My guest today for Episode #331 is Eric W. Dickson, MD, MHCM, FACEP, a Professor of Emergency Medicine at UMass Medical School and Chief Executive Officer of the UMass Memorial Health Care system.
You might have heard Dr. Dickson speak in Episode #231 of the podcast, which was audio from the CEO panel at the 2015 Lean Healthcare Transformation Summit. In that audio, Dr. Dickson talked about the beginning of what has been quite an impressive turnaround at UMass Memorial Health Care. By the way, I hope you can join me at this year's Summit, where Dr. Dickson will be a keynote speaker.
I invited him to formally be a guest on the podcast to talk about their progress, and what it means for him to be creating a culture of “Everyday Innovators: Everywhere, Every Day,” which has led to over 65,000 ideas being implemented in five years. This is also a topic he blogs about quite a bit.
In our conversation, we discuss how he found Lean originally “almost out of desperation.” How can we shift from “knowing the answer” to “continuous experiments?” Why is it important that he, as CEO, not be “throwing solutions out” when working with people? Does it help that he works a few shifts a month as an emergency medicine doc? We talk about that and more.
Streaming Player:
For a link to this episode, refer people to www.leanblog.org/331.
For earlier episodes of my podcast, visit the main Podcast page, which includes information on how to subscribe via RSS, through Android apps, or via Apple Podcasts. You can also subscribe and listen via Stitcher or Spotify.
New! Subscribe and listen with Spotify:
Memorable Quotes
- “Improve quality and flow and take the waste out. Life gets better for everyone.” — Eric Dickson
- “We saw marked improvements in terms of the performance of the emergency department and really getting people through the emergency department.” — Eric Dickson
- “Celebrating the red. I'm glad we know there's a problem now because once we know there's a problem, we can deal with it.” — Eric Dickson
- “You want to hold someone accountable to their analysis and executing the plan, not to the measure.” — Eric Dickson
Questions, Topics, and Links:
- How did you first get exposed to Lean?
- What was appealing?
- Was there anything you were skeptical of?
- When you became CEO at UMass Memorial Health Care (2013), how and why was Lean an important part of your strategy?
- What happened?
- What were the results?
- What were some of the key success factors?
- Tell us about “Everyday Innovators: Everywhere, Every Day”
- Why is it important to engage everybody in improvement?
- What do you do as CEO to create the culture and environment where this can happen?
- How did you work to spread continuous improvement throughout the system?
- How uniformly / universally has this been embraced by managers across the organization? What do you do to encourage (or require?) them to lead in a certain Kaizen style?
- If you were in an elevator with another hospital
CEO, what is your elevator pitch for “Why Lean?”
Blog post about their Kaizen approach:
Video of Dr. Dickson:
Thanks for listening!
Automated Transcript:
Mark Graban:
Hi, this is Mark Graben. Welcome to episode 331 of the podcast. It is February 5th, 2019. My guest today is Dr. Eric Dickson. He's a professor of emergency medicine at UMass Medical School, and he's also the chief executive officer of the UMass Memorial Healthcare System. You might have heard Dr. Dickson speak in episode 231 of the podcast, which was actually audio that was from the CEO panel at the 2015 Lean Healthcare Transformation Summit. And by the way, I hope you can join me at this year's Summit in Washington, D.C. this June. There's a link to that, the previous episode and more if you go to leanblog.org/331 so in episode 231, it's coincidental that it's exactly 100 episodes ago, Dr. Dickson talked about the beginning of what has been quite an impressive turnaround at UMass Memorial Healthcare. And so he'll touch on that a little bit at the beginning of this episode. But I invited him to come formally be a guest so he could talk about their progress over the last couple of years. You know, what it means in particular for him to be creating a culture of what they call everyday innovators everywhere every day, which engages people in improvement. It's led to over 65,000 ideas being implemented over five years. That's a topic that he writes about a lot. In fact, the blog is called Everyday Innovators. You can find that@everydayinnovators.org so in our conversation, we'll discuss, you know, we'll go back to some of his starting points, even before he was at UMass, how he found Lean, almost out of desperation, as he puts it, how can we shift as leaders from knowing the answer to continuous experiments? How can we encourage employees and managers to think that way, too? Why is it important that he, a CEO, not be throwing solutions out when working with people? And I asked, does it help that he works a few shifts a month as an emergency medicine doc? So we'll talk about that and a lot more. To find the link to the episode, if you'd like to subscribe, you can go to leanblog.org 331eric hi. Thank you so much for taking time out of your schedule to join us on the podcast. How are you?
Eric Dickson:
I'm doing great, Mark, and I really appreciate the opportunity.
Mark Graban:
Well, you've got, you know, there's so many aspects of your story to tell. I guess let's just jump in and ask, you know, if you can talk about your first exposure to Lean as an emergency medicine physician and sort of when and where and how that even happened.
Eric Dickson:
I got my first exposure to lean was in 2003. I had just left University Massachusetts Medical School, where I went to med school and residency and was working primarily in the basic science lab and doing research and then practicing emergency medicine. And I got an opportunity very early in my career to become an academic department chair, but that required that I went to University of Iowa, which is an absolutely wonderful place. And so six years after graduating residency, I found myself in a job that Most people do 10 and 30 years into their career. And I found Lane almost out of desperation because I had really probably taken on too much too early in my career. Instead of just running a research lab, I had to run a 24, 7 operation that was a very, very busy emergency department and high acuity trauma center, had to get a residency up and running and try to lead that up at the same time was trying to keep my science going. And I needed help and went and asked the CEO of the health care system there for help and she got me a coach. And that coach, a guy by the name of Sabi Singh, was very proficient in Lean and really won me over in terms of the methodology and how I could use it to fix a lot of the problems that we were having there.
Mark Graban:
I mean, what was appealing about Lean as a way of fixing those problems? I mean, there might have been other strategies or other approaches that people suggested or that you had looked into what was appealing about Lean.
Eric Dickson:
I was naive at the time in terms of what management was. Right. That somehow that you were going to build up this expertise in managing an emergency department over a few years and you would have the answer to all the questions that would come before you. And that was my idea of management. They picked me to be chair because I had some knowledge. And then you very quickly find out you didn't have the knowledge that you needed to be able to run something you were put in charge of. And what really appealed to me about Lean is what Sabi had described to me is this method of continuous experimentation towards a predefined goal. And I knew that because I was about 75% of my time as an academic physician was in research. And this concept that we would try to stabilize a process and then do an experiment to see if the new process, the process change would improve results came very naturally to me. That's what I did all day in the research lab. And I think the most important thing that Savi taught me is that the experiment you do, you want the people doing the work to pick that experiment. That's the way he described it to me. Because if the leader is picking the experiment, there's not going to be any buy in from the people that are going to have to execute the experiment. And in fact, the leader often won't pick the best experiment. And so through the series of continuous experimentation and asking people and learning to be better at leading by asking questions and asking people what do they want to try next, we saw marked improvements in terms of the performance of the emergency department and really getting people through the emergency department. And it stuck with me. Here we are 15, 16 years later, and that concept of the people doing the work know what experiment to do next, what to try next, as long as you put it into a structure for them such that they are empowered to try something different. And we'll know whether or not there's an improvement. Because a lot of people do experiments, a lot of people try things, and they haven't structured it in a way to know whether or not things are better or not. And that's really what I got out of those first early years in Lean. And it went extremely well. And by the time I left there, five years after arriving, they had made me chief operating officer of the hospital because they thought that it's a physician executive, I could help, really Savi and others spread that across to other departments. And my understanding is he's gone on and continues to do great things there.
Mark Graban:
So what were some of the results, I mean, within the emergency department you alluded to? It sounded like patient flow, getting people through the department. What were, to your recollection, some of the measurable results to know Things were getting better from those experiments and improvements in emergency medicine.
Eric Dickson:
There is, you know, time sensitive illnesses, stroke, myocardial infarction, trauma and severe infections. The time from the person arriving in the emergency department, especially if they come in the front door instead of with an ambulance, to the time that the physician sees them and makes the diagnosis is critical. We call that door to dock time. And what we had there was a very long door to dock time and people would deteriorate from that wait because they had a time sensitive illness. And so, you know, the biggest thing that we saw improve there was a shortening of door to dock time, improvement of outcomes in patients with, you know, acute, severe, life threatening time sensitive illnesses. And, you know, we went from an average wait of about two and a half hours to be seen for a walk in patient in the emergency department to going weeks without a patient ever having to be put in the waiting room. And we talked about designing the emergency department to get rid of the waiting room. At one point, as we moved to New Ed.
Mark Graban:
Did that end up happening.
Eric Dickson:
As a. I remember once we went three weeks without anybody having to be put in the waiting room. And you know, we. There's family members and there's. Sometimes you get so overwhelmed in a trauma center that patients do have to wait. So when we, when we built the emergency department, we did build it with what would be a much smaller emergency department department waiting room than typical places.
Mark Graban:
Yeah, yeah. And that's a great example where flow and quality go hand in hand. And I think it's great that you had exposure early on to the idea of engaging the people who do the work in experiments where sometimes people, you know, whether it's doctors or engineers like myself, you continually, you continue the expert trap so well. I've learned lean and now I'm going to tell people what to do. I'm going to tell people what the lean answer is. And some of us then eventually get coaches who steer us in the direction of not being the expert and engaging others. And I think there's also a great lesson that you had there early on about flow. Sometimes people talk about the idea of efficiency and they're really thinking more about keeping people or resources like X ray machines fully utilized. But that's quite different than focusing on flow. So I'm curious if you have other reflections as a leader. Did you face pressure or how did you strike the balance between pressures to increase utilization versus ensuring smooth flow?
Eric Dickson:
I think in emergency medicine especially improvement of flow is an improvement of the quality of care because we deal with time sensitive illnesses. But it's also really an important way to increase the productivity of the people that are doing the work as you take that waste out. We saw physician productivity go up significantly as we try to keep the physicians doing physician oriented work and make things flow smoothly around them. One of the big revelations during all of this for me, and you know, as you go through your career, there's these things that just stick, was this sense that when you listen to the people doing the work and you let them pick their experiments, there's automatic buy in. Whereas if I say I want you to do this, your job this way starting tomorrow, right, there's an automatic rejection. So a triage nurse, this is a nurse that sees the patients as they walk in the door, asked, could you put three chairs right in front of me for each of the next patients that I have to see so the patients don't have to walk way out to the waiting room and I don't have to find them and call their name and if they start getting sicker, I can pull them out of order. For the doctor running the emergency department that has never done triage, you're not coming up with that idea. More importantly, if I did come up with that idea and I told the triage nurse, this is the way I want you to do your job moving forward, how much buy in is there? And really very little. They'll find a way to make it not work sometimes, I believe, even if it's a good idea. And so you get this immediate buy in and you take waste, the getting up and the walking and the looking for the patient out of their day. And it's better for the caregiver, it's better for the patients. It really is. You improve quality and flow and take the waste out. Life gets better for everyone. And they just have to. People have to see that, that it's okay to change the way that I do my job. A lot of times everybody wants to change the way somebody else does their job to try to improve things. And what I really think the skill that I started to develop there and continue to try to get better at is how do you get a group to come up with a new our way to do things towards a predefined goal. You know, the single ideas are great from a single individual, but when you get three, four and five people that have added to the idea, you get five people that have now bought into it and are going to make it work. And what you have to start to learn is at what point do you Say, okay, we've got enough, we're going to move on, we're going to try it. Because the conversation can go on and on and on of, let's do this, we could do this, we could do this, and how about this? And there's a point at which you want to. There's a right size change in the process that you want to. That you want to get the team to try. And that's what becoming, I think, a lean leader is all about. I still know emergency medicine very well. I worked in the emergency department, seeing patients today, the 99% of what we do at UMass Memorial Healthcare, I am not in any way an expert in, but I do feel, you know, 15, 16 years in, I'm an expert in facilitating a conversation about how to get better towards a predefined goal. And that's the funnest thing I do. Yeah.
Mark Graban:
So there's some steps in between, and maybe you can talk through a little bit more of your own career progression in your different moves up into the point of becoming CEO at UMass Memorial Healthcare. I mean, what were some of the other leadership roles you were in in different places? What were some of the things that you learned as you continued practicing lean this way, practicing leadership this way?
Eric Dickson:
I think two big ones for me were process stabilization, standardization, and thinking of it from a research perspective. You have to have a stable control set before you can do an experiment and then making it visual. And that's something that came much, much later. Steven Spear once said to me that what Toyota does is they make information available and visual for people to see, such that they can see the waste easily from the information flows. And it took me a long time to understand what he was talking about, but it is amazing that you know what a difference that can make in terms of if any, problems that we've been able to make visual, we've been able to make progress on solving. And right now we're struggling a little bit with, in the emergency department here with trying to get consults done quickly. So if you consult a surgeon to see a patient, how long does that take? You can't move the patient forward until the consult is done. And as I work with the team, and I'm close to this one because it's kind of my home department, I keep on asking the question, how are you going to make this visual? Because if you can't make that problem visual, then it's going to remain hidden and you're not going to know when it gets worse or if it's getting better or if your experiment is working. And it became the thing that allowed me to progress from running a department to being COO of a hospital, to being, you know, when I came back to UMass, I was president of our medical group. And then to be CEO of the healthcare system. As you move further and further away your position from where the real value is created, you have to find ways to make sure that people can see where the problems are and align those sources of information. So stabilization and continuous improvement and make it visual. The problem that you're trying to olve have been two of the key, key learning for me that allowed me to progress into the newer, newer roles. My office that I'm in right now is not at a hospital, is far away. It's a car drive to anywhere where value is created. How do the people that work here, the senior leaders of the organization, understand the current state of the core processes and whether they're going well or whether they're going poorly? And because it would be easy to sit in the office and just assume that everything was okay when I can tell you from working, being in the Gemba today, it wasn't okay. It was a backup of patients. It was people, customers, needs weren't fully being met because of some challenges we faced. Do the leaders in the organization know that that problem was going on, the people that are responsible to try to help fix that problem on behalf of the caregivers that are trying to take care of patients? Right.
Mark Graban:
So maybe just a couple of quick follow up questions. So when you talk about making problems visible, in my experience there are times where people have trouble seeing waste because the waste has just, it's become the work, it's become normal, it doesn't jump out as being wasteful. And so, you know, I think there are some lean frameworks that can help people discover waste. But then I think there are other problems where in some organizations people don't want those problems to be visible because they're afraid that they'll be blamed for what might be a very systemic problem. So to that point, I'm curious what you've done as a leader to help create an environment where it's safe for people to identify problems and risks and opportunities for improvement.
Eric Dickson:
And that in itself is a journey. And we talk about celebrating the red. And every one of our key metrics, you know, we picked 10 most important metrics we call our true north metrics, is posted on every wall in every room in the executive suite, updated as soon as new information is available. And this is where the board of trustees meets, and all of our key leaders from across the healthcare system, which is spread out over 100 miles or so, come together and see. And you can't at least those 10 metrics, these are things like observed versus expected mortality, really important things, and safety measures. If they start heading in the right direction, everybody knows immediately. And I think one of my first experiences was with my own board of trustees in the early days of being CEO, where they said, you know, I'm seeing a lot of red on the wall, and I'm concerned about that. And what I said then, and I would say that to all of our people now, is, I can change the metrics, I can change the goals, and you can see a lot of green instead, and you can be comfortable because you're seeing green. But the problems will still exist. If we beat people up because a metric turns red, because something's not going in the direction that you needed it to go, wanted to go, then people will change the metrics, people will change the goals, people change the colors, but you'll still have the problem. And the celebration of the red is, I'm glad we know that there's a problem now, because once we know there's a problem, we can deal with it. And we do. We had some of the worst for observed versus expected mortality in 2013, was horrible at some of our hospitals. And people say, how did. How did it ever get that bad? And I said, well, because it wasn't anywhere anybody could see it. And then when they did try to talk about it, we beat people up for it. Right. They buried it. The people buried data. So what we've tried to do is create a safe environment by standardization of the process for reporting the metrics. So that very, very critical metric when you're running hospitals, observed versus expected mortality, you want to be less than 1 and really to be a top decile, want to be 0.7. There's a standard way. You report out the metric. Here's the current result, and each metric has an owner. Here's where we expect it to be, want it to be, our plan was to be. And if there's a gap, then here's the analysis, the root cause analysis we've done to determine why that gap exists. And here's the specific actions that we're going to take to get back on track. And for us, at our core team meeting, you know, nobody likes to see observed versus expected mortality go red or get worse than it was the previous year. That means to us, the person that owns that isn't in trouble for the metric going red, where they can get themselves into trouble and the whole team holds them accountable is have you really done a thorough analysis as to why there's a gap from where we were supposed to be to where we are? Right. What specific countermeasures are you going to take? Now sometimes people say I don't know and I need to do more work to understand why the problem exists. And we'll give them that time. Or sometimes people understand or think they understand, they haven't done the work on the root cause analysis. And the team is constantly trying to coach them, provide them feedback. But in the end, once we've bought into this is why the gap exists, this is the specific actions that we're going to take. And we say go ahead and execute the plan and keep us updated on that. The team does not hold that person accountable for the metric. They hold them accountable for the analysis and executing the plan. And if they come back at the end of this and the metric is even worse than before, I say, what do you want to do if the metric doesn't get better or if it's worse? And the answer is always do another experiment. And if the team bought into your analysis and your and your countermeasures you're going to put into place and then metric got worse. Well, it got worse for all of us because we all bought into the plan. And so what we try to do is to say and we say it and it's hard to say celebrate the red because now that we know there's a problem, we have an opportunity to get better. But let's make sure we've empowered somebody to understand the problem, why the gap in performance exists and what specific actions are going to be taken. And everybody understands that once we've approved a plan, that senior leadership team, you got to execute it. And it comes down to the who, what, when, after that.
Mark Graban:
What I hear you describing is the senior leadership team being a team and working together and sort of like the New England Patriots have team accountability for a win and a loss. If there's a problem with the metric, one leader, one player isn't being thrown under the bus, right?
Eric Dickson:
As long as that person is truly working to understand the problem and is executing what we've agreed on, they don't own the performance. Now you do get into the situation and there's some people are better at executing than others and we just that you see there or there are some people that are jumping to the countermeasures. I want to do this. And often they'll I often I've said to a person once, your root cause doesn't match up with your countermeasures. And they said, okay, I'll go back and change my root cause. But that's the coaching of it. Right. Because. Right. You know, I still have so much to learn and the people that I work with have so much to learn and we've got to be on this journey together to understand that. So a lot of it is just coaching about how do you get better at execution. There's some people here that are just naturally always get whatever they say they're going to do. They get it done. And there's some people that need a more standardized process and structure around that. But I think that what you really want to move away from is you own a performance metric versus you own development and execution of a plan to improve that. And that's what you would you want to hold someone accountable to, not to the measure. You create very bad behaviors if you hold somebody to getting a result. I think it's appropriate to hold people to do what they promise the rest of the team that they're going to do. And I think that's the way a great football team or a great baseball team, basketball team, you know, that's what they're doing. They're expecting that you're going to make that block. You're going to know what you were supposed to do in any particular play that's called. And that's what we expect from our senior leaders.
Mark Graban:
Yeah. Yeah. One other. That's great. And then one other follow up question I wanted to ask going back to you working today, earlier today as an emergency physician. I mean, there's such a unique opportunity in healthcare, it seems, where a health system CEO is also at times a frontline employee. I don't imagine there's an airline where the CEO is formerly a pilot and they still go out and do a few flights every month to see what? To see what customers and employees and people are dealing with at the front lines. Akio Toyota and Mary Barra, I'm sure, aren't going out and working an hour on the assembly line each week, if you can forgive the, the analogy, the parallel. But I'm curious, how important is it to your success as a lean leader, as a CEO, to have that time working in the Gemba compared to organizations where, let's say, a leader has stopped practicing medicine and they're.
Eric Dickson:
I don't think it's critical to me as an individual and that I just love being a physician. I've worked so hard on my life to be a physician. The actual act of taking care of a patient, I just really enjoy. And I think, you know, there are. I only work in one out of our six emergency departments now. So I think that I get, I could make the mistake of thinking that when I come down there, it works the same as it does every day for people, you know, consult times take. It takes a long time sometimes to get a consult unless I'm on. Right. And so it's kind of the. You think, what are these people complaining about? The consultants come right down. Well, they know you're working today, so they come down. So I don't think it's that important. I think what is important is that time spent in the Gemba and, you know, labor and delivery is one of our most stressed out areas right now. And so going to them and huddling with that team and listening to them about the problems that they face, rather than hearing about it after it's passed through three layers of management, I just think is one of the most valuable things we do as leaders. So I don't think that it's critical that I practice medicine. I think there's lots of great lean leaders that are physicians that no longer practice. I wouldn't want, you know, a vascular surgeon or a heart surgeon that only practiced a couple times a month operating on me if that went on for a lot of years. So I. But I do think that time spent on the shop floor, especially those areas that are stressed and where things aren't going well, is absolutely critical. And some people don't, I have to admit, some people don't like it when I show up at an area that's having a problem because they, they felt like, they feel like, well, you know, you're trumping our authority. You're not following the chain of command. And so you have. But I'm just saying, I'm just there to listen. I'm just there to listen and learn about the problems that they face. I'm not throwing solutions out. If I go down and try to say, listen to people in labor and delivery as the example and say, okay, we're going to do this, we'll do this, we'll do this because you told me and totally ignored the three, four layers of management between me or them, then that's problematic. But if I listen and learn and I hear their ideas and then I go talk to the managers in that area and say, this is what I've learned. What do you think of this? What do you think of that? And I think it can be seen as a positive thing. It is. And I don't know if this is true everywhere, but it's been true everywhere in the places that I've worked, and even here in what we call a place that is really trying to adopt TPS as best we can. Most frontline managers and vice presidents that they report don't like it when the CEO comes down and is on the shop floor with the people doing the work. I just think that's sad. Why wouldn't you be excited that the CEO wants to come down and see your area and potentially help you solve a problem? I think here we get better and better at it because all of our executives have an area that is not under their control that they round on so they can learn. It's so easy in a place like ours with 14,000 people and almost 600 supervisors and managers to think, you know, how the place runs and be totally wrong until you're a patient or somebody you care about as a patient. And I just. That time on the shop floor, just critical and just asking questions and listening, just learning. I'm here to learn. I don't fully understand what the problems are that you're having. What can you tell me? And then just ask questions. Just lead by asking questions. And the people doing the work, love it. Love the fact that you took the time to come down and listen. And we've actually surveyed and asked what's the best part of executive rounding? And the caregivers tell us it's senior executives listening to them, and they get to tell you about the problems they face on a daily basis and trying to meet the needs of the customer. Right.
Mark Graban:
But, you know, coming out to the Gemba, I mean, it takes time to build up some trust. Right? Because, I mean, I can think back to times working in the auto industry. The first plant manager I was one that I worked under, you know, if he was out in the shop floor, that was because there was some serious problem, and he was out there really just to kind of blame and to pressure people. And that was a bad sign, you know, and when we had a new plant manager come in, you know, he spent months being out in the Gemba and building relationships and building trust so that his presence was not seen as an indictment. It wasn't a threatening presence. But one lesson I learned from seeing him operate and talking with him is that people don't know your mindset. If you were parachuted into a different organization, you're the same Dr. Eric Dickson. They don't know you. They might feel threatened until they got comfortable with you. Right?
Eric Dickson:
Yeah. I think when you go out to an area and you are humble and are not afraid to say, look, I don't know how this works. Teach me about what you do here. But it's the same questions kind of all the time for me, no matter where I go. It's what measure would I follow in this area to know whether things are going well or not going well on any given day? Where do you see that there's the biggest waste of your time in here? And it's because I feel very comfortable going out to any clinical area. And pediatrics was stressed for a while. So I spent every day I could, I'd walk up on pediatrics and I'd say, how is it going? What problems are you having today? What can we do to help? And just asking questions. Well, for a lot of people, they're uncomfortable going up to a clinical area like my CFO or a chief human resource officer cio, you know, how comfortable are they just popping onto pediatrics and asking how's it going today? But I go over to our central scheduling office or central billing office and you know, they're talking in denials management. And I. And it's. And I say, I really don't understand what you do here. And like, can you teach me about what it is that you do? And you do that to somebody who's detached from care. And then you ask, start asking the questions, what are the things that waste your time? What are the things that you think we could do better as a healthcare system? Just what are the things that frustrate you the most in this job? And let them teach you. It's great for your knowledge so that you make better decisions as a leader in the organization, but it's great for the people. I mean, they love teaching you about their job and senior leaders listening. And so I just feel like it helps you make bigger decisions, better decisions later.
Mark Graban:
Yeah. So a couple other things I want to touch on in the time that we have left. I want to ask about some of the things that you've been leading at UMass Memorial Healthcare. And I will point listeners, as I mentioned in the introduction, Back to episode 231 where we shared some audio of Eric talking at the 2015 Lean Healthcare Transformation Summit about coming in to UMass in 2013 and the first couple of years, that turnaround story. So I don't necessarily want to ask you to tell the whole story again, because we can point people out of that other episode. But I was wondering if you could tell kind of the high level story arc in the context of coming in and what those first couple years were and then how have things progressed since 2015?
Eric Dickson:
So I became CEO in 2013. We were losing about $8 million a month on a $2.5 billion base. We lost 55 million that year. Our major nursing union went out on strike a month after I got the job. The quality scores are very low. The patient satisfaction scores are very low. The engagement scores are very low. And the first thing that I did, and this comes right from the book of Lean. This was not something that I created, was to stabilize the process and the processes we needed to stabilize how we managed as an organization. How do we set goals, how do we set strategy, how do we deal with results? What our standardized problem solving process, and that was version one of what we call our framework for performance excellence. And it's just to try to stabilize our management processes because most places don't have a standardized approach to how they manage. Certainly don't have it written down. And we're on version 10 of that standardized process now. And you know, maybe when we get to version 20, we'll have something that's good. I think it's all we have today is something that's much better than version one and much better than flying by the sea of pants is what, what we were doing in 2013. And with each PDCA cycle for our management processes, we've gotten a little bit better. And almost all of our numbers, there are a few that have been a bit more challenging than others have headed in the right direction for the past five years. And we're not knocking it out of the park, but when you start from the bottom one percentile and observers expected mortality, being in the top quartile is a success. But I think that the key has been we have written down how we run the place, a standardized approach to managing UMass Memorial Healthcare. That's 10 PDCA cycles through. And the senior leadership team gets together in every six months and we review that process and we say, what change? What new, what experiment do we want to do next? And I think if I handed anyone the version 10 and said, oh, this is the way you should run your place, it'd be complete mistake. And you have to have gone through the 10 versions and the learning cycles to be okay with where you're at and what I coach people to now and other CEOs that are coming in and I just standardize your process for how you're going to run the place and continuously improving, get your team to agree. This is how we're going to set strategy. This is how we're going to measure performance. This is how we're going to, this is how we're going to deal with problems, standardized problem solving methodology. And then every six months, get together with your team and huddle with your team and say, okay, what's working, what's not working and what are we going to change? And a big part of that standard process is how we information flows and how we make sure we know when something is going off track because that's what we didn't have before. And then how do we engage every one of our people every day in terms of trying to improve that performance? So in the, in our CEO, in our strategy suite here, right on the wall, emergency department boarding hours for all of our. This is weights in the emergency department for all of our emergency departments. But I was in one of the seven today and that same number for that one out of the seven you could see all the way down in that individual emergency department. So there was that alignment of what's important at the system level to what's important at that business unit level. Yeah. And I just can't overemphasize enough. For people that are just getting into this or just put into a leadership role, it comes down to getting together with your team and saying, okay, how do we want to run this place? And let's write it down. If you want to reduce ventilator acquired pneumonia, there's a bundle or surgical patient safety, there's a surgical checklist and you know, or central line placement. There's a standardized approach that we can continuously improve. And I, if you looked at those things, you'd be amazed what's on there. Wash your hands before you put a big IV in someone's neck. Introduce yourself before you start the case in the or talk about what might go wrong and what actions you would take so that you can be prepared for them before you start the case. This isn't these novel groundbreaking things, but the fact that you write them down and you do it every time and you follow a standardized process, that's what's novel. That's what about, I think our organization and many others that people come and work for. There's nothing special in version 10 of our management process, but the fact that we've been through 10 learning cycles together. The fact that we write down and we can refer back to, okay, this Is the way we do this, the fact that it can bring a new president of the medical center. Just started a few months ago. Hand him that. And actually before he took the job, I said read this. And you know, if you can't follow this management or management structure, please don't come here because things won't go well. And we're going to ask for your ideas about how we can change our standard management process. But when you get here on day one, you've got to follow the standard management process because everybody has to follow the standard work to make it successful. I think that's the big lessons. And this is kind of 15 years in, 20 years in, they'll probably be different. And hopefully 30 years in there'll be different things that become important to you and to me overall on this kind of journey, on this learning journey. But I'd say that standardization of your management processes is absolutely. And then getting your team's buy in to what, how you're going to run the place is one of those key takeaways from all of this.
Mark Graban:
Well, there's common themes there and maybe the last thing we can touch on. You talk about leaders, including yourself, running experiments, having standardized methods, but continuously improving them. And I'm sure that sets a great example for engaging all of the employees. And one thing I love about what you've been doing there is what you call everyday innovators. So I was wondering if you could talk about how important that has been to the overall lean approach in the organization.
Eric Dickson:
I think the so for us it's engaging every one of our people every day and trying to perfect the customer experience and the caregiver experience. Best place to give care, best place to get care. And that's every new employee that walks in the door, that's the first message that they get. I deliver it. If I'm available on most weeks I am, is that, you know, that's the special part about working here is that we want you to do that job that you were trained for, but we also want you to find new and better ways to do it. And if you come and work here, your idea will be important and we will help to implement it. Now does that mean everybody's ideas get implemented 100% of the time? Unfortunately not. I think the biggest metric that I could use or analogy that I could use about how far we've come is on my first retreat with the managers as CEO, I said, okay, we lost $55 million. That means we need $5,510,000 idea for how to improve either cost reduction, productivity improvements. And, you know, there's 5,500 ideas out there in terms of the people doing the work about how we can. How we can get back on track. I said, you know, right now, today, what percentage of those are going to get implemented? And the consensus in the room of 300 people was 5 to 10%. Right. The ideas about how we can get back on track. People have great ideas here. What percentage of them are going to get implemented? And it was 5 to 10% was the answer. And I said, well, that fundamentally why we're having the problem that we're having. We haven't engaged every one of our people in trying to improve the organization. And I did a recent survey where we asked the people doing the work, if you have an idea about how to improve, what, what's the likelihood that it will be implemented? And I wanted it to be 100%. Our people told us that it's about 75% of the time if I have an idea to improve, it gets implemented. And, you know, as much as I want it to be 100%, where that's, that's so much better than where we were.
Mark Graban:
Absolutely.
Eric Dickson:
And I, and I would bet you that if, you know, there's few organizations out there that if you ask the frontline workforce, if you have a great idea about how to make things better here, what's the likelihood that it's going to get implemented? I think there's fewer organizations where it would be 75%. I've never worked at one up until here, where it was 75%.
Mark Graban:
I mean, the one benchmark that I've heard from Toyota and others is about a 90% implementation rate. And some of that comes from leaders coaching employees. It's not necessarily the initial idea that's implemented, but 90% of the time, something gets implemented. I don't know if that's how people are estimating that. 75%.
Eric Dickson:
Yeah. And it's the years and years of ideas implemented. And we have a tracking system. And we don't capture every idea. We don't want to capture every idea, but we, you know, it's nice to measure things that are important to the organization. And we've implemented about 65,000 registered ideas in our ideas out there in the last five years. And some of them are paying off, will pay off forever for us. It's just remarkable. I just, you know, there's one thing that I'll always remember is that a nursing assistant on the floor without a huddle and the chief of transplant surgery said, you know, we've got to find a way to get the patients walking more sooner, and that's so important for their recovery. And she had been learning about making things visual, and English was not her primary language. So it was a little bit threatening with, you know, that doc there, because he's such an important person in the organization. And she said, well, what if we marked off the number of feet on the floor? 10, 20, 30, 40. And then we had the patient record how many feet they had walked that day. And we told them that the higher that number goes, the better they get. And it was, you know, the chief of transplant loving the idea, helping get it implemented. And, you know, that medical assistant, I see her now today, and every floor now has that, because everybody thought that was a great idea to help. You know, every time she walks by those numbers on the floor, she swells with pride because people listen to me. And that's. For me, it's always that ultimate piece of respect for people that I think you have something to contribute to the organization. Your ideas matter, your ideas count. Even if it's. If you're a nursing assistant here and you're solving a problem for the chief of transplant surgery, you know, we have a long, long way to go. As an organization, our challenges are enormous. And as a safety net provider with a very, very high share of Medicaid, we get paid less than most places. But this is, for me, I often say, this is the thing that gives us hope, is that we know we can solve problems now faster than we could in the past. More problems being solved faster and faster every day, and problems come up now. And in the past, you'd say you do nothing but complain and whine about it. And now people have confidence that now we'll find a way to solve that. And I saw it the other day. We took a $40 million hit in Medicaid payments. And the team said, we'll find a way. We'll find a way to fix this, find a way to get through, because we always do. And it's that confidence that comes with. We've solved a lot of problems here, and we become better problem solvers. And that's just what takes time. And I think that's. You can't replicate that. In Iowa, there's a Saying it takes 21 days for a chicken to hatch an egg. 21 chickens can't hatch the egg in one day. Right. It just. And it's, it's, it's true that there's just, there's a process you have to go through in terms of the organization developing and learning together and becoming a better problem solver that nobody can replicate for you, nobody can give. People can help you and, but, but they can't. You have to go through the journey to be able to get there. And I'm glad we started in 2013 because if we, you know, if we hadn't started back then, I think we'd be in a world of hurt right now as an organization, given all that's occurring health. And so we're going to keep on working it. And it is what gives us hope. And no matter what's thrown at us, we believe we'll make it through and we'll be all right.
Mark Graban:
Well, that's so great to hear that. That's, you know, the growing attitude. And you know, it's always challenging times at health care and there's, there's what, who knows what future challenges ahead. But to develop that sort of can do spirit, you know, what some would call it, you know, the spirit of Kaizen, the spirit of continuous improvement, that's really, really special to hear about. So I want to thank you so much, Eric. Again, our guest today has been Dr. Eric Dickson. He's the President and CEO of UMass Memorial Healthcare. He's an emergency medicine physician. He's a professor of emergency medicine at the University of Massachusetts Medical School. Eric, thank you so much for taking time out of your. I'm sure it was an incredibly busy day, and thank you for sharing your thoughts and reflections here with us.
Eric Dickson:
Well, it's my pleasure, Mark, and thank you for all you do to help us get better faster. And we've all learned a great deal from your podcasts and your books and other things that you've done. So really appreciate it.
Mark Graban:
Well, thank you. Thank you.
What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.
Did you like this post? Make sure you don't miss a post or podcast — Subscribe to get notified about posts via email daily or weekly.
Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation:
