Category: Culture

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Executive Rounding: Taking the Organization’s Vitals

Background:

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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.

Results

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:

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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.

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Make Sure Failure = Learning

Take a look at this cool video from Space-X that highlights all of the failures that preceded their successful (and now more or less routine) landing of a recoverable orbital booster rocket. Then let’s discuss it a bit.

(Here is the direct link if you don’t get the embed in your feed: https://www.youtube.com/watch?v=bvim4rsNHkQ)

When we see failure, or even failure after failure, it is easy to forget that learning is rarely linear.

A Culture of Learning

Organizations like Space-X (and their counterparts such as Blue Origin) are in the business of learning. They are pushing the edges of what is known and moving into new territory. For organizations that understand that setbacks, mistakes, failures and the like are an inevitable part of learning, these things – while costly and unpleasant – are regarded as part of the process.

We have seen the same mechanisms in play – a process of experimentation toward progressive target conditions toward a visionary challenge – behind pretty much every breakthrough achievement throughout history.

No Mistakes = No Learning

At the opposite end of the spectrum are organizations with no tolerance for mistakes. They expect everything (and every one) to get everything right every time. They dismiss as incompetent any notion of failure, and attack as weakness any admission of “I don’t know” or “I don’t know how.”

A few years ago, as I was teaching Toyota Kata coaching with a client, a middle manager approached me during a break and said – point blank – that it was not his responsibility to develop his people. “Our policy is to hire competent people, and we expect them to be able to do the job.” He wasn’t the only one to say that, so I built the impression that this belief was, indeed, part of their culture. Needless to say they struggle a bit with getting innovation to happen because they try to mechanize the process.

Mistakes = Tuition

Here’s how I look at it. When a mistake happens – especially one that is expensive – you have paid considerable tuition. Your choice now is to either extract as much learning as you can from the event, or to try to ignore it and move on. The later choice is like paying your tuition up-front, then skipping all of your classes and wonder why you aren’t getting it.

Learning = Adapting to Change

Organizations that manage in ways that regard learning as part of their everyday experience are much more adaptive to changes and surprises than those who just execute their routines every day. The paradox here is that organizations who value learning are generally the most disciplined at following their routines. This discipline makes execution a hypothesis test, and they can quickly see when their process isn’t appropriate and adapt and learn quickly as an organization. They strengthen their routines, and through those routines, embed what they have learned in the organization’s DNA for future generations.

Organizations that figure it out as they go, on the other hand, tend to rely on individuals to adapt, but there is no mechanism to capture that learning beyond the individual or small group. Sometimes there is a “lessons learned” document, but that’s it. Those reports rarely result in the changes in organizational behavior that reflect learning. I suppose the most egregious case would be the loss of the space shuttle Columbia upon re-entry for exactly the same organizational failures that resulted in the loss of Challenger.

Technical vs. Cultural Learning

Space-X is solving a technical problem with science and engineering. I hope (and expect) that as they become more successful they will always be striving for something really hard that will drive them to the next level. Based on what I see publicly, I think that is embedded into their culture by Elon Musk. (But I don’t really know. If anyone from Space-X is reading this, how about getting in touch? I’d love to learn more.)

I expect this works for Space-X because they have a culture of learning.

What doesn’t work, though, is to try to apply technical solutions to transition a rote-execution culture into a learning culture. Changing the culture – the default behaviors and responses of people as they interact – isn’t about improving the mechanics of the work process. You certainly can work on the work processes, but the starting condition is what evolved in the context of the organization’s culture. The mechanics of the “improved” process that we try to duplicate evolved in the context of a learning culture. The ecosystems are different. It is difficult for a lean process to survive in a culture that expects everything to run perfectly and doesn’t have robust mechanisms to turn problems into improvements.

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There Are No Silver Bullets

There are no quick, simple solutions

Occasionally I get an email from someone who asks a question like “How can I improve cycle time in the [fill in the blank here] industry?” Generally my reply is along the lines of “I don’t know, but I can help you figure it out.” I’ll give them some homework, often pointing them at Mike Rother’s Toyota Kata Practice Guide online, and asking them to do the Process Analysis step and get back to me with what they have seen and learned.

Lone Ranger with Silver Bullet
Who was that masked man?

This is usually followed by silence (cue the crickets here). Perhaps they think there is an easy answer and a single email can just tell them what to do to get that 20% performance improvement.

Unfortunately it doesn’t work like that. Process improvement involves work. There aren’t easy fixes (that last). There isn’t any solution anyone can give you that can just be implemented, nor can anyone learn it for you.

The real work is adjusting your culture

Digging a little deeper, if you want that productivity improvement to reach even a fraction of your full potential or sustain for any length of time, you have to go beyond technical solutions. When I said process improvement involves work, the technical mechanics are the easy part. The real work is understanding what social and cultural norms in your organization are holding you back and dealing with those.

Fortunately we have learned a lot more about the influence of the organization’s culture and how to influence the culture. But influencing the culture doesn’t happen by accident. And you can’t outsource your own thinking, reflection and learning.

 

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Learning Starts With “I Don’t Know”

If an organization wants to encourage learning, they have to get comfortable with not having all of the answers. Learning only happens when we discover something we don’t know, and then actively pursue understanding it. Many organizations, though, equate “having the answers” or “already knowing” with “competence.” Thus, if I say “I don’t know” then I am setting myself up for being regarded as incompetent.

What I see in these organizations is people will take great pains to hide problems. They will try very hard to figure things out, but do so in the background always reporting that everything is going fine. They live in the hope that someone else’s problem will emerge as the show-stopper before theirs does, and give them the extra time to sort out their issue.

Meanwhile, the bosses are frustrated because people aren’t being truthful with them. But what should they expect if “truth” attracts accusations of being incompetent?

But… there is hope.

I was talking to a friend last week who works in a huge company that seems to be making an earnest effort to shift their culture. There is nearly unanimous agreement that the existing culture isn’t working for them. On the other hand, actually changing culture is really, really hard because it involves changing people’s immediate, habitual responses to things.

Nevertheless, I was encouraged when my friend recounted a recent meeting where someone admitted two things:

  1. There was an unexpected problem that came out in a recent test.
  2. They, right now, don’t know how to fix it.

Just to be clear, these two things coming out in this meeting is a big deal. This has been a culture where unexpected problems have not been warmly received. Bringing them up without a confident assessment about a prospective solution was inviting the kind of intervention that is rarely helpful.

This time, though, was a little different.

The leaders started going down the expected responses such as “What do you mean we don’t know what to do?” then… stopped short. They paused, and realized this was not in line with their newly stated values of creating trust and accepting failure as an inherent part of learning.

And they changed their tone. They shifted the conversation from trying to assign responsibility blame for the test failure toward asking what we, the organization, needed to learn to better understand what happened.

My thoughts are:

Kudos to the person who was brave enough to test the waters and admit “I don’t know.”