This podcast is sponsored by Cardinal Health.
Joining me again for episode #301 of the podcast is Joe Swartz, my friend and co-author for our books Healthcare Kaizen and The Executive Guide to Healthcare Kaizen. You can learn more about our books here. He also contributed a chapter to the book Practicing Lean. (read an excerpt). Joe is also a co-author of the book Seeing David in the Stone.
Today, we're talking about “Champions of Change,” as I've been writing about for Cardinal Health.
Joe is Administrative Director of Business Transformation for Franciscan Alliance, which owns Franciscan Health in Indiana (his full bio is here). He was previously the guest in episode #187 and episode #299, where he talked about 10 years of Kaizen at Franciscan and the evolution of their approach to Lean and improvement.
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- How do you define a “Champion of Change?”
- People who step up and challenge their peers make the real difference
- Good examples of “Champions of Change” Joe has worked with?
- Someone who can shift their perspective, step out of their comfort zone, take a real risk
- People who go above and beyond the scope of their project
- “Pain and possibility” as motivation for change and improvement
- What if a goal is too audacious?
- How can a Champion of Change help reframe a big challenge?
Mark Graban: I've been writing a couple articles that are sponsored by Cardinal Health on the theme of champions of change. In one of those articles, I shared some stories from your work in Franciscan and your colleagues there. In a nutshell, what does the phrase champion of change mean to you? How would you define a champion of change?
Joe Swartz: I was thinking back on some of those big changes we made. It often came down to one or two people that stepped up. I had a big effort in the emergency room, and we changed everything except the doctor processes. The doctors just, “Nursing should change, but we shouldn't change.”
Joe: Spent a lot of time trying to convince them on a few different things. I took a number of the physicians on a trip to another hospital system, so they could see what they've done. The doctor, you met the doctor, Mark, really neat guy. He turned to me on that trip and he said, “Joe, you know, I really came along for the food.”
Joe: He said, “Now that I've seen this in this other hospital system, I think it could work.” I said, “Well, if you think that, then I need you to help me convince your other doctors.” He said, “I'll do that.” That was the pivoting point.
From then on, we steadily engaged all the physicians in the ER, and some of them were pretty tough to engage. But this doctor stepped up. That's a champion of change. He's potentially going to maybe go against some of his other fellow colleagues and their strong opinions. He's going to have to challenge those strong opinions.
That's what I've found. It's those people that see the vision. They catch a glimpse of the vision and say, “I think this could work.” I say, “Well, here's what we need to happen so that would work.” They step up, step into that, and challenge their peers to convince them why we should be doing this.
It's those people that have made the real difference on project after project after project. Someone has to step up, otherwise it's not going to make it. Sometimes more than one person steps up, but often one person can make all the difference.
Mark: Sometimes that takes courage for someone to go against the grain and to be a leader, to spark others to participate.
Joe: Yes. It has huge risks for them, and they're willing to step into that risk, which I commend them.
Mark: Can you think of an example of somebody who's been involved in supply chain work in your organization that maybe would be a good example of a champion of change at whatever level of the organization that might be?
Joe: You mentioned that when we talked the other day, and I've been thinking about it. I started thinking back all the way to the beginning of the work with Franciscan. Starting in 2005, I had a project in our Lafayette facility on supply chain.
I remember, at one point in that project, we were considering doing color coding. There was a nurse that sat in the front row in the event, and I noticed she had color-coded highlighters. She was highlighting all her notes.
I turned to her and I said, “Hey, I see you like color coding. Would you be willing to think through a set of color codes for our supplies, so that you tell it to a nurse once, and they get it, and it's very obvious.” She said sure, and she worked with her other nurses. They came up with color-coding system, and it was good.
It was really obvious, like urinary tract items were yellow. It was that kind of color-coding system. We put it in place, and it worked really well. That system is now spreading throughout our systems, slowly, but spreading throughout our system.
Her name was Shelly Paddock, and I remember, to this day, she was the champion. I asked her to do something, but stepped into it and did it, and did it really well. It made a huge difference.
Then in that same project in 2005, we introduced two-bin systems. That same nurse stepped in and said, “I'll drive that.” She drove it, and we piloted it on one unit, and it worked really well. Then I left it and came back to Indianapolis and focused on Indy.
They assigned another guy to Lafayette, in my role, Brian Hudson. He stepped up and took that two-bin system and spread it throughout the hospitals in Lafayette. In 2007, I brought it to Indianapolis. I remember a champion of change in Indianapolis, Pat Gillock-Roe. She was the manager of materials.
She was resistant at first, but after she saw the benefit, the value of two-bin, she was onboard. She shifted. That's a champion of change, someone that can shift their perspective, that's not just stuck in a way of thinking. They're willing to look at a different approach and try it, because that's risky. Someone willing to step out of their comfort zone and take a risk is a champion of change.
We did it in two units at Indy, but then spreading it was a challenge. Spreading all these improvements are a huge challenge. It actually took four more years before that could be spread. I remember going through a cost-justification exercise for the two-bin system. We really couldn't cost justify it.
It would lower inventory levels, so our holding costs would be lower, but when I calculated it out, we're going to do 10 more units, it was only $3,000 a year that it would save us. It would cost us about $3,000 per nursing unit to put in a two-bin system. You had to change the shelving. You had to change all the little bins, so that you had one bin behind another.
Even when you considered outdated supplies, stock-outs, the search time for nurses, and even the supply tech — we needed less of a supply tech — it wasn't a whole person. It was just a partial, so it was one of those windfall to the bottom line today. Someday down the road, it might…
It was really hard to cost justify. At the time, I was working for the COO who was a CPA. He looked at me after I pitched my proposal. He said, “Joe, I think you've got more important things to work on.”
Joe: A two-bin system is more robust. It's more stable than what they had. They had a PAR-level system. PAR level stands for periodic automatic replenishment. It's really the max-min. It's really the maximum out.
What they'd have is a supply person go up every day. They were supposed to count every single supply in every single unit, and replenish up to the max, every single day. At one point, that was a good system, but over the years, they reduced staffing levels to the point where the stocking people were not counting, they were just eye-balling, and glancing and making best guesses.
There were being more stock-outs, and the system just wasn't as robust. The two-bin system would be a much more reliable system, based on the fact that they weren't really doing the true counting and the true PAR. I tabled it, but I communicated to a number of people that, if we get to the point where we ever do change these supply rooms, I think a two-bin system would be a better system.
Matt Pierce, in Indianapolis, had an opportunity when we were going to consolidate campuses. They were going to redo all the supply rooms. He approached me. He said, “Joe, I think the timing is now.” He's now our director nursing operations there. He just took it on to convert all the nursing units to two-bin systems.
One of the things he used was a little simulation, a little game they played that showed nurses the difference. The nurses got to actually play this game with real supplies to show them the difference between a PAR-level system and a two-bin system. They could see the difference before they even had to make the change, so they bought in. That really helped accelerate that.
Matt was that champion of change that said, “You know it's not the most important, highest-leveraged thing to focus on, but it is a really important practice to put in place. So, I'll step up and I'll make sure it gets put in place throughout Indy.” Now that system is being spread throughout our system.
Mark: It sounds like, in the story there, there were a lot of champions of change. Are there other, another example, other champions of change who come to mind?
Joe: Yeah. Picking up with the supply chain thread, when we did the project in 2005, in Lafayette, the materials manager, Mike Draper, after, he kept calling me and asking me questions. We kept a dialogue going for a while. He came out of manufacturing and wanted to know how some of the manufacturing stuff…
Both you, Mark, and I, we came out of manufacturing. He had that kind of background. He kept asking, some of the stuff he'd seen in manufacturing, how does that apply to healthcare. We bounced ideas back and forth. He was interested in pick-to-light systems and carousels, some of the stuff we'd seen in manufacturing that he hadn't seen in healthcare. He asked a lot of questions about those.
We had this dialogue going back and forth for a few years. What was interesting with Mike, he actually implemented a lot of the things we talked about. He implemented carousel. You know a carousel's a pretty expensive system. We talked about when you use it, when you don't use it, what you augment it with.
Any time you apply technology, it's not so much the technology, it's how you use the technology. We dialogued for quite a while. He implemented a carousel system in Lafayette and a pick-to-light system. He did it in a nice way, where it wasn't totally reliant on the carousel. He had fast-moving shelves for the fast movers. The carousel was for the slower movers.
Through that, he reduced his inventory space. He had a special need to reduce the inventory space, because they were moving into a new building that would have much less space, and he'd have the inventory all stored on hospital space, which is very expensive space.
It actually reduced his total inventory space by 400 percent and improved productivity by 400 percent by thinking through how you would apply this technology in a healthcare setting to achieve certain goals. I just thought that was really impressive.
That's a champion of change that goes above and beyond the project you're working on. He continued it and made a huge difference in his facility. That's another one that comes to mind with supply chain.
Mark: It's interesting. That story you tell makes me think sometimes change and innovation is born out of necessity, of somebody being in a situation and say, “Well, we don't have enough space, so therefore we have to come up with something creative instead of adding more space.”
I'm curious what you've seen through Kaizen or other projects. How often is change born out of necessity? Are there times when people are just inspired to find a better way because of the challenge involved or because of the benefit to the organization?
Do you have some thoughts on that, necessity being the mother invention versus people just finding a better way because they want to or because they can?
Joe: We wrote about it in our book. One of my pastors years ago taught me the two parents of transformation are pain and possibility, pain being necessity. Possibility is not necessarily a necessity, it's, “What could we do?”
Mike was clearly in that realm of possibilities, “What could we do? How could we do it? What if these were the constraints? How would you fit a system into an area like this? What would you do?”
I think, unfortunately, most improvements come out of that pain dimension, but if you can drive people to think about the possibilities, you actually get, I think, better improvements that are more creative, they're more positive. They pull on a different part of a someone's brain when you get them focused on what could be, rather than what we have to do.
It's, “What could we do?” instead of, “What do we have to do?”
Joe: I knew you had a phrase for that. [laughs] I'm glad. Thank you for remembering that, pain and possibility. I think sometimes the risk with pain is if the pain is too severe, it leads to fear, and fear can get in the way of creativity. I've seen situations where leaders find a good balance.
I'm having a flashback now back to 1999 at Dell Computer. Executives decided they were going to build a new factory. Unlike the other factories, this one was going to have no materials warehouse. “Now, go figure out how to make that work.” [laughs] They created a situation where there was a lot of necessity.
Thankfully, there was a team of people who had enough time to figure out how to make that work. [laughs] There was necessity, and, at the time, there were a lot of people who thought the leaders were overreaching. There were people who were pointing out this seemed like an impossibility [laughs] instead of a possibility.
They made it clear there was no going back, and the team had to figure out a way. I think there's times where, if somebody sets an unrealistic goal. I heard a story this week. I won't go into the details, but somebody had given an estimate on how long it was going to take to go through, unit by unit, revamping some of the materials systems.
An executive said, “Well, I need you to do it in one-fifth of the time.” Unfortunately, they couldn't figure out a way to do it in one-fifth of the time. The organization ended up backing off. Maybe it's the art of it. The big, hairy, audacious goal can inspire people or sometimes it's just [laughs] too audacious.
Joe: Yeah, I agree. Sometimes it is too audacious. But I think it's our job, as change agents, to help people reframe. If they can't think of possibilities within a certain frame, it's our job to help them rethink it, look at it from a different angle. There's a quote, and I can't think of it right now. What we end up with, often, is determined by how we look at it when we go into it.
If we can reframe our thinking when we start a new venture and think about it correctly, I think we can get farther into the possibilities realm than we could if we were to look at it from just the, “Do it in one-fifth time or space,” and whatnot.
Mark: Can you think of an example either through your work as a champion of change or with other champions of change that you've coached, an example of helping somebody reframe a situation to make it seem more possible, in a way that that helps them accomplish something?
Joe: One comes to mind, but I'm sure, if I think about it, there'll be a bunch more. I remember, in the ER work, emergency room work, when I first go into it, we were trying to dramatically reduce the time that our customers sit waiting in an ER.
When I first started pitching that, the caregivers thought, if we reduce time, it's going to reduce quality. I had to reframe that into, “The goal is not to reduce time. It's to reduce all the unnecessary waiting time for our customers. Not to do things that that take five minutes in two and a half minutes, it's to cut out all the unnecessary, wasteful delays in the process.”
When they had this new frame to look through, they saw different possibilities. Before, they were looking at the things they do. When they looked at this other direction, they saw not what they were doing, but they saw the customer. They looked at the customer's perspective and all the waits and delays they went through.
Also in that emergency room work, at one point we were going to change how nurses practice. Before, they would see a patient and carry through with that patient all the way to the end, until they're either discharged or admitted.
With the nurses, we were going to break that up into small bite-sized chunks. We'd had an intake nurse do just the intake. Then we'd have a procedures nurse just do the procedures. A number of the long-time nurses objected to that, because it was not the nursing practice they were used to, where they saw a patient all the way through.
I had to reframe that into a different level of thinking and ask them, “Is it really important that a nurse has that continuity, or could we assign that to the doctor? Would it be better to have the doctor have that continuity, if we had to choose?”
Of course, they said, “Well, yeah. If we have to choose, it'd be better to have the doctor have that continuity throughout the process,” so convinced them that the doctor would have that continuity through the process, and they wouldn't necessarily need to.
Most of the nurses accepted that reframing. I had, I think it was, two or three nurses decide they didn't still like it, and they would not work in this new process. They elected to work in the other processes. We had two processes in the ERs, the walkie-talkies, have a fast-track kind of process. The patients that needed a bed would get a room.
They elected to work just in the part of the process where patients get a room the whole…still a twist, which was fine, but I was able to reframe it for most of our nurses to where they accepted that, and then they tested it and realized it was a better way of doing things.
I think we end up doing it a lot, and a good practice to get into is helping people see a different perspective on things. Often, I do that regularly, trying to look for different perspectives, so I can see perspectives of a lot of the people involved, so I can anticipate questions, approaches and whatnot.
Mark: One other thing I've seen that can help is helping reframe things back to the patient perspective. There are times when I think working with teams, and you're identifying how the work is being done. Are there inconsistencies? Are there opportunities?
Within a team, somebody might say, “Hey, I have a better way of doing,” whatever the work might be, “I have a better way.” Somebody else might say, “Well, you know, but meh. Nah, I like my way. It works for me.” I think there's a gentle way of bringing up that, [laughs] a more polite way of saying, “It's not all about you.”
Mark: “If you think about the patient, which works best for the patient?” can sometimes refocus people and saying, “Well, you know, you're right.” There's constructive ways of bringing that up, of reminding people of the alignment or the agreement that patient care, patient safety, patient waiting times, things like that are a priority.
Regaining that agreement and saying, “OK, well, now how would you evaluate these different methods?” Trying to make it less about them giving up a way that works for them, and more about them discovering and choosing to do things differently in way that's, let's say, better for the patient.
Joe: I agree. The fortunate thing is, in healthcare, most of our employees are patient-centric and patient-focused. It doesn't take much to re-center them back on the patient and the customer. Sometimes, you're right, they get off and they forget why they got into healthcare. They get focused on themselves. Any time you can do what you're talking about is huge.
Mark: Yeah, and I wouldn't fault the individuals for ending up in that situation. This is one thing that's been great about what I've seen visiting at Franciscan. I think leaders do play a role in continually reinforcing values and mission.
I think, a lot of times, in other organizations, when people are struggling to get by, if they're not getting the same type of support, if they're overworked, work is too difficult, they're not being engage in Kaizen, it's understandable why people retreat into that mode of saying or thinking, “Well, it works OK for me.”
You're right. People in healthcare, there's a lot of great people that are sometimes in challenging circumstances. I appreciate you bringing that up.
Joe, I really appreciate you taking time to share some reflections on your 10-plus years of Kaizen, you're not just where you started in Central Indiana, but as it spread and broadened throughout the Franciscan Health System. Thank you so much for sharing some of that today.
Do you have a final thought that you might want to leave the listeners with?
Joe: No, I'm just grateful for you, Mark. Thanks. It's always great to talk to you, and I learn so much from you.
Joe: I'm just so appreciative that you would include me on your call today.
Mark: Thank you. I hope we'll be able to do another podcast. I know I'll talk to you and see you soon, but for the podcast listeners, we'll do one again, I hope.
Thanks again for joining us.
Joe: Thanks Mark.