Podcast #354 — Kim Hollon on the CEO’s Role in Lean and Patient Safety


Joining me for episode #354 of the podcast is Kim Hollon, the CEO and President of Signature Healthcare, based in Brockton, Massachusetts.

I first met Kim about a decade ago and, as we discover during the podcast discussion, one of my Lean healthcare clients in Dallas was later an important influence in Kim's discovery and embrace of Lean.

What prompted the podcast interview was Kim's recent article titled The Health Care Leader's Role in Safety,” which I blogged about not long ago. So, in this episode, we talk about the article, his personal history with Lean, and much more.

Scroll down on this page for the full transcript.

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  • Looking at your article, “The Health Care Leader's Role in Safety,” do you remember initial reactions to the 1999 report “To Err is Human?
    • Why do some focus so much on arguing the numbers and methodology? Does this distract us from making progress?
  • Lean principles might seem simple… but unlearning and relearning behaviors is difficult right?
    • “Relearning how to lead after 30 years of success was difficult for me and all of our team.”
    • How do you help other leaders work through that challenge?
  • What's the daily role of leaders at various levels now at Signature Health?
  • Being patient — “Approximately 20 percent of our leadership team chose to leave rather than change their leadership style.”
    • Can you talk more about that and the impact on the organization?
  • Why is it important to not frame this as cost savings?
    • “Dechaos-ing the organization” allows you to see defects as they happen
  • “…my belief that a hospital could be error proof and checklist its way to zero harm was fundamentally flawed.”
    • What is flawed in that approach?     
    • How difficult was it to admit this? What happened next?
    • Valuing productivity or safety?
  • “If anyone had told me 10 years ago that we could reduce our serious safety events by 80% I would not have believed it, because I had no mental model of how different an organization could be.”
    • 90% reduction in employee injuries
    • 90% reductions in patient harm examples
  • What's your approach to succession planning and why is this so important?

Video of Kim Hollon:

Thanks for listening!


Mark Graban: Again, our guest today is Kim Hollon. Kim, thanks for being our guest today. How are you?

Kim Hollon: I'm great, Mark. Thanks for having me on. I followed your work for years, tremendously impressed in what you've been able to help healthcare accomplish and excited to be on with you today.

Mark: Thank you. I appreciate that. We're going to talk about the important work that you've been doing at Signature Healthcare and your article. Before we get into that, I always like to let people tell their own story a little bit, if you don't mind introducing yourself.

I'm curious, in particular, if you can talk about what your interests were, how you got into senior leadership roles in different health systems.

Kim: I was fortunate, Mark, to get into senior leadership roles early in my career. I got interested in healthcare when I was a sophomore in college and went to work as an orderly in a small, community hospital in Alabama.

After finishing undergraduate school at Montevallo, went to the University of Alabama Birmingham and received my graduate degree in hospital administration from them.

That took me to Dallas, Texas. I completed my administrative residency at Baylor University Medical Center during the early years of Baylor's expansion both into non-healthcare business, sort of horizontal integration, as well as the establishment of their multi-hospital system in those early years.

I was promoted quickly, rose on the staff at Baylor, and then went to Methodist Hospitals of Dallas as a president of one of their hospitals when I was only 29.

During the years I was at Baylor, I got really interested in quality, quality improvement, was actually doing some quality circles back in the early '80s. Then learned about value stream, management, and TQM when I was at Methodist and taught some of the courses there.

Now, I understand what I was doing was touching part of the Toyota Production System, but never really realized I was touching a system. I just saw it as what I was hearing and trying to implement, but never realized there was a management system underlying it.

Mark: Well, it's funny…

Kim: Anyway, I was so fortunate to come up in healthcare at a time that some of us were promoted probably before we should have been or were ready to, but I broke into senior leadership really early in my life.

Mark: I'd like to hear a little bit more about how you got exposed to TQM. I just wanted to comment first that, I just got back from Japan again. When I've been there, it's been a little surprising. I've met somebody who's now retired from Toyota, and he was responsible for Toyota's Total Quality Management or TQM initiatives, even in recent years.

I think a lot of people view TQM as being something maybe from the past. I've seen within Toyota and other organizations there, that quality circles and practices like that are still very much active today. I'm curious of your thoughts on how you got introduced to that, originally. Was there a bit of a trend there in the '80s? What was your personal experience?

Kim: I've always been a really curious person, and really curious about how industries outside of healthcare work. I've always thought leaders in healthcare often came from healthcare, and we were too inbred.

I remember a program on television that was an hour-long or something, about the automobile industry, and about Ford, and quality being one, talking about the rehabilitation of the American auto industry. I think that was the first introduction I had to quality circles and total quality management.

I was a young vice president at Baylor, looking for tools and ways to help the people that reported to me. I began looking and studying about what that was. Really I saw it as tools in process at the time, but I think got interested through the story about the American automotive industries.

I didn't see much adoption at all in healthcare at the time. I got interested, I think, probably deeper, at some point ran across Deming's material and Juran's material. I don't know what had me do that seven or eight years later, but I know I was struggling to get alignment at the hospital I was the president of, struggling to find a way to get sustained quality improvement over time.

I started reading the materials. I went to my boss, the president of the multi-hospital system, David Yin, at the time and said, “Hey Dave, you mind me getting into what's going on with Juran and Deming, and doing some self-study, and implementing what I can at my own hospital?”

He always let me run as far as I could. He got interested in it and started reading the books. Then for two years, probably, redid these Friday group studies of Deming, Juran, and did watch the videos as a senior team of a three hospital system, really trying to self-educate ourselves.

That was before you saw much adoption at all in hospitals. We wound up hiring a lady from the New York phone company, NYNEX, to come down and teach value string mapping and team-based quality improvement in our organization, and set up a department to do that.

I would say that's still late '80s, early '90s.

Mark: You mentioned, and you touched on this in the article as well, that back then you were reviewing… I'm paraphrasing what I heard you say about TQM in the '80s, that it was about tools and process, but you came around to see all of this, and maybe including Lean as being, as you describe in your article, not just a philosophy, but also as a management system.

What do you think led to that evolution in your view of all this?

Kim: I had the privilege of having a wife who was also a manager in healthcare systems. She was the director over at Children's Hospitals of Dallas.

I would frequently download with Ellen my frustration with conducting town hall meetings at Methodist around the clock, about 24 one-hour meetings in a stretch of a month, month-and-a-half, trying to assess our organization's alignment in how people understood what we were trying to accomplish as an organization.

I was always frustrated that, even in some departments where they were doing great work, the people on off-shifts and evening shifts had no idea what they were working on. They even had no idea that they had done a great job.

I found that frustrating. I was downloading to her one day and she said, “Kim, I don't know what this guy has done. We have a lab director over at Children's. He keeps talking about alignment and the improvements he has in his department. I've never seen anybody this excited about leadership before. If you want me to make an introduction, I will.”

I went over to see the lab director at the time. I think you may have used them as an example before, but they had Johnson & Johnson in…

Mark: I was the person from Johnson & Johnson. [laughs]

Kim: Oh, were you?

Mark: This was Jim Adams. Jim Adams is my director.

Kim: So you'll appreciate this. I went over to Jim Adams for an early morning meeting, like eight o'clock in the morning. I left Jim Adams' office for what was supposed to be a one-hour meeting something like three to four hours later. He gave me four or five books to read and a message.

“Kim, what we've done is incredible, but this is a leadership system, and senior leadership has to understand it and buy into it. Here's some books.” He gave me The Toyota Way, The Toyota Way Fieldbook.

He gave me Mann's book on culture and supervision. He said, “You need to go read these. Before you think about implementing anything you've done, you need to see this as a management system.”

I started reading them, and it began to lay out to me that Toyota production system. It's a crescendo to me of 20 years worth of administrative work taking parts of a system well-meaning, trying to make change, and then suddenly seeing the system provided to me.

It's like, “Oh, I never realized that the frustrations I was having was because this was a management system and I was implementing the pieces separate from each other, but they work as a system. If I'd implemented it as a system, I'd get more traction.”

That was a dramatic event for me. Jim was so passionate. I was able to see in his lab what he had accomplished. I left Dallas and went to Pittsburgh shortly after that and met David Adams, who was at Adams Strategy.

David you may know…

Mark: I know David. He's great.

Kim: He was teaching at St. Vincent's operational excellence. I had two years in Pennsylvania to deepen my knowledge of the Toyota Production System as a management philosophy.

Mark: I think there were no relation. I think it's just coincidence that it was Jim Adams and David. [laughs]

Kim: Oh yeah, totally no relation, yeah. So funny. I didn't realize you were the person that put out that at Children's. Too funny.

Mark: Yeah.

Kim: That's awesome. Thank you, Mark. Thank you for starting my journey that you didn't know you started.

Mark: I'm glad to have that indirect impact. I worked with them for a year or so. That was such a great situation to be a part of. Jim Adams is the administrative director who had a great background in military medicine before he retired and went into the civilian sector, around leadership, and servant leadership, and systems thinking.

I don't know if you ever met his co-leader the pathology director, Dr. Beverly Rogers. The two of them together were such good leaders who were focused on their people, and systems, and doing the right thing for their patients. It was fertile soil for Lean, and Kaizen, and continuous improvement.

Kim: Really? I don't think I met her. I walked away understanding that the lab was an island in a hospital. He was frustrated at the time with batch work coming to him that he was trying to do one-piece flow with and found that frustrating. I can't remember what the policies were, but he thought that senior leadership often created policies that didn't work well in that leadership environment.

They did some great work. We later sent a team of people from Signature down to see Children's Lab as a good example. Here's what I'm talking about when I'm talking about Lean and what it can accomplish.

Mark: They've managed to sustain. The last time I visited the Lab was maybe two years ago. Even though Jim and Dr. Rogers both ended up going to Children's Healthcare of Atlanta and Jim has since retired, there was a good foundation there. Their process for Kaizen and continuous improvement was still very much active. It had become the new expectation. It had become the culture within the laboratory.

Kim: That's great to hear. I have always worried about what happens when I eventually leave Signature and have we stabilized and hardwired this culture so that it will remain.

Mark: I'm going to jot down. Maybe we can come back to that later on. I want to take a deeper dive into your article. Again, the title was, “The Healthcare Leader's Role in Safety.” I really appreciated your reflections and what you shared there.

One thing you touched on in the article I was going to ask you to elaborate on for the listeners…For the listeners, I'll link to the article in the blog post for this episode. I was wondering if you could talk a little bit about your initial reactions going back 20 years now to the Institute of Medicine report, to err is human.

You were talking about you already have been embracing quality improvement and had been working on leading that. What were your reactions to those reports that had their estimates around the number of patients who died as the result of medical error?

Kim: My reaction, Mark, was very typical of the reaction I saw from other people at the same time. Total disbelief. “That can't be right. There are not that many people harmed in the healthcare. That certainly isn't happening in my hospital. Yeah, we may have a rare event.” I could not believe it.

My style of curiosity and intellectual curiosity is, “Well, OK then. I'll go get the book and I'll start reading the research.” I will start sometimes looking at the references and going back to the original references to come to my own conclusion. I did not do that with IOM.

I immediately got the book, and read the book, and then began to try to understand the research that they had done in the two states that led to that.

I walked away from it saying, “Oh my goodness. This is a real call to the healthcare industry to do something about a problem that's not being discussed at all in any of the administrative meetings that I went to.”

Mark: One of the challenges, trying to go back to the original source or even with later studies, is my understanding of trying to come up with these estimates is they do limited chart review. They're trying to identify after the fact where errors occurred and if it caused or contributed to death. Then there's extrapolation. It does, in a way, invite people to question the estimates.

To me — I'm curious of your thoughts — this seems to be this catch-22 where healthcare doesn't openly report the number of errors, and the harm, and death. Then people are forced into estimates. Then it seems like arguing the numbers maybe causes a bit of distraction from working on reducing harm. What are your thoughts?

Kim: There's a fundamental issue in being able to see the harm. That almost means you have to do chart review to get two and two to come up with four or five. Maybe the easiest example is there's something residing in the primary care office's note that would lead you down a different path. Patient comes into the emergency room. No one accesses that note or talks to the primary care physician.

We go down a pathway that's incorrect and it leads to harm. You're never going to see that self-reported. Nobody knows what was sitting in the primary care office's note that was available to us. Some of the studies do assume correctly that failure to have recognized something that was available to us is a mistake and a defect in the system.

If that failure led to harm, then that was something that was preventable harm. We don't see it easily. There's so many handoffs in healthcare with the number of people and shifts. The nurse that, unfortunately, makes an error in medication, they wouldn't have made that error if they knew they were making a mistake. They don't see their mistake often. They thought they did what was correct.

We may never know we made a mistake until someone draws blood trying to figure out what's going on with a patient. Then you may discover it. It's really difficult to see harm. Then it's even more difficult to ascribe where in the process the harm happened and what the root was.

Healthcare's just prone not to see it easily. That's when you have to starting to reviewing. That gets you the estimates. People can push back at the estimates.

Yes, I absolutely think that the numbers get in the way of improvement. Frankly, it doesn't matter to me whether it's a hundred thousand or 400,000, whether it's the third-leading cause of death, the second-leading cause of death, or the sixth-leading cause of death. All the studies tend to say there's more harm than there has to be in healthcare, and we need to do something about it.

We should quit arguing about what the right number is and do something about the improvement.

Mark: What are your thoughts or what have you tried to do even just internally around encouraging reporting of errors, of near misses, of harm and risks?

Kim: It's one of the things. We have matured our operational-excellence system with culture safety. They're getting closer and closer to contemporaneous reporting of harm in situations and working through that step-wise over time. We've had the typical fill out the computer report and send to quality arm. That's a high barrier.

It needs to be really significant before people are going to fill it out. It often doesn't include near misses unless a near miss was almost dramatic like “We almost did the wrong surgery” but to subtle near misses they're not including in that system.

We've moved forward over the years to finally having during our huddles, which happen multiple shifts a day at the work site, what we would call tier one. We've developed situational-awareness questions. They're specific to the department. They're done to help the staff think about situations they've encountered in the last shift that might tend to allow harm to happen.

It may be direct or indirect. It may be workload issues to have more work than we can get in the people that we have. Then we have a Catch Program that we started calling Great Catches to begin with. Then realized that some people thought that had to be an earth-shattering catch. We took the name “Great” away and just call it a Catch Program.

Both of those generate an 8-and-a-half-by-11 list of issues that are on our multipurpose board that get reviewed as part of our balanced scorecard system on a daily basis. That is helping us see recognition of potential harm/near misses contemporary in the workforce by staff doing the work.

A contemporaneous list are feeding problem-recognition problem sheets and our daily Kaizen or suggestion system. That has become very rich. Over the last two to three years, we've finally gotten into a cadence in most of our clinical areas. You can go pick of those lists and see that there's something hitting the list every day.

Mark: Is there anything beyond local initiatives that different organizations have to try to make it safe for people to report errors? Is there anything that you've heard of or that could be done at more of a national level in terms of policy, or does this need to be just addressed within each organization?

Kim: That is a great question because there's a couple of things there. We're having an interesting discussion right now about, “How comfortable are we as a team talking about the near misses broadly?” Even in our own organization, near misses are more comfortably talked about in the department. We're not sharing across departments often.

Had a great discussion with physician leaders and clinical directors yesterday of, “Are we to a point with our culture that it's OK to grab stories, de-identify the patient, and tell them knowing that organizations may be able to figure out who was involved in the story?”

There were two clinicians that said, “Well, that probably depends on whether you have been around for a long time or you're brand new to your practice.” If you take a physician straight out of their residency program and they're involved in a near miss, they're not going to want it socialized in the organization because it's going to impact their career.

You take somebody that's been out for 20 years. They know that by the grace of God somebody has helped them spot something in their practice. They don't mind telling those stories. Very dependent on where you are. We acknowledged as a team you have to be careful doing that internally because you don't want to shut down people telling you about near misses.

You're balancing the value of telling the stories with people bringing them up. That seems to be a nuanced issue internally. I thought, if you had an issue, wouldn't it be great if there was a database you could go to so you didn't have to just de-identify the patient? You'd just take the scenario and go get a story from a website of…

Let me just print in enough to get the scenario and pull that story down. Go tell that story and say, “In another hospital, X happened” because the stories are powerful.

The Betsy Lehman Center in Massachusetts is starting its website where they are going to take state-reported data. They're going to try to create a way for us to get stories out of that database. They're just starting it.

I haven't had a chance to go look and see if they have the reported issues in there yet or how we're going to be able to access them. They are trying to get at the issue of, “How can we provide information that might help other people learn from the stories?”

Mark: Betsy Lehman, if I remember right and listeners might have heard her name, was a “Boston Globe” reporter who died after a medical error I believe. Right?

Kim: A drug error. A cancer-related error. She was a Boston Globe reporter. Then in Massachusetts, they established a government center in her name responsible for trying to improve patient safety in healthcare in Massachusetts, a non-regulatory state-supported small group of people.

Mark: We talk about changing culture and developing new ways of thinking. One thing you touch on in the article, you wrote, “Re-learning how to lead after 30 years of success was difficult for me and all of our team.” I appreciate the humble reflection there. I was wondering if you could maybe elaborate on that a little bit.

Also talk about how you help other leaders try to work through that challenge of un-learning and re-learning different ways of leading.

Kim: There were a number of think points of recognition in my own search to understand how that production system worked and worked to understand what leader-standard work was and self-reflection. I kept running back into, “Boy, this is really hard because I have so patterned how I do administrative work” and realized that my pattern is set and confirmed because I had been successful.

If I really wanted to transform my organization, I had to be willing to transform myself. I went through the experience of writing down standard-leader work checklists. I just kept changing the checklist until I got into a cadence changing my daily work knowing that I had to do that.

I'd just keep laughing at myself of making a checklist and not following it and then having to do my own PDCA cycle. I remember someone coming in here once and saying, “Kim, what's your PDCA cycle for your own standard-leader work?” I thought, “Wow. I don't have one.” What a fascinating question…

Kim: …which was really helpful for me. It's hard to change. It's hard to change what you've patterned with in terms of how you do your leadership work. I've realized that, certainly for the people below me, it requires a significant amount of coaching, patience, and a combination of both of those. I do believe in Rogers' work for change and how people change over time.

It takes a long time to have people change. People change when they can see what worked, and they can learn from peers. They can emulate it, practice it, and see that it's valuable. That is a necessary process. Some people are late majority. They're not going to change until they see other people change, which means you have to just be really patient. Take a lot of time coaching.

I developed over time leader-standard work that has GIMPA time built into it every day. I don't as a CEO always have time to get out in the GIMPA, but we have scheduled time on our calendars in the morning.

People know where I'm headed if I can get there. I usually bring the vice president with me. I see that as coaching opportunity knowing I have much more leverage with the VP and the managers than I do coaching employees. I spend it as coaching time. I spend much more time now coaching to help people be effective than I do actually working on problems anymore.

A subtle change over time. As that began to get traction and work, I really didn't have to worry about the problem. I just have to now worry that they see the problem and that I have such trust that they'll go fix the problem that they just see it, whether that's a process problem or a leadership problem.

Mark: Dr. John Toussainthas talked about his evolution and his leadership style back when he was CEO. He said something to the effect of “Not needing to have all the answers is very freeing.” Would you agree?

Kim: [laughs] It really is.

Mark: I hear you saying similar things.

Kim: Yes. Oh, it is. Not having to have the answers is freeing. Not having to solve the problem is freeing.

Then, once this management system is really working, senior leadership is freed up to go work on other things or handle a crisis in an organization while the rest of the organization fundamentally working on process improvement for quality and safety on a daily basis, because that system lives and breathes with its own energy.

We found over time as executives we've downloaded so much responsibility to middle managers entrusting them to do the work and improvement.

When we have a financial-crisis year, the organization still meets its quality-and-safety-improvement objectives because the people in the system closest to the work are actually doing that improvement. We get to put focus on other things.

Mark: Going back a minute, you talked about being patient and realizing that coaching people, helping people change, takes time. Maybe not everyone is able to eventually come around. One thing you wrote in the article, you said, “Approximately 20 percent of our leadership team chose to leave rather than change their leadership style.”

I was wondering if you could just share a little bit more about that. At some point, do people see the writing on the wall? They're being coached and that there's different expectations. “I can't sign onto this.” At some point, does the patience run out and maybe people are asked to go someplace else where they can still operate that traditional way?

Kim: It's a great question. I was seeing multiple points of recognition I thought from various directions in the organization. We did not have the senior team aligned and, because the senior team, we're on a bell curve of change themselves.

We had people that were late majority and people that were early majority. They're coaching people that were early majority and late majority.

I would pick it up when we would, in quality meetings, review problem sheets. I would see problems that were being worked by a manager, where the senior person had signed off on their work, but it wasn't a very good point of recognition.

They hadn't gotten to the root cause. They were doing parallel processing. They didn't understand the system and their demand. Their area had very few suggestions. If you went to look at their area, they were stymied. If you ask the senior manager how they were doing, they would say they're doing an awesome job because you had a late majority making that assessment.

I started making structured rounds, trying to hit areas under all vice presidents, and then I saw more points of recognition of what I thought I was seeing. I saw early adoption all over the organization.

Then alignment issues of the senior team, that led me to working with the Lean staff on competencies. I thought, “OK. Well, we need to get in writing this system, and in writing what competence is, both in problem-solving and what competence mean in terms of standard leader work.”

We developed a competency grid, and then we started using the competency grid to make rounds and that grew to me, including multiple senior people, plus Lean, plus human resources in making rounds. We were using the competency grid to talk about what are we seeing as a senior team. That helped me align the senior team.

We got on the same page about what we were trying to accomplish from a leadership, organizational effectiveness, philosophy and standard. Then I was still seeing tremendous variation in managers.

I finally reached my own inflection point of…We were about three years into operational excellence. We have what is probably 40 percent or so of the organization still not trying. They just weren't leaning into using the system. They were trying to do their routine work and do some Lean problem-solving just enough to get by. We decided to take this competency grid.

I went out on a limb with the organization and said, “OK. Enough is enough. We're establishing is ‘this is the standard.'” I've said it was the standard. It is the standard. If it is the standard, then we need to measure to the standard. If a manager chooses not to manage the way we're going to manage and we've declared, then they shouldn't be a manager here.

We decided or I decided on behalf of the organization that we would hold raises for a year for anyone that had been here long enough to understand the system but was not competent in using the system. We would pay the raise whenever they accomplished competency during the year.

I wasn't interested in the financial savings. I was interested in change. I said, “If you get a raise halfway through the year for being competent, I'll back pay you for the rest of the year, when the year started.” I didn't want anybody to be able to say we're doing this from a financial reason.

When we implemented that, people self-selected out. That was the signal to the organization, this is real. Some people self-selected and were very direct with me when I talked to them as they were leaving. I don't want to manage that way. I went and found a job somewhere else.

That was helpful to the organization. If I'm fair and honest with myself, I created tremendous fear in the organization. It's taken us years to get past that inflection.

As I've made rounds in subsequent years where we weren't using the competency grid anymore, because we did that for one year, we sent the matches to the organization, got people competent and then abandoned the test.

People still felt like they were being graded for a test rather than coached. It has taken a few years to pass that inflection point. I've had to work hard at getting past that over time. I do think it helps speed up our implementation.

The other harm that created is that this has happened probably in implementation when you do it across the whole organization because we implemented organizational effectiveness and about 110 departments simultaneously.

All up, system-wide, everybody is up with what I would call the Toyota Production Management transparency daily ties in system. Where we were experiencing management turnover in those first three to four implementation years, the staff in those areas never got into a cadence of understanding the system.

The third manager going into a unit had no current system working for them to engage with. We have senior leaders for five years in, totally understanding the system and what should be, and we would forget that this manager's only been here a year. It's a manager that's in a unit that has turned over managers every year for three years.

We needed to back off our expectations to become much more patient. We went back and grabbed that competency grid and created a two-year orientation process for new managers, so that all senior leaders would acknowledge, “OK, let's don't hold people responsible for knowing X, until they've been here 6 months, 9 months, 12 months, 18 months.”

That slowed us down, helped us reduce our turnover. We're now far enough into this. A new manager can come from the outside and learn it almost by OJT because the systems are running at the daily level in departments. Working through management turnover during an implementation was really hard.

Mark: This is going back a little bit. Can you talk about why it was important to not frame Lean or these efforts as being focused on cost and finances?

Kim: I totally believe that you have to reach the hearts and minds of people to get them to change. To reach the hearts and minds of people in healthcare, most people, regardless of the job in a hospital, went to a hospital or clinic to make a difference for their community, and that's what drives them every day.

I believe that daily improvement is something somebody willingly gives on their own. I believe in this whole management philosophy of the power. From a power perspective, the power I have as a leader is to terminate somebody. Any work they would do less than a termination level are [inaudible 37:59] . Anything more than that was self-will.

There's a tremendous amount of self-will that we're responsible for getting from people. Self-will has to come at their choice and because they want to give it to me, which means I don't have the power to make them. Therefore, I have to get to their hearts and minds, and we lean heavily into that.

The whole finance notion takes you away from doing things because it's the right thing to do. I do believe that finance will come. You de-chaos the organization, you take defects out, you improve process in clinical quality, and finance will follow, but if you lead with finance, people won't even try.

Mark: I like the way you put that on “de-chaosing” the organization. That has a different implication than talking about eliminating waste.
Kim: I finally learned over time. Success wasn't just the supply closet.

Kim: This is 6S-ing is a layered thing that I now understand of what I call de-chaosing the organization. We focus on what's important. We get rid of enough defects and chaotic behavior that you can actually see defects when they happen and see important defects and work on them. It's an alignment strategy.

It's only happened over years that we've reduced enough defects, waste, and chaos, that it's allowed us to focus on things that are easier to accomplish but critical for us to put our efforts in.

Mark: Touching on things that are important. In the article, you talked about working toward zero harm and you describe that as a moral obligation, which is, that's also very strong, evocative language. Why do you frame it? I don't disagree with you, but I'm curious, how did you come to frame it and describe it that way as a moral obligation?

Kim: There are a couple of things, Mark. One, it is a strong language on purpose because language matters when trying to reach people's hearts. Then the language we choose to use needs to grab them and shake them out of their current belief system. That's done on purpose.

I went through an exercise with our managers of taking gold coins and dropping them into a silver bucket, each coin to represent a certain number of deaths in America. I used it through a management meeting. The entire meeting dropped another coin and said, “I want another moment of silence for another person who's died in American healthcare,” because I wanted to get through to people.

We're talking about patients. We're talking about families. We're talking about people's lives. We need to grab that emotionally and through that emotion to have compassion. I've become to understand much more about reasons Swiss cheese than I ever knew 30 years ago.

Mark: At the Swiss cheese model…

Kim: That Reason's talking about…yeah, and what I thought he meant was the slices of cheese were things like the barcode system and the Omnicell or the dispensing system and the electronic medical record doing away with the reading, handwriting issues, and pharmacy double-checks, those were all the defenses he was talking about in the pharmacy delivery system, but that's only part of the story.

I only understood later that Reason had also included organizational impact and does the unit productivity more than they do safety as another slice of cheese or another defensive system.

Supervision is another defensive system, which means senior leadership has a defensive system, and the board has a defensive system. Media and the public have a defensive system. If there are holes in any of those systems, those are just as important as a hole in the bar-coding system. I never had a fundamental understanding of that.

Once I understand it, well, that means I own a slice of cheese as an executive, and that means, to me, I have a moral obligation to close as many of those holes as I can in that slice of cheese, because it might be my hole that opens up a patient for harm.

That's just as responsible to me for harm that happens as it is to the individuals delivering the care. That becomes then a moral obligation. Once you understand it, you've got a moral obligation to close the holes, and they belong to us. I don't think that's fundamentally understood by a lot of executives.

Mark: In the article, and this is what you were getting at, you said, “My belief that a hospital could be error-proof and checklist its way to zero harm was fundamentally flawed.” Is that because it was missing that leadership responsibility for systems, or what was flawed and missing?

Kim: There's a couple of other things I've become to understand more, and maybe it's just the way we implemented Lean, but we implemented Lean as process improvement and, in some cases, had the administrative processes in there.

I never fundamentally understood that if it is not a knowledge issue, and this goes back to a medication process which has a lot of process in it, all the error proofing and processes in the world doesn't necessarily help the individual delivering the care make a personal decision about what happens when the barcode wand reader is not working.

What do they do? Do they honor productivity over safety? Does the person set it down and go find another one that works and come back in the room because they would never do it without it, or do they bypass the system because all of our systems have bypasses?

That becomes the compliance with non-rule issue, and then as I understand compliance with non-rule issues, I now understand there's like three components to compliance, the non-rules. One is what are the barriers to complying? Well, that's where process improvement has its clear ability to help. We have to remove the barriers.

I've got to make sure the barcode wand has a good battery in it. Then there's a perceived risk issue, and that's all leadership. That's all culture of safety, and that's an obligation of leadership to work on perceived risk, which gets you into caches, sharing stories, and elevating the perception from an individual at the point of delivery that they're about to do something that might have risk with it.

The third issue in following non-rules is what coworkers are doing. We have to make visual somehow that coworkers are all doing it this way, and coworkers honor safety more than they do productivity. That is, again, another leadership issue.

One form of getting to zero harm and high reliability has to be managing, following non-rules. The airline industry understood this years ago, their whole cockpit training is around that effort. Then there's other subtle issues in healthcare we have to acknowledge. There are over 200 forms of cognitive biases.

When we are thinking about even something as simple as, “Well, is the behavior I'm about to perform a risk?” We have a cognitive bias about not being able to see what we do today having significant risk related to it. There are people that think one in a thousand seems like low risk.

One in a thousand in medication delivery means we're going to make a lot of errors on a fairly frequent basis. When you look at it, what's the chance of an error in a day? Pretty high. Chance to an individual, pretty low in their mind, and so managing cognitive biases are important.

Well, how in the world do you manage a process that you can't see because of how people think? I realized that's extremely important. I'm never going to get to it through a visible process improvement methodology. We had to come alongside the process improvement within an entire process aimed at how do people think, how do people perceived risk?

How will people work in a team? Will they speak up? Do they see potential risk? Those were all unseeable in terms of observing work going to the genba, things that we needed to do with it. Then our work and Lean were different from process improvement.

Mark: We're going to wrap up here. I want to talk a little bit about some of the results and the success. I appreciate that you've shared your reflections on challenges and things you would have done differently, and I appreciate that.

In the article, you talked about reducing serious safety events by 80 percent. You shared the reflection, you wrote, “If anyone had told me 10 years ago that we could reduce our serious safety events by 80 percent, I would not have believed it.”

I was wondering if you could share a little bit more about that success, and is it chicken and egg? Do you see results and then believe it, or did you in different ways, maybe being inspired by others, realizing, “Yes, it was possible, let's commit to it”?

Kim: It was seeing results and then believing. It's interesting. Because we are in an industry that is not highly reliable, comparing yourself against the industry, we were often better than the average.

Over years, when you're better than the average, and in many Medicare measures, we were in the top 10 percent in the country, we had had dramatic improvements in worker injuries. Our employee injuries have gone down by almost 90 percent.

For things like pressure ulcers, falls with injury, CLABSIs, CAUTIs, most of those were down by 90 percent. We thought we were good. We've been a safety A in Leapfrog for year after year. The only time we've had a B was the very first six-month interval. We've been straight As since then. We thought we were doing an awesome job.

We brought in someone to start helping us measure healthcare performance improvement, people that are owned by Press Ganey now, and they created a measure of serious safety events. They told us that if we implement a culture of safety, we'd see an 80 percent decrease in serious safety events. I thought it's not possible in our organization. We've been in serious safety As for this period of time.

Our measure through chart abstraction in the Medicare and other forms of things people were focused on where 80 and 90 percent already lower than expected. They came in and said, “Wow, you're serious safety event rate the way we would measure it is really low. We don't know if you're going to see an 80 percent improvement.”

We double down and implemented culture of safety holistically, just like we did organizational effectiveness, and we saw our serious safety events dropped by over 80 percent. I was honestly shocked. I thought we would see an improvement. I didn't think we'd see a level of improvement, and we think to sustain it over time.

I guess I have to say and admit, we brought in somebody else to measure something we weren't measuring before, and implemented things that we weren't doing before that helped people feel much more safe telling us about near misses than we had ever seen before and then saw our tremendous drop in safety events.

Mark: Maybe one other question here. You brought up earlier the importance of succession planning. Is there anything more? I'm not trying to push you out the door, but is there anything else you want to share about some of your plans for that?

Kim: I'll go back to a rare event for me and rare for CEOs. How often does a president of a hospital get to go back to be the president of a hospital they had been the president of before with an interim gap in between?

When I was at Methodist Hospitals of Dallas, I was leading one of their institutions, left to lead another one, and then we decided to build a third hospital. For a period of time, I was the operating officer over both hospitals, which included the place I had been at previously.

I had an opportunity to witness a lot of the management systems I had put in place had disappeared over the intervening two or three years. It was a tremendous lesson for me. I had been there for either 10 or 11 years as the president of that hospital.

I thought, when I left, that some of those management processes were hardwired and they were going to stick. Within a couple years, they were gone. I've never forgotten that.

Knowing how difficult, I think, implementing operational excellence is across the system. From day one, I worried about, “How do I do this at a pace that will more likely have it stick? Then what else do I do to help the organization value it, so that it will stick?”

One of the things that we did with the board's support — it's a great board here — is we added two Lean experts to our board's quality committee. Changed our by-laws, opened up two seats on the trustee quality committee. Two seats dedicated to professionals in operational excellence, who had plant manufacturing backgrounds, that sit on that committee.

One of them is also a board member now. The other one continues to serve on that committee.

Then throughout the years, we've done Lean training for our board. In hopes that they would understand, when they see improvement here over time, it is because we have a Lean operating management system. I have those two people in the documentation of CEO succession planning.

I don't know if the board will follow it. My suggestion has always been go grab those two Lean people. They're there for you to help you find the new CEO. When people talk about Lean, they might be a project person, but say they've really done Lean holistically in the organization.

Then there's operational excellence people that really have a management philosophy, and they're different. If you're not an insider in the industry, you can't pick up the verbal cues that might tell you what kind of experience someone has. They really need the expertise. They've been now around for five, six years. That's one.

Trying to convince the board by storytelling our improvements, two. Then three, the work I've been doing the last couple years. Telling our story locally and nationally, trying to build pride in the organization.

Have people feel really good about what they've accomplished, have them not want to see anything slide. We even now have started presenting some of our clinical data with five-and-six-year run charts.

Because we're so good and stable now, you no longer see, “Wow, it used to be much higher than it was.” I'm afraid with management turnover, if people come in and just assume, “Oh wow, your rates of infection are really low.”

Oh, but if you just knew where it was before, you might be more willing to say, “When it sneaks up a little bit, you see the drift up.” We're presenting data in a way that I'm hoping helps whoever comes after me spot variation and threat over time.

I'm doing everything I can to poke at our systems that might create visual ability of the next person to see trends over time drift back, if it does after I leave. That's all I can do. We have a good succession plan in process with the board and the board's committee and talk about multiple levels. We try to promote from within rather than going into the outside.

We find it's easier to do that, easier to self-develop now than it is to bring someone in from the outside. CEO succession is, I think, really critical to stabilize this level of management philosophy.

Mark: Kim, I really want to thank you for what you've done and your willingness to share. Really, really appreciate you taking the time to do this.

Again, I want to encourage the listeners to go find the article on “The Healthcare Leader's Role in Safety” by our guest, Kim Hollon. Kim, I'll give you the last word if there's anything else that you'd like to share with the audience before we wrap up.

Kim: Thanks, Mark. Kudos to the team here. This is mostly the team that I found when I came here, other than some turnover four or five years ago is the team that exists. I think all I did as the leader was establish this system and get out of their way and coach them.

The capacity for this team to sustain change over time has been a humbling experience. They are an incredible group of people, and they deserve really a lot of credit for transforming this system.

Mark: Thank you again, Kim, for being a guest here on the podcast. Hopefully, we can do it again sometime. There's plenty more that we could talk about, I'm sure if you have a few minutes.

Kim: Oh, boy, there's plenty more. There's plenty more in the story about what I think I've learned, and operational excellence in Lean, and culture of safety. Mark, I really have been shocked, as we've implemented what I would consider the human performance tools, and added it to Lean. There's a synergy there that I couldn't have predicted.

Mark: It seems like you're going to keep learning. We'll catch up.

Kim: Yeah. Never a day. Never day I don't. Thank you. Thanks for doing this.

Mark: Let's catch up again sometime about the latest developments.

Kim: Thanks for doing the podcast and thanks for retweeting the article.

Mark: I'm very happy to do so. We'll talk again soon, I hope.

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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.


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