Guest Post: The Chain of Improvement


Mark's note: Today's guest post is from  Dr. Mark Jaben. I first met Mark in person at  Cindy Jimmerson's Lean Healthcare West conference in Montana last year.  I'm happy to publish this new guest post to follow up his previous post, inspired by New Zealand.

This is really born out of a recent medical trip to Bolivia, reading Drive by Daniel Pink, my wife's struggle as curriculum director in a pre K-12 private school and the faculty's frustration at students' seeming lack of motivation, and a dinner I had with Ricardo Peyerda, a Bolivian businessman who works with large corporation boards. His main focus is to help these boards think about how they develop relationships. As an emergency physician and in trying to promote Lean concepts and practices in health care, I have struggled with how to help people take the leap from an attraction to Lean ideas to being willing to carve out some time and effort to devote to their use. It seems that, despite their interest, nobody has any time or energy.

In Bolivia, I watched as my 13 year old son, David, and a retired engineer, named Dick, both without any medical experience, gradually become more and more involved in figuring out ways to help our eye surgery go better in our makeshift operating room. We didn't ask them to do more; they took it upon themselves.   Their motivation and engagement only took off once they had enough mastery in the tasks we asked them to do, like running the A scan machine ( a device that measures patients for the right size lens implant), sterilizing the equipment, turning the room over between operations, coordinating surgeries with consults, performing eye screenings, and medicating patients. We all understood our hope was to improve people's eyesight.

This is what I think I learned:

Purpose + Mastery = Motivation + Autonomy = Engagement

PURPOSE, reason to act; what is needed to be successful; recognition that the problem at hand impacts your ability to be successful at what you are doing; this creates an interest to act

MASTERY, enough competence to act, which creates the sense you can be successful

So, RELEVANCE, the reason to act, and

ABILITY, the competence to act, together create a foundation for

MOTIVATION, the willingness and confidence to extend oneself

ADD AUTONOMY, the latitude to act;

LEADS to ENGAGEMENT, actually extending oneself to act

In practical terms, engagement requires establishing an atmosphere where people can act without having to fear the consequences, if their actions fail to achieve the aims. Dan Pink's research indicates that once fair compensation is established, autonomy is promoted through giving people control over their time, tasks, technique and team.

His work also indicates that mastery requires training and appropriate feedback. Mastery includes not only the skill and knowledge to perform the task at hand, but also the skill and knowledge in how to solve problems and learning to improve.

But what creates relevance and purpose?   This is where Ricardo's insights were illuminating. Purpose and  relevance are built upon establishing mutual goals; and this depends on each party understanding what each needs to be successful; and this is based on their assumptions about their world, how to be successful in it, and what does work and what won't work. The dialogue necessary to expose these assumptions will only occur once a relationship is established, where the parties recognize they need each other to be successful.

For David, once he understood that removing the cataract was only the first step, and that the right implant was crucial to getting the desired result, he recognized that his job running the A scan machine was incredibly important and a valuable step- he had a reason to act. Once he gained enough skill, by using TWI (training within industry) methods to get him up and running quickly, he was motivated and then found better ways to also keep the schedule on track and document the work. He was engaged in the work because we provided him enough skill and because we gave him the encouragement and support to act (we had little choice if we wanted to get all the surgeries done!). Sharing in the happiness of removing the eye patch of a patient the next day and discovering that person could now actually read for the first time in years was feedback enough.

Sometimes, however, what constitutes success is not so obvious. Often, we have not clearly defined what success entails, or the workplace environment makes this sharing difficult or even risky. Occasionally, people are very willing to share their beliefs about what success means to them, but often this is difficult because it revolves around deeply held, personal beliefs that people don't often feel comfortable sharing with others.   Unless these assumptions are acknowledged, and either validated or refuted, it is hard to move further up the chain of improvement. And this is the importance of relationship building.

Purpose <– shared goals <–understanding success <– surfacing assumptions  <–dialogue <– relationships

Ricardo is very interested in how societies and cultures over time have developed their rituals to foster these relationships, particularly,  when the topic is difficult or painful. Perhaps there is some guidance in how best to advise us on relationship building.

Peacebuilding, by Lisa Schirch, suggests that rituals work to inactivate social structures that feed conflict.   Creating shared identities through rituals helps individuals alter their world views and perceptions, allowing problems to be reframed and approached in new and novel ways.

Lean practice supplies its own set of rituals, most of which do establish a common method and language to allow such dialogue to occur when it is otherwise difficult or too risky. For instance, a kaizen event places everyone in the same room, removes the obstacles of their day to day work lives, and puts those with the insight together with those who have the ability to make the changes happen.   A value stream   map puts the actual current situation on paper, enabling everyone to agree on   a common place to work from. The A3 format creates a platform to focus on the truly important information and acts as a guide for how to proceed. A PDCA cycle might really be needed to test the validity of an assumption, so as to better understand someone's notion of success. Unless these aspects are addressed, you may never get to the engagement needed to learn how to get results.

Cultures and religions certainly have defined protocols for the proper way to initiate communication inside the group, with outside parties and even with adversaries, and certainly with their central figure. So where people find it difficult to share their assumptions in the workplace, we can create rituals to assist.

For instance, a communication kata might establish these ground rules:

  1. How I will give information to you, ie, email, visual board, newsletters, communication book, calls, personal contact
  2. How exactly you can give information to me, ie, visual board, email, personal contact,
  3. A pledge as to how I will respond, ie, ‘I will always listen earnestly and take into account your views'; ‘my default response to any issue is to examine the process, not cross examine the person.'
  4. What to do if you feel at any time I am not fulfilling this pledge, ie, establish a personal “andon cord”, a visible sign, for example, like raising a finger, that we agree will serve a your signal to me that it does not appear I am complying with this pledge.
  5. What we will do together with the information, ie, problem solving.

In the Lean community, we all recognize how to get the results and learning through continuous improvement. It is the engagement I have struggled with. Now I think I have a better insight and understand that sometimes before I even first work to put the Lean practices in place, I really need all of us to understand that getting results:

  • depends on learning how to get those results (ie, innovation)
  • this requires people to even be interested in pursuing these results, (ie, engagement)
  • this depends on relationships: what success actually means for people, and establishing an infrastructure for sharing difficult, closely held assumptions.

I believe this is where the basic concept of Respect for People applies, and why it is so essential to the chain of achieving results.


These linked steps in the chain of improvement provide a troubleshooting guide to assess your organization, or those you have been tasked with helping, to better understand what needs to be in place before learning and results can occur and where efforts need to be focused when there is resistance and push back.

The point is to be mindful of where you are along this chain.   It may be that in your current situation, the purpose of the lean tool you choose is not really to achieve a result, or even to make the problems visible, but to be a ritual that creates the conditions where a relationship can be established, a common denominator can be found, a dialogue can emerge and an assumption can be safely challenged. As my lean mentors always repeat, “what's the problem?” Determining the right need is always the first step.

Dr. Mark Jaben currently resides in North Carolina, where he is a board certified emergency physician with over 25 years in community practice.  After more than 20 years at one institution, he has spent the past 5 years doing locums work at more than a dozen hospitals, from small rural to large volume urban facilities, which has afforded him the great opportunity to experience both the unique challenges as well as common issues shared by health care institutions in the US and around the world.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Fantastic post. I have frequently focused on the value of developing new metaphors and stories in the development of “lean” culture, but I loved the conceptualization of rituals in this process.

    Currently I am butting heads with a PMO that is focused on “projects” – discrete, time limited deliverables – and not on culture – enhancing the capacity of the system to self regulate and improve. Our organization still has a long way to go on its lean journey, but it is coming.

  2. I think this post is a great explanation of what can happen as the people involved in any process gain confidence and autonomy. As related to the “Stopping the Blame Game” post, – when you can create a culture in your organization that allows people to act without fear of being chastised for honest mistakes – then you will have confidence and therefore more action. This quote from the post hit home with me:
    “In practical terms, engagement requires establishing an atmosphere where people can act without having to fear the consequences, if their actions fail to achieve the aims.”

    Read more: Guest Post: The Chain of Improvement – Lean Blog

    I have seen the transformation from the blame game to the “no fear” culture. It is like a miracle took place. People come up with ideas and share them. They do things you never dreamed possible. I can’t put into words the satisfaction a leader feels when his team realizes this kind of confidence.

  3. On the whole I think this is a very good post that shows if the correct factors are in place Lean will happen as an almost natural reaction. There is on thing I would point out the equation,

    Purpose + Mastery = Motivation + Autonomy = Engagement

    does not work. A better equation would be,

    Purpose x Mastery x Motivation x Autonomy = Engagement

    this is because if anyone of those four factors is missing engagement would not occur. But when all four are present the results can be powerful and will consistently appear. And that is the true message of the post given the opportunity Lean action is a natural result of an enabling environment.

    I have discussed this same issue on several occasions on our blog.

  4. Thanks to each of you for your comment.
    I would love to know if using this ‘chain of improvement’ is a helpful construct as you work with people, diagnose the situation and help them move along in their journey.



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