Skip Steward, the Chief Improvement Officer at Baptist Memorial Health Care in Tennessee, was a guest on Episode #314 of the podcast talking about TWI and Toyota Kata in healthcare (he was joined by Brandon Brown).
Today, I've asked Skip to come back and chat 1×1, in Episode #320, about his experience with Don Wheeler, learning from W. Edwards Deming, and more. I hope you enjoy his reflections, our discussions about healthcare, and connections to my book Measures of Success (Skip undoubtedly has a book in him too). Check out the fantastic “Baptist Management System” channel on YouTube.
Skip describes his early introduction to Deming's philosophy through Don Wheeler's workshops and VHS recordings of If Japan Can, Why Can't We?. He recalls how Wheeler patiently pushed him to think deeper, teaching him that true understanding requires repeated study and practice. These formative lessons also led him to embrace Deming's “System of Profound Knowledge,” especially the importance of psychology and treating people with respect.
The conversation highlights the difference between knowledge and skill, illustrated through examples from Training Within Industry (TWI) and Baptist Memorial's improvement system. Skip explains how tools like process behavior charts act as catalysts for better thinking, helping leaders distinguish real improvement from mere fluctuation. He also emphasizes the danger of misaligned systems, quoting Deming's reminder that “a bad system will defeat a good person every time.”
Mark and Skip connect these themes to healthcare, where metrics like readmission rates or falls often mislead leaders unless viewed through the “voice of the process.” They also discuss leadership behaviors that build trust, respect, and empathy, contrasting punitive cultures with systems that empower people to succeed. Throughout, Skip reinforces the timeless relevance of Deming's principles and their practical application to modern challenges.
Listeners will come away with a richer appreciation for how statistical thinking, systems thinking, and respect for people come together in effective improvement.
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Transcript:
Announcer:
Welcome to the Lean Blog Podcast. Visit our website at www.leanblog.org. Now, here's your host, Mark Graban.
Mark Graban:
Hi, this is Mark Graban. Welcome to episode 320 of the podcast. It's October 9, 2018. Skip Steward, the Chief Improvement Officer at Baptist Memorial Healthcare in Tennessee, was a guest on episode number 314 of the podcast, talking about Training Within Industry and Toyota Kata in healthcare. He was joined by Brandon Brown.
Well, today I've asked Skip to come back and chat with me one-on-one here in episode 320 about his experience with Don Wheeler, learning from W. Edwards Deming, and many other topics. I hope you enjoy his reflections, our discussions about healthcare, and connections to my book, Measures of Success. I think Skip undoubtedly has a book in him. I hope he writes it someday. I hope he comes back on the podcast. If you want to find links to everything we talk about here–Skip and Baptist have a great YouTube channel, I would encourage you to go check that out–you can find links to all of that by going to leanblog.org/320.
Well, Skip, hi. Thank you for coming back this time to the podcast. How are you today?
Skip Steward:
I'm doing great, Mark. Thank you for having me back.
Mark Graban:
Well, I'm glad we'll have a chance to explore some things that we just barely touched on the last time you were on the podcast. We'll just jump right in. I'm curious, how did you get introduced to Dr. Deming's work and philosophy?
Introduction to Deming and the “Profound System of Knowledge”
Skip Steward:
When I started my career in 1992, I was in an industrial engineering/quality engineering role. I had also enjoyed statistics and tutored folks in statistics in college. I was sent to some workshops with Dr. Don Wheeler, the gentleman that endorsed your new book, Measures of Success. Dr. Wheeler was very kind; for some reason, he took me under his wing. I would call him on a regular basis, and then I would start going to Knoxville, Tennessee, where a lot of his workshops were.
During those same workshops, Dr. Wheeler would introduce us to Dr. Deming. That's where I think I got my very first Out of the Crisis book. And I met a lady at that workshop named Margaret, and she was an assistant to Dr. Deming up at NYU. She was a very kind lady, and she would send me articles that Dr. Deming had written. So I was introduced that way. Back at that time, we didn't have the internet, so we had VHS tapes. And I would get these tapes from Margaret and others about If Japan Can, Why Can't We?–the famous NBC documentary they did with him. I was just soaking it all up about Dr. Deming's view and what happened in Japan, not only his experience with things like Statistical Process Control, but also his perspective on how we should treat people and how management should think about managing an organization.
It kind of became a domino effect. I was introduced to the work of Dr. Brian Joiner, which I really enjoyed a lot with his book Fourth Generation Management. And then also Peter Scholtes. I was wrestling through what Dr. Deming, Peter Scholtes, Dr. Joiner, and Dr. Wheeler would do: they made me wrestle through why I believe what I believe in and how I should think about things like purpose, people, and process. Dr. Wheeler was always so kind to let me call him anytime. I can't tell you the number of times that Dr. Wheeler would say, “Skip, have you ever read chapter three of this book?” “Oh, yeah, Dr. Wheeler, I've already read that.” “No, no, you didn't understand it. Go back and read it and call me again.”
Mark Graban:
I'll tell the listeners, I'm going and taking Don Wheeler's four-day workshop in Knoxville. I'm really looking forward to that because his book, Understanding Variation, has been incredibly influential to me.
Skip Steward:
That's great. I highly recommend it.
Mark Graban:
You mentioned the NBC program, If Japan Can, Why Can't We? The Deming Institute was able to get the rights, and that's available freely now on YouTube. That was a show from 1980. Have you been able to revisit that at all?
Skip Steward:
No, I did go back and look at it on YouTube a while back. But the ones that I personally enjoy the most feature Dr. Russell Ackoff. Many people refer to Dr. Ackoff as the father of systems thinking. There are a couple of YouTube videos out there of him and Dr. Deming talking and having a conversation. It was very neat to wrestle through their thinking and to see how they thought about things and why. I think both of those men left us lessons, but unfortunately, some of those lessons we have to keep on learning.
Mark Graban:
Yeah. A lot of these lessons are incredibly relevant today. Even though Dr. Deming passed away in 1993, I think in a lot of ways, he was very, very far ahead of his time. When I've been to Japan in recent years, I've seen hospital executives and business leaders bring up Dr. Deming quite frequently. The Deming Prize is still an active prize, sort of like the Baldrige Program in the U.S., and Dr. Deming is still very revered over there.
Skip Steward:
That was my experience, too. My friend Margaret that worked for Dr. Deming, she had him sign a book to me in '92, and then he passed away in '93. My wife always teases me when you play those newlywed games, “If the house was burning, what's the one thing you would grab?” And my wife's like, “Oh, he would grab that Dr. Deming book on the shelf.” But when I have talked to Toyota executives, I find it interesting that two things they'll bring up to me in conversation are Dr. Deming's name and PDCA.
PDCA, Knowledge vs. Skill, and TWI
Mark Graban:
Yeah, and I think that'll be familiar to a lot of listeners. Plan-Do-Check-Act. People will call it the Deming Cycle; Dr. Deming called it the Shewhart Cycle after Walter Shewhart, who preceded him.
Skip Steward:
I've done some work with Mr. Yoshino, that was John Shook's boss, and I remember one time we were having dinner, and I said something to the effect of, “In your 40 years at Toyota, what was the one thing that impacted you and you learned the most?” He didn't blink an eye. He said, “PDCA.” And then he goes on to say, “Skip, it took me 10 years to learn each letter.”
Mark Graban:
On the surface, it seems so simple. And I think that's one fascinating thing about a lot of Lean concepts. When you really unpack it and practice, you start realizing what you don't know.
Skip Steward:
That's a really good point. What you're talking about is the difference between knowledge and skill. They are so radically different. I've been trying to teach my daughter how to drive. When we first started, very smart young lady, went and took a driving test and aced it. Big deal. I put her in the car, and she didn't know where the brake was or the gas pedal. So she had knowledge but no skill. Even at Baptist Memorial Healthcare, we think a lot about the difference between knowledge and skill. I can do a workshop on various subjects, but that doesn't mean you have skill.
Mark Graban:
And as we talked about in the last podcast, when you and Brandon Brown were talking about Training Within Industry, there's the idea that the teacher needs to validate that the student has learned, not just fall back and say, “Well, you attended the class, therefore I assume you absorbed it.”
Skip Steward:
You're absolutely right. We do a tremendous amount of TWI training–Job Instructions, Job Relations, and Job Methods. And what I continue to discover is that there's much profoundness in simplicity. Even that phrase, “If the worker hasn't learned, the instructor hasn't taught.” John Wooden is said to have used that in his coaching. But sometimes I'll actually have folks that get a little offended with that statement because they fall so in love with their PowerPoint slides.
One of the quotes from your book that I really liked a lot said something to the effect of, “It's better to have the thinking without the tools than it is to have the tools without the right thinking.” I really like that quote. Dr. Wheeler used to always say something to the effect that the process behavior chart was a way of thinking and that the chart acted as a catalyst for this thought process, but without the way of thinking, the chart had nothing to act upon.
Mark Graban:
Yeah, I think I was inspired by Dr. Wheeler, and I cited him in my book. Process behavior charts are a way of thinking with some tools attached. You could say the same thing about Lean. A3 problem solving is a tool, the template, but it's the way of thinking.
Skip Steward:
You're right. The other thing that makes a lot of that a challenge is sometimes within the Lean community, we tend to violate, in my opinion, our own thinking. For example, we tend to do batch teaching. The way the TWI class is set up, we do no more than 10 people, and it's two hours each day. I've probably personally taught that class 50 to 60 times. What's very interesting to me, watching human behavior, is that right at two hours, people's eyes will tell you they're done.
Process Behavior Charts and How We Treat People
Mark Graban:
I want to come back and dig deeper into process behavior charts and this idea of how we should treat people. Because Dr. Deming sometimes gets labeled as a statistician, which I think sells him short. In his System of Profound Knowledge, he talks about the importance of psychology. I'm pretty sure he said at one point, “The most important thing for a manager to understand is psychology and to understand their employees as unique individuals,” which to me sounds like Toyota and respect for people. Could you give a bit of a summary of process behavior charts? What would your elevator pitch be?
Skip Steward:
Yeah. At the Baptist Management System, we've been focused on showing people a certain framework of thinking. But your book did such a great job of reminding me that we've got to let people also know, how do they know if they actually have improved? And so we definitely introduced run charts. But as I've literally started in the last couple of weeks, I've handed out your book and Dr. Wheeler's book, Understanding Variation.
I was looking at some readmission rates and falls, and I started off the conversation with people I knew I could have a conversation with because at first when you introduce people to process behavior charts, it's going to hit their paradigms in a hard way. We had one chart where they were looking at the readmission rates. And I asked them, “Do you think that you've gotten better over the last couple of years?” It is natural to say, “Oh yeah, we've gotten better.”
I said, “Well, would you be open to having a conversation about what I'm seeing in your data?” I explained that there is something called the “voice of the process.” At this point, I've got four or five years built into a relationship with this person of treating each other with mutual respect, so I knew I could have a conversation. I said, “Well, there is something called process behavior charts.” And I showed them the chart. This chart is incredibly predictable.
Mark Graban:
And by predictable, you mean the metric is just fluctuating around some average.
Skip Steward:
It's fluctuating around the average, and it is statistically consistent. I explained how the limits were developed, but I said, “We refer to this as the voice of the process. If the chart could talk to you, it would tell you this: ‘I'm doing the very best that I can do. On the average, I'm going to be at, I think it was like 15%. But on any given month, I could be as low as 8% or as high as 24%.'”
“And none of that is unusual. So on any given month, if you had a readmission of 8%, it doesn't mean you should have a pizza party. And if you had a readmission of 21%, it doesn't mean that anyone should get in trouble. The process is telling you, ‘If you don't like me, then you better change me.'”
Mark Graban:
If you don't like that range. Yeah, I've had people read the book and say, “Yeah, that's really familiar. People get too excited about every above-average point and too upset about every below-average point.” And then the other common dynamic is someone calculates those natural process limits, and they say, “Well, I don't like those limits. Those limits are too wide.” Well, that's back to your point of, “Then you need to improve the system.”
Skip Steward:
Right. One of the things that I think we've been conditioned to is we tend to spend so much time thinking about the voice of the customer. That could be a specification, a Medicare target, a penalty. Those are all targets and metrics that are outside of the process. The process doesn't even know that those exist. It's leadership's requirement to line up the voice of the process and the voice of the customer.
Respect for People and the Role of Leadership
Mark Graban:
So I want to come back. You talked about those dynamics with process behavior charts where people working within that system are doing as well as the system will allow. This comes back to the question of how we should treat people. Can you elaborate on that?
Skip Steward:
Yeah, I'd love to. A phrase we like to use a lot with the Baptist Management System is “purpose, people, and process.” I would argue that Dr. Deming was talking about all three of those when he gave us the 14 points. His very first point was, “Create constancy of purpose.” He talked a lot about people when he talked about eliminating slogans, numerical quotas, and removing barriers that rob people of pride in workmanship.
At the end of the day, you're not going to get anything done without people. TWI Job Relations is a very important piece of our Baptist Management System. For me, it's the best way that I personally know on how to operationalize respect for every individual. I can't tell you the number of people, once they go through Job Relations and start practicing it, they'll come and say, “Skip,” they almost have a confession time. They'll say, “I've been a leader for 20 years, and I've just realized that my job is not just to watch people and write them up when they step outside the rules, but my job is to have a relationship with them.”
We have a phrase that we say in the class: “Leaders have followers.” You are not a leader just because of your title or your degrees. You're a leader if you have a follower.
Mark Graban:
And I just want to add a thought there, bringing it back to Peter Scholtes. People may formally be told they report to you, but they choose to follow you. One of the key insights of motivational interviewing is that you can't make anybody change. People choose to change. And the Peter Scholtes-ism that I always come back to is, “People don't resist change, they resist being changed.”
Skip Steward:
That's a great point. And to keep on building on that, a lot of times, what some people refer to as “catchball,” one CEO in our system refers to it as “catch anvil.” My boss, Dr. Paul DePriest, does the best example I've ever seen. He'll shut the door and ask me, “What do you think about this?” and he's really asking my opinion. I can't tell you the number of times I'll say, “I don't agree with that, Dr. DePriest.” Now, many times I come to discover on my own that he was right and I was wrong. And there have been many times he's called me up and said, “You know what? I think you're right about this.” But he respected me in such a way to allow me to wrestle with him mentally.
And here's the thing. A system is more than just a physical system like a car. Dr. Brian Joiner has a great quote that when people are forced to hit a goal or a target, they do one of three things: they either distort the system, distort the data, or improve the system. If they don't know how to improve a system and if they don't understand variation, then it's going to be natural for them to distort the data or distort the system.
We think a lot about respect for people. That's a principle we embrace from the Shingo Model in our Baptist Management System. Our leader, Jason Little, our president and CEO, I don't know if there's been a week that's gone by in the last five years that I haven't heard him talk about empathy, not just empathy for the patient, but empathy for the real folks that do the patient-caring work.
Final Thoughts on Deming's Legacy
Mark Graban:
As we wrap up, of the 14 points or other lessons from Deming, what's the one lesson that you wish more people would embrace today here in 2018?
Skip Steward:
I guess the one that I reflect on the most is two thoughts. One would be his very first point about creating constancy of purpose. It's so easy to get distracted. But then, you remember his quote where he says that a bad process will destroy a good person every time?
Mark Graban:
Right. “A bad system will defeat a good person every time,” or something like that.
Skip Steward:
Well, as you know, Mark, when I get into this work, that phrase comes to mind quite often. It came to my mind two weeks ago when I was looking at how nurses at a hospital handled IV pumps. And I remember thinking to myself, “Oh my gosh, this process is killing these poor nurses. They just want an IV pump, and they're having to hunt and find and hoard and steal an IV pump.” So I think those are the two that come to mind quite often.
Mark Graban:
And I'll build on it as a final thought. I think the influence of Dr. Deming on Toyota is so clear. The expression I've heard from Darrell Wilburn, who's an American who worked for Toyota for a long time… Darrell said these really profound words: “It's the responsibility of leaders to create a system in which people can be successful.” And I just see too many cases where, unfortunately, leaders are blaming individuals for the system, and those individuals don't have the ability to improve the system.
I think we can tie it to the process behavior charts because that will help us show what the system is capable of.
Skip Steward:
That's right. That's exactly right.
Mark Graban:
I've really enjoyed, as always, having the chance to talk with you, Skip. Thanks so much for coming back and taking time to be part of the podcast.
Skip Steward:
Well, thank you for having me, Mark. I appreciate it.
Videos of Skip on Strategy Deployment:
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