In this early Lean Blog Podcast episode, John Toussaint reflects on how culture change and collaborative care shaped ThedaCare's healthcare transformation.

Our guest for Episode #54 is John S. Toussaint, MD, the CEO emeritus of ThedaCare, and CEO of the ThedaCare Center for Healthcare Value. Dr. Toussaint is very well known for his leadership of the Lean efforts in the ThedaCare system, done under the heading of the ThedaCare Improvement System. ThedaCare has been profiled in the WSJ and many other articles about the quality and cost improvements they have achieved.

This is the first of two podcast discussions we recorded, so check back for the second by visiting and coming back to www.leanpodcast.org. In this podcast, Dr. Toussaint looks back at ThedaCare's accomplishments, reflects on their journey, and shares his advice for other hospitals.

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Episode Summary

In Episode #54 of the Lean Blog Podcast, Mark Graban talks with Dr. John Toussaint, CEO Emeritus of ThedaCare and CEO of the ThedaCare Center for Healthcare Value. Widely regarded as one of the foremost leaders in Lean healthcare transformation, Dr. Toussaint reflects on ThedaCare's journey applying Lean principles to dramatically improve patient safety, quality outcomes, and cost-effectiveness.

Dr. Toussaint shares some of ThedaCare's most impactful results, including zero medication errors in a 19-month span and a 30% reduction in the cost of inpatient care. He details how the Collaborative Care model–which empowers nurses as process owners–helped transform roles, teamwork, and accountability within the hospital system. This episode highlights how Lean thinking isn't just about processes–it's a culture shift that starts with leadership.

The conversation explores the challenges of change management in healthcare, the critical role of executive participation at the Gemba, and the shift away from “shame and blame” toward systems thinking and continuous improvement. Dr. Toussaint also emphasizes the importance of leaders being teachers, not just decision-makers, and explains why cultural transformation in healthcare requires serious investment in learning and unlearning.

Whether you're a healthcare leader, Lean practitioner, or simply interested in improving patient outcomes, this episode offers powerful lessons from one of the industry's most influential change agents.

Quote Highlights

“Lean is really about managing all of the people side of things too. If you don't spend time on that, it just doesn't work.”

“As a leader, you need to be able to teach. And if you don't know what you're doing, you can't teach.”

“Whenever I went to the Gemba, I walked away with homework. That was my real work.”

“The problem is us. We have to change as managers if we're going to change how frontline workers think about their work.”

“This is not a project. This is a journey to change the culture of your organization.”

Lean Blog Podcast Episode 54: Dr. John Toussaint on ThedaCare's Lean Journey

Published December 2, 2008. Host: Mark Graban. Guest: Dr. John Toussaint, CEO Emeritus of ThedaCare and CEO of the ThedaCare Center for Healthcare Value. This is part one of a two-part conversation.

Introduction

Announcer: Welcome to the Lean Blog Podcast. Visit our website at www.leanblog.org. Now here's your host, Mark Graban.

Mark Graban: Hi, this is Mark Graban. This is episode number 54 of the Lean Blog Podcast for December 2, 2008. I'm very happy to have as our guest today Dr. John Toussaint, the CEO Emeritus of ThedaCare Health System and currently the CEO of the ThedaCare Center for Healthcare Value.

Dr. Toussaint is very well known for his leadership of Lean efforts at ThedaCare, done under the heading of the ThedaCare Improvement System. They've been profiled in The Wall Street Journal and many other articles about the outstanding quality and cost improvements they've achieved in their years of implementing Lean.

This is the first of two discussions we recorded a few weeks back. In this episode, Dr. Toussaint talks about ThedaCare's accomplishments, reflects on the Lean journey, and shares advice for other hospitals. I hope you'll come back for part two in a few weeks. Thanks for listening.

Again, I'd like to welcome Dr. John Toussaint from the ThedaCare Center for Healthcare Value. Thanks for joining us on the Lean Blog Podcast.

John Toussaint: Thank you.

The Results from the ThedaCare Improvement System

Mark Graban: Listeners and readers of the blog have been exposed to some of the history and the ThedaCare story with Lean and the ThedaCare Improvement System. I was wondering if you could start by telling us what the overall impact has been, in terms of the results and improvements that you and the hospital are most proud of.

John Toussaint: There have been a huge number of improvements. It's hard to say there's any one of them that we're most proud of. When you look at our inpatient care process, called collaborative care, we've had zero medication errors for the last 19 months. Then you go into the ICU, and we've had no ventilator-associated pneumonias at Appleton Medical Center for the last 14 months.

Mortality rates in heart surgery have dropped dramatically. We were at 0.5 percent last year, 2007, which is significantly better than the STS benchmark. And the costs are coming down. We've taken about $25 million out of the cost structure of ThedaCare and improved our operating margin by about twice what it was when we started.

So there are significant improvements just about everywhere. Are there a lot of improvements that still need to be made? You bet. But the reality is that a lot of things are improving.

How Collaborative Care Changed Roles at the Bedside

Mark Graban: How does the collaborative care model fit in with Lean thinking? How does that contribute to the improvements you've made?

John Toussaint: We didn't start our inpatient redesign until about four years into the Lean journey. At that point, we had enough understanding of the philosophies and tools of Lean to be able to radically change our inpatient model.

We took an old wing of the hospital, blew it up, and rebuilt it as the new inpatient care process. In doing that, we changed all of the roles and responsibilities of the individuals, and we changed the process owner. The nurse is now the process owner in the collaborative care unit, and it's quite interesting to see the nurse-physician interaction.

It's completely different than in the old world, where the nurse took the orders. Now the nurse is the process owner in inpatient care. In many cases she is calling the doctor to say, “Doctor, we haven't met these criteria for moving the patient on to the next tollgate of care, so you'd better order this test.”

That's been an interesting dynamic to deal with, these changes in roles and responsibilities. But when you see the data, which is basically 100 percent compliance with the quality bundles, about a 30 percent reduction in the total cost of care, and no medication errors, even the doctors can't argue with that.

The Change Management Side of Lean

Mark Graban: I'm sure that even with the results, when you talk about radically changing roles and responsibilities, the change management and people side of that was still a challenge.

John Toussaint: It still is, because this exists in an alpha unit and we're now spreading it to the rest of the units. Changing the roles and responsibilities of 1,200 or 1,500 people is no small task. We spend a lot of time trying to understand how you actually do that. There have been a lot of good books written, a lot of good things coming out of John Kotter and William Bridges and others.

Lean is really about managing all of the people side of things too, which is the change stuff. If you don't spend a lot of time on that part of it, it just doesn't work. That's especially true in our industry, where we have so many barriers to improvement. Changing an entire culture requires a serious commitment to really understanding the key components of change management.

Spreading Lean Results for Quality and Patient Safety

Mark Graban: I wanted to come back to what you were saying about preventing errors and improving patient outcomes and mortality. It seems, not in a bad way at all, unusual. You often hear hospitals talking about productivity, patient flow, and labor costs. But to see the impact of Lean on quality and patient safety is pretty exciting. I can't help but look at this from the standpoint of being a patient. At the same time, do you have some thoughts on what we can do to spread results like that, and the use of Lean for quality and patient safety, to more hospitals?

John Toussaint: One of the things I'd like to see is that those of us who really are on the Lean journey be more willing to share these results.

At ThedaCare for several years now, we've offered the opportunity to come and visit four times a year, and we usually get 50 to 100 people to come to these Gembas. We don't charge for them. We've really opened it up to pretty much anyone who wants to come and touch and feel it.

There are certainly others on the journey throughout the country. Maybe not quite as far along as we are, but there's some good work being done in other places too. It would be helpful for everybody to be willing to share with each other. That's certainly one of the things I'm working on now at the center: how do we facilitate a network of Lean practitioners to do that and allow others to learn? Because I truly believe you can't learn unless you go and see and really understand what's going on. You don't learn this stuff by sitting in a classroom.

Advice for Hospital Executives: Commit, Then Learn It Yourself

Mark Graban: ThedaCare has been working with Lean and the ThedaCare Improvement System for about five years now. Looking back, what are some of the most important lessons learned? And more specifically, from your role of having been the CEO of the hospital, what advice would you have for other hospitals, or particularly other hospital executives?

John Toussaint: It's important for hospital executives to first understand the journey they're committing to. This is not a project or another fad, where you can do a few week-long kaizen improvement events and think that you're doing Lean. This is really about changing the culture of your organization to one of continuous improvement.

That requires a significant focus. It also requires the executives to learn this themselves. That's the biggest issue. You don't learn by sitting in your office. You learn by going out and participating on teams and spending time where the work is being done, in the units, in the ICU, in the clinic, or wherever.

So the executives first need to learn what they don't know, and the only way to learn it is to go do it. That's the number one thing: commit, and then learn it yourself. Because as a leader, you need to be able to teach. And if you don't know what you're doing, then you can't teach.

Communicate, Communicate, Communicate

John Toussaint: The other lesson learned, which we really did not do well, and which I did not do well, was communicate, communicate, communicate. That's one of the key components of change management, and I did not do that well, either with physicians or with our staff. We had to back up three years into the journey and go back and spend a lot of time describing to people what we were doing and why we were doing it, and then also train them in some of these tools.

It's very difficult to get 5,000 people on the same page just by doing rapid improvement events or kaizen. You really need to train and explain things.

The final thing for executives is that this is a cultural change, so you have to have a process in place to actually change the culture. But you don't know what that is until you've studied it and understand it. So what you need to do is go to Lean companies and really begin to understand what they're doing differently in a Lean company versus a non-Lean company. That's what we did in manufacturing. Again, this process of learning is really critical. And it's not a project, so don't think of it that way.

Why Healthcare Lacks a Culture of Continuous Improvement

Mark Graban: I think that's really important when you talk about culture change and trying to move toward a culture of continuous improvement. If you were to step back and diagnose why there was not a culture of continuous improvement, or at least not as much of one as you might have liked, either at the starting point at ThedaCare or in what you hear about at other hospitals?

John Toussaint: The root cause is multifactorial. I don't think there's one cause. Part of it is the way we're trained. I never got one minute of continuous improvement training in seven years of post-college training. Not one minute.

The training system is all based on the guild. I trained with Dr. So-and-So, and he's the greatest doctor in the world, and I'm going to do it the way Dr. So-and-So says, whether it's best practice or not, or evidence-based or not.

What we need is a training process that takes continuous improvement into account, and we're actually moving toward evidence-based performance. So part of it is training. We don't have a clue how to improve anything.

Shame, Blame, and Why Errors Go Unreported

John Toussaint: Part of it is that healthcare providers are extremely competitive, and frankly they're not very compassionate when it comes to their relationships with each other. If you make a mistake, you're sort of considered to be defective as a person. When we've studied these mistakes, we know that 99 percent of the time they're process problems, not competency problems.

So it reinforces itself. Somebody makes a mistake, and then you get blamed as a bad doctor or a bad nurse, and you develop this shame and blame culture. Then everybody goes underground with their performance. They're not willing to report medication errors, and they're not willing to talk about transparency of performance.

So we have this self-reinforcing loop around no transparency. And if you add to that no methodology for improvement, you can never break out of it. At least now at ThedaCare there's a methodology. Everybody knows there's a ThedaCare Improvement System, what its purpose is, and how to use it in some respect.

What Going to the Gemba Actually Looks Like

Mark Graban: When you talk about going to the Gemba, I was wondering if you could share some examples of what you learned as CEO, or what you helped accomplish in trying to teach other leaders throughout the organization about the importance of being at the Gemba.

John Toussaint: Gemba simply means going to the place where the value is created, or where the real work is done. We as leaders get trapped in our little worlds of firefighting, so we sit in our ivory towers thinking that we're going to… As one cardiologist told me, you're at mission control and you've got your hands on all the red buttons.

Of course, that's not where value is being created for the customer. If you want to influence your customer, you have to go to the place where the value is being created for the customer, which is right on the floor of the ICU, in the patient room, at the clinic where the process is being delivered or the product is being delivered.

So when you go to Gemba, you spend time with the frontline workers and the supervisors, and you ask them a series of questions. What's the biggest problem on your unit? What are you focusing on to try to improve that problem? What are the things I can do to help you as a leader? Can I remove some barriers?

Whenever I went to Gemba, the last question I asked was, if there's one thing that I could do for your unit, what would that be to help you improve performance? And I would always walk away with homework.

That homework was what I considered to be the real work. All the other stuff I did as CEO was just waste. The homework of trying to help those frontline workers improve their performance was my real work. What was interesting is that it gave you a whole different view of what was important to the organization.

Now I know that the nurse in the ICU is dealing with a problem with a physician, for example. So sometimes I'd have to remove physician barriers. Or maybe there was a resource issue that we hadn't prioritized high enough. I'd go back to the senior team and we'd say, these people are really struggling over here. If we simply change the prioritization of what we've already decided, we could really help them.

So we began to focus on how we could really help the people doing the real work. That's the power of Gemba. Then, as you learn more, you're able to teach people how to ask the right questions, and how to have them solve problems rather than waiting for somebody else to solve those problems for them.

Two Schools of Management

Mark Graban: So it sounds like there's a real element of servant leadership in that.

John Toussaint: There are two schools of management. There's the Sloan School of Management, and we're all seeing the aftermath of that mess in Detroit. And then there's the Toyota School of Management. Who would you rather be working for right now?

In general, I think people who have worked in Lean companies can't work in other companies. The entire management and leadership component of Lean companies is about 180 degrees different from what's being taught at most business schools today.

“We Have Seen the Enemy and It Is Us”

Mark Graban: Was it challenging to get people to start opening up when you're asking those questions? I could see that being intimidating because of the position you were in, or the position of other senior leaders in the organization. Was it difficult to get people to open up to you about what the problems were, instead of hiding things or just wanting you to go away and not see?

John Toussaint: Yeah. But we're the problem. We have seen the enemy and the enemy is us. Our management systems are what created the fact that nobody's willing to share anything.

I tell the story about the nurse who point-blank told me, when I asked why they were doing so well with medication errors in their unit, that she wasn't reporting them. As we did the five whys on that, the first answer was that we had set up this stupid computer system that takes her four or five minutes to get into just to report the error.

But then you keep digging and you find that there's this shame and blame culture, and she's worried she's going to lose her job. Then you say, how can that be? Why is that? Because one of her colleagues was fired for making a medication error.

And how could that possibly happen? Because management doesn't have a clue about continuous improvement. If they did, they would absolutely recognize that 99 percent of the medication errors are based on some poor process that's in place, not because the nurse is poorly trained or incompetent.

So the problem is us. We have to change as managers if we're going to change the way frontline workers think about their work, and frankly, about management.

What Comes Next for ThedaCare: Standard Work and the Acting Part

Mark Graban: Looking forward, we're going to talk in our next conversation about your new role at the ThedaCare Center for Healthcare Value. But looking back at the hospital, what do you think the most important next steps are for Lean at ThedaCare under your successor, the new CEO?

John Toussaint: The most important thing is that he understood it as well as I do. He reported to me for some 20 years, and he actually understands it better than I do, so that's the most important thing.

The real challenge now at ThedaCare is that we've been really good at the planning, doing, and studying, but we're not very good at the acting part. So what we need to do is build that standard work, make sure that it's being applied, and then improve it.

Any company on the Lean journey constantly struggles with this, especially in healthcare: applying standard work to the regular workday, and then making sure that it actually is being applied. And then having every one of our employees understand how to continuously improve the process, so that you've got 5,000 improvement experts out there working the system every day, and you're implementing many of the suggestions that those 5,000 people are making every day.

This is a journey. We graduated from first grade last week. There's a lot more to learn from great companies like Danaher, Toyota, Autoliv, and others. That's going to be the next 10 years of work: continually learning and trying to apply these principles.

Closing

Mark Graban: That's very true. We're all learning, and I appreciate you sharing some of what you've learned with our listeners. Thank you especially for the leadership role you're taking in helping spread improvement in the quality of healthcare through Lean and through other methods. I really appreciate that, and I appreciate you taking some time to talk with us today.

John Toussaint: Thanks a lot, Mark. I enjoyed it.

Announcer: Thanks for listening. This has been the Lean Blog Podcast. For Lean news and commentary updated daily, visit www.leanblog.org. If you have any questions or comments about this podcast, email Mark at leanpodcast@gmail.com.