A Lean Guy Visits Scott & White Hospital – Leader Standard Work, Huddles, and Lean Culture


Hosted by Steve Hoeft, author of the book Stories from My Sensei: Two Decades of Lessons Learned Implementing Toyota-Style Systems, I had a chance to visit Scott & White Hospital in Temple, Texas. With his permission (but without editorial review), I am sharing some stories from my visit to their excellent health system (which is in the process of merging with the larger Baylor Health system in the Dallas / Fort Worth area).

Baylor is one of the largest health care providers in North Texas with about $4 billion in annual revenue. Scott & White, with a national reputation for quality care and efficiency, is dominant in Central Texas. (link)

Huddle Room

The visit started with a stop in their “huddle room” where the senior leadership team, including the hospital CEO and the system CEO, Dr. Bob Pryor, have their daily stand up meeting. It's a room similar to the “visual room” at ThedaCare that's full of strategy deployment objectives and actions. Dr. Pryor is expected to be the system COO at the merged Baylor/S&W system. 15 senior leaders packed themselves int he room, as part of a cascading series of huddles that go all the way down to the front line staff for rapid communication up and down the chain in both directions.

One wall of the room has “leader standard work” posted for many executives, including the CEO. Each posted document lists items that are done daily, weekly, monthly, or quarterly. This is a new initiative, so not every leader had their SW document posted yet.

leader standard work

The second wall is their Hoshin Planning board (another term for strategy deployment)… the “Scott & White Alignment Tool” (or SWAT), to gain alignment in the organization around their goals (in five categories) and HOW the goals will be accomplished. The system CEO was personally reviewing progress against these goals.

The third wall was their “SQDCM” metrics board, showing performance in the typical Lean areas of Safety, Quality, Delivery, Cost, and Morale. These goals are aligned at each level of the organization (as we also see at ThedaCare, see their DVD on this process: Thinking Lean at ThedaCare: Strategy Deployment).

The fourth wall is a white board that has in-progress “A3s” and other working initiatives.

Walls 2 and 4 (I just realized I didn't describe them in order):


The leadership team models a problem solving behavior of four questions:

  1. What's the target?
  2. How are you doing versus the goal?
  3. What are your ideas or action plan?
  4. How can I help?

As the leadership team review metrics, common questions were “are we working that action plan?” and “do we understand why?” As one bit of progress was discussed, Dr. Pryor said “I'd like to go see that” (and I'm betting that he did). As another issue was discussed, Dr. Pryor emphasized the classic “no problems is a problem” mindset of Lean.

Dr. Pryor ended the huddle by asking, and it seemed very sincere, “Any suggestions for me? How can I do things better?”

Lean Management Systems

Lean is by no means new to Scott & White, but their Lean Management System effort started about a year ago after visiting the Toyota Georgetown plant in Kentucky.

The LMS includes four levels of “accountability meetings”:

  1. Front-line staff
  2. Supervisors, managers directors (ideas that Level 1 can't address get escalated)
  3. Directors / VP / Chief Nurse Executive
  4. Senior leadership team

It also includes leader standard work (as seen in the executive meeting), visual controls, and daily accountability – combining for a process focus for the organization.


Team huddles are used to work issues that can be worked on quickly, measuring the impact of changes. For example, a team might work on:

  • Reducing the number of call lights per day (by more effective hourly rounding on patients)
  • Noise at night
  • Pain management for patients

A team worked on an issue related to labor and delivery, measuring patient wait times DAILY and huddling to talk about reasons for delay and capturing suggestions for improvement.

The CNE said this whole management process was a “life changing experience for me as a leader” and “I wouldn't go back to the old ways.”

They emphasized that the improvement process “has to be easy” and they had been “making it too hard” before. The teams charted data by hand now, for example. The process was “challenging for the first few months, but one success happened” it took off. I have seen this with the Kaizen process in other organizations. Once people see that it works, you no longer have to push. The improvement process and the things being measured “has to be meaningful to them” (the staff).

Dr. Pryor said, “For 115 years, we didn't do this… we didn't ask what's meaningful and we didn't ask for their ideas.”


I saw many great Lean management practices at Scott & White. The years of Lean leadership provided by Marji Henry have been supplemented with the addition of Steve Hoeft (formerly of the University of Michigan and Altarum Institute). They have hired people away from Toyota and have a lot of internal coaches and talent.

Many teams presented projects and huddle board work that they had done. It's great to see educated and passionate healthcare professionals have a methodology for reaching their goals for improving patient care.

More impressively, the senior leaders, from Dr. Pryor on down, are VERY committed to the Lean management system, including modeling these behaviors themselves. It's easy to find a place to see Lean tools and tactics — it's much harder to find a place where you can wee Lean management being practiced every day.

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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. Mark,

    Thanks for sharing this. Very nice to see visual management at work. Similar to meeting rooms I have put in place when running continuous improvement efforts at production sites and warehouses. Great to see these tools in use in health care and the involvement of everyone is nice to hear about. The culture is definitely one of continuous improvement.

    Best regards,

  2. Scott & White is an organization that gets it, with leadership that understands. I worked there for a few months, and I enjoyed every minute (well, except for the 100 degree heat).

  3. Sensei Hoeft – It is great to hear and see how you are transforming the thinking at S&W. You are missed up in Michigan.

  4. Mark, what a great example for Lean strategies working on a daily basis! This is not only a great Lean example it is a good example of how we can attack all of our major day to day issues in healthcare.

    Great article!

    Bob Yokl

  5. Leader standard work is the “what to do.” They are not done. They need to move to the next step: the “how to do” the work They need to create standard work combination sheets for leader standardized work.

    • They have standardized work documents written and posted for most executives.

      I don’t think it necessarily has to fit the rigid traditional “combination sheet” format that is helpful in, say, a production cell.

      I think they also have a good understanding that they’re not “done” in developing and improving this approach, nor will they ever be.

  6. Standard work combination sheets are beneficial for leaders’ work as well. Why? Same reasons as for operators. Quality in each leadership process will vary greatly from one leader to another without SWCS.

    Leaders will not understand their work (their process) if they do not break it down. Doing so will identify where the waste is, and all the benefits that ensue from that (for employee as well leader).

    They will learn more by creating standard work combination sheets. And, they should be consistent in what they ask of workers and what they should so themselves. Examples of SW and SWCS are here in my book: http://wp.me/P3kI3Y-2oE

    • I think we’re saying (or meaning the same thing) about leaders breaking down their work and practicing what they preach.

      What I’m saying is that they can utilize standardized work, conceptually and practically, without following this specific SWCS format with the lines and all.


      A SWCS is great for illustrating the steps and sequence of a repetitive job cycle, whether that’s 60 seconds in a production cell or a 10-minute cycle in a hospital core lab cell. I wouldn’t ask a leader to draw those lines. I’d ask them to document what they do, find waste, find ways to improve… but that’s just me.

      • No, we’re not saying the same thing.

        When leadership is understood as processes, then we can understand leadership as repetitive job cycles. SWCS works for leaders as well workers. SWCS is necessary in order to understand the process and identify waste.

        Understanding leadership as processes reveals the hundreds of errors that leaders make every day. Knowing these errors leads to a scientific (rather than behavioral) approach to improving the quality and effectiveness of leadership.

        • The new book “Managements Lessons from Taiichi Ohno” makes my point, as Takehiko Harada says that “For people who are working in a cyclical fashion, showing one cycle of work on the standard work sheet is enough” but defining standard work for team leaders and supervisors is “a lot more difficult.”

          If you can show me an example of a SWCS for a leader or an executive, that would be helpful. Because I’m not convinced that format is helpful for anything other than a repetitive job.

          As Harada quotes Ohno… keep it simple. The job instruction for the team leaders was basically “see the andon, start moving, fix the problem.” That wasn’t a SWCS.

  7. What kind of mistakes could a leader make in this repetitive process:

    – See the andon
    – Start moving
    – Fix the problem


    “a lot more difficult” does not mean impossible or that it is not worth doing.

    • Yes, lots of mistakes are possible. There’s where a capable coach and mentor is invaluable. The behaviors matter, not just the job cycle. That’s where I think a TWI style job breakdown sheet with key points and reasons why would be more helpful than diagraming a SWCS cycle like this.

      Ohno was saying “keep it simple” to start and I’m sure they built upon that.

      I’d still be interested in what a SWCS looks like for a front-line manager or executive. I’ve helped people do them in manufacturing and hospital laboratory settings where you have repetitive “production cell” job cycles of a minute (manufacturing) or eight minutes (hospital lab).

    • Doing so would lack context and meaning. Like JIT misunderstood and taken out of context decades ago, which led to bad outcomes. If all there was to it was an leadership SCWS chart, a book would not be necessary to explain it and I would honor your request. I’m presenting a new conceptualization of leadership along with practical methods for improving leadership.


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