ThedaCare’s CEO: “The Goal is Zero – The Target is Improvement”


On his blog, John Toussaint shared this letter from ThedaCare CEO Dean Gruner to all employees. Toussaint said the letter is inspired by Paul O'Neill and his thoughts on patient safety (you can hear my podcast with O'Neill here, as well as a podcast with Dr. Gruner).

Can download the Word document from the Center blog and I'll share some highlights below.

Dean starts the letter with:

For about a year now, several members of our team have been having conversations about what is possible, what is likely, and how we use the words “goal” and “target.” Much of this started when we had a conversation with Paul O'Neill, U.S. Treasury Secretary from 2001-2002 and former Alcoa CEO. Paul was insistent to the point of almost being annoying! He kept saying, “The goal must be zero.”

Gruner explains the difference between their “target” (50% reduction in infections) and their “goal” — zero.

Setting goals or targets does nothing to create improvement, in and of themselves. Goals can be inspiring – who wants to see a patient suffer through a painful infection? Targets, used in the wrong environment, can be incredibly dysfunctional.

If people have a target and they fear being punished or fired for not meeting that target, all sorts of dysfunctional things can happen. Dr. Deming famously told a story about a factory that was offering a prize for workers if there were zero injuries (or some such target). What happened was simple and understandable – people just stopped reporting injuries. That's not real improvement. And we have to be careful for the same thing in healthcare. Read about what happened in the British NHS when fear of targets led people to game the system.

From my visits to ThedaCare, my hunch is that their use of targets and goals will not be punitive. It's more likely to drive improvement than fear because they also have a METHOD for improvement – Lean and the ThedaCare Improvement System. Dr. Deming used to ask, “By what method?” ThedaCare has a method and I think they have the right culture for improvement, a culture they are tirelessly working to improve.

Dean ends his letter with the following:

To me, this goal of zero is very motivating because it reminds all of us of what we would want for ourselves, our families and friends. Yes, it is very daunting and we will not get there as quickly as we might like. In fact, for some of our work we might never get to zero. But by choosing the right goal we will work like heck to improve our performance year over year and achieve progress that we otherwise might never dream of. So to be clear and unambiguous, the goal is zero defects and the target is improvement. Let's use these words properly as we go forward so we know what each other is talking about.

It's not just the words – it's the culture and the mindset that creates improvement instead of fear.

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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. Dear Mr. Graban:

    I am surprised to see that you didn’t provide any rational theory and methods to lend any validity to your allegations of Zero incidents. you didn’t provide a description of the process in question. No data and analysis on process stability and capability. No context. Instead, you pretend to support your claims based on anecdotal information by using three individuals as subject-matter experts.

    You stated that “Dr. Deming used to ask, “By what method?”” and I ask the same question of you. Your comments are merely opinions, and lack the application of the required engineering and statistical methods to arrive at rational conclusions. I must tell you that as an engineer, I find these omissions unacceptable.

    I take the opportunity to share what our Code of Ethics for Engineers states regarding this matter:

    II. Rules of Practice

    3. Engineers shall issue public statements only in an objective and truthful manner. Engineers shall be objective and truthful in professional reports, statements, or testimony. They shall include all relevant and pertinent information in such reports, statements, or testimony, which should bear the date indicating when it was current.

    b. Engineers may express publicly technical opinions that are founded upon knowledge of the facts and competence in the subject matter.

    c. Engineers shall issue no statements, criticisms, or arguments on technical matters that are inspired or paid for by interested parties, unless they have prefaced their comments by explicitly identifying the interested parties on whose behalf they are speaking, and by revealing the existence of any interest the engineers may have in the matters.

    Source: NSPE Code of Ethics for Engineers

    Fianally, may I ask if you are affiliated with any of these organizations?


    Fernando J. Grijalva

    • Fernando – I’m not a “professional engineer.” I am a consultant and an author with an education in industrial engineering and mechanical engineering.

      Your implication that I’m unethical is offensive, uncalled for, and out of line.

  2. Mark,

    All engineers abide by the same cannons. I am sorry, but I cannot remain silent when unproven claims are mis-represented to the public. People need to be reminded of the methods required to design, implement and manage organizational systems.

    As an author and public figure, I believe you have the duty to adhere to basic engineering standards, when the situation requires it.

    I consider this an important matter given the mis-information is a terrible and expensive source of waste in our society.



      • Mark,

        I’ve said all I could, based on the available information and your responses. I expressed my concerns and proposed a basic C/PA.

        Followers, like the guy below, can choose to believe based on their current level of development.

        Unfortunately, one can only communicate these matters through mutually agreed operational definitions and proper methods of analysis. Both are absent at this time.


        • With all due respect to the memory of the late great Dr. Deming, the “Deming follower” in the room is usually the know-it-all who thinks they are smarter and more evolved than the rest.

          I can’t imagine a whole conference full of those types.

          But, wow, we are really off topic now, aren’t we? Congrats to Dean Gruner for his leadership at ThedaCare.

    • Where’s the misinformation? The standards of decency in public discourse require you to prove a claim before asserting that it is true. It is not Mark’s burden to prove anything because, as you state, the situation does not require it. This is a blog. Relax. Go referee an engineering journal and preach your canon there.

  3. Mark,

    How does ThedaCare reconcile their approach with Deming’s view on “management slogans”?

    I tend to believe that it’s ok to shoot for a Zero Defects goal if the culture and management system support achievement of that goal with proper means:

    driven by sustainable, continuous improvement
    achieved through development of people & process capability
    not just to win a third-party award or certification like JD Power, Shingo, ISO, etc.

    • Zero defects is a goal, not an empty slogan. They aren’t hanging a ton of signs that say “Only YOU can prevent infections” or the usual claptrap.

      They have an improvement method to work toward getting there, as does Dr. Rick Shannon at UPenn and others who have gotten near or at zero infections and zero deaths from said infections.

      The ThedaCare culture, as I have seen and understand it, is not coercive and it’s driven by people and process development and expanding the capabilities of their people.

      • Makes sense – I like to see how dogmatic and irrational some people can be when quoting Dr. Deming… I always ask if they would prefer we don’t have slogans like Zero Plane Crashes or something else catastrophic. Some people can take Deming too literally…

  4. I like the distinction between Goals and Targets. It gets around the age old problem we face when setting annual improvement objectives. For things like safety, people get bent around the axle when we set objetives at anything other than zero accidents but these can become deflating since zero isn’t attainable this year.
    The distinction solves this issue.

    • One approach I have used in hoshin kanri is to set three-year improvement targets, and cascade those down to the annual, monthly, and daily level. If the organization can commit to a longer-term horizon of stretch goals, it doesn’t distort behavior and force people to commit unnatural acts to achieve the target.

      The challenge is with organizations that change leadership teams often, and also cast aside the previous leadership team’s goals. A shared, long-term management philosophy is critical to make this type of target-setting possible.

  5. The part I really like about this post is the behavior certain goals can cause (not reporting injuries). I find it amazing that most people I have met do not consider how setting certain goals without a change in mindset or culture can drive wrong behavior. Even more astounding is that they are then surprised about the evasive behavior.


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