Executive Rounding: Taking the Organization’s Vitals



I wrote an article appearing in the current (October 2017) issue of AME Target Magazine (page 20) that profiles two very different organizations that have both seen really positive shifts in their culture. (And yes, my wife pointed out the misspelling “continous” on the magazine cover.)

The second case study was about Meritus Health in Hagerstown, Maryland, and I want to go into a little more depth here about an element that has, so far, been a keystone to the positive changes they are seeing.

Sara Abshari and Eileen Jaskuta are presenting the Meritus story at the AME conference next week (October 9, 2017).

Sara is a manager (and excellent kata coach) in the Meritus CI office. Eileen is now at Main Line Health System, but was the Chief Quality Officer at Meritus at the time Joe was presenting at KataCon.

Their presentation is titled Death From Kaizen to Daily Improvement and outlines the journey at Meritus, including the development of executive rounding. If you are attending the conference, I encourage you to seek them out – as well as Craig Stritar – and talk to them about their experiences.

Mark’s Word Quibble

In addition, honestly, the Target Magazine editors made a single-word change in the article that I feel substantially changed the contextual meaning of the paragraph, and I am using this forum to explain the significance.

Here is paragraph from the draft as originally submitted. (Highlighting added to point out the difference):

[…][Meritus][…] executives follow a similar structure as they round several times a week to check-in with the front line and ensure there are no obstacles to making progress. Like the Managing Daily improvement meetings at Idex, the executive rounding at Meritus has evolved as they have learned how to connect the front-line improvements to the strategic priorities.

This is what appears in print in the magazine:

[…][Meritus][…] executives follow a similar structure as they visit several times a week to check in with the frontline and ensure there are no obstacles to making progress. Like the MDI meetings at Idex, the executive visiting at Meritus has evolved as they have learned how to connect the front-line improvements to the strategic priorities.

While this editing quibble can easily be dismissed as a pedantic author (me), the positive here is it gives me an opportunity to highlight different meanings in context, go into more depth on the back-story than I could in the magazine article, and invite those of you who will be attending the upcoming AME conference to talk to some of the key people who will be presenting their story there.

Rounding vs. Visiting

In the world of healthcare, “rounding” is the standard work performed by nurses and physicians as they check on the status of each patient. During rounds, they should be deliberately comparing key metrics and indicators of the patient’s health (vital signs, etc.) against what is expected. If something is out of the expected range, that becomes a signal for further investigation or intervention.

“Visiting” is what the patient’s family and friends do. They stop by, and engage socially.

In industry, we talk about “gemba walks,” and if they are done well, they serve the same purpose as “rounding” on patients in healthcare. A gemba walk should be standard work that determines if things are operating normally, and if they are not, investigating further or intervening in some way.

I am speculating that if I had used the term “structured leader standard work” rather than “rounding” it would not have been changed to “visiting.”

Executive Rounding

Joe Ross, the CEO at Meritus Health, presented a keynote at the Kata Summit last February (2017). You can actually download a copy of his presentation here: http://katasummit.com/2017presentations/. The title of his presentation was “Creating Healthy Disruption with Kata.” More about that in a bit.

The keystone of his presentation was about the executives doing structured rounding on various departments several times a week. These are the C-Level executives, and senior Vice Presidents. They round in teams, and change the routes they are rounding on every couple of weeks. Thus, the entire executive team is getting a sense of what is going on in the entire hospital, not just in their departments.

Rather than just “visiting,” they have a formal structure of questions, built from the Coaching Kata questions + some additional information. Since everyone is asking the same basic questions, the teams can be well prepared and the actual time spent in a particular department is programmed to be about 5 minutes. The schedule is tight, so there isn’t time to linger. This is deliberate.

After the teams round, the executives meet to share what they have learned, identify system-wide issues that need their attention, and reflect on what they have learned.

In this case, rather than rounding on patients, the executives are rounding to check the operational health of the hospital. They are checking the vital signs and making sure nothing is impeding people from doing the right thing – do people know the right thing to do? If not, then the executives know they need to provide clarity. Do people know how to do the right thing? If not, then the executives need to work on building capability and competence.

In both cases, executives are getting information they need so they can ensure that routine things happen routinely, and the right people are working to improve the right things, the right way. In the long-term, spending this time building those capabilities and mechanisms for alignment deep into the operational hierarchy gives those executives more time to deal with real strategic issues. Simply put, they are investing time now to build a far more robust organization that can take on bigger and bigger challenges with less and less drama.


Though they were only a little more than a year in when Joe presented at KataCon, he reported some pretty interesting results. I’ll let you look at the presentation to see the statistically significant positive changes in employee surveys, patient safety and patient satisfaction scores. What I want to bring attention to are the cultural changes that he reported:


Leadership Development

Actually points 1. and 2. above are both about leadership development. The executives are far more in touch with what is happening, not only in their own departments, but in others. Even if they don’t round on their own departments, they hear from executives who did, and get valuable perspectives and questions from outsiders. This helps break down silo walls, build more robust horizontal linkages, and gives their people a stage to show what they are working on.

Since executives can’t be the ones with all of the solutions, they are (or should be) mostly concerned with developing the problem solving capabilities in their departments. At the same time, rounding gives them perspective on problems that only executive action can fix. In a many organizations mid-manager facing these systemic obstacles would try to work around them, ignore them, or just accept “that’s the way it is” and nothing gets done about these things. That breeds helplessness rather than empowerment.

On the other hand, if a manager should be able to solve the problem, then there is a leader development opportunity. That is the point when the executive should double down on ensuring the directors and upper managers are coaching well, have target conditions for developing their staff, and are aware of who is struggling and who is not. You can’t delegate knowing what is actually going on. Replying on reports from subordinates without ever checking in a couple of levels down invites well-meaning people to gloss over issues they don’t want to bother anyone about.

Breaking Down Silos by Providing Transparency

The side-benefit of this type of process is that the old cultures of “stay out of my area” silos get broken down. It becomes OK to raise problems. The opposite is a culture where executives consider it betrayal if someone mentions a problem to anyone outside of the department. That control of information and deliberate isolation in the name of maintaining power doesn’t work here. Nobody likes to work in a place like that. Once an organization has started down the road toward openness and no-blame problem solving, it’s hard to turn back without creating backlash of some kind within the ranks.

Creating Disruption

Joe used the term “Disruption” in the title of his presentation. Disruption is really more about emotions than process. There is a crucial period of transition because this new transparency makes people uncomfortable if they come from a long history of trying hard to make sure everything looks great in the eyes of the boss. Even if the top executive wants transparency and getting things out in the open, that often doesn’t play well with leaders who have been steeped in the opposite.

Thus, this process also gives a CEO and top leaders an opportunity to check, not only the responses of others, but their own responses, to the openness. If there are tensions, that is an opportunity to address them and seek to understand what is driving the fear.

In reality, that is very difficult. In our world of “just the facts, ma’am” we don’t like to talk about emotions, feelings, things that make us uncomfortable. Those things can be perceived as weakness, and in the Old World, weakness could never be shown. Being open about the issues can be a level of vulnerability that many executives haven’t been previously conditioned to handle. Inoculation happens by sticking with the process structure, even in the face of pushback, until people become comfortable with talking to each other openly and honestly. The cross-functional rounding into other departments is a vital part of this process. Backing off is like stopping taking your antibiotics because you feel better. It only emboldens the fear.

These kinds of changes can challenge people’s tacit assumptions about what is right or wrong. Emotions can run high – often without people even being aware of why.

Toyota Kata, Kaizen Events and A3

I’ve been asked to explain the relationship between “Toyota Kata” and Kaizen Events, and I am guessing that the person asking the question isn’t the only one who has the question, so I thought I’d take a crack at it here.

To answer this question, I need to define what I mean when I say “kaizen event.”

Kaizen Events

In a typical western company, a kaizen event is geared toward implementing lean tools. There are exceptions, but I think they are different enough to warrant addressing them separately. (If you don’t read this, I changed my mind as I was writing it.)

At this point, I am going to borrow from an earlier post How Does Kaizen Differ From a Kaizen Event:

The kaizen event leader is usually a specialist whose job is to plan and lead these things, identifies an improvement opportunity. He might be tasked by shop floor management to tackle a chronic or painful problem, or might be executing the “lean plan” that calls for a series of implementation events.

It is his job to plan and execute the event and to bring the expertise of “how to make improvements” to the work force and their leaders.

Here’s the Problem

The full-time kaizen event leaders typically get really good at seeing improvement opportunities, organizing groups for improvement, and quickly getting things done. They get good at it because they do it all of the time.

The area supervisors might be involved in a kaizen event in their area a few times a year if that. Some companies target having each employee in one kaizen event a year.

That’s 40 hours of improvement. All at once. The question is: What do they do (and learn) the other 1900 hours that year?

What do they do when something unexpected happens that disrupts the flow of work? Usually kaizen events don’t deal with how to manage on a day-to-day basis other than leaving an expectation for “standard work” in their wake.

But “standard work” is how you want the work to go when there aren’t any problems. When (not if) there are problems, what’s supposed to happen?

This is why many shop floor leaders think “kaizen” is disconnected from reality. Reality is that parts are late, machines break, things don’t fit, Sally calls in sick, and the assembler has to tap out threads now and then. In the hospital, the meds are late, supply drawers have run out, and there is a safari mounted to find linens.

These things are in the way of running to the standard work. They are obstacles that weren’t discovered (or were glossed over as “resistance to change”) during the workshop.

The supervisor has to get the job done, has to get the stuff out the door, has to make sure the patients’ rooms are turned over, whatever the work is. And nobody is carving out time, or providing technical and organizational support (coaching) to build his skills at using these problems as opportunities for developing his improvement skills, and smoothing out the work.

OK – that is my paradigm for kaizen events. And even if they work really well, the only people who actually get good at breaking down problems, running PDCA cycles, etc. are the professional facilitators or workshop leaders. Many of these practitioners become the “go-to” people for just about everything, and improvement becomes something that management delegates.

What are they good for? Obviously it isn’t all negative, because we keep doing them.

A kaizen event is a good mechanism for bringing together a cross functional team to take on a difficult problem. When “improvement” is regarded as an exception rather than “part of the daily work,” sometimes we have to stake out a week simply to get calendars aligned and make the right people available at the same time.

BUT… consider if you would an organization that put in a formal daily structure to address these things, and talked about what was (or was not) getting done on a daily basis with the boss.

No, it wasn’t “Toyota Kata” like it is described in the book, but if that book had been available at the time, it would have been. But they had a mechanism that drove learning, and shifted their conversations into the language of learning and problem solving, and that is the objective of ALL of this.

Instead of forcing themselves to carve out a week or two a year, they instead focused on making improvement and problem-solving a daily habit. And because it is a daily habit, it is now (as of my last contact with them a couple of months ago), deeply embedded into “the way we do things” and I doubt they’re that conscious of it anymore.

This organization still ran “event” like activities, especially in new product introduction.

In another company, a dedicated team ran the layout and machinery concepts of a new product line through countless PDCA cycles by using mockups. These type of events have been kind of branded “3P” but because changes and experiments can be run very rapidly, the improvement kata just naturally flows with it.

Kaizen Events as Toyota Kata Kickstarts

If you take a deeper look into the structure of a kaizen event, they generally follow the improvement kata. The team gets a goal (the challenge), they spend a day or so grasping the current condition – process mapping, taking cycle times, etc; they develop some kind of target end state, often called a vision, sometimes called the target and mapped on a “target sheet.” Then they start applying “ideas” to get to the goal.

At the end of the week, they report-out on what they have accomplished, and what they have left to do.

If we were to take that fundamental structure, and be more rigorous about application of Toyota Kata, and engage the area’s leader as the “learner” who is ensuring all of the “ideas” are structured as experiments, and applied the coaching kata on top of it all… we would have a pretty decent way to kickstart Toyota Kata into an area of the organization.

Now, on Monday morning, it isn’t what is left to do. It is the next target condition or the next obstacle or the next PDCA cycle.

Toyota Kata

If we are applying Toyota Kata the correct way, we are building the improvement skills of line leadership, and hopefully they are making a shift and taking on improvement is a core part of their daily job, versus something they ensure others are doing.

One thing to keep in mind: The improvement kata is a practice routine for developing a pattern of thinking. It is not intended to be a new “improvement technique,” because it uses the same improvement techniques we have been using for decades.

The coaching kata is a practice routine to learn how to verify the line-of-reasoning of someone working on improvements, and keep them on a thinking pattern that works.

By practicing these things on a daily basis, these thought patterns can become habits and the idea of needing a special event with a professional facilitator becomes redundant. We need the special event and professional facilitator today because a lot of very competent people don’t know how to do it. When everybody does it habitually, you end up hearing regular meetings being conducted with this language.

We can be more clear about what skills we are trying to develop, and more easily assess whether we are following sound thinking to arrive at a solution. (Luck is another way that can look the same unless the line of reasoning is explained.)

What About A3?

When used as originally intended, the A3 is also a mechanism for coaching someone through the improvement pattern. There are likely variations from the formal improvement kata the way that Mike Rother defines it.

However, if you check out John Shook’s book Managing to Learn, you will see the coaching process as primary in how the A3 is used. Managing to Learn doesn’t describe a practice routine for beginners. Rather, it showcases a mature organization practicing what they use the Improvement Kata and the Coaching Kata to learn how to do.

The A3 itself is just a portable version of an improvement board. It facilitates a sit-down conversation across a table for a problem that is perhaps slightly more complex.

An added afterthought – the A3 is a sophisticated tool. It is powerful, flexible, but requires a skilled coach to bring out the best from it. It can function as a solo thing, but that misses the entire point.

For a coach that is just learning, who is coaching an improver who is just learning, all of the flexibility means the coach must spend extra time creating structure and imposing it. I’ve seen attempts at that – creating standard A3 “templates” and handing them out as if filling out the blocks will cause the process to execute.

The improvement kata is a routine for beginners to practice.

The coaching kata is a routine for beginners to practice.

Although you might want to end up flying one of these (notice this aircraft is a flight trainer by the way):


They usually start you off in something like this:


The high-performance aircraft requires a much higher level of instructor skill to teach an experienced pilot to fly it.

And finally, though others may differ, I have not seen much good come from throwing them up on a big screen and using them as a briefing format. That is still “seeking approval” behavior vs. “being coaching on the thinking process.” As I said, your mileage may vary here. It really depends on the intent of the boss – is he there to develop people, or there to grant approval or pick apart proposals?

So How Do They All Relate?

The improvement kata is (or absolutely should be) the underlying structure of any improvement activity, be it daily improvement, a staff meeting discussing changes in policy, a conversation about desired outcomes for customers (or patients!).

The open “think out loud” conversation flushes out the thinking behind the proposal, the action item, the adjustment to the process. It slows people down a bit so they aren’t jumping to a solution before being able to articulate the problem.

Using the improvement kata on a daily basis, across the gamut of conversations about problems, changes, adjustments and improvements strengthens the analytical thinking skills of a much wider swath of the organization than participating in one or two kaizen events a year. There is also no possible way to successfully just “attend” an improvement activity if you are the learner being coached.

The Kata of Leader Development

I’ve been parsing Turn the Ship Around to better understand David Marquet’s message from his experience as captain of the USS Santa Fe (SSN 763), a Los Angeles Class nuclear powered attack submarine.

And I’ve been promising to link his concepts back to Toyota Kata. So now I’m going to try to do that.

You can see part of the back story by reviewing my original post and watching the video here: http://theleanthinker.com/2013/11/06/creating-an-empowered-team/

Here is the rest of the back story.

Capt. Marquet was originally programmed to take command of the USS Olympia (SSN 717) which is also a Los Angeles Class submarine.

Except that the “improved” versions of Los Angeles Class submarines, from SSN 751 onwards, are really a completely different design. In any other navy, those later versions would be a different class of ship.

The Olympia is the earlier version, the Santa Fe is much newer.

The Olympia looks like this:


This is the Santa Fe:


The obvious difference is the (lack of) dive planes on the sail. The Olympia doesn’t have those forward missile tubes. The sonar is different. The reactor and power plant is different.

Capt Marquet’s problem was that he was ordered to take command of the Santa Fe at the last minute, after studying everything about the Olympia for an entire year.

Traditionally, a (US Navy) submarine captain’s credibility and authority is anchored on him as a technical expert on every aspect of what the machine can, and cannot, do. This is the foundation for him giving good orders to the officers, NCOs and crew. In practice, the command model is that the ship is a machine with one brain and many hands.

A lot of businesses run the same way.

Except that Captain Marquet wasn’t a technical expert. On the first cruise he gave an order to do something that the Santa Fe couldn’t do, the Navigation Officer knew it wasn’t possible, and passed the order along anyway “Because the Captain told him to.” That is where the little video in the previous post picks up.

OK, that’s the back story.

Developing Leaders with the Improvement Kata

Challenge and Direction

Like in the Improvement Kata, Capt Marquet got a clear challenge and direction from his boss, Commodore Kenny. The performance of the Santa Fe was sub-standard. They were doing poorly on inspections, making mistakes, morale was poor, reenlistment (an indicator of morale) was the worst in the fleet. Officers were resigning. Capt Marquet’s task as the new Captain was to get that performance up to where the Navy needed it to be.

Grasp the Current Condition

Chapters 4, 5 and 6 of Turn the Ship Around describe Capt Marquet’s careful and deliberate effort to understand the normal operating patterns of life on the Santa Fe. How did people interact with one another? What mechanisms were inhibiting initiative? What were the sources of fear, hope on board? All in all he found a competent, but dispirited, crew who was not as bad as they allowed themselves to believe they were.

But the process of “making decisions” was paralyzed by mechanisms pulling authority and control to the highest levels of the organization.

He was looking for the mechanisms of the process, of the way work was organized, of the way decisions were made, that were casting the shadow of poor performance and poor morale. He knew he could not address those things directly. He had to deal with the underlying process mechanics, and ultimately learn which ones impacted his key performance metrics.

Establish the Next Target Condition

Capt Marquet was…well… the Captain. His target conditions became challenges for his next levels in the organization. Though he didn’t follow the Improvement Kata precisely, we can see from the actions he took that the mental structure was there.

If we zoom in a level, and look at Capt Marquet’s initial meeting with the Chiefs as outlined in Chapter 8, we actually see the entire pattern.

If you have served in the military, you can bleep over the next section on the role of the Chiefs.

The Role of Non-Commissioned Officers

imageIn the Navy*, “Chiefs” are Chief Petty Officers, senior non-commissioned officers. They are (very) roughly equivalent to supervisors in industry. The saying is that the Officers are responsible for doing the right things, the Chiefs are responsible for doing things right.

The sailors’ day-to-day interactions are mostly with the Chiefs and more junior Petty Officers, which might be thought of as leads or team leaders.

Thus, it is really the Chiefs that set the tone for the experience of the rest of the crew. If they aren’t “into” the job, aren’t working as a team, it is unlikely the organization below (or above!) them is as effective as it could be, and morale is likely mediocre at best.

The same goes for your supervisors.

Where a military organization differs from industry is that there is a senior non-commissioned-officer paired with an officer at every level of the hierarchy. The most senior noncom on the ship is the “Chief of the Boat” who reports directly to the Captain.

This structure is very beneficial in making sure the Enlisted perspective is brought into every level of decision making.

Although it can, and does, happen, it is relatively rare that an enlisted non-commissioned-officer would become a commissioned officer during his or her career. This is a significant shift in the career path.

Pushing Authority to Create Responsibility

Capt Marquet’s initial experiment to shift the crew dynamics on board the submarine involved the Chief Petty Officers. He meets with them and works with them in an exchange: They get authority. They take responsibility.

A few key points that emerge here are:

  • Lecturing people about “taking initiative” and “stepping up” doesn’t work. If it did, our organizations would be operating at phenomenal levels already.
  • Capt Marquet talks about the Chiefs as individuals, each with his own strengths, level of commitment, etc.
  • There was a clear challenge for them in Capt Marquet’s mind. He knew what he needed from them.
Coaching Through Grasping the Current Condition

Capt Marquet met with the Chiefs, and facilitated a conversation that first sought to arrive at a common understanding of the level of authority the Chiefs really had on the submarine. (almost none, decision making for anything of significance had been pulled up above their level).

Key Point: Capt Marquet likely already knew that the Chiefs had very little authority. But it wouldn’t work to act on that assumption without validating it in the minds of the Chiefs themselves. Further, the Chiefs had to arrive at their own truth, and they had to want to change it.

Based on his assessment, Capt Marquet guided the chiefs through a discussion about their current condition. At this point, they are the learners, the improvers, and he is taking the role of the coach. This is the bullet list he cites in the book:

  • Below-average advancement (promotion) rates for their men.
  • A lengthy qualification program that yielded few qualified watch standers.
  • Poor performance on evaluations for the ship.
  • A lean watch bill, with many watch stations port and starboard under way, and three-section in port (the objective was to have three-section at sea and at least four-section in port; this meant that each member would stand watch every third watch rotation— typically six hours on watch and twelve hours off— at sea, and every fourth day in port)
  • An inability to schedule, control, and commence work on time.
  • An inability to control the schedules of their division and men.

While this is really just a laundry list describing the general working environment that is summarized in the book, my impression is that the group had developed a good common grasp of the processes behind most of these issues. It really came down to the Chief’s authority to decide who needs to do what, and when, had been usurped by various other mechanisms in the chain of command.

If the Chiefs have no real authority to act, then the commissioned officers must make every decision and provide every direction. Those orders are often separated in time and space from the events they are trying to influence. The officers simply can’t be everywhere at once.

The dynamics can easily trigger a downward, reinforcing spiral of more and more control being pulled higher and higher, which makes the orders even more detached from reality.image.png


And, again, the same is true for your supervisors and team leaders in their relationship with management.

The Chiefs Establish their Target Condition

You can’t direct someone to accept responsibility.

My next question built on what we had all agreed on, namely, the chiefs did not run Santa Fe.

I asked, “Do you want to?”

Reflexively they answered, Yes! Uh-huh. Of course!


And that’s when we began to talk honestly about what the chiefs’ running the submarine would mean.

– David Marquet in Turn the Ship Around

I wanted to make sure they deliberately decided to take charge. It wouldn’t be any good if I directed them.

– David Marquet in Turn the Ship Around

Something that is often lost on managers learning to be coaches is that the coach can’t impose a target condition. Certainly the coach can (and should) structure the challenge in a way that ensures the learner is working on the right things. And the coach must provide guidance to ensure the learner is working on those things the right way.

But it is up to the learner to figure out how to get there, and up to the coach to ensure the learner has the skill and persistence to succeed. It is a mutually dependent relationship.

Many managers are uncomfortable with this because it means giving up control even if they know the right answer (or think they do). It means giving up control especially if they know the right answer! This is actually a lot easier for a coach who doesn’t know exactly what to do!

As the discussion continues in the book, some of the Chiefs begin to realize that with control comes accountability for the results. They won’t be able to hide behind “well, they told me to do it” because “they” is now the face in the mirror.

That is actually harder than just waiting to be told what to do. It is also a lot more rewarding if the work environment is supportive of growth vs. punishing mistakes.

The shape of a target condition

At the end, we were agreed: the sole output would be concrete mechanisms.

While it feels good to describe a future vision with words like “The supervisors will be empowered” that doesn’t address the adjustments and changes that must be made to the mechanisms that are driving the current situation.

If you want your supervisors to have more authority, but aren’t willing to dismantle the mechanisms that are withholding it from them… that isn’t going to work.

I put this question to Santa Fe’s chiefs: “What can we do so that you actually run the ship?”

The target condition they established was to have the Chiefs responsible for authorizing leave (vacation time) for the sailors in their organizations.

(In the military, you can’t just go on vacation whenever you feel like it. They have a mission to accomplish, with or without you there, so there is always a process to ensure too many people aren’t gone at the same time.)

What obstacles are keeping us from reaching the target?

There were a number of things that had to be dealt with to make this work. One of them was that Naval regulations required the Executive Officer (2nd in command) to approve the leaves of Enlisted Men.

This meant that even after the Chief of the Boat reviewed the leave plan, at least three additional officers had to approve as well. This added time and bureaucracy which, in turn, hurt morale because it might be weeks before a sailor knows if he can go home for Christmas, for example.

Related to that was the fact that, because of those additional checks, the Chiefs were inclined to approve leave requests without really thinking about the consequences. They knew someone else would be on the hook to say “no.”

They could be the White Hats, and shift the responsibility elsewhere. This was a consequence of the mechanism. The mechanics are part of the “death spiral” I illustrated above.

Which obstacle are we addressing now?

Here is the dilemma. Capt Marquet could ask the Chiefs to prove they could act responsibility, then give them the authority.

Or he could give them the authority, and trust that to drive responsibility.

In reality, I think only one of those choices actually works: Creating responsibility by pushing authority. The obstacle they addressed was the Navy regulations.

What is your next step or experiment?

The experiment was to actually break Navy regulations. On the Santa Fe, the non-commissioned officers would be solely responsible for approving the leave requests of Enlisted Men.

What result do you expect?

They expected that the Chiefs would start thinking through the consequences of these decisions.

This one-word administrative change put the chiefs squarely in charge of all aspects of managing their men, including their watch bills, qualification schedules, and training school enrollments.

The only way the chiefs could own the leave planning was if they owned the watch bill. The only way they could own the watch bill was if they owned the qualification process.

It turned out that managing leave was only the tip of the iceberg and that it rested on a large supporting base of other work.

– David Marquet in Turn the Ship Around

(I added the line breaks for readability online.)

This, in turn, set off multiple cycles of learning as the crew of the Santa Fe gelled into a true mutually supporting team.

In other parts of the book, Capt Marquet talks about the exchange of intent. These decisions are delegated, but they are not made independently. Rather, they worked to progressively create a working climate where people were saying out loud, both formally and informally, what they intended to do and why.

This created an environment were people could hear, and add to, the collective wisdom being shared around them. Knowledge was out in the open and spread quickly thorough the organization with these mechanisms.

But that was all a future consequence of what they learned by making this single change: To actually break the Navy Regulation, and turn 100% of the leave authority over to the non-commissioned officers.

The Overall Theme

This is just one example. The book is full of learning cycles.

People made mistakes. People acted without understanding the consequences. People acted without thinking.

But each time something happened that was contrary to the vision of the right people making the right decisions with the right information at the right time, instead of engaging in the death spiral, they sought to break it.

The crew (with the Captain as their coach) took the first opportunity to pause, reflect, digest what they had learned, and apply a mechanism into their interaction rules that applied a countermeasure.

Capt Marquet didn’t have a concrete step-by-step plan to get there. He just knew where he wanted to to go, had a clear idea of where he was starting, and took the next logical step.

As each step was taken, the next step was revealed. And so there was a little improvement every day. There was a big improvement on some days. But every day they were paying attention to see what they could learn.

And that is what continuous improvement is all about.

What You Can Do

Read the book. Study the book. Parse the book. Each chapter is a parable with a lesson. Don’t get hung up on the Naval environment, that is just a container for the higher-level story.

Study the lessons that were learned. Ask yourself what analog situations you might have, then go and study them. What mechanisms in your organization are driving people to do the things that they do?

What single change can you make that will have a high leverage impact on the level of authority?

That establishes a target condition.

What would “keep you up at night” (as David Marquet says) if you made that change?

Make that list. Those are your obstacles. Which one are you addressing now?



*Just to be clear, I did not serve in the Navy, and my interactions with the Navy were only occasional and brief during my time in the military. I was a commissioned officer in the Army, and the non-commissioned officers are just as important there.

Performance is the Shadow of Process

“Time is the shadow of motion” is an observation usually attributed to Frank and Lillian Gilbreth, pioneers of modern industrial engineering.

What they realized was this: You want to save time. But you cannot directly affect how long something takes. You have to look at the motions, at the process structure that is casting the shadow of time. To change how long the shadow is, you have to change the structure of what is casting it.


As you start your improvement effort, your challenge is often to change the size or shape of the shadow.

Grasping the current condition is looking at the process structure so you can see what patterns and characteristics of the process are shaping the shadow.

It is important to understand how the process patterns and characteristics are affecting the shadow before you just go changing stuff.

You might think “Oh, this part of the process ought to look like this…” and change it. There might be a lot of effort involved. But if you don’t have a sense of cause and effect, then you might end up with something like this:


Change have been made, but we really haven’t changed anything on the outside.

Your target condition has three components, and it is good to develop them in this sequence:

1. The “achieve by” date.

2. The target process pattern and characteristics, and the internal process metrics that will tell you if you are working to that pattern.

3. The expected change in performance if the target working pattern becomes the norm. Then check your expected performance change against the challenge. Is it moving you in the right direction? Is it moving you enough in the right direction? If not, then go back to #2.

Edited to add: In the purest sense, you should start with the performance change you require, then determine the pattern you need to achieve it. That is what it says in Toyota Kata, and in the Improvement Kata HandbookI don’t disagree with that sequence. However beginning improvers, when asked to first decide the performance target tend to just make a guess and can struggle if they over-reach.  I find that this is more of an iterative process than a fixed sequence.

Key Point: The target process pattern has to be what you must do to get to a specified level of performance. It isn’t “Well… we can make these improvements, and therefore might be able to deliver this improvement.” It’s “We have to make these changes in order to reach the goal we have set.”

The pattern of work is what should be emphasized. The performance level is an outcome, the shadow, of the work pattern. Your target condition is really a hypothesis: “If I create a process that follows this pattern, then I will get this level of performance.”


Why am I emphasizing this?

Because a lot of managers have been taught, by pretty much every MBA program out there, to manage to results.

They believe that by measuring and asking about results that those results will be achieved.

That may well happen, but often the changes made are (1) not sustainable and/or (2) people are creative at finding solutions that are destructive to the long (and intermediate) term interests of the organization.

The exchange of intent that is inherent in the Improvement Kata is a way to open up this communication channel.

The person making the improvement clearly has a result based challenge, and the boss ought to be asking the questions to confirm he hears it spoken back to him in the same way he understood it.

Then the boss should become intently curious. “What is it about the way we do things now that is creating (this result we want to change)?” In other words, ‘What is the actual condition now?”

“What process changes are you proposing as your initial step? What result to you expect? When can we see what we’ve learned? These questions are summarized in “What is your target condition?”

Be Ready for Empowered Employees

“I want my employees to feel empowered.”

“You realize empowerment means your employees start making decisions, right?”

“Oh… I want them to feel empowered. I didn’t say wanted them to be empowered.”

(from a presentation by Mardig Sheridan)

This is a further exploration of one of my notes from the Kata Summit a few weeks ago.

Think back to your own organizational history. When people were “empowered” how often did management struggle to retain control of everything?

These same managers complain about having to make every little decision themselves, and not taking initiative.

When organizations try to take on Toyota Kata there are a couple of common patterns that frequently emerge.

One is where most of the actual coaching is done by staff practitioners, with the higher level managers pretty much staying out of the mix. Previous posts not withstanding, that actually works pretty well up to a point.

The limit is reached when the next obstacle is a limiting policy or organizational boundary that can’t be crossed.

So… while this process does build the skill of individual managers at the middle and lower levels, it doesn’t do so well building a management team. Those enlightened middle managers can be in a tough spot if their bosses are expecting them to just be a conduit for direction from above. The coaches are working to engender independent thinking in the middle level of an organization that, by the actions of its leaders, doesn’t actually want it. (Yes, that is a bit black and white, the truth is more nuanced.)

The other common approach, and the one we encourage, is one where the coach is the responsible manager – usually the learner’s boss, or at least in the chain.

Novice coaches, especially if they are actually in the chain of responsibility, often struggle with the boundary between “coaching” and “telling the learner what to do.”

He often knows the answer. Or at least he knows an answer. Or, perhaps, he knows the conclusion he has jumped to with the limited information he has.

So, creating some rationale for why, the coach gives direction rather than coaching. This can be very subtle, and is often disguised as coaching or teaching. For this, I remind coaches to “Check your intent.” If it is to “Show what you know” then step back.

The learner may well have better information. Now this puts the learner in a tough spot. He is being encouraged to explore, yet also being told what to do.

Leaders who want to create initiative, leadership, and decentralized action in their organization have to be ready to give up on the idea that they know the best answers.