Retired Navy F-14 pilot and airline captain Steve “Monty” Montague spends his non-flying days helping hospitals adopt the safety culture that made commercial aviation the safest way to travel. In this episode, we talk about why standardized work frees people up to think, how to be assertive without being aggressive, and what leaders have to do so that speaking up is actually safe.

Joining me for episode #195 is my friend Steve Montague from LifeWings. Steve is a retired Navy pilot who flew the F-14 Tomcat, and he currently flies as a captain for a major commercial airline. About ten years ago, the president of a children's hospital asked him whether the practices that made commercial aviation so safe could be brought into a hospital. That question turned into a second career. Through LifeWings, Steve has spent the past decade helping healthcare organizations adopt “Crew Resource Management,” known in healthcare as “TeamSTEPPS.” He's also been on the forefront of combining Lean and TeamSTEPPS, something we both agree is a great idea.

We recorded this in honor of National Patient Safety Awareness Week, and Steve makes a point early on that's worth sitting with. Aviation did not get safer through better technology. It got safer through a low-tech change in how people talk to each other. Pilots in the 1970s had tremendous technical skills. What they lacked was a shared way to raise a concern, to be assertive without being aggressive, and to make decisions as a crew rather than as a captain issuing orders.

Steve also pushes back on the idea that a checklist is the answer. He quotes Peter Pronovost, who described the simple checklist concept as a technical solution to a sociocultural problem. In Steve's framing, the checklist is a prompt for a conversation, not a substitute for one. He walks through the four-part assertive statement that LifeWings teaches, and he tells a story about being challenged by his own co-pilot while taxiing at DFW. He turned out to be right. He thanked the co-pilot anyway and told him to keep doing it. That response, repeated over time, is what actually builds the culture.

We spend the last stretch on where Lean and TeamSTEPPS complement each other. Both came from outside healthcare, both engender Respect for People, both have to be implemented at the gemba, and both insist on measuring results. But TeamSTEPPS does very little for supply issues, case carts, layout, or workflow, and Lean has historically had less to say about professional hierarchy, conflict, and recognizing an unanticipated situation as it develops. Steve's view is that you don't prescribe either one until you go look at the actual problem.

In honor of National Patient Safety Awareness Week, we talk about topics including:

• Steve's background with CRM in aviation and healthcare
• Why CRM isn't just about checklists, but also learning how to “communicate more assertively” in the cockpit or operating room…
• How Lean and CRM / TeamSTEPPS fit together conceptually
• How standardization and iterative improvement fit together

There's so much we could talk about, so we barely scratched the surface on this topic. If you have questions, we can do another podcast. Please post them as comments on this post.

For a link to this episode, refer people to  www.leanblog.org/195.

Related links:

• Podcast #112: (2/10/11) Naida Grunden, Lean and Checklists
• Description and video portrayal of the Tenerife air disaster that killed 583
• Steve on Twitter – @LeanSTEPPS

For earlier episodes of my podcast, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple Podcasts.  

You can also listen via Stitcher. 

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If you have feedback on the podcast, or any questions for me or my guests, you can email me at leanpodcast@gmail.com or you can call and leave a voicemail by calling the “Lean Line” at (817) 372-5682 or contact me via Skype ID “mgraban”. Please give your location and your first name. Any comments (email or voicemail) might be used in follow ups to the podcast.

Lean Blog Podcast #195: Steve “Monty” Montague on Aviation Safety, TeamSTEPPS, and Lean

Originally published March 3, 2014, in honor of National Patient Safety Awareness Week.

Introduction

Mark Graban: This is your podcast captain speaking. This is Mark Graban, and this is episode 195 for March 3, 2014. I apologize to you, and I apologized to my guest today, for the pilot announcement reference. I think you'll forgive me.

My guest today is a good friend of mine, Steve Montague. We're going to be talking, in honor of National Patient Safety Awareness Week, about Lean and aviation safety practices as applied to healthcare.

Steve is both a retired Navy pilot and a currently active commercial airline captain. He's also involved, through an organization called LifeWings, in the movement to bring aviation safety practices and that culture into healthcare via a process called TeamSTEPPS, and he's been combining Lean and TeamSTEPPS, something that we agree is a great idea.

I've known Steve for probably at least five or six years now. We met through our shared interest in Lean healthcare and discovered that, at the time, we both lived in Keller, Texas, which is also coincidentally where Ron Pereira from Gemba Academy, my guest for podcast 181, is from. So I don't know what's in the water or what's drawing Lean thinkers to Keller, Texas.

It's always great talking with Steve. This is just our first chance to record something to share with all of you. I hope you find this interesting. I think we just barely scratched the surface, so if you've got questions or things you would want us to cover in a follow-up podcast, please go to leanblog.org/195 and leave a comment.

Well, Steve, it's great to have you joining us here as a podcast guest today.

Steve “Monty” Montague: Thanks a lot, Mark. I'm glad to be here.

Mark Graban: We've talked many, many times. This is the first time we're recording it. I'm excited to have you introduce yourself for the listeners. I think you've got a really interesting background, if you can tell people about it.

From F-14 Tomcats to the Operating Room

Steve “Monty” Montague: Sure. I am a former naval officer. I graduated from the Naval Academy in '82 and went to flight school. Out of flight school, I was fortunate to fly the F-14 Tomcat. I flew that on the East Coast.

I flew for about five years on active duty, and then I transitioned in 1989 to the Reserves, and I continued to fly in the Naval Reserves until 2003, when I retired. In '89, when I left active duty, I went to work for American Airlines, and so I've been flying as a co-pilot and more recently as a captain for American Airlines since '89.

Then about ten years ago, I was approached by the president of a children's hospital about taking some of the ideas that have made commercial aviation as safe as it is today and helping to implement some of those ideas in healthcare. It's turned into a real passion for me, and it's what gets me out of bed in the morning.

It's just really neat, kind of like the work that you do, seeing the principles that have grown largely out of the manufacturing sector and seeing how applicable they are in knowledge work and in healthcare. They're universally applicable concepts and ideas.

Mark Graban: The listeners are learning now that we share that passion for healthcare improvement, and that we've really enjoyed finding connections between different methodologies. Before we come back and talk about Lean later, some of our listeners might not be familiar with crew resource management. Can you define that and talk a little bit about the history of how that got into healthcare? And maybe in the course of talking about some of that history, weave in how you got involved in LifeWings and a little bit about the work you do there.

What Crew Resource Management Is and Why Aviation Needed It

Steve “Monty” Montague: Sure. For people who are in healthcare, crew resource management is now known as TeamSTEPPS. So anytime that you and I say crew resource management, I'll typically flip back and forth between the two.

It got its birth in commercial aviation. In the '70s, we recognized that even though it was already much safer to be in an airplane than it was to be in a car on the way to the airport, we still were having accidents. Not because our pilots were not very well trained — they had tremendous technical skills — but we had interpersonal communications, leadership, and decision-making practices that were no longer adequate. We got to the point where we realized that there were cultural elements that were missing.

NASA became involved and created a syllabus, some ideas about things that needed to happen. The airlines themselves each went and developed their own crew resource management program to teach pilots how to be more appropriately assertive, to communicate more clearly, and to involve team members in making decisions, instead of the old John Wayne command and control, “I'll make the decision and you do what I say.”

We implemented those through the '80s, with a lot of false starts in the '80s. But we began in the early '90s to really see some tremendous results. It has made commercial jet aviation in the United States the safest transportation system in the world. And it was not with high-tech innovations. It was a very, very low-tech innovation, and that is changing the way people interact with one another and the culture that surrounds how we work.

That's the background on crew resource management. It's still very much a part of my training. Every nine months, when I go to training at the airline, I get refresher training on human factors and just the basics of crew resource management. It's that important.

Bringing CRM into Healthcare

Steve “Monty” Montague: In the late nineties, some really smart folks in healthcare began to look and say, “A lot of our sentinel events are very similar to accidents in aviation, in that one of the leading root causes is interpersonal communications in interdisciplinary teams, especially as the complexity grows in healthcare.”

We saw more and more sentinel events, untoward outcomes, that were a result of many of the things that crew resource management addresses. So over the last fifteen years, a lot of smart folks have been coming up with clever ways to lift the skills out of commercial aviation and then implement them in healthcare.

Mark Graban: And you've been involved in particular with LifeWings for how long now? Give us kind of an introduction there.

Steve “Monty” Montague: For ten years. It's been really gratifying. It began as fairly low impact on my schedule. As we began to get more and more work, mostly with academic medical centers, I just, like I said, have a real passion for it. I've thoroughly enjoyed it. So these days, if I'm not flying an airplane, I'm working with somebody in a hospital somewhere around the world. And like I say, the results are gratifying. So it's a lot of fun.

Why Each Airline Built Its Own Program

Mark Graban: Just a quick follow-up question. I didn't know the history, that as you mentioned, each airline developed their own approach to crew resource management. I'm curious, do you think that was because of differences in each airline's culture, or was it just working independently? Has that come back to become more consistent over time? I'm just curious why that developed separately, either good or bad.

Steve “Monty” Montague: Great question. I think it was probably a mix of pragmatism and the fact that the airlines did have different cultures. They are a lot more similar these days than they were in those days. But certainly, depending on how long the airline had been around, what part of the country they flew in, what kind of people they hired, each airline was different. So it would have been difficult at that time to create a one-size-fits-all.

The other part of it is very similar to the Lean idea of small trials and, okay, let's see what works. As the airlines all implemented their programs, some of the programs were very, very successful, and others were moderately successful. Then researchers had the opportunity to go and look at each system and see what was working well and what was not.

This is an area where commercial aviation does not compete on safety. If somebody figures something out, we share liberally. We all learn from one another. While a particular acronym at Delta Airlines may be different from what they use at Alaska Airlines, the fundamental principle is identical, because we do know what the evidence-based practices are in aviation.

The Standardization Problem in Healthcare

Mark Graban: Building on that, let's talk about some of the applications of CRM or TeamSTEPPS into healthcare. We've talked before that this is by no means as simple as going out and buying a checklist or having some carbon copy, cookbook approach in hospitals, which seems like what the airlines did. They were developing their own based on some science and some standard principles. Can you comment on that, or share some other thoughts about how this is developing in healthcare and how that's different from getting things started in aviation?

Steve “Monty” Montague: One of the things that really surprised us — remember, this is a bunch of pilots walking into a hospital — is that just conducting training in these ideas gets people to say, “Okay, yeah, that makes sense.” But then they turn around and say, “Okay, so how do we apply this in healthcare?”

I remember when we were up at Vanderbilt University, back in the early 2000s, long before The Checklist Manifesto and some of the other great things that have come out. They wanted to implement these ideas, and they said, “Okay, so how do we do this?”

And we said, “Well, how do you start a case?” You know, an operation in the OR, how do you start a case? And the answer was, “Well, it depends.” No matter how much we drilled down, we kept getting the answer, “It depends.” We recognized that there was very, very little standardization in healthcare.

Just as your listeners struggle perhaps a little bit, maybe not as much now as we used to, the idea of standardization in healthcare was not readily grasped and appreciated. So that was one of the things that we had to make the case for.

A Checklist Is a Prompt, Not a Fix

Steve “Monty” Montague: A checklist is not going to do something for you. You still have to do the work. You still have to use these skills. The checklist itself is not a fix. In fact, there's a great quote by Peter Pronovost, and I'll paraphrase, but he said, “The problem with the simple checklist concept is that it's a technical solution to a sociocultural problem.”

That comes right back to these ideas in TeamSTEPPS or CRM. We use the checklist as a prompt to make sure that we are having important conversations. Not only can we cross-check to make sure that things are in fact completed, it's not simply a grocery list. It is a prompt. It is a structure to ensure that we each talk about what we have done to prepare for this case, and to make sure that we're creating a forum where people are going to ask questions to clarify information, and to set a tone or an atmosphere in the OR that if at any time you have any questions or concerns, I'm counting on you to speak up.

We really struggled with getting the idea of standardization across. Of course, you and your listeners have really helped us out a lot, because people get the idea of, okay, I see how standard work does make things easier and better and more predictable. So we often, especially if we're working with somebody who is already on their Lean journey, describe many of the things that we do as standard work for teams. This is a way that we interact with one another in a very predictable way.

I'm not sure if I answered your question there, Mark.

Mark Graban: No, you did. There are a couple things I'd like to dig a little deeper into. For one, just reacting to what you talked about with standardization. I think there's still controversy that comes from misperceptions when we use the word standardized work or standardization in healthcare. I think especially among physicians, where people jump to a conclusion that means, well, by standardized you mean check your brain at the door and be completely rigid and inflexible. And, well, no, of course not. That's not what we mean. But like you said, it provides some structure to make sure that we don't forget things by using the checklist.

Standardized Work Frees Up Critical Thinking: Flight 1549

Mark Graban: One other thing I'd like to talk about is some of the structure around how to communicate more assertively if we identify a risk in the operating room. I think we're still trying to communicate some of those subtleties.

I saw Captain Sullenberger, now retired from the famous Miracle on the Hudson landing, and he said checklists were helpful, but they didn't have a checklist that said, “Here's what happens if you lose both engines due to bird strikes right after takeoff, and you're considering having to possibly land on a river.”

He said the thinking and the judgment was between him and the co-pilot, figuring out which different checklists to piece together to allow them to do that problem-solving and decision-making more quickly, which I thought was a really fascinating point. I'm curious about your reaction, before we come back to healthcare, from your perspective as a pilot.

Steve “Monty” Montague: You've hit so many things. Going to Sullenberger's event, US Air 1549, the Hudson River landing — you're right. I've watched that reenactment hundreds of times, and there's just so much there. They're skipping from this checklist to that checklist. But they had something standardized that they could fall back on and say, “Okay, I know that I need to get this piece done, and I know that this checklist will help me get this piece done.” Once they had that part done, then they set it down and said, “Now I need to do something else, and I have another standardized way that I can get this done.”

It freed their minds up from the mundane task of what's the correct sequence of events to accomplish this, and allowed their critical thinking skills to still be readily available. Sully was doing a lot of big picture thinking. Where's Teterboro, which is another airport over there in New Jersey? I might be able to get over to there. He was trialing so many different ideas.

Roles and Scripts: My Aircraft, Your Aircraft

Steve “Monty” Montague: The reason he could do that is because, in a very short period of time, they fell into a script. My aircraft, your aircraft.

In healthcare, my patient, your patient. Those simple words speak volumes about what your primary responsibility is, your secondary responsibility, what is my primary responsibility, my secondary responsibility. You can drop into roles with just a simple script like that, and you know.

Sully said, “You're trying to get the engines relit, I know that, and you're running these checklists, and I'm trying to think through this big picture problem while we try and get the engines started.” But neither one of them completely dropped the other role, either. Sully was still helping to start the engines, and Jeff Skiles, the co-pilot, was still thinking big picture stuff. He came up with a couple of really solid recommendations in there as he was fulfilling his primary responsibilities.

That's a great example of how standardized work fits in so well. This idea of standardized protocols fits in so well with completely unpredictable situations. It gives you something to fall back on so you are communicating very effectively.

Mark Graban: As you were saying, they were handing off my aircraft, your aircraft. Some of the awful stories that you hear from back in the day, before crew resource management was developed, are scenarios where a pilot and a co-pilot are each doing all these different things and nobody was keeping track of the altitude. Clearly that didn't happen here. Or if the co-pilot had a concern about altitude, they might not have spoken up.

The Four-Part Assertive Statement

Mark Graban: To build on that and bring it back to a healthcare setting, I was able to sit in a couple of years ago on, I think it was, a half-day class that LifeWings did with a hospital. As we talked about afterwards, the thing I was really impressed by, or that was new to me, was not just checklists. People out there in the Lean methodology would recognize that as a form of standardized work that guides your work or confirms your work.

But the thing that really impressed me was that standardized way of speaking up, based on experience of how to speak up in a way that would be more likely to be listened to. Can you tell the listeners a little bit about that approach, and especially how that applies in an operating room setting? If you have a surgical tech or a circulating nurse, why would they have trouble speaking up, and how does this method teach them a better way?

Steve “Monty” Montague: Sure. You really zeroed in on it. In my opinion, there are a lot of benefits to the entire package of skills and techniques that TeamSTEPPS or CRM bring into healthcare. But if I was going to pick the one that I think is the most important, it is a standardized way that I can be assertive without being aggressive, and that you recognize, “Oh, I see what he's doing. He's making an assertive statement here. I might be missing something.”

It removes me and you, or any potential perception of adversarial relations, from the equation, and now we're zeroed in on, okay, what is the problem? What is going to happen?

So if I'm the circulator and I think we're missing the tip of the catheter, not only do I know how to speak up and I'm empowered to speak up, but I'm held accountable for speaking up. That's part of my job. Part of my job description is to speak up when I think another member of the team is about to make a critical mistake or is missing something.

So I'm the circulator, and I'm going to say, “Hey, I think that the catheter tip is missing.” Most of the time, just a simple statement like that is going to fix the problem. But every once in a while, people are tired or fatigued, or they are stressed, or they're thinking about the next case, or whatever the reason, and they ignore the statement.

So now this person — let's say I'm the circulator and I'm the one who thinks that this catheter tip is perhaps still inside the patient and we're getting ready to close — you can see that this is a very stressful situation for me. I was just told that it's not in the patient. Do I continue to advocate? Well, the tip is missing. What does the patient want? What does the patient's family want? Figure out where it is.

They're counting on me to make some kind of an assertive statement, and for it to be heard in the context of, this is not about who's right and who's wrong. Let's talk about what's right and wrong.

There's a four-part assertive statement that is an effective stop-the-line statement when hierarchy, fatigue, stress, or anything like that is becoming an impediment to that communication and it has to get through.

The first part is you call them by name. Especially if it's somebody that you work with all the time and you're on a first name basis, perhaps you add their title. So, “Nurse Susan,” something to get their attention quickly. That's going to snap them around.

Then you make an “I” statement of concern. “I'm concerned.” That tends to deflate any perception of adversarial relations.

Now you clearly state the problem.

And then you propose a solution in “we” or “let's” language.

What you did in the class that you attended, Mark, is you practiced making that kind of an assertive statement.

Where I think it's particularly helpful is this. If you have created standard work with an organization — if you have listeners who created some standard work and it requires something — and I walk in and I see that you are not in compliance with standard work, you're blowing it off, “Yeah, I know, but I have my own way of doing it,” it's a way for me to speak up and say, “Wait a minute. Jim, I'm concerned, because we've created this standard work and we're going to use the standard work. And if it's not working well, then we're going to continue to iterate to make sure we do get it right. Let's break out the standard work card, and let's go through it and do it this one way. And if you have some ideas, let's add those in and let's change it and make it better.”

I think that kind of agreement among all of the stakeholders, all the disciplines, all the professions, is that we owe it to the patient and their families to instill a culture where it's not just okay for us to have these types of conversations. We must.

Saying Thank You When Someone Speaks Up

Mark Graban: The one thing I really liked about the approach was the statement of, “I have a concern,” because I think Lean teaches us to try to recognize and state facts more so than just opinions or assumptions. I was taught in the class that when you say, “I have a concern,” that's a factual statement that really can't be argued with. And it could turn out that I had a concern, and that concern is resolved because the catheter tip is actually there and I just didn't see it.

Steve “Monty” Montague: Right. And I think you've hit upon another important part of this. Part of the culture also is that when somebody speaks up and it turns out that they're incorrect, you say thank you. Thank you for speaking up.

I'll tell you, in my own professional life, believe it or not, one of the most difficult things to do when you move from the right seat to the left seat is drive around the airports. Especially back in the old days, every airport labeled their taxiways differently. We've done a lot of standardization work on that. But still, every airport's laid out differently. Getting from the gate to the runway is a really important task.

Up in Detroit, where you and I are both from, there was an awful accident at Detroit Metro Airport where they got lost, and they taxied onto a runway in heavy fog, and there was a terrible accident. So you want to get that right. It's mundane, but you really want to get it right.

After I checked out as a captain, I was probably four or five months in the left seat, and we were taxiing at DFW Airport, and my co-pilot challenged me and said, “We're supposed to turn here.” So obviously we stopped. I thought we were supposed to go up to the next taxiway. But we stopped the airplane, called the tower, and it turns out that I was correct.

But I turned to my co-pilot and I said, “Thank you for speaking up. Keep doing that.”

That's how you keep that culture moving forward. So when I challenge you on standard work and you say, “Well, no, it's been updated. See, this is the new one.” “Okay, I'm sorry.” “No, no, no, thank you.” That's how we do that. That's how we make this work. It does deflate some of the ego, perhaps, and it really focuses us on what's right and on the facts.

What Leaders Have to Do to Make Speaking Up Safe

Mark Graban: Like you said, what's right for all the passengers sitting behind you, what's right for the crew, what's right for yourselves. And in the operating room, that question should be coming from the perspective of what's right for the patient. The patient would want us to make sure that we have enough units of blood before we start the procedure, and if it turns out we did have enough, I think that's a big cultural difference, for someone to say thank you for asking.

You mentioned culture early on, and I want to come back to this. How do you address it when you go into a hospital where it's one thing to say you're empowered, but people still might be scared to speak up? Or what happens if somebody speaks up and the doctor does not listen or does not respond constructively? Are there expectations that you're setting, or that you're signing up senior management for, whether that's chief of surgery or chief medical officer? At what level do senior leaders really create that environment to say, “Well, if you don't respond properly…” Would they leap to say, “We'll take your privileges away”? How does that play out generally?

Steve “Monty” Montague: That's a great question. Again, back in the early days, it didn't occur to us that we needed to do that. But we did figure it out, because somebody would take the training seriously and would speak up, and then they got smacked down and abused, and it's, “Hey, I'm not doing that anymore.”

So one of the first things we do is teach the course that you just discussed to the senior leadership of the organization, the executive level: the CEO, COO, chief medical officer, chief nursing officer. Then typically they'll begin in a particular department, so the chairs of the appropriate specialties and then the department managers and such.

We teach the leadership the course, and then we continue with a two-day offsite, if you will, where we go through those types of scenarios and they come to a consensus on policies and a philosophy of, “Okay, if we're going to do this, this is how we're going to do it, and this is why we're going to do it.” And if we're going to do it this way, then we need to have policies in place to make sure that we actually are successful.

One of our guys has a great saying: people are watching. They're watching to see how the leadership of the organization responds, because it's not just that one person who's going to learn the lesson. Everybody's going to learn the lesson very quickly as to whether we are serious about this change in our culture.

Where Lean and TeamSTEPPS Fit Together

Mark Graban: One other thing I want to talk about, and we've got a couple of minutes — maybe we can do a second podcast at some point down the road. I did want to talk a little bit about how you're combining Lean methodologies and TeamSTEPPS into what you're calling LeanStepps. I'm curious if you can talk about, practically speaking, what some of the synergies are. You and I have agreed for a long while that there's a high level of conceptual and philosophical overlap. But what is that LeanStepps approach that you're putting in place?

Steve “Monty” Montague: I should be clear that LeanStepps is really my Twitter name, and I'm the only one who uses it.

Mark Graban: Oh, right.

Steve “Monty” Montague: But it's because I do think that either one on its own is great, and you really get a lot of synergy from an integrated approach.

We've talked about the standardization, and they were both developed outside of healthcare. I think they both engender respect for people. They're both bottom-up methodologies. Now, you and I just talked about how essential the leadership actions are. But the fact is, the chief pilot at the airline is not there in the cockpit to make sure that things happen, that the first officer does speak up if they have a concern, that the flight attendant calls up and continues to advocate if they have a concern. It has to be implemented at the gemba, if you will. Both of them are very well aligned on that. They both say you have to measure the results or it doesn't matter, and both value servant leadership. So there's a lot that's very similar about the two.

That said, TeamSTEPPS or CRM is very limited in its ability to address material and supply, equipment and instrumentation issues, workspace organization and optimization, workflows, pathways, and engineering or ergonomics issues. Most of those are things the Lean techniques and Lean philosophies are optimized for and really handle well.

Lean, on the other hand, has some challenges, as we've just discussed, with professional hierarchy, sometimes conflict resolution, and unanticipated situations — recognizing unanticipated situations as they're developing.

No Cookie-Cutter Approach

Steve “Monty” Montague: So when we work with a hospital now, we don't prescribe anything until we go with them and look and see, what's the problem?

If they're bleeding on their supplies or on their case carts or that kind of thing, I can tell them how to make an assertive statement or how to do team problem-solving and decision-making all I want. That's probably not going to fix those case carts. Whereas the Lean techniques and methodologies, they just handle that.

So we work with the leadership of the organization and say, “Here's where we would begin and here's why.” But we let them make those decisions.

Typically, honestly, in today's environment, that begins with financial. The leadership of these organizations still understands the importance of the cultural piece, but implementing some of the Lean methodologies gets them the savings that they need right up front in order to continue to do this culture change.

There is no cookie-cutter approach. Every implementation has to be customized. There are some places where they say, “Look, I'm going to be losing people. I can't keep my nursing staff. I can't stay fully staffed here because of the toxic relations.” Well, then maybe it makes more sense to shift and do more of the human interaction piece first and follow in with the Lean, or perhaps do both.

It's nice to have more tools in the toolbox to help address problems. There are some things where we would just kind of say, “Hey, we don't do that. We don't have an app for that.” So using some of the ideas of Lean and the techniques has really helped us out a lot in helping our partners, and therefore helping them help their patients.

Closing Thoughts

Mark Graban: Thank you for pointing that out. Thank you for sharing the concern. You're right, I should have asked the question in terms of Lean plus TeamSTEPPS, and I'll link to a couple of different articles and press releases that LifeWings has put out talking about that combination of Lean and TeamSTEPPS.

As we see so often with Lean plus whatever, these different methodologies can be very complementary and very consistent. People might get confused by terminology, but they shouldn't be confused by, like I said, I don't know if there's any inconsistency in these approaches, which is why I'm so excited about it, and I know you are as well.

So we're at a point where my concern, unfortunately, is that we're running out of time. Steve, my concern is that we're running out of time. So what I suggest we do is just wrap up. I know there are lots of other things I could ask you about. It's always nice talking to you, but maybe listeners will have follow-up questions. May I just ask you to wrap up? Do you have any final thoughts you would want to share, and maybe share some contact info for how people can find you online?

Steve “Monty” Montague: Sure. I think you really nailed it in saying it's not one or the other. They are highly complementary. I'd be happy to visit with anybody about some of the things we've learned, some of the challenges they face, and whether I believe there's anything that CRM can do to assist them on their Lean journey.

As far as my contact information, we are at saferpatients.com, and I'm Steve Montague. Steve Harden is our president. So there are two Steves there, but Steve is very adept at discussing Lean and CRM and understanding which one is appropriate where.

Mark Graban: Again, I'll post links to the website and to your Twitter account, which is @LeanStepps, with two Ps. People can find you and hopefully reach out.

As always, it's fascinating to hear what you're working on and to learn about the background with aviation safety, how that's being applied, and how it's being combined with manufacturing practices. Really exciting times, and thank you again for talking about it here on the podcast.

Steve “Monty” Montague: Well, Mark, thanks for making the assertive statement. And thanks for having me on. I'm a big fan. I appreciate it.

Mark Graban: Thank you.