KataCon 2017 Keynote: Joe Ross

Joseph P. RossLast year I nominated Joe Ross, the CEO of Meritus Health in Hagerstown, MD to be a keynote speaker at the 2017 KataCon. I did so because I think Meritus has a compelling story.

Like many organizations, Meritus had engaged in several years of staff-led improvement focused on events and things like “A3 Training.” And like many organizations, while the individual events seemed successful, the actual long-term traction was limited.

A little over a year ago Meritus started exploring Toyota Kata as a possible way to change the cultural dynamic. The 2017 KataCon will be on the anniversary of our first training session.

In the meantime, Meritus also applied the same thinking to how they did their senior leader rounding, as well as applying the thinking shifting the way the staff interacts with patients and each other.

Joe’s talk will cover these key points and the lessons they have learned along the way.

I hope you will be there to hear his message and meet him as well some of his key people.


Delivering the Patient Satisfaction Experience

“Our challenge is to improve our patient satisfaction scores.”

This seems to be a fairly common theme as I continue to work in the health care arena.


In the U.S. at least, most major health care operations use one of a couple of major service providers (such as Press Ganey) to survey their patients, and report aggregated patient satisfaction scores to them. Those scores provide a percentile rank of how that facility stacks up against others across various categories. The scores are also made public, and often influence public funding decisions within a region. Thus, they are a big deal.

Chasing the Patient Satisfaction Numbers Doesn’t Work

Here’s the problem. More than a few times I have seen an improver working on a challenge to improve these patient satisfaction numbers. It might be something like “Achieve a 70th percentile score on ___.) with a specific score that has to do with their area.

So far, that’s not a real problem. But what happens next might be.

It is very common to focus solely on the end result, without a lot of thought into the underlying things that drive that result.

Specifically, I have seen more than a couple of cases where a manager is working to directly influence how a patient (customer) will answer the questions on the survey. They parse the question, and try to determine what this word, or that word, actually means to “the patient.” The worst case was trying to introduce fairly heavy handed scripting… “Is there anything I can do for you to be more comfortable?” into every patient interaction.

I certainly can’t speak for the population of patients, but I can say that when I pick up on a scripted phrase, I become very aware of what it is, and it leaves a disingenuous taste.

It’s About the Patient Experience

The patients’ experience is what drives how (and even if) they will answer the questions on these surveys. If their experience was overall favorable, they will be biased to give favorable replies. The opposite is even more true. One bad experience will negatively bias all of their answers.

Here’s the question I ask that sometimes stumps people:

What experience to you want the patient to have?

(If you aren’t in health care, substitute the word “customer” for “patient.”)

If your scores on “Were the staff concerned for my comfort?” are low, think about what experience would give the patient confidence that staff were concerned. Being continuously asked about it with a rote phrase probably isn’t going to do it. But leaving them parked in the hallways with no interaction might be (for example), something that creates discomfort.  (“Comfort” has a psychological, as well as a physical component.) People will put up with a lot of discomfort if they know the higher purpose. It’s hard to make the case for parking the patient in the hallway. That just says “I don’t have anywhere to take you.”

So think deliberately. If everything the patient experienced were something you were doing on purpose, because it contributed to the experience you want the patient to have, what would that look like?

Don’t worry right now about whether that is hard or not. Let go of your internal issues for a while. Just sketch out that awesome “insanely great” patient experience. You don’t have to think of every detail. What are the attributes? What is the flow, from the patient’s perspective – the sequence of events they will experience.

For example, construct a story, told from the patient’s point of view, of coming in for outpatient surgery.

What happens from the time they have their initial consultation until they are on their way home. (And what happens after they get home?) Again, don’t worry about “we can’t do that because…” stuff, we’ll deal with that later.

What experience, what story, would leave the patient with the impression that you are working as a team, that you know what you are doing, that there is a competent process at work to provide safe, effective care and actually care about their experience?

Don’t forget to include your administrative communications in this process – what phone calls do they get? What paperwork do they get? What does crystal-clear billing look like?

Build a block diagram, a story board, of the patients’ ideal flow through the system.

What would a wait-free, smooth flowing experience look like?

Learning From Disney

In Disney theme parks, they make a clear distinction between “On Stage” and “Off Stage.” Their employees (all of them) are referred to as “Cast Members.” Anytime a Cast Member is visible to guests, they are “On Stage.” They are performing. They are part of creating the story, the experience, they want the guest to have.

Meanwhile, behind the scenes, in the tunnels, off stage, are the processes required to create the “On Stage” performance. It’s a show.

The guest experience is designed. Once it is designed, it is created by the process.

Disney’s priorities (in order) are:

  • Safety
  • Courtesy
  • Show
  • Efficiency

Translated, they place putting an a good performance above being efficient. But if pushed, a cast member may break character if required to be courteous. And they will get snippy with someone who persists in doing something unsafe in spite of courteous requests.

What on Earth does this have to do with health care?

Everything. That is if you are trying to create a safe, professional and competent impression to your patients.

What is the Actual Patient Experience?

Now we have a sense of the ideal, it’s time to understand what is really happening. Again, start with the patient’s experience.

What happens at each interaction? What questions are asked? Who asks them? How often are they moved? Where and when are they waiting, and why? 

Use “typical” rather than exceptional cases here. One thing I am seeing is, yes, every case is different but in reality, most are handled within a routine.

Pay attention to the “on stage” part of your process. This is what the patient sees, and what creates their experience.

At the same time, look at the behind-the-scenes “off stage” flow to see what might be causing a less-than-ideal patient flow. For example – The patient’s experience is that he is alone in an exam room waiting, reading Time Magazine for 20 minutes. That is the “on stage” part.

Meanwhile, “back stage” you have a nurse on the phone trying to get the results of tests that were done by another provider. (This is a real-life example.)* (There was also a physician waiting on them!)

Your Processes Create the Patient Experience

(Again, substitute “customer” for “patient” and this becomes an essay for everyone.)

Your Patient Satisfaction scores are driven by the patients’ experience.

The patients’ experience is established by your “on-stage” (patient facing) process.

Your “on-stage” process is the result of your “off-stage” execution.

The people making the improvements need to be challenged, and focused on, creating a specific experience for the patient.

Linking to Policy Deployment

All of that begs the question: Who should make the linkage between process performance and patient satisfaction, because those scores do matter, in a very big way.

Let’s look at this from a policy deployment standpoint.

Certainly Administration (the executives) should be tracking their scores. From their perspective, these are an important (along with patient safety, quality, length-of-stay, financial performance, etc) aspects of how the organization is performing.

They see the overall performance and trends. And they can see how each department is performing.

But the patient’s experience is cross-functional. The patient only sees “the hospital.” He doesn’t see, and doesn’t care, that Admissions, the lab, the Emergency Department, Outpatient Surgery, Environmental Services (who cleans his room) and Radiology are all different departments. The patient doesn’t see, and doesn’t care, that “the clinic” and “the hospital” are separate legal entities.

As part of Policy Deployment, Administration should be establishing operational standards and challenging the Department Directors to meet them. Those standards are based on what Administration believes will move the needle on the patient satisfaction scores. In reality, this is also an experiment. Does this operational standard meet our customer’s expectations?

They also are making sure the Directors are working on the cross-functional interfaces between their departments. (If it isn’t the Directors’ job to do this, whose job is it?)

Key Point: Until you are consistently delivering the product or service, there is little point in trying to change things up. Set a standard, strive to meet it. Once things are somewhat stable, then you can evaluate whether your standard is adequate or not. Think about it… what is the alternative? You have random execution that is randomly working. You don’t know why. You can’t talk to people about performance until they can demonstrate consistent execution.


Your patient satisfaction scores reflect the experience of the patient.

The patient experience is the outcome of your on stage process performance.

Your on stage process performance is ultimately driven by your back stage process execution.

If you want to improve your patient satisfaction scores, establish the operational standard you want to strive for that you think will improve patient satisfaction.

Then strive to develop a process that meets that operational standard.

THEN you can evaluate whether your process is adequate.


*This was an obstacle in front of a target condition focusing on hitting a standard for “In, Seen and Out” within a specific time frame for routine pre-procedure consultations. They fixed it. Patients no longer have to sit and wait while someone hunts down those test results.

Toyota Kata in Health Care

I’m about four months into helping a major regional hospital develop a solid foundation for applying the Improvement Kata and Coaching Kata to learn “improvement thinking.”

They now have active improvement boards running in pre-op, post-op, surgery, radiology, the lab, the emergency department, the cardio-vascular floor, medical-surgery floor, ICU, cardiac rehab, billing, admissions, case management, and supplies. I think that’s everything going right now.

Several of these departments have more than one board, and a few are beginning to get started spontaneously.

We are starting to see the culture begin to shift in many of these departments. Staff are getting engaged in improving the work flows, administration team members are more engaged with the staff.

Directors and managers are starting to reach across organizational boundaries to deal with obstacles and problems at the departmental interfaces.

And the organizations are starting to shift how they talk. When confronted with a list of problems, leaders are starting to ask “OK, which one are we addressing first?” Leaders are asking “What do you expect to happen?” and “What did we learn?” when talking about actions. They are working to engage thinking in their organizations vs. just giving direction.

Is it all rainbows and unicorns? Of course not. But the effort is clearly being made, and it shows. My overall process coaching is getting much more nuanced, because they are “getting” the fundamentals.

OK, so what did we do?

We started out with two weeks of pretty intense “kick-start.” One week was half-days of training and simulation (with a morning and afternoon group), getting a feel for the rhythm of the improvement kata, and a taste of the coaching kata, and culminating with the first round of improvement boards getting set up with at least a direction, if not a clear challenge.

We deliberately did not use industrial examples. And now that I’ve done it a few times, I can incorporate more health care language and examples into the sessions, which just makes it easier.

Week two was pairs of learners/coaches being coached through grasping the current condition, establishing a target condition, and the first couple of PDCA cycles / experiments.

But what made it work is they kept at it.

The next month, we did it again. We coached the established boards to tighten up their game, while establishing a series of new ones.

Because they had kept at it, the first round of boards now had a routine for their improvement cycles and coaching. And once there is a pattern, then we can work on improving it.

What I am learning.

Just get them going, then leave them alone for a while to keep at it. That lets the team establish a baseline routine for how they are practicing. Then I can come back periodically and propose adjustments on one or two items that let them step it up to the next level.

I am finding this much more effective than demanding they get it perfectly from day one. There is just too much to think about.

Establish a target condition, have them practice to that pattern, grasp the current condition, establish a new target… for the team’s practice. Get the improvement engine running, even if roughly, then work on tuning it for performance.

To be clear, this is my normal approach (and it is different, I am told, from what a lot of others try to do), but I am getting a lot of validation for it here.


A member of the administration (leadership team) who is actively coaching shared this chart with me today. I have “sanitized” it a bit. Suffice it to say these three lines represent the percentage of deliveries of three separate (but related) processes within or before the target turn-around time of 30 minutes. Their challenge is to turn 95% of them around in 30 minutes or less.

The vertical red line represents when they started applying the Improvement Kata to this process.

Otherwise, the picture speaks for itself.


They have recognized that there is no silver bullet here. Rather, there have been dozens (or more) of changes that each save a little bit of time that is adding up.

As one of my early Japanese teachers said “To save a minute, you must find sixty ways to save a second.” and that is exactly what they are doing here. They are finding a minute here, a few seconds there, and anchoring them in changes to the way they organize the work flow.

Lab Team: “Way to go!”

NPR: Hospitals New Face Pressure to Reduce Infection Rates

This article on NPR is chiefly about the dilemma that hospital administrators are facing as escalating government reporting requirements are being tied to their Medicare payments. (For my non-US readers, Medicare is the U.S. government medical insurance program for seniors and retirees. It pays a huge portion of hospital’s revenue, and thus, its policies carry a lot of weight).

The article’s lead does a good job of summing up the issue:

Under laws in more than two dozen states and new Medicare rules that went into effect earlier this year, hospitals are required to report infections — risking their reputations as sterile sanctuaries — or pay a penalty. That’s left hospital administrators weighing the cost of ‘fessing up against the cost of fines.

So, in effect, the administrators are faced with weighing the financial impact of lost Medicare payments vs. the financial impact of telling the truth about their infection rates. This is, in my mind, yet another symptom of the General Motors style of management that is taught by every MBA program in the world.

It also suggests that there is a viable alternative of continuing to maintain the illusion that it is not a problem.

Is it a problem? Hospital infections kill about 90,000 people a year in the USA. Compare that with the 40,000 or so that are killed in traffic accidents, and you get the idea.

Add to that the fact that the patient ends up getting billed (and usually insurance pays the bulk) for the treatment of these infections.

Fundamentally this is about quality, and the problem is certainly not limited to health care. (it is just that lives are at stake)

How does your company respond when there is a known issue that is impacting quality?

If you deliver a defective product or service, do you charge your customers for the rework? This is not a facetious question. Some companies do.

Do you avoid collecting information for fear of revealing the true magnitude of a problem?

Do your workers fear bringing it up when they are directed to carry out inappropriate actions, or actions which violate the company’s written policies and procedures?

Is it OK to improvise outside of your known process in order to get the part out the door?

Back to the hospital – we know how to tackle this problem. It is merely extremely difficult. That doesn’t make it impossible. I am glad it is getting attention. I am disappointed that it takes government generated threats of visibility to get action.

Some Healthcare Observations

A couple of weeks ago I had the opportunity to return and see my friends in the Netherlands, and I’d like to share some observations from the Lean Thinking in Healthcare Symposium I attended over there.

But that conference was on Friday. I arrived in-country on Monday morning at 7:30am. By 10:30 am I was in sterile scrubs in an operating room observing a knee replacement operation. (I was told of this agenda while on the way there, at about 9:30.) I’ve got to say it was quite an interesting experience, and here is my public, if belated, thanks to Dr. Jacob Caron, who graciously brought me into his domain. Thanks, also, to his patient for allowing me into this bit of her life as well.

The experience was fascinating, and enlightening. Here is the core value-add of a long and complex process as the patient is moved through the various stages of treatment. And at that core, things are organized, quiet, efficient. Of course it is nothing like an O.R. on television. Drama is the last thing a real-life surgeon (or patient, for that matter) wants in the O.R.

The work flow of instruments caught my eye. We all know that the surgeon asks for the instrument he needs, and the O.R. nurse hands it to him, usually anticipating his request.

But there is a return flow as well. As the surgeon is done with an instrument, he puts it down as he asks for the next one. The O.R. nurse then quickly picks it up, wipes it (if necessary), and re-orients it so she can pick it up quickly when it is needed again.

None of this is really surprising with a little thought. I imagine the tight circle around the patient is organized pretty much the same way in every operating room in technologically advanced countries. In manufacturing, we use the “like a surgeon” analogy to describe how team members who directly add value should be supported.

Later that afternoon, I was touring the ward where the orthopedic surgery ward with the supervisor.

They are working on kaizen, they have an Problem – Improvement board and do a decent job keeping track of things that disrupt work.

“No time” seemed to come up a lot as a reason for the nurses. And, from what I know of the workload of hospital nurses, this is not a surprise either.

But where does their time go?

Let’s consider that nurses are the front line. Yes, the physicians get the attention, but aside from cases like surgery, it is the nurses who actually deliver the care to the patient. In other words, though the physicians design the care, it is the nurses who actually carry it out.

So here was my question / challenge to the audience at the conference:

No operating room in the developed world would ever tolerate a situation where the surgeon had to go look for what he needed to deliver care to the patient. The surgeon’s world is fully optimized so she can devote 100% of her attention to the patient.

Yet, in those very same hospitals, all over the world, we tolerate – every day – conditions where nurses, who are also primary care providers, spend too much of their time fighting entropy, looking for what they need, improvising, dealing with interruptions – all of the things we would never tolerate in the O.R.

Why the disparity?

British NHS Executive Talks About Lean

Lesley Doherty, the Chief Executive at NHS Bolton in the U.K. was recently interviewed by IQPC as a precursor for her being a keynote speaker at a conference IQPC is sponsoring in December (Zurich). In the spirit of full disclosure, IQPC had invited me to participate in a “blogger’s panel discussion” (along with Karen Wilhelm, author of Lean Reflections) earlier this year in Chicago.

The Chicago conference turned out to be very Six Sigma centric – in spite of having Mike Rother as a keynote. But that is history.

I want to reflect a bit about this podcast. I invite you to listen yourself- it is an interesting perspective from a senior executive who discusses her own learning and discovery. I will warn you that you may have to “register” on the web site – though you can uncheck the “send marketing stuff” box. I will also say that the interview’s sound is pretty bad, so it is hard to hear the questions, but I was able to reconstruct most of it from context.

What is interesting, to me a least, is that the methods and experiences are pretty standard stuff – common to nearly all organization undertaking this kind of transformation.

A summary of the notes I took:

They have to deliver hard budget level savings on the order of 5% a year for the next several years. That is new to them as a government organization.

They started out with an education campaign across the organization.

Initial efforts were on increasing capacity, but those efforts didn’t result in budget savings. In one case, costs actually increased. They don’t need more capacity, they need to deliver the same with less.

They have identified process streams (value streams), and run “rapid improvement events.”

Senior people have been on benchmarking or study trips to other organizations, both within and outside of the health care arena.

They are struggling to sustain the momentum after the few months after an “event” and seeing the “standard” erode a bit – interpreting this as needing to increase accountability and saying “This is how we do things here.”

“Sustaining, getting accountability at the lowest level is the biggest challenge.”

In addition, now that they are under budget pressure, they are starting to look at how to link their improvements to the bottom line, but there isn’t a standardized way to do this.

They believe they are at a “tipping point” now.

There is more, having do to with Ms. Doherty’s personal journey and learning, and knowledge sharing across organizations who are working on the same things, but the key points I want to address are above.

Please don’t think that this interview is as cold as I have depicted it. It is about 20 minutes long, and Ms. Doherty is very open and candid about what is working and what is not. It is not a “rah-rah see what we have done?” session.

As I listened, I was intently trying to parse and pull out a few key points. I would have really liked it if these kinds of questions had been asked.

What is their overall long term vision? Other than meeting budgetary pressure and “radically reviewing” processes, and “transformation.” What is the “true north” or the guide point on the horizon you are steering for?

What is the leadership doing to set focus the improvement effort on the things that are important to the organization? What does the process have to look like to deliver the same level and quality of care at 5% lower costs? What kinds of things are, today, in the way of doing that? Which of those problems are you focused on right now? How is that going? What are you learning?

What did they try that didn’t work, and what did they learn from that experience?

When you say “local accountability” to prevent process erosion, what would that look like? What are you learning about the process when it begins to erode?

The “tipping point” is a great analogy. What behaviors are you looking for to tell you that a fundamental shift is taking place?

As you listen, see if you can parse out what NHS Bolton is actually doing.

Is their approach going to sustain, or are they about to hit the “lean plateau?”

What would the “tipping point” look like to you in this organization?

What advice would you give them, based on what you hear in this interview?

If Air Travel Worked Like Health Care

This would be funnier if it were not true.

The video was apparently produced to dramatize this piece in National Journal Magazine.

Then again, the air travel industry should not go unscathed here, so for your amusement, the TSA Theme by the Bar and Grill Singers, a group of Texas attorneys whose works include “The Jury Sleeps Upright.”

Information Transfer Fail

While the dentist was looking over my x-rays, he saw something he would like checked out by a specialist. He used words like “sometimes they..” and “might be…” when describing the issue he saw.

I get a referral. The information on the referral slip is the name of the referring dentist (which I can’t read), no boxes checked, and “#31” in the comments.

I call the specialist and start getting technical questions about what my dentist wants them to look at / look for, etc.

So the process is to use the patient as a conduit for vaguely expressed (in layman’s terms) technical information between highly trained specialists.

Sadly, I think this happens all of the time in the health care industry. It seems that there is so much focus on optimizing the nodes that nobody really “gets” that the patient’s experience (and ultimately the outcome of the process) is defined more by the interactions and interfaces than it is by the nodes themselves.

I am really not sure how fundamentally different this is from a pilot asking a passenger to find the maintenance supervisor and tell the mechanic about a problem with a plane.

The net effect is, as I am writing this, the specialist’s office is calling the referring dentist and asking them what, exactly, they want done.. a net increase of 100% in the time involved for all parties to communicate.

While the national debate is on how we pay for all of this, we aren’t asking why it costs so much (or kills more people than automobile accidents do).

Health Insurance Overprocessing Muda

If I had a category for “What are they thinking?” I would probably tag this post with it.

Patient has an eye exam that is covered by her health insurance.

The doctor’s office bills the insurance company.

The insurance company disallows $29.32 in charges because they are above a contractual amount.

The insurance company sends a check for $29.32 to the patient to cover the disallowed charges when she gets the bill from the doctor for the balance.

Do I even need to frame a “Why?” question here?

I think it stands on its own.

Just scratching my head.

Yes, I saw the statements and the check with my own eyes.

Looking at the wrong stuff: America’s Best Hospitals: The 2009-10 Honor Roll

This news piece, America’s Best Hospitals: The 2009-10 Honor Roll, originally got my attention because I hoped someone might be actually be paying attention to the things that make a real difference in our national debate about health care.

Unfortunately, it looks like more of the same.

This survey looks at things like technical capability – what kinds of specialty procedures these hospitals can perform, and their general reputation  and then ranks them accordingly.

But where are we asking about the basics?

Which hospitals kill or injure the fewest of their patients? What is the rate of post-operative or other opportunistic infection? How about medication errors? These are the things that all hospitals should be “getting right” and yet the evidence is overwhelming that most don’t. Further, nobody seems to be paying attention to it except tort lawyers.

Now take a look at this post on Steven Spear’s blog, and especially the Paul O’Neal commentary that he links to.

Tell me what makes a “good” hospital?