The CEO Leading the Culture Change at ZSFGH


Yesterday, I blogged about a CNO who was changing the culture at a hospital away from blaming individual nurses for system problems. The HealthLeaders article I wrote about didn't talk about “Lean” per se. But, that single idea about moving away from blame is probably one of the most powerful notions from the Toyota Production System (which was influenced heavily by W. Edwards Deming's views on this).

Deming said the CEO and senior leaders are responsible for the system — and the system includes the culture and management system of an organization.

In January, I blogged about some concerns that had been brought up by the unions at Zuckerberg San Francisco General Hospital about overwork and how Lean should be part of the solution to that long-standing problem.

Today, I'm writing about another view, from an article co-authored by our friend Dr. John Toussaint and the CEO of ZSFGH, Dr. Susan Ehrlich:

Changing Leadership Behavior Gets Real Results

As I blogged about yesterday, new leadership behaviors (sometimes as the result of getting a new leader) can make a huge difference for an organization — this was true during my time at General Motors and I've seen it in healthcare.

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In some cases, as John Toussaint has talked and written about a lot, he was able to change his own behaviors away from what he calls “white coat leadership.”

I don't know Dr. Ehrlich, so I'll presume that Toussaint is co-authoring with her because she is going through that personal leadership transformation (and that's something that takes time for anybody). It's not like flipping a light switch. You're not a “Lean leader” or “not Lean leader” in some strictly binary way.

The article begins:

“The behavior of senior executives, and especially the CEO, is known to be directly related to an organization's performance.”

That's all the more reason for executives to stop blaming employees for bad results — transformation starts by looking in the mirror. Lean isn't about training, certifying, or fixing the front line staff. Culture change starts at the top.

I agree with their assessment of history and what's too often, still, the current state in healthcare organizations:

“Health care has been slow to adopt modern management principles. Most health care organizations are still managed in a traditional autocratic style that does not allow for much worker input. The manager or leader makes most decisions and tells everyone what to do. “

If that autocratic model worked, then healthcare wouldn't have the problems it has today, including major patient safety and quality issues.

They write:

“Many hospitals around the world are building a different management system to combat this unacceptable medical error rate. Leaders are taking lessons from world-class manufacturing and software companies to build systems that transfer decision-making to those who do the actual work.

I don't know if “transfer” is really the right word to use about decision making.

Leaders can better ENGAGE and INVOLVE those who do the actual work in decision making and problem solving.

But, the reality is that the front-line staff can't fix the bigger systemic problems that interfere with them providing ideal care.

Nurses and other front-line staff can make small “Kaizen” improvements in the details of how their work is done. They can participate in broader “value stream” improvements. But, nurses are powerless to fix things like chronic understaffing, balky computer systems, or bad business models.

As I've heard John Shook (formerly of Toyota and now with the Lean Enterprise Institute) describe it, Lean leadership is neither completely top-down, nor is it completely bottom-up. It's a blended model of delegation and empowerment, along with servant leadership. There are some problems only senior leadership can fix.

As Darril Wilburn, formerly of Toyota says:

“Leaders are responsible for providing a system in which people can be successful.”

Toussaint and Ehrlich write:

“In manufacturing, frontline workers have clear expectations that any problem identified in quality or workflow is their responsibility. The workers suggest ideas, test them, and make changes in real time.”

Again, I don't think that's really true. The word “any” should read “many.” It's critically important to involve front-line staff, but they can't do it all.

Research from Robinson and Schroeder (listen to my podcast about this) shows that about 80% of improvement results in an organization come from “small Kaizen” improvements — in other words, from front-line staff and managers tweaking and refining the process they work in.

So, front-line staff can do a lot — if the organization and its leaders create an environment where it's safe to speak up about problems and they're given time to fix them.

Toussaint and Ehrlich's description of the current state seems accurate in many organizations I've seen, unfortunately:

“In health care, on the other hand, a nurse with an idea to improve the patient experience typically keeps it to herself, knowing it would need to go through layers of management. It's just not worth her time.”

One of the hospitals featured in the HealthLeaders piece that I blogged about yesterday identified a systemic reason why the hospital had such trouble filling open nursing positions. They had a policy that said they'd only hire nurses with experience. Front-line staff couldn't change that policy, only the CNO could.

I understand why people stop speaking up when they're neither empowered nor supported by leaders. Professor Ethan Burris writes about the “futility” factor as the biggest reason why employees don't use their voice in the workplace.

Toussaint and Ehrlich again write:

“But for traditional health care managers, relinquishing responsibility for problem-solving to the people closest to the work is hard to swallow. It requires a different way of behaving.”

Again, I don't think it's a matter of “relinquishing” responsibility. Leaders can delegate problem solving work in many cases, but they don't give up “responsibility” for the results or for the system. Again, leaders can involve and engage more than they can relinquish or abdicate.

Strategy is one example of something that can't be delegated to staff.

“ZSFGH adopted six True North goal areas — equity, safety, quality, care experience, workforce care and development, and financial stewardship — and decided how to measure each performance category. These measures are ZSFGH's must do, can't fail metrics for organizational performance.”

That's great. That's an example of behaving and leading differently — trying to gain alignment around those goals and supporting people in their improvement work.

I've heard Toussaint say this a lot, including in this video:

“If organizations are to change, then leaders have to change.”

ZSFGH wants to encourage these behaviors:

  • “willingness to change
  • leading with humility
  • curiosity of how things work
  • perseverance
  • self-discipline”

Behaviors like that need to be modeled and demonstrated by the CEO, Dr. Ehrlich, and other leaders who work with her.

Another key behavior described there is going to the “gemba” or the workplace to “observe, learn, and coach” through “open-ended questions” and “listening carefully.”

I'd presume that Dr. Ehrlich is leading by example in all of those behaviors.

I recently interviewed a healthcare CEO, Vance Jackson, who talked about the power of going to observe the work. The willingness to do this seems to be a rare trait in this field.

The article describes some the Lean management practices they've adopted and some of the improvements that they say are a result of those new behaviors. Some of those emergency department improvements are also detailed in this article.

Please do check out the Toussaint and Ehrlich article. What do you think about this?

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.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. For more than 100 years, the focus has been on finding ways to improve leaders’ behaviors. Sure, there will be some successes, but this path to improved leadership, overall, has been a failure. Also, improving leaders’ behaviors is ephemeral, as leaders come and go. There is so much more going on than just behaviors. Leadership behaviors is the surface-level or apparent problem, it is not the actual problem(s). For that one must drill down into the details that span several different categories: economic, social, political, historical, philosophical, legal, and business. People’s unhappiness with their leaders typically stems from leaders striving to maintain the status quo. That is much more than just a behaviors problem.

  2. Thank you for your thought provoking post about Zuckerberg San Francisco General Hospital and Trauma Center (ZSFGH). As a staff RN at ZSFGH, and someone who is passionate about using the principles of the Toyota Production System to improve the delivery of care, I believe your post touches upon many important issues, but my comment will focus on only one statement.

    I agree completely with Dr. Susan Ehrlich and Dr. John Toussaint’s statement: “In health care, on the other hand, a nurse with an idea to improve the patient experience typically keeps it to herself, knowing it would need to go through layers of management. It’s just not worth her time.”

    I can attest to the fact that nurses on the frontline have many ideas for improvement, but are reluctant to express themselves because there has been no system designed that proactively welcomes the discovery of problems and the active collaboration of the staff – the subject matter experts – to solve them. I believe a system empowering staff to discover and solve problems is the antidote to the above problem raised by Ehrlich and Toussaint.

    In order to develop such a system, it requires embracing the Toyota philosophy that “problems are mountains of treasures.” Additionally, when a nurse raises a problem, the leader (in whatever capacity or role) must have the humility to thoughtfully listen to the nurse and show engagement by asking questions. Only then, will leadership start to fully understand the problems at Gemba and foster an environment of openness, staff engagement and continuous improvement.

    ZSFGH, like most hospitals, has been using an Unusual Occurrence (“UO”) reporting system to record problems and safety incidents and also has begun stand up meetings and Kaizen projects, but has no real-time system for structured surfacing and solving of problems.

    At Toyota, on the other hand, when an employee detects an emerging problem, they have been trained to immediately trigger the andon system by pulling a cord or pushing a button. Typically, within less than 30-seconds, an experienced team leader will respond to help, quickly determining the problem and responding accordingly. Last September, I toured the San Antonio Toyota plant and was amazed at how frequently Toyota team members activated their andon system. I heard the andon chimes throughout my visit. According to Art Smalley, a former Toyota employee, author and Lean Consultant, in a 7,000-person Toyota vehicle plant with two shifts, will have approximately 10,000 andon activations per day.

    In contrast, on those occasions when I have needed assistance on the floor, I normally must leave the patient’s room and search for someone to help me. Frequently, the person that I am asking help from is preoccupied and it may require me asking multiple people before finding someone to assist, after which, there is usually a delay before the assistance is available.

    Hospitals need to learn from Toyota and develop an andon-like system that ensures there will be immediate response to even a hint of a problem; and importantly, when problems do arise, effective short-term and long-term countermeasures are developed so problems do not continually reoccur.

    A hospital based andon system would likely be met with great enthusiasm by the frontline nursing staff because it would begin to address “muri,” – the unreasonableness and the overburdening of people and processes. In my experience, overburden is the root cause of many issues impacting our hospitals, affecting safety, morale and the quality of patient care. I believe a hospital based andon system with real time problem solving could have a transformative effect on the delivery of care and address the issues raised by Ehrlich and Toussaint concerning nurse engagement in problem solving.

    • Tiffany —

      Thanks so much for your comments as a nurse.

      You make a lot of great points about the andon cord system and the help chain that a Lean organization has.

      It’s not just Toyota… here is a recent article about Volvo.

      It says:

      “Employees are quick to pull the “Andon cord” that signals a problem on the line requiring help—and halting the line. Workers are quick (and empowered) to offer suggestions to improve the process. There is a palpable pride.”

      I know people in healthcare cringe at the idea of “assembly-line medicine.” Lean doesn’t aim to turn healthcare into an assembly line, literally. But, there are things that can be learned from well-managed assembly lines, including the andon concept.

      Since healthcare is arguably more important than manufacturing, shouldn’t healthcare workers be able to “signal a problem” any time they “require help”?

      In healthcare, it seems that nurses (and others) are left to fend for themselves. If they are overburdened at the moment or have a concern about quality or safety, they’re expected to just power through. They might be labeled as “bad” or “weak” if they ask for help. And, if without a formal help chain mechanism, they might not get an immediate response when they ask for help.

      If RaDona Vaught had an andon cord (meaning if she worked in a health system that embraced this view), when she had trouble finding Versed in the med cabinet, she should have been able to ask for help. I’m not blaming her, I’m blaming the environment. She did her best to power through and, due to a number of SYSTEMIC factors, an error occurred and a patient died. Now, she’s being prosecuted, which I think is horribly unfair. Read the ISMP article on this.

      With a proper Lean culture and environment, this error would have never occurred and RaDonda Vaught wouldn’t have her life turned upside down.

      Yes, patients are not cars… hosptials are not factories… all the more reason to embrace these principles for the sake of patients and providers.

      • Mark –

        Thank you for your thoughtful reply.

        When I raised the concept of an andon system at ZSFGH, I don’t believe it was fully understood in terms of its usefulness. I have spoken with several remarkable leaders in organizations that have undertaken such a task with good result.

        Ideally by developing an enhanced help chain/andon system, it would serve to surface problems in real time, in the system and perhaps most importantly it could help to stop small reoccurring problems, which have been long tolerated, from coalescing in unpredictable ways and becoming a catalyst for the next catastrophic failure.

        It is true, that many times in healthcare, nurses are asked to power through to get the work done, to make sure to check all the boxes that represent good care but nurses are seldom asked what is getting in the way of their work, or how leadership, who possess the resources beyond a particular silo, might pave the way for staff to complete their required work safely. Instead, it is not uncommon to have 75 minutes of work to do in an hour and with swift and safe being the goal, the question becomes- what gives?

        Quality does not start and end with the skill and determination of the front line; it is a product of a system and a supported workforce. To support the workforce, the people doing the work need a system to speak up not just after-the-fact. I believe that a hospital based andon system can be rapidly deployed maximizing existing resources. Initially, to develop a proof of concept, an andon system could be tested on a small scale, on one unit with a couple nurses. As learning develops, the andon system could continually evolve and made more effective and gradually expanded, one nurse at a time.

        There is much value to be had by stopping the line, where we can examine an issue before information and memories around it fade. Similarly, there is much wisdom to be shared when we humbly connect and support those in doing the work on the Gemba, whether between colleagues on a unit or between a CEO and a nurse with an idea.


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