MP3 File (run time 35:59)
My guest for episode #197 is a hospital leader I really respect, Kim Barnas, author of the new book Beyond Heroes. Until very recently, Kim was a Senior VP at ThedaCare, leading Appleton Medical Center and Theda Clark Hospital. I’ve seen Kim speak to groups at ThedaCare and a few conferences and she has a lot to teach us about Lean leadership, using her stories and experiences in a way that’s very powerful. I hope you’ll check out the book. Read a press release about it here.
In the podcast today, we talk about topics including her initial reactions to Lean when first introduced to it as a hospital leader, why “heroes” are overrated and sometimes create “chaos” in healthcare, and the importance of moving beyond tools and projects to a Lean culture and management system.
Kim talks about the need to “create more value” (not just reduce waste), saying “just trying to do more with less makes no sense – you need a plan.” We also talk about programs like GM’s “Speak up for Safety,” where she says that speaking up “needs to be a conversation, not a reporting” transaction.
For a link to this episode, refer people to www.leanblog.org/197.
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Mark Graban: Hi. This is Mark Graban. Welcome to episode 197 of the podcast for April 29th, 2014. I apologize, it’s been over a month since the last episode, but I got a couple of great ones coming up, including today’s discussion with a hospital leader I really respect. Her name is Kim Barnas. She is the author of a brand new book called, “Beyond Heroes.”
That’s just been published by the ThedaCare Center for Healthcare Value. Until very recently, Kim was a senior VP and a leader at ThedaCare, the health system where was leading Appleton Medical Center and Theda Clark Hospital.
She has lot of great experience, a lot to teach all of us regardless of industry about Lean Leadership and Lean culture and what we can from a practical perspective. I certainly hope you’ll check out the book. Kim is also doing a free webinar for the Lean Enterprise Institute, on May 6.
You can find links to that, to the back, to the upcoming “Lean Healthcare Transformation Summit” that I’ll be attending and participating in June. Kim is going to be a keynote speaker there.
Spend $35 on the book and, if you’ve got the budget for it, the Lean Healthcare Transformation Summit. It’s now the fifth annual event. This is by far the best Lean healthcare conference of the year. I hope I’ll see you there. Anyway, back to the podcast, Kim and I are going to talk about why the idea of heroes can be overrated, or create chaos in healthcare back to the title of the book, “Beyond Heroes.”
We’re also going to talk about, put her on the spot a little bit, asking her what she would do if she was leading General Motors. GM has a new, “Speak Up for Safety” campaign that the CEO announce and I’m skeptical about. I’ve blogged about that recently but Kim has some good thoughts about — how to get the environment to a point where it’s not just about employees speaking up, but about leaders listening and collaborating with people.
Mark: Kim, hi. It’s great to talk to you and it’s a real pleasure to have you as a guest on the podcast. Thanks for being here.
Kim Barnas: I’m delighted to be invited, and excited about our conversation.
Mark: We’ve got so much to talk about between the great things you’ve been doing at ThedaCare, what you’ve been sharing and teaching with people through articles and talks. Now, the new book, “Beyond Heroes,” that is now available, and we’ll talk about how people can find that later. I’ll have links on the blog. I had a chance to read an early version of the book and I really, really enjoyed it.
I think it’s a book that’s going to be very helpful to a lot of organizations, so congratulations on that, Kim.
Kim: Well, thank you. It certainly was a labor of love. I had lots of help and support and I want to thank you for that. You were one of those folks that gave me some good advice, but I tried to take this book and make it a story. So, that it’s a little bit less academic and a little bit more about our journey and the stories that will help people learn.
Mark: It hit the mark. Those stories are powerful and make this real for people in our organizations. Before I talk about the book, to maybe start, I’m curious to hear some of your reflections about when you first learned about Lean. Where you were in the organization? I’m guessing — correct if I’m wrong — that you are at ThedaCare when this was all getting started.
I’m curious to hear about what role you are in and some of that early journey of how you reacted, or what your early experiences were about Lean.
Kim: Well, it’s fun to reflect on those days because I learned so much and I knew so little about Lean. In fact, I considered myself one of those spontaneous people that Lean would never be able to tame me. It’s fun to look back and be in this position today. When we started Lean and John Toussaint brought it ThedaCare, I was a vice-president in the hospital division.
One of the first value streams was our open heart value stream. My first kaizen event…my first value stream experience was with our open heart team. We had brought in a consultant to teach us Lean and the focus of that group was to be on value stream analysis and kaizen events and two piece, three piece and projects that came out of those.
One day when I was struggling with this language, I had my little “Lexicon” book in front of me all the time. We had a new “Sensei” who joined us and he said to me, “I don’t know anything about healthcare.” I said, “I don’t know anything about Lean, so here’s the deal. If you teach me Lean, I will teach you healthcare.”
That was Jose Bustillo and we started our journey together. I still consider him my personal sensei. He helped me understand how deep Lean can go. He helped me understand how it really helps develop our people and build our people in to stronger participants in the process to own the work, and to see improvement as an opportunity for them rather than a burden.
Mark: Yeah, because I think that there is a concern there that taking on your new roles, new responsibilities in a lean leadership style is adding new things to people’s plate. This is something I end up talking with people about a lot.
I’m curious from your own experience, from what you’ve seen with other leaders, is there a period where it is a bit of an extra burden because we’re learning something new, it’s uncomfortable, and then we work through a cycle where it becomes more comfortable?
Kim: I think you summarized it well. I think in the beginning, because you’re on a learning curve and it’s a big change, it’s exhausting, and it’s trying to understand how this fits with my real work.
Until people recognize that this becomes your real work, it feels additive. You have to create the capacity in your day, and in the day of your peers and your employees, to make sure that they have the time to learn and experiment with it and celebrate it.
Then when it becomes part of their thought process, it changes the culture.
Mark: I think that’s a interesting point…that of creating the capacity. There are some things I’ll let you talk about that ThedaCare has gotten fairly well known for in terms of creative ways or systemic ways of trying to free up time, if you can talk about that, and some of the other ways that you actually create that capacity.
Kim: In the beginning, we took people offline. We hired facilitators, and we gave them the time to learn through the kaizen process which, by the way, I think is critical.
I’m going to talk later about our management system, but I don’t believe you can have a management system without the rest of the lean package. That’s just part of it.
John was elegant in his perception that we needed to develop our leaders, so many of our leaders left their leadership roles to become facilitators. That created the capacity for them to learn.
Then, as we moved into our events, we pulled people offline for the week to do that work. Then we created time to teach them in the work. We made them the communicators and the owners in the work.
What we also did in the beginning was, rather than taking the waste out and cashing it in every time, sometimes the cashing in was investing in our people to create time in their day to do improvement work. That was a significant investment, and it really paid off.
Mark: Then later on, at what point…there’s the famous, “No-meeting zone.” I don’t know if that’s the exact term that’s used…but can you talk about that as a different way of freeing up time?
Kim: Yes. That came later as we decided we were going to develop a management system. One of my concerns was, how are we going to have the time to do this work?
The leadership chain in the hospital at that time had a conversation about it, and I said, “I think we need an hour or two a day to learn how to manage and how to work on improvement.”
One of my colleagues said, “I agree. I think we should have a no-meeting zone,” and I said, “I think it should be from eight to ten. We should start our day that way.” The COO at that time, Matt Furlan, said, “I agree. Let’s have a no-meeting zone from eight to ten.” That’s the scientific method that we used to get to the no-meeting zone…
Kim: …and it was profoundly effective. It still exists today. That was in 2008, I believe, that we formally set that.
What we do in the no-meeting zone is we go to Gemba, we work on projects, we influence each other, we look at our huddle boards, we do our stat sheets, we have conversations, and we may still have a meeting here and there.
The goal is 80 percent of the time you’re in the Gemba, 20 percent of the time you may have to go to a system meeting, or you may have to meet with physicians because that’s the time that they have available. But, it is very effective and it’s been very much embraced in the hospitals.
Mark: I guess the scientific method aspect of it was there was this hypothesis that creating that no-meeting zone would be helpful and that’s what played out through those experiments.
Mark: So I think having a culture of scientific experimentation is different in a lot of ways than a culture of heroes. I’d like to bring things back to the title of the book because it’s an interesting title and a provocative title, “Beyond Heroes.” A lot of people think, “Wait a minute, heroes, that’s a good thing.”
It’s a very positive connotation. They’re doing great things. They’re going above and beyond, but why would you say…Tell us about the title? Moving beyond heroes, why do heroes sometimes not make things as effective as they could be, and you’re proposing, I assume, some alternatives to that heroic behavior. Can you talk about that?
Kim: There is still a role for heroes in the hospital. It’s a limited role. When you have a physician who’s trained to do surgery a specific way, and to think in a critical way, and something doesn’t go well because the anatomy is different, the physiology is different, the equipment fails, you want somebody that can be heroic, in terms of taking that next step.
Everything around him, or everything around that work, should be managed by a process. If you manage the process, and the right equipment is in the right place at the right time, it’s clean, and it’s positioned correctly, it makes the flow of all of the work much more effective, and doesn’t require the nurse or the CNA or another staff person to be heroic in trying to find, grab, and clean, and move things around.
When we talk about heroics, we think about how do we use teams to develop processes, and within those teams, how do we experiment with the process and create the standardized work, and the standardized process, and then once we have that standardization, how do we see the variation from that process, and come back and improve it again, as a team, so there’s not one hero that comes back and makes the changes that everyone else has to influence.
The second aspect of that is we have 6,500 people, that are all…We want to make changes every day. If we weren’t making changes in a methodical, processed way, those 6,000 heroes would create chaos.
It’s important that we understand why the processes are in place, we recognize that you improve from understanding the variation, and that you have a controlled experiment for improvement, so that you always have the best known way to solve the problem, or to do the process.
Mark: Is it fair to say that the part of our brain, and our motivation, that kicks in to be a hero is now something that’s used much more rarely? Occasionally, there’s still going to be a time for a hero, but it shouldn’t be a regular everyday thing.
Kim: Exactly. We want people to use their brain, and to use critical thinking, and we think by establishing stable processes, and allowing them to improve them, we’re actually creating more value. There is still a role for a hero from time to time, but it should not be an everyday occurrence.
Mark: There’s one thing that you said there that I’d maybe like to ask you for an example of. You say, “Creating more value,” I think that’s a key lean idea. Sometimes people get so wrapped up in the idea of eliminating waste. Can you give an example where lean has helped staff, physicians, provide more value, or the right value, for patients?
Kim: I think about when we are using our collaborative care model, and we have used our lean methodology to develop how the team works together with the patient and their family.
When you’re part of that team, and you’re the pharmacist, or you’re the physician, or the nurse, or you’re the patient, or their family member, when you get together and you follow the protocol of discussion for a care conference, so that everybody is on the same page, you not only create value because the patient knows why they’re there, what’s going to happen next, what their medications are, who their nurse is, who their doctor is, what their care plan is, when they plan to go home.
You have one conversation, and the pharmacist is there saying, “These are the medications that you’re on, and I’m going to help you understand how to take them when you get home,” and everybody’s working from the same playbook, it eliminates the redundant work that every one of them had to do in the past, by reiterating their part of the care plan, and not being connected to a whole process.
It adds huge value to everybody to have that one conversation, but it also removes the waste in the process of reiterating, and redoing, and reworking those processes, based on your particular perspective, nursing or physician perspective.
Mark: Is it fair to say…we talk about — I know there’s been goals for productivity improvement at ThedaCare. Sometimes people, and I’ve blogged about this recently, people talk about, focus on, the doing more with less, and unfortunately then people are just thinking about, “Oh no. Less, less people.”
The doing more part, can you talk about instances where perhaps productivity improvement led to increased capacity, and maybe being able to do more with basically the same resources, the same number of people?
Kim: That’s a important concept, that you have to have a plan. Just trying to do more with less makes no sense at all, especially at the bedside. If you say to your team, “OK guys, we’re going to get three percent productivity improvement, go get it,” if you don’t have a plan to do that, you start doing silly things, like cutting back hours, or cutting back education, and those kinds of things.
We have all done that, if we’ve been in healthcare for any length of time at all. One of the things that we are doing at ThedaCare, specifically in the hospital division, it’s been an experiment that will spread through the system, is every unit has their own value stream map, where they’re looking at their patient’s lows, and where their opportunities for waste removal are.
When they pull out waste, then how do they create capacity in the schedule of the nurse, or the schedule of the physician, or the others? That’s how we try to target our productivity improvement. Again, I think it’s important. There’s so much happening in healthcare right now, I’m a little concerned about the effect of only taking a productivity approach, without a plan on nursing.
Nurses have so much that they’re responsible for. They are the reason that hospitals exist. They’re the touch of the patient, and value is added when they’re there to listen, to talk, to educate, to support, that family, and I want to make sure that that’s never what gets cut. I want the other things, like a more efficient medication distribution process, to give them an extra 20 minutes, or an extra 40 minutes, in their shift, that they can then spend with patients.
Those are the kinds of things that we’re working for.
Mark: I apologize, I’m certainly not one to normally fixate on productivity…Maybe if you can recap for listeners who aren’t familiar, one thing that’s impressive about ThedaCare is the clear articulation of the true north objectives that include safety, and quality. For people who don’t know, can you recap at least what the latest iteration of that true north looks like?
Kim: Our true north metrics, we consider how we measure the health of our organization, and one aspect of true north should never be done at the sacrifice of another. We look at it as a triangle, and in the middle of the triangle is the customer, our patient, and we actually give her a name. She’s called Lori, and everything we do is around Lori. It’s to improve the experience of Lori.
At the top of our triangle, we’re looking at safety and quality, and we have metrics around mortality and safety bundles, and those kinds of things at the top. On the lower left-hand side of the triangle, we talk about our people, our engagement. How do we take care of our people? On the right side of the triangle is financial stewardship, not productivity, financial stewardship.
We try to keep all of those things in balance and assure that we have metrics around those at a system level, and then that cascades down to the divisional level, and then it cascades down to the front line. All of the work that we do, that we resource in a significant way, has to tie to those true north metrics so that from the front line staff to the CEO, we’re all rolling in the same direction.
Mark: On that note, that’s one thing that I’ve been so impressed by when I’ve been able to visit ThedaCare is that alignment there. You get that sense people are rolling in the right direction. That seems like such an important aspect of a lean management system.
I was wondering, on that note, can you describe maybe some of the origins or how you would define a quote, unquote lean management system as something to build upon lean methods, rapid improvement events, creating that culture?
Kim: We were into our journey about two years when we decided to get some exposure to daily continuous improvement.
The way we moved forward with that was to run an experiment where we took one of the facilitators that was trained by our consultants and our sensei, and we picked out a manager and we sent that facilitator and that manager to find a problem on their unit, and to create a way to work that problem daily.
They created visual management, they did an A3, and they were looking at root cause. The facilitator stayed with that manager for 30 days, and then they left, and the manager was left to manage that process on his or her own.
What we found was, other things got in the way. That may have been the priority 30 days ago, but this next 30 days, we have another priority, and then we have another priority. Pretty soon, that was lost. After trying that a couple of different times, I met with my sensei who had worked in other organizations that had some a system.
I’m embarrassed to say this, but it’s important that people hear it. He and I went to dinner every time he was here for like a year, and he pulled out a napkin at every dinner and he drew me this picture. He said, “Kim, this is a cell and when you approve things in one cell, then you can spread it to two, and if it works in two, then you can spread it to four, and if it works in four, then you can spread it everywhere.”
I would say, “You know, that’s really nice, and thank you for sharing that with me.” Being the Socratic sensei that he was, he would never tell me what he really meant. One day, I got it. What he was trying to say was you can’t sustain things by sending a facilitator to lead something, and expect people who have no infrastructure to spread it.
I asked him to teach me in a less Socratic way, more as a subject matter expert, what it looks like in industry. He drew me pictures and we had a lot of conversations and we pulled in another sensei.
We actually did a kaizen-like event, where we spent a week looking at what is good look like in industry that has an infrastructure to support their lean methodologies. In particular, we were thinking about, how do we sustain the gains that we have been getting from our value streams and our kaizen events?
In that event, we actually came up with 56 pieces of standard work, that we thought we needed to create to make this system structure begin. A month later, we pulled together 30 other team members, and we started writing the standard work and then we began experimenting with it.
It took us about two years to get to the point where we actually had a foundation of a management system.
Mark: By having a foundation of a management system in all this time, this is by no means a quick fix was it to change…?
Kim: It is not. It’s not.
Mark: What were some of the next things that moved it along, or maybe in hindsight, might have been able to move things along…I don’t know if faster would that even have been helpful? Or was it just important it went that along? was it sort of moving at a natural and sustainable pace?
Kim: I think that it needed to take us that long because we needed to experiment with it, and we didn’t know where we were going, to be honest. We had this vision at the end of what it would look like, but we didn’t know what all the pieces were going to be.
I need to be really clear that this is how we developed a management system. We’re hoping that, by us talking about it and writing the book and sharing the book, that other people can do this much more quickly. We in fact, have seen that, where we have taught other systems and they’re up and running within a year. They’re running within six months and running smoothly within a year.
I believe that it needed to take us that long because the way we went about it was, we wrote the standard work, and then we chose two VPs with two managers each to be our developmental, experimental labs. We’d go, and we’d execute the standard work with two facilitators watching us and making notes. Then we’d come back and critique it and tweak the standard work. The next day we’d go back and do it again.
When we thought it was running well enough in one cell, one unit, then we’d spread it to a second cell and say, “Does it work as well there?” Before we got into any spread methodology, we worked with four primary cells, and we ran experiments every week.
Mark: I guess that thing about experiments work well. Were most of those experiments successful? Were some of them just OK and you had to tweak it? Were any of them a quote, unquote failed experiment as part of that learning process?
Kim: We experienced failure when things didn’t go the way we thought they would, but I don’t think any of those experiments truly failed. We learned from what didn’t work, and we made it better.
The best example I can give is when we first started trying to do a stat sheet. We took the VP, the manager, and the lead supervisor to ask these questions, and they’d ask these questions.
Then, when we’d get done, we’d say, “Did that help you? Is that going to help you manage your business any different today?” They’d say, “No.” We’d say, “What would help you? What are the questions that would make your day better?” We’d go back and we’d experiment with those.
Then, it was we were asking these questions, and we’re getting yes or no answers. “Is that what we want? Isn’t the purpose of this to get to their critical thinking? How do we ask questions differently?”
Now that we’re asking these questions and we’re understanding where our problems are — and by the way we’re seeing problems we never knew we had. “How do we coach them to improve? How do we use the lean tools? How do we teach at that level, A3 thinking in the work?”
It uncovered lots of opportunities. None of them were failures, but we learned that we weren’t going deep enough in the beginning and how to go deeper each time we’d do it.
I would venture to say that if you go see a stat sheet now after eight years in those units, it looks nothing like it did when we started. I guess that’s the point. We’re on a continuous improvement journey, and so we continually change.
Mark: That’s a healthy attitude to try to bring into the organization that a quote, unquote failure is not something to punish people for, but something to learn from and to build upon…
Moving this in a little bit different direction, in terms of trying to change culture and responding to things, there’s been a lot in the news recently about General Motors. The CEO there, Mary Barra, has this big push and this program and I get skeptical of programs, but it’s called, “Speak Up For Safety.”
They’re trying to encourage all the employees, if you see a problem, you should speak up. They promise, “Well, OK, of course, we won’t retaliate against you. We’re going to help you. We’re going to respond.”
But the traditional culture at GM is one where, a lot of times, people tried to speak up, and the system, managers, the culture wouldn’t let them.
I’m curious…thinking about culture change and healthcare, there’s often similar dynamics of trying to encourage people to speak up and to call out near misses and to do a better job of reporting errors.
Do you have any reflections on all the time you’ve been involved in? What helps create a culture where people are speaking up and things are actually being fixed?
Kim: It’s very important that the leadership is present in the work and that it’s a conversation, not a reporting.
I would love to say that we were stellar at safety, and we’re working hard at that. My teams would make safety rounds every day, and as part of our huddles, we always ask safety questions. Solving safety problems is, for some reason, harder than you think it’s going to be. But it’s not because people won’t speak up anymore.
Let me just talk about an average week at ThedaCare, an average day. On Monday morning, my leadership team meets at our huddle board, our visual management, and we talk about what happened last week. “How are we driving performance? Have we improved? Where did we fall down? What do we need to do differently, and when? Now that we know that we’ve got this, where can we go and see it?” The second question is, “Are there any safety concerns?”
We bring our safety officers with us, and we take our managers, and we all divide up the hospital. We go to different floors, and we’re looking for safety issues in a way that says, “How can we help you?” People are comfortable speaking up at that point.
When we see safety issues, we then bring that to the stat sheet in the morning on the next day, and also to the huddle. Of course, if it’s an eminent safety issue, we do something on the spot. Safety is number one.
It comes to the huddle board, so let’s say we noticed that there was a cord hanging in front of the bed of the patient where there was a blood pressure cuff. The safety issue is that somebody could knock that off, they could hit somebody in the head, they could break the equipment, it could fall and hurt a patient.
If you see that, and you go to the huddle which is a couple hours later and say, “This is what I saw. How can we make this better on your unit, and if it works, then how do we spread it somewhere else? Is there somebody who has a particular interest on your unit that would like to help us solve this safety problem?”
Whoever brought you the concern, you never assign the follow-up to them, because once you do that, no one will ever bring you anything again. When someone brings forward a defect, we ask for volunteers, and then we offer the resources to help them solve it.
We give them a facilitator to support the A3 thinking and the root cause analysis. The manager may join them, if there seems to be some sort of a power differential in terms of working with another unit to get it done, we decide whether this is a big enough project that we could just do it, it takes three steps or less, or do we need to have an event because it involves another floor?
There’s a lot of discussion about how do we support the improvement. There’s not a blaming aspect to it in any way.
Mark: Any interest in going and helping GM with all this? [laughs]
Kim: Are you volunteering?
Mark: I’m trying to volunteer you, or I’m nominating you. They could probably use some help because that’s an organization much bigger than 6,500 people, so it’s a much bigger culture change challenge.
Kim: It’s hard to move.
Mark: Final question after you put me on the spot with GM talk as we talked about health care. It may be a question that applies to people even if they are not in the health care. If you’d had an advice for aspiring Lean leaders, let’s say, those people who are in the middle of the organization.
They’re director, they’re vice-president, they’ve done great things with Lean, locally within the department or various streams, but the organization is not moving fast enough. We don’t have that support from the top. What’s your advice, of you to them?
Kim: It’s very hard to move forward without the support from the top. The way you get support from the top is you show them results. What we found with our lean management system was, we started with those poor-selves, and when all of them were doing better with their metrics than everyone else, then people wanted to know what was the magic.
They sent BPS and then we had our next class with eight managers in it. When they started doing well, more people wanted to come. Positive results garner support and garner poll. It’s important to not push these kind of things, but to create the environment where people see the benefits and pull for it.
My advice is to start somewhere, and to show results and engage your one-ups and find ways to celebrate and present your works to them, but when you start seeing those results, other people will start to start to take notice.
Mark: Thank you for sharing that advice. Again the book is called, “Beyond Heroes” and I recommend people here, either working in health care or just interested in health care. It’s a really well done book and I want to thank you and applause for that Kim, you and all people at ThedaCare who help share these stories.
Can you talk a little bit about the best way that we can find the book and other resources and information about it?
Kim: My understanding is that it will be on sale at the center. The website is createvalue.org, on the 29th of April.
I know there are some planning to be available through Amazon and at some point there will be a kindle version at some point. I don’t have firm dates on that yet. But it will be available for purchase on the 29th, the website is createvalue.org.
Mark: If people have questions they want to follow up with you can they contact you through the center or through the website there for the book…?
Kim: They should contact me through the center.
Mark: Again, that’s createvalue.org. Well, Kim Barnas, so happy we’re able to finally have you as a guest on the podcast. When we started talking about this I thought, “Oh, no way. I haven’t interviewed you yet.” I’m happy that we had a chance to do that. Hopefully we can do this again sometime, because there’s so much we can delve into. Hopefully you’ll be open to that?
Kim: I would be totally open to that and welcome. Thank you for inviting me and I hope I added some value today.
Mark: I’m sure you did. And I hope I did not create too much waste in the process for our students in there?
Mark: But thank you for a good interview. Appreciated it.
Kim: Thank you.
About LeanBlog.org: Mark Graban’s passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all.
Mark is a consultant, author, and speaker in the “Lean healthcare” methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. Mark is also the
VP of Customer Success for the technology company KaiNexus.