, and and apply it to how they run the place in a way that would generate great things beyond safety as well. We created this trusted advisory group called Value Capture. And in the early years, when the patient safety movement was really rising, we were privileged to work with a lot of the leading medical centers, academic medical centers in the US, on the early stages of their journey and getting beyond sort of just the very classic quality approaches that, you know, to be frank, were still more regulatory and orientation than excellence-oriented. And because of all the wonderful bright people and leaders there, you know, they were able to substantially, you know, upgrade. And of course, there were others working, you know, in the field as well. But those were very rewarding years. But we also picked up lots of partners, you know, in smaller community systems in the in the Midwest and other places where the sense of community and commitment and dig in and you know, going to be here for the long haul, and maybe a humility associated with that led to some of the best results, you know, that have been generated to date. And then uh some wonderful work in Ontario with Hamilton Health Systems, more recently with Lakeridge Health and some recent learning days associated with those. So it's terrific. But along the way, you know, it's been it's been difficult. I mean, in the States, you know, we all know the challenges of healthcare and the challenges of uh the patient safety movement. It's waxed and waned as uh emphasis. And, you know, there are a lot of big forces uh working in different directions, you know, north and south of the border, um, that have perhaps uh dulled the full application of the ideas, which could so benefit not just patients, but the people doing the work supporting them as well.

SPEAKER_00 16:06

Yeah, and as you were as you were listing those, I think you you mentioned Lakeridge Health, which for our listeners is uh is a hospital in Oshawa, Ontario. I don't know that we we covered this the last time we spoke, but I as a 21 or 22-year-old, I did a summer summer research internship there for the summer. So that's uh one more shared kind of connection in our past, but uh I know it well. And uh, you know, you started to see, I think, through this work, if I'm reading you correctly, the fact that this needs to be about leadership and operating systems rather than episodic improvement or accreditation-driven improvement. Can you tell me a little bit about that?

The Adaptivity Gap In Healthcare

SPEAKER_01 16:49

Absolutely. I mean, I think you know, we can all feel good about the work that's been done, but we also all have to be very humble about the evidence that's being produced, right? In the states, data from 2022 shows that of elderly patients hospitalized, about one in four will experience a um, you know, a hack that, you know, is is significant, that requires a change in their treatment and perhaps harm. And that's, you know, that tells us how unreliable we still are, um, despite all of this. And I think the roots of of some of our challenge lie in, you know, if we look at data first, if you look at sort of various measures of increasing complexity in the healthcare environment over the past 25 years, it is up seven, eightfold, right? Because of clinical discovery, because of all kinds of factors. Some, you know, some good, some bad. And yet our administrative productivity or our ability to sort of cope with with that amount of complexity is up perhaps, you know, 50%. And um, that gap is sort of the adaptivity gap in healthcare. And to in it, it's not like it was closed 25 years ago either, right? So in the causes of that gap, I think start with the sort of framework around how you think about achieving sort of habitual excellence every day across an enterprise. And healthcare traditionally, for lots of reasons, you and I could talk about still gravitates a little bit toward a specialist and project-based approach where we have patient safety experts who are sort of, you know, without saying it, put in the lead of driving quality and safety. You know, and and we do we still have so many places where the quality team is separate from the safety team, is separate from the patient experience team, et cetera. But it takes, you know, going to the front line and watching care flow for about 20 minutes for us to help leaders realize they're all the same thing. Because if care is not flowing, you know, for various different reasons, interruptions, wasted time, you know, the risk of the wrong thing showing up, all kinds of things, it all comes together in whether we are flowing in a stable way and whether we're able to pick up signals quickly and solve them to root cause or not. So the implication of that coming back up is that we have to think of safety and other good qualities that we're trying to engineer in as the responsibility of the operating leaders, the clinical operating leaders and the administrative operating leaders. And that means the CEO is the chief safety officer, and she, you know, she has the CMO and others to advise her if she's not a physician or a nurse, et cetera, et cetera. But everybody in the organization has to realize it's operations responsibility. And that leads to a whole different set of thoughts in different places to make sure the quote unquote operating system you're going, you're building to make that possible comes to life fully in a practical, powerful way. And, you know, I'd be happy to talk a little bit more about the core components and some of the differences with how we see these things typically being exercised within health systems even today.

SPEAKER_00 20:11

Yeah, I actually love to hear you talk a little bit more about that. I I do also want to just make a little more explicit what you said before, which I think bears um a little more unpacking, which is that so much of this work uh explicitly or implicitly has been shunted to specialists, people who are appropriately expert in safety, in quality improvement, in implementation science, etc. Those people, I think you'd agree, have probably have a really important role in healthcare. But I think what you're arguing is not that they don't have an important role, but how the work becomes kind of peripheral rather than central or rather than more distributed. Am I getting at the right idea there?

SPEAKER_01 21:00

100%. And let's and let's look, you know, thank you, Jason. Let's unpack that a little bit. So the world's highest performing organizations across industries, when you look at the data, Singo Institute, others, you know, real academic research, the quality leaders, the safety leaders are the best, and they're satisfied. And because they act as the advisors to leaders, to the operating leaders, clinical and administrative, and in the healthcare's case, who recognize themselves as the owners of the responsibility to produce a safe enterprise and you know, a safe patient attorney for everybody. And so instead of you know, consciously or unconsciously being deployed to knock on the door and you know, you know, and ask to be let in, you know, in operations otherwise, they are advising the leaders. Who knows it's their responsibility, right, to run a you know an operation that sort of makes safety a precondition. And it's a different thought process and it's it's less common, but it's fundamental.

Quality Experts As True Advisors

SPEAKER_01 22:13

You know, I was at uh the Beckers Healthcare Conference in Chicago recently, and um the the Chief of Population Health for Wellspan Health, who here in the States uh recently won the American Hospital Association top award for quality. He talked about the shift from sort of, you know, being um the named expert, but the health system is really not doing much in this yet, to sort of having a department um and getting sort of you know some project, you know, authority and things like that. And he he described that as being in the sidecar of a motorcycle, you know, going 80 miles an hour, and you're sort of yelling at the person driving the motorcycle, but they only can, you know, turn and listen to you a little bit of the time, you know, versus the CEO, who in his case is clinical, and you know, the CFO sort of unitedly sending to the organization, we are going to become, you know, an accessible lower cost health system providing the best care for everyone and how that shifts everything, right? And including their role. And I think um, you know, one of the reasons, including at Wellspan, one of the reasons we've had great relationships with the quality and safety experts in the institutions that we've had the privilege to advise in this way, um, is because we help them, we help their leaders especially reposition around that dynamic, if that makes sense.

Share What You Are Seeing

SPEAKER_00 23:55

I wanted to pause for a moment to invite you into something I'm starting with this podcast. If something from this episode connected with your own experience, where you've seen it work or not work, I'd love to hear about it. There's a short link in the show notes where you can share what you're seeing in your own work. It takes about a minute. I read every response, and over time I'll be sharing what we're learning together in future episodes and in other ways, and giving shout-outs during future episodes to people in the community who share ideas that really move the conversation forward. If you're up for it, I'd really value your perspective. Thanks.

The Three Parts Of Operations

SPEAKER_01 25:11

What we've we've called, we're not the only ones, but sort of an operate clinical operating system framework. And the operating system is the way we run the business every day. And it is a clinical enterprise in healthcare, right? And it has sort of three subsystems that have to work together very tightly. And we'll I'll try to make this concrete. But the first is the work system, the clinical work, the flow of how we structure our care flows to patients or person served. And a lot of healthcare quality and safety efforts and improvement efforts do not actually have a fundamental focus on this workflow. It is, and again, it's sort of tagging back to the operating leaders are responsible. It's, you know, that the work system needs to be, the clinical work system should be set up according to some principles that we know are correlate highly with being highly reliable and adaptable at the same time and making problem solving easier. And it is very rare to encounter a health system that says we structure our everybody who's in clinical operations is trained to structure their services with these pre these characteristics embedded. And so that's one, the work system. And that's prime, right? Because that's where the rubber hits the road in terms of, you know, does the person serve the patient get the right thing at the right time, the right way that they need from diagnosis to improvement or support, you know, preserving their health status. And that's where the work of clinicians is, that's where the work of people supporting clinicians is right, you know, behind it, etc. So the work system. The other is the problem-solving system. Things are going to happen, they do happen, you know, and the question is how well and effectively do we pick up the signals and correct them for the moment, yes, and healthcare does that forever. And you know, getting the root causes of those problems out. And in the improvement system, you know, one of the things we really try to help people adapt to is going from this project sense and just the rear-view mirror data-based approach to real-time problem solving, using uh uh what's the third part of the system, which is the leadership system and the management system, in a much more agile way to be on those daily challenges that affect flow, that affect risk, et cetera. And so that's the leadership system, whose main job is to make sure that care is flowing, stable, and built according to the right principles and problem solving is happening as quickly and as deeply as possible. And those lessons are being shared across the enterprise. And, you know, most of our structures still are much uh sort of uh more awkward than that and slower and more sort of full of uncertainty. Um, you know, one of the things we help institutions do is build a very explicit what we call a help chain of tying the leadership chain to the to the floors, if you will, if we want to talk about a hospital and the wards or the or the units, you know, or or to the clinical units, because that is where everything needs to happen. And it's different from just a huddleboard roll up and roll-down approach. It's a it's a real-time access to sort of drive those things. And to be a little bit more concrete, there's an example of the discipline of creating these sort of operating systems. Um, there are several. You know, we just talked about Lake Ridge Health. They went from 1.0 operating system, and we were pleased to advise them to go to 2.0, and they're getting many more gains out of it. Because the thing that has to happen is a lot of the tools and ways that we've approached quality and safety, there's nothing wrong with the tools, but they're not connected together in a very powerful practical system that's super efficient. And so a lot of what we're doing is helping people take a lot of well-meaning activities, et cetera, and say, well, do we have a very simple way to make sure that our workflows are based on the core, some core principles that make them safer, more adaptable? Are we problem solving it? Have we taught people to really problem solve quickly and in real time, et cetera, at this level? You know, are leaders attached to the floors in the right way so that they can do that? And by the way, when you tighten a system like that, it it actually creates free time for everybody because things flow better and you you can do the sort of look forward strategic work or others. So, one example that just published on that is Prisma Health and New England Journal of Medicine. They they have a clinical operating system that they call Pulse, which they have sort of stripped away everything out of their sort of EMR flow and other things that don't really support what the clinicians need, the EMR need, etc. There's not 50 different products coming together. There's sort of one system they use to manage care. And they've had, I believe, a more than 59% drop in um serious preventable injuries, 57% drop in serious safety events. At the same time, they're yeah, 59% rise in top box patient satisfaction. So, you know, these things sort of go together when you again take this operating system approach.

SPEAKER_00 30:50

Yeah, and and so I I love that you're we're getting kind of more concrete with this. That's a that's a a space that I like to dwell in because it's just so much easier to kind of understand, you know, my what does my daily flow look like as a clinician working on the floor? You mentioned in the Lake Ridge example, and and there are maybe others, uh, moving from operating system kind of 1.0 to 2.0. You've also mentioned a couple times uh principles, having a set of shared principles that you organize your activity around. Can you tell me a little more about what the kind of transition from 1.0 to 2.0 looks like concretely and what are maybe some of the principles that that people who are succeeding in this work are are applying?

SPEAKER_01 31:33

Absolutely.

Principles That Make Flow Safer

SPEAKER_01 31:35

And again, what it feels like is a thoughtful, you know, people in our field and listening may understand, you know, PDCA or PDSA cycle of taking a hard look with real evidence but also observational evidence and a systems view, a PDSA on our on our way of producing safety, you know, and and taking a look at the work system elements, the improvement system itself, and the leadership system tie-ins and say, how connected is this? How effective are the activities and the different things and actually knocking these root causes out? How much of this is producing wonderful paper and screensavers, et cetera, but not resulting in practice changes or growth and capability? And what if we imagine together a clearer sense of how to connect these three things together around supporting clinical flow and rapid problem solving and rapid sharing of information so that uh Dr. Meadows has a great interest in the areas that he practices and um he is going to want to make sure he learns quickly from things that happen in other areas where similar practice is going on. So he pulls to you know the transparent information. And meanwhile, the operating leaders, everybody understands that there are a few principles based here, and we're seeing that they uh we have some lessons about how to do that. So you asked about specific principles. So one is that are the the sort of paths of clinical care set up to be as simple and direct as possible, with no loops sort of built in or forks, uh, you know, ways different things could go on different days. Um, you know, well, we do it this way sometimes, we do it that way sometimes. Well, what's you know, what's the real rigorous way connected people to people? And is it as simple as possible? Because when we build complexity in or vagaries into how care flows, uh, when it's ideal, even in our, you know, even in our ideal state thinking, uh, it leads to more risk, more harm, etc. So simple and direct as possible. The second is have we constructed those care flows so that at each point the the people responsible for connecting to pass along information or material to help the patient, that there's a binary connection between them, that something is stated to that next person. Can you help me with this particularly? And you get a yes or a no. Binary. A lot of stuff is much fuzzier in this world, etc. And then the third that may be more familiar to people is standard work. Do we have a standard way to do this that we think is the best way to do it? And have we thought about things like the sequence it should be done, et cetera? And is it obvious to the person doing the work, not just them, but also a person coming to observe the work that the standard is being followed or not? And then the critical stuff is what happens when you can't follow the standard or when a binary signal is missed. And that is how improvement occurs. And it needs to occur with the people at the lowest level of the organization, quickly, while the information is fresh, using the scientific method. And those are sort of four very powerful principles that when you use them in plain language and give people examples and tie them together, they can say, well, hard to get there because we're not sort of structured right way to get there, but they begin to see dramatic gains in problems that have bedeviled them for a long time. So, for example, in the states here, perioperative care has been, you know, challenging episodically in many institutions over time because of the various stresses and strains that have been in the system since COVID. And the flows in operative care have gotten very complicated and with new people and different training, etc. And when you help people rebuild around these ideas, you know, first-case sometime starts go from the 40s to the 80, 85th, you know, very quickly. And, you know, and uh it with ripples throughout the day, and people have problem solving systems that they realize they can bring anything to, you know, relationships between anesthesia and surgery and nursing improve dramatically because they know they have a common way to problem solve and like they problem solve today in ways that you know work for them versus going into meetings a month from now, you know, when they have patients flowing over here and they need to learn and improve rapidly, which is they want to do. So there are real implications for the transition, as you rightly brought out, because any transition causes cognitive load on us, right? But one of the great things about that we make a point about in this work is the wins don't take that long to generate. Because, again, when you do a thoughtful PDCA cycle with the experts, the safety experts, but also the people doing the work and leaders, we have a sense in most institutions that it could be going better. We could be getting more out of this. There are times when it's frustrating. Um, there are times when we think our yield is, you know, more about, you know, dotting the paperwork than it is about really having fundamental change that everybody owns in the front lines, etc., and that relationships could be better, you know, around if we were able to solve problems more effectively together in the work. So, you know, that just gives you a sense, I hope, of some of the transition work and some of the characteristics and principles that you want to follow.

SPEAKER_00 37:23

Absolutely. Yeah. And for our listeners, as I'm, as I'm hearing you go through this, I'm now hearing strong notes of the four rules in use that were described uh, I think first by Steven Speer and Kent Bowen in their uh decoding the DNA of Toyota work. So I'll I'll link to those in the show notes because I think they help to kind of you know add some some concrete dimension to what you've described. But but what it but what it's what it sounds like you're also describing is is kind of a really concrete and really sounds like a very effective way to apply those principles directly to to healthcare. And that's really cool.

SPEAKER_01 38:03

Very direct, very direct, very practical. That's the only stuff that works, right? A good uh a good principle base, but then very a system for making it happen every day with real people who don't need a lot of jargon, you know, and just you know, are in the work and supporting those in the work. So absolutely. And yes, you're exactly right, DNA of the Toyota production system. And I want to tip my hat to you and your colleagues at Memorial Sloan Kettering back in the day, Lee Erickson, etc., who sort of uh did, you know, a lot of the great work to make those principles really come alive, you know, in that institution and shared with the rest of us. We've been using them since the Pittsburgh Regional Healthcare Initiative and Lee, of course, coming through there. And then your work um is one of, you know, you all have been great practitioners and moving the moving those forward in in in the movement. So thank you.

SPEAKER_00 38:57

Oh, thank you. I mean, we we clearly were the uh the beneficiaries of of work done long before us, and uh those were exciting times to work at MSK. I learned a lot and uh I'm certainly grateful for for the opportunity there. So

What A Mature System Feels Like

SPEAKER_00 39:11

in the work that you've done and the work that you continue to do with value capture, when you're seeing uh institutions on either side of the border, and it sounds like you are doing you know some pretty robust work on both sides of the border, um US and Canada, as you're seeing people seeing institutions transition to higher levels of this work, what does it feel like? How does it feel different to be in those places that are moving higher and higher in their maturity in this journey?

SPEAKER_01 39:45

That's a wonderful question. And I think the main feeling one gets and what clinical leaders and frontline teams have told us is that they're being led differently, that there is a uh simpler and more aligned sense of where we're going and who we are and how we get there. You know, a big a big difference is um, you know, the most institutions really make clear the goals. You know, we have to, we're trying to reach these clinical goals, but you know, as you know, often finance, right, is a big part of it. And but but this is the power of what happens when you clarify a way. This is the way we work toward the goals together, and so conflict, as you you know, and it takes some practice, but conflict is reduced because it's not people pursuing the goal in different ways. It's no, we're learning to get good at this way together to bring innovation or problem solving or improvement or breakthrough thinking together, and and it feels practical and it feels real and it feels really good. And so, you know, I've heard leaders describe it as you know, leading in a way that you want your people, be they a you know, a transport worker or the you know, one of your most senior physicians, you want them to roll out of bed in the morning and say, I gotta get to work, I have to be part of this. You know, so there's an aspirational part of it too, right? It gets exciting, right? Because it's like, oh, we're really getting our act together. We're sort of not just running around with a million projects and you know, 50 different things coming down from the C-suite. We're we're sort of moving forward together with some core ideas behind it and a relatively simple but powerful system that we get works. And this is going to allow us to achieve some great things. And I really feel, you know, supported and good getting to work. So that's the, you know, those are the, you know, there's again, there's the mental load while you're making the switch, which is hard right now because people have a lot of mental load already, but uh it does, it does start to feel quite different and better.

SPEAKER_00 42:04

You mentioned the the finance part of it, among other things.

The Myth Of Quality Versus Cost

SPEAKER_00 42:08

Yeah. And I imagine that in talking to different organizations, you encounter the feeling that quality and safety and finance are things that you have to choose between. Uh that you may have to, you know, you optimize these two and sacrifice the third, something like that. Do you encounter that? Is that true? Um, and if it's not true, kind of what's been your experience with those those dimensions?

SPEAKER_01 42:39

Yeah, so absolutely. You know, one of the one of the challenges I think we have in the quality and safety movement is that institutions still think largely in terms of um balance scorecards, you know, and dashboards where they have say perhaps four different dials, you know, as I heard a physician leader say, you know, along the lines that you just said, Jason. And that conceptually brings in sort of a top-down thinking of, oh, we have to go after the money first, you know, or this quality goal is bugging us, and we'd like to be better in that, so you work on that. And again, as I said, it doesn't take long with the proper structured observation to realize that it's really all about effective flow of the right thing, you know, to the patients and for the clinicians and having them have what they need when they need it for the patient. And that that's what produces the gains together. And so it is not true. And again, if you look at, you know, again, real data across industries about the leaders, the institutions that have persevered competitive advantage over others over time, with the exception of healthcare, for a reason we'll talk about, you know, it has been making the switch to sort of, you know, there's the famous. Toyota, cost, quality, lead time, safety triangle. They're trying to sort of optimize those all at the same time through making their processes great, their support for their people and producing the value for their customer great. And the finance sort of falls out of the back end. So we do face it. We of course face every institution, most institutions are not fat and happy financially. So they need to see that the financial piece comes with the work, right? And unfortunately, most of them are just organizing a lot of their efforts around the finance piece first. But the ones that are willing to do deep quality and safety work, they need to see that it produces gains, you know, and sort of is helping that triangle move forward. And the great thing is it doesn't take long, you know, if you're helping them address a significant um clinical safety business challenge, you know, and you look for the right ones that, you know, will absolutely have that dimension because they're associated with flow to help leaders realize that. And once leaders get it, you know, and you can sort of help them PDCA their own thinking and the system that they're running, it goes it, you know, it you know, it moves forward, which is great. But there's no doubt that the current state in most places is still the dashboard thinking and the optimizing, you know, a project for this, a project for that, etc. And of course, when those all meet the clinical units, it's chaos, right? They're trying to care for patients and they have 20 different corporate imperatives that they're supposed to undertake. And it's really all characteristics of the same system.

SPEAKER_00 45:40

Yeah, and I think what you're what you're speaking to will be really familiar to to audiences on both sides of the border that uh, you know, there can be many disparate priorities that that need to be, need to have committees or projects organized around them, to have dashboards upon dashboards that are organized to measure them. And it's a yeah, I can I can imagine that that's a a big challenge to organize people differently around principles and around quality and safety

Why Healthcare Changes Too Slowly

SPEAKER_00 46:09

first. You know, you promised in that answer that you'd uh talk a little bit about the healthcare's um not getting on board maybe as quickly or as fully as industry has. And and any other quality improvement nerds in the audience will have read a lot on the background of this and how industries, companies across industries have made such big gains using principles like the ones you just described. And and maybe there are some really great examples in healthcare too. But uh, I'm curious your comments on you know, why is it that we're doing this too slowly?

SPEAKER_01 46:49

So and I think you led into that by saying, you know, healthcare has not adopted, and you we let into it with a financial question, right? Yeah. So south of the border, the way healthcare institutions get paid is crazy, right? So, you know, it is largely, you know, revenue per piece still with all kinds of incentive programs around the edges for quality and safety, but they're really still more the edges. But from 20 different payers, and with, as Mr. O'Neill used to say, at least two sets of books, right? So there's what the what you know, what the the bill the hospital sends out, and then there's what the insurer is willing to pay, and then there's chaos around, you know, what people see, et cetera. You have it a little bit simpler north of the border, et cetera. But um, what that does is create an absolute fog about how folks get paid and leads health systems here to really focus at the end of the day on just we need to be as big as possible, we need to generate as much revenue as possible, and we need to keep our costs as low as possible. And so it becomes sort of um a chase for financial, it's it's sort of like uh, you know, you know, the moving shells in a game where you're just sort of chasing money wherever you can. Instead of we're running one system of care for our patients, and we need it to be as effective as possible and as efficient as possible by doing the same work, and that will produce the right outcome financially, and it always does because it eliminates, if you really do that well, it eliminates 40 to 50 percent of the resources you're pouring in and are frustrating your people because it's their time, you know, and allows them to produce it more productively on the outside. So the way, at least in the set in the south of the border, we get paid is an excuse, I would say, but it causes a lot of confusion around these issues, etc. Another factor, though, that applies everywhere is I think the quality and safety movement in the process improvement movement has at different times, because people need to have places to do work, accommodated dashboard thinking too much. You know, said we can run projects that will attack this and that, etc. And you'll see it in your dashboard this way without really teaching leaders the connection between them. And I think, you know, so then you have a real problem because the supposed experts are not optimizing the sort of the way things can flow. So that's that's that's another piece. And I think healthcare also has a cultural component whereas financial pressures across North America have led to greater discipline on sort of the back-end services, there is still a real wariness of bringing the sort of discipline that you and I have been talking about, Jason, into the clinical end because of, you know, a fear of, you know, how we practiced in different professional silos, the difference between people who've been trained clinically and others, et cetera. And so there's a lot of worry about toes and politics and you know how incentives are aligned there, et cetera, that keeps us from making the commitment to be as disciplined in the ways that we should be on that end to really produce what we want for patients, but also for ourselves. And I think there's a lot more work to be done there. And I think a lot more work by our movement, too, because it is not a rigid approach. It is a disciplined approach, but it actually sets free the expertise of the clinicians and those closest to the clue the patients to drive care and be the center of the action. So we have more work to do to overcome that barrier as well.

SPEAKER_00 50:41

What you just said is is really important and and worth our our audience um making note of. So, you know, applying these principles, I think it is my understanding and certainly my experience, you know, applying this work uh frees people's energy and creativity and intellect to be able to focus on solving these important problems with a principled approach. And so, you know, the standardization of the work being the best standard we currently know, and applying that standard so that we can build with our creative, you know, intellectual capabilities on top of that. So I'm I'm really grateful that you that you share that. I'm curious then, um Yeah, so I do want to understand um a little more about how your organization, how um value capture fits into

How Value Capture Catalyzes Change

SPEAKER_00 51:36

that picture. You work with with a variety of different hospitals, as we've said, um, in the US and Canada. You know, what is that process like? How are you helping to to kind of catalyze this this principled adoption of an operating system?

SPEAKER_01 51:52

Yeah, so so thanks for that question, Jason. So we go in with certain a compact, if you will, with the institutions that we get to advise. And the first is that they are it's their system. The operating system that they build will be theirs, not ours. We do not come in with a fixed set of tools connected in a certain way that you know you copy it and now you're running the value capture system, etc. Instead, our role is to act as trusted advisors to the senior leaders and to help them lead the learning and then lead the application in very practical, quick ways, often around challenges that they have in the business that they sense are sort of a combination of the factors that we've described. And so we roll up our sleeves and we help coach the people that are going to produce the change to make things better quality, safety, cost, all those things all at the same time, while building the rudiments, you know, and cardboard, if you will, of an effective, integrated, simple but powerful um operating system around that. It then becomes the place where others can learn and leaders sort of light bulbs go off, right, about how they can begin to spread this stuff. And spread it not through as we've often done sometimes, well, we got to roll out huddle boards across the whole system, things like that. But how this really spreads is by growing the capability of people. So, you know, it might be the clinical director of, you know, the first sort of learning lab that we call them, that, aha, okay, great. This is how I want to lead and grow my skills, et cetera, and lead my people a little differently. But I also am over these two other areas. How do I bring them in, et cetera? And I bring them in through my own coaching and evolving leadership and all of that stuff while we are spreading some of the core behaviors around this stuff and simple elements of the system, but with a focus on people development. And again, our role is we do some teaching, but it's really trusted advisory. And it is sort of coaching and observing through learning through doing, you know, after just a little bit of didactics and experiential training at the beginning. Um, and you know, to give people a concrete flavor, how we always start is going to where the work is done with the leaders in structured ways to help them see how is the how is the workflow going, how is the problem solving happening, how effectively, and how um it how is the leadership system supporting those things and helping them design quick experiments or places where they can experiment to tie those things together.

SPEAKER_00 54:39

That's that's great. I can start to see this this picture forming in my mind of of the clinical leaders and you kind of going to the floor and and um them being exposed to kind of discovering you know these processes through the structured observation of work.

Humility And Accountability In Leaders

SPEAKER_00 54:56

So, you know, when this really clicks and and leaders are starting to accept this, adopt this, spread this, what are the the kind of leadership capabilities that are that matter the most for for these people? What is it that they are thinking, saying, doing that is that you say this person's really got it or this person is is really going to move in the right direction? And maybe are there some common challenges that you have to overcome to get people there?

SPEAKER_01 55:28

Yeah, absolutely. And I think let's um we can start with the challenges. So changing how we do anything for any of us, including those of us in the quality and safety movement, is hard. It is hard to shift our patterns, it is hard to shift our thought patterns. It is particularly hard when we're in complex institutions where relationships are webbed and formed and have been in place for a long time, often, right? And so what we we have to do, what leaders have to do in themselves, and what we try to help them do it with humility is recognize that they're gonna need to shift their behavior, what they do, around these new ideas that they're getting very excited about, and then the structural elements and the sort of daily practice elements that are bringing them to life. And it's that commitment to be willing to learn, to shift, to practice shifting without expecting to get a perfect that sort of is fundamental to whether the change is gonna happen or not, right? And yet when leaders do that, when they show that vulnerability, when they lead with humility, they are sending a very powerful signal to the rest of the organization that it's okay to evolve, right? And it's okay to evolve together, and um that the leader is gonna learn from them too, right, about some of this. So learning and humility are are pretty fundamental, but the the leaders also need to recognize that their role is the to lay out the principles and the guardrails by which the system has to operate. And then to how would they know it's happening? And so shifting their work a little bit to thinking about the health of the systems they are responsible for overseeing. They don't do the mechanics of them, right? That's the directors, the VPs, the managers, etc. But how healthy is that system? And if they in the in it, what we do something called leader looping, where leaders periodically, as a group out of the C-suite, come and into structured observations, assess the health of the system. And when they see things that are challenges, they don't react on the spot, they don't tell people what to do, et cetera. But they're thinking systems-wise, right? They're not saying it's about this particular challenge today, etc. But they're saying if we want that to be different at the point where value is being provided for our patients and our, you know, we all just saw it together. What aspect of our improvement system, our management system, our workflow system, training people has to shift to better embed that principle. And they then have to be great teachers, right? So they have to be able to explain the larger idea, the larger framework that is being shifted to, but they have to be able to give examples, concrete examples, right? And the best leaders you see, they have that framework in their mind. You can tell, right? Things are almost simple and powerful. This is the way we are, this is who we are, these are our core behaviors. And then they give example after example from the front line, right? How could this be designed so that you know you couldn't do it any other way but perfect every time? They start asking those kinds of questions. What would ideal like, you know, look like? You know, what would allow you to go home excited about your work here and what changed, and how can we all work together to make that happen for each other? You know, they start to ask a lot of questions, right? As opposed to providing answers and and and create infection, you know, with their um aggressive aspirations, right? But they're trying to unlock the energy with everyone behind these alignments that can occur through good systems building and operating every day. The other thing they do have to do is hold people accountable, right? Um, what has to become non-optional is doing things different ways, you know, being outside the system without it being an experiment. And another point I'd make is, and sometimes it's hard for those in the quality and safety movement to hear is this is about results. You know, it's not enough to just, you know, run processes that are well-meaning and you know, treat people well on the surface. But if we're not making things better, we have to strengthen our accountability for PDSAing faster, moving faster together to get it done. And I think, I think, you know, this is not about just being nicer to each other and our processes and our behaviors. This is we have to get the results. And, you know, the most highest performing organizations in healthcare and the highest performing organizations around the world twin this kind of aspirational, beautiful support for people with high levels of accountability. It is not our these are not relaxed environments, you know, um, to lead and work in.

SPEAKER_00 1:00:30

So yeah.

A Five-Year Vision For Healthcare

SPEAKER_00 1:00:33

Um when you think about this work, you know, spreading these principles, this principled way of working to more places, what does the the five-year aspirational timeline for the work that you do, the work the value capture does look like? If this work achieves its its highest ambition, let's say five years from now, what does the world look like?

SPEAKER_01 1:00:58

Well, Jason, you you know, I love that you're asking the question, and that in the and the truth is you're catching me a little bit short in a way that I shouldn't be caught short. And let me explain. So that when we started value capture, we our plan on a page, which you and I will know to refer to sometimes as A3, a single logic-based plan on a page that is shooting for an ideal state, that we would have, you know, first American health care straightened out within seven years. Okay. And this was 21 years ago, based on an elegant model of we'd have three health systems that were outperforming everyone else so dramatically on these ideas that everybody would come a calling and it would spread like wildfire and it would scale and all of that stuff. And 21 years later, we're proud of the work we've done. We're proud of the support we've given to our colleagues in healthcare who have, you know, changed whole worlds. As we know, these healthcare institutions serve tens of thousands, hundreds of thousands of people every year, and and therefore, you know, whole universes of change that have happened. But the truth is the larger scale stuff has is still has lagged, as we started acknowledging at the beginning, for all the good work. And so when you ask me, as you should, what's the ideal state, what does it look like, is what I'm hoping for is that through podcasts like yours, podcasts like ours, but deeper looking inward from policy makers to people running healthcare and the clinical generations of tomorrow, that we look deep in and we take a harder look at how we're running the organizations. You know, the ideas have been proven, they are there and they are life-giving in a sense of human relationships, not just medicine delivered. And if we can adapt our organizational designs and behaviors to better match the speed, complexity, risk, and joys that are happening on the front line every day, so much more is possible, and so much less of the ick that is affecting all of us is possible. And, you know, I think it will come from the clinical leadership side. And of course, if uh governments and bankrupt themselves north and south of the border, um, you know, there may be deep, uh, deep rethinking. But everything still is possible, you know, and including, you know, the pace of biomedical discovery, the pace of clinical discovery that's coming online, it's really remarkable how fast things are changing in wonderful ways. And if we could just deliver it in ways that were less hard on everybody in the system, including patients and less harmful, sadly, sometimes, you know, it's it truly be a miracle time to be alive. I mean, in some ways it is. And all we have to do is take a harder look at ourselves, how we're organized, how we deliver, um, how we problem solve every day. And I think uh the clinical generations of the future, and hopefully the administrative leaders of the future and health systems will see it and grab it. Simpler, not easy, but simpler.

SPEAKER_00 1:04:03

What an inspirational vision of the future. I uh I want to be a part of that. Um I'm glad that we're we're doing our small part here to help co-create it. Thanks so much for taking some time with me today, Ken. Um, really great to talk to you. Uh, thank you so much.

SPEAKER_01 1:04:18

Jason, Dr. Meadows, uh, again, uh tribute to you and how you framed your career around these ideas and the work that you've done at the bedside and at the systems level, and we'll continue to do around the world. So thank you very much for having me.

SPEAKER_00 1:04:32

Yeah,

How To Connect And Closing

SPEAKER_00 1:04:33

thank you. And and before we go, um, I'd love to let our listeners know how they can connect with you and follow your work. We'll link to the value capture website, but is there anywhere else that uh people should connect with you?

SPEAKER_01 1:04:43

Yeah, so connect with me on LinkedIn, you know, KT Siegel. You're hard, not hard, not hard to find me, Ken Siegel at Value Capture, and uh be happy to chat and talk about ideas, thought leadership back and forth, and understand where you're coming from and what your needs are. So connect with me on value capture and we'll go from there.

SPEAKER_00 1:05:00

Very good. You also have the uh excellent habitual excellence uh podcast, which uh I'll link link to as well and would encourage our listeners to go and check out. So we'll we'll link to those as well as any other resources that we've mentioned in the course of this conversation. Um again, Ken, uh, thank you so much for helping move this conversation forward in um in healthcare, and uh thank you for being here today. We've got it. Absolutely. 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.budsprout.com or in your favorite podcast app. The show is written and hosted by me, Jason Meadows, edited by Milan Milostavievich, and produced by Thrive Healthcare Improvement. See you next time.