Lisa Yerian, MD on the Cleveland Clinic’s Improvement Journey and How Lean Got Them Through COVID


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My guest for Episode #449 of the Lean Blog Interviews Podcast is Lisa Yerian, MD.

She joined Cleveland Clinic in anatomic pathology in 2004, and has held several pathology and enterprise leadership positions. After 10 years serving as Medical Director of Continuous Improvement, Dr. Yerian was named Cleveland Clinic's first Chief Improvement Officer of Continuous Improvement in December 2019.

She's going to be one of the keynote speakers at the 2022 AME Conference, being held in Dallas — Oct 17 to 20. I'll be there and I hope you will be too.

Lisa was previously a guest here in Episode 282 back in 2017. Also joining that for that episode was our friend and her colleague, Nate Hurle.

Today, we discuss topics and questions including:

  • Remembering Nate Hurle (my blog post)
  • My last podcast with him (episode 404), Nate talked about how the CCIM and your continuous improvement work was helping with Covid testing, treatment, and vaccination… new processes.
  • As you shared recently at the Catalysis Lean Healthcare Transformation Summit, how did your Lean management system get you through Covid? 
    • Daily management system
    • Tiered daily huddles
    • Problem solving systems
    • “Covid put that system to the test”
    • Adaptations were required — learned how to make changes to the standard work in hours, not weeks
    • Urgency – had to work past the old expectation that it takes 3 months to solve problems
  • The Cleveland Clinic journey
    • 2006: project-based work and some basic tools
    • 2012: deliberately focused on building culture
      • Started a “culture of improvement” A3
      • Defined current state, future state — and the gap
      • Challenge: perception that we're already doing well enough
  • Little Red Book of Selling (a book Nate loved)
  • Culture of excellence – “Not getting better fast enough”
  • A3 problem solving
    • “Having a piece of paper is a way to de-escalate…”
  • Building on a culture of patients first
  • Lisa's appearance with me on the Habitual Excellence podcast
  • Good enough, world class, vs. aiming for zero harm?

The podcast is sponsored by Stiles Associates, now in their 30th year of business. They are the go-to Lean recruiting firm serving the manufacturing, private equity, and healthcare industries. Learn more.

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Automated Transcript (Not Guaranteed to be Defect Free)

Announcer (2s):
Welcome to the Lean Blog Podcast. Visit our website Now here's your host Mark Graban.

Mark Graban (12s):
Hi everybody. It's Mark Graban here. Welcome to the podcast. It's episode 449 for June 29th, 2022. Our guest today is Dr. Lisa Yerian from the Cleveland Clinic. She's going to be talking about their journey with continuous improvement and problem solving and lean management systems. It's a journey that started in its earliest form for them way back in 2006, we're going to be talking a lot about the last two years and how lean got them through COVID or how the methods and approaches they've been developing and practicing made really difficult and unprecedented times go more smoothly than it would have gone otherwise.

Mark Graban (54s):
So as always, it's great talking to Lisa, hearing her thoughts and reflections, and as always, I want to thank you for listening now. Here's today's episode. Well, hi and welcome back to the podcast. My guest today, a returning guest is Dr. Lisa Yerian. She joined Cleveland Clinic in the anatomic pathology department back in 2004. She's held several pathology and enterprise leadership positions. And after 10 years serving as a medical director of continuous improvement, Lisa was named Cleveland Clinic's first chief improvement officer of continuous improvement in December, 2019. Lisa is going to be one of the keynote speakers. I want to mention at the 2022 AME conference, that's being held in Dallas, October 17th to 20th.

Mark Graban (1m 41s):
I'll be there. I hope you'll be there too. You can learn more at, and there's a link to the conference in the show notes. So like I mentioned, Lisa was previously, I guess here episode 282, five years ago, and also joining us to that episode was our friend and her colleague and friend Nate Hurle. So Lisa is as I welcome you back to the podcast, you know, thank you for being here. And I know we wanted to start by taking some time to remember Nate.

Dr. Lisa Yerian (2m 15s):
Thanks so much, mark. Thanks for having me. It's a, it's really good to see you. I appreciate it. Spending some time with you at the Catalysis conference. I guess it's been a couple of weeks now and it's good to see you, and it's nice to have a time to remember Nate, and it's a little sad to be here together with Nate. Nate's really the person who introduced me to you. Mark, you might remember you very deliberately saw a conference that you would be at or the sole and attended for the sole purpose of meeting before meeting you, befriending you and convincing you to come and visit us

Mark Graban (2m 50s):
Well, that wasn't a hard sell. That was a nice offer, an opportunity that the he and you provided.

Dr. Lisa Yerian (2m 58s):
We certainly the partnership. I know he was a big fan of you. And one of the things that I really can appreciate and miss about me is that he always made things fun. And so when we did podcasts with you in the past, he had a really nice combination of pushing our thinking forward with great questions and reflections and doing it in a way that was not only challenging, but really fun to be challenged in that way. So we miss him a lot.

Mark Graban (3m 30s):
Yeah, for sure. I appreciated Nate and, you know, admired what, what he was doing, what you to, you know, we're, we're doing together those opportunities to visit, to do the podcasts, to have some fun going out to a baseball game together. So a lot of memories and you know, it's been about a year since his passing and we, we, we do miss him and, you know, thankfully have other recordings, including, you know, the podcast that the three of us did together. The episode that Nate and I did episode 404, I'm going to make a bad computer joke here.

Mark Graban (4m 13s):
It's ironic, you know, 404 is the error code for not found. And it's, you know, I'm glad the recording is still there. We miss, we miss Nate, even though he's not found with us everyday, he's remembered. And I'm sure you think about you and your colleagues. I know. Think about them a lot.

Dr. Lisa Yerian (4m 32s):
Yep, absolutely. We actually had a team picnic yesterday and one of his favorite events of the year and a nice to be together as a team and nice to have community in which to mourn and, and miss him. But it's not the same without him, for sure.

Mark Graban (4m 53s):
Yeah. You know, so, you know, Nate and I, you know, he, he was, you know, generous in, in his sharing and what y'all were doing, you know, in that last episode we talked about COVID times, you know, ramping up new processes are radically different, new versions of processes around mass testing and, and standing up new treatment options. And then, you know, the mass vaccination era. And one, one thing I remember, you know, Nate didn't take credit for that. You know, he was very gracious and generous and talking about what the team, what the organization had done.

Mark Graban (5m 34s):
And there was, there was a lot of great work. I know he played a big role in leading and challenging and bringing people along.

Dr. Lisa Yerian (5m 44s):
Yeah, that's for sure too. I think that I, I agree with you, Nate, didn't take credit because he could see how many other people were involved in doing that work. You know, we always, you know, there's very little that we do, if anything, on our own, right. We're always working with doctors, nurses, techs, other caregivers in the organization. But I think what Nate brought that was so unique and powerful was the method. And it was a very clear focused method on what is our next problem to solve. And early on in the pandemic, you know, many everybody in healthcare maybe was facing essentially the same set of problems, right?

Dr. Lisa Yerian (6m 26s):
How do we, how do we, how do we keep our patients safe? How do we keep our caregivers safe? How do we prepare for this massive unknown? So in some ways we had different, very different versions of those problems, but in some ways we were all dealing with the same problems. And you know, that initial reaction is commonly, you know, even at the Cleveland Clinic or places that have been doing continuous improvement for awhile, I suspect a initial reaction of firefighting and overwhelmed because you don't have a method or if you don't have a method when it came to the vaccination or sorry, when it came to the testing center, which was really that first big effort, as soon as COVID arrived in Cleveland, what he brought was a sense of order and how do we solve this big complex problem by breaking it down into very clear, next problems to solve and taking a very rapid PDCA approach to it.

Dr. Lisa Yerian (7m 27s):
And I think just having a clear method that was already recognized and known to be effective provided this tremendous sense of reassurance to the team that enabled them to calm down and focus on the problem that was in front of them. So, yes, there were many, many other people who, you know, stood in a very cold parking garage in March and in Cleveland. And, you know, it was scary and patients were scared and you know, it was hard. But I think that that core focus on problem solving and having an, a known effective method really gave everybody confidence and hope.

Dr. Lisa Yerian (8m 12s):
And when facing a really, really scary, hard challenge, that's complicated and can be overwhelmed, whelming that clarity, that confidence and hope just makes a world of difference. And he really continued to do that throughout the pandemic. And I think that's one of the things that, you know, across our, our Cleveland Clinic community and many places in healthcare, but something that folks will remember and appreciate me for, for a long time.

Mark Graban (8m 39s):
Yeah. And you know, that approach that you described and this, this methodology for solving problems, you know, it was powerful. There, there are many that look for best practices. They look to journal articles, not discount any of that, the right place, right time. But when you're doing kind of unprecedented things and unprecedented times you have to develop something and there had been, you know, years of practice with that model. And it was, you know, as a recap for listeners, how w when, when did that journey began before I want to come back and talk with you more about pandemic times, but when, when would you say that journey started?

Dr. Lisa Yerian (9m 25s):
So we first created what would be recognized as a continuous improvement team in 2006. So that was before I was involved, Nate was recruited in 2007, in 2009, I started to work with the team. And at that point we were doing a lot of project based work. So we would take on big projects and some tools. So there were some basic tools we were offering. It was really in late 2012, that we started to deliberately focus on building a culture. And I've spoken before about really the charge to shift from, okay, we've been doing this continuous improvement stuff for years.

Dr. Lisa Yerian (10m 8s):
When are we going to fundamentally change the culture? And so in late 2012, we started our culture of improvement A3. So we articulated the current state, the desired state, and really analyzed what was between here and there. What was getting in the way, what was going to help us. And it was through that that we developed our initial model areas, and it was really that deliberate model area work. And I want to clarify many people do model areas for like the model nursing unit or the model laboratory testing process or something. Our model was about modeling the culture. How could we develop a way to create the ideal culture?

Dr. Lisa Yerian (10m 50s):
And for us, that was a culture we defined as every caregiver capable, empowered, and expected to make improvements every day. And so when we started to work on that, we met the first team and the first thing they told us about was problems. And we found that pretty consistently, you know, people don't come to us saying we want a daily management system or a visual management system. They face problems in their work. And so we started with problem solving. And so that was 2013, really that we were working with that team and evolved from the initial problem solving, which was a three based to how do we create a system that enables this team to continue to identify as all problems on an ongoing way.

Dr. Lisa Yerian (11m 39s):
So we developed the problem solving system, which really became the first system in our model as that continued to work. And then other teams began to come see and engage. We then identified new needs or additional needs, and then centered on over time, the four key systems of our model, but it took us years before we really spread that broadly. So in 2013 was when the nursing leader, the executive chief nursing officer at the time Dr. Kelly Hancock came to see it and asked us to work in nursing and the nursing inpatient nursing unit. Mark was one of the first sites that you visit president when you first visited us.

Dr. Lisa Yerian (12m 23s):
It was years before we really got broad involvement, capability, traction engagement in problem solving as a methodology.

Mark Graban (12m 35s):
Yeah. I remember the visit and I believe Kelly was there to kind of see, continue to see what people were working on and, you know, to share the progress and to share the credit for all of that. So let let's, let's do some, some time hopping though. So let's, let's jump ahead then. We'll, we'll maybe jump back in time. You know, this is maybe then, you know, early 2020, seven or eight years into that part of the journey around focusing on culture and problem solving. And, and you addressed this on stage at the Catalysis Summit, but I want to ask you for this audience, you know, what what's, what's your summary, you know, looking back at how the Cleveland Clinic Improvement Model, continuous improvement, problem solving lean management system, all of these different labels we could put on this.

Mark Graban (13m 23s):
How, how was that helpful from, from your perspective during pandemic times?

Dr. Lisa Yerian (13m 28s):
Yeah. Good question. I would say that the two key systems that we found most helpful were our daily management system. So our tiered daily huddles in 2018, we developed a, an enterprise wide tiered daily huddle system to enable us to identify and solve problems, rapidly support our caregivers and really foster this culture of identifying and solving problems, problems, or opportunities across the enterprise. That was really a dramatic shift for our organization. I, in reflection, I never thought about this at the time when you're, when you're learning about, as a physician learning about continuous improvement and we, you hear all these things and you're like, okay, okay, I hear this problems or opportunities.

Dr. Lisa Yerian (14m 21s):
We should, you know, embrace problems and ask people to elevate them. But there's this very practical translation that seemed to never became apparent to me. I can't say it's not out there, but never became really clear to me that just sort of saying that and does it enable people to do it and certainly does it get them to do it. So there's this very practical component for elevating problems. That is okay. When do you want me to do that? Where do you want me to do that? How do you want me to do that? And then what's going to happen when I do. And none of that gets completed when we just say, you should embrace problems as opportunities, and you should encourage your team to bring forth problems.

Dr. Lisa Yerian (15m 6s):
It's sort of something that folks could nod their head to, but never actually do. It's kind of hard, right? Like it's like be nice or be good. You know, it's sort of vague the cheer day, ready huddle system gave every manager and leader a very concrete time place, opportunity, agenda method, where they could do that. Right? So they would say, okay, what problems happened in our area today? They might be a potential serious safety event. It might be a patient fall. It might be a caregiver experience, issue, or patient experience issue. People would, could bring needed to bring those sports.

Dr. Lisa Yerian (15m 46s):
So there you were, as a manager asking for that, and then people bring it to you. There's your ideal opportunity to embrace it and say, thank you for bringing that forward. Let's talk about it. Let's, you know, whatever your, your next step is, your method is what do we understand about root? Cause you can move into the coaching kata, but it provided that anchor. And because it's scheduled, it gave you time to practice being that type of problem, embracing leader on a regular basis. So that foundation was in place. What COVID did was enabled us to really put that system to the test because suddenly we had a whole lot of new problems that we had never faced before and never would have been able to anticipate if we didn't have the system in place that enabled us to, and a tiered cascaded fashion every day, same time in the same place, identify what are the new, you know, what are the existing problems?

Dr. Lisa Yerian (16m 45s):
And then what are the new problems that our team members are facing because of COVID and then help support each other and our teams in solving those problems through the tiered daily huddle system. So we took that system. We had some standard work around, how do we change the agenda? We accelerated the modified that standard work, because before it would take us weeks to make a change, we made it to changes within hours to say, okay, now we need to know how many patients do we have with COVID? How many are under investigation? Because at that point we were treating them essentially, as though they did, how many caregivers are out with COVID and how do we aggregate that information across the entire organization?

Dr. Lisa Yerian (17m 26s):
So we were able to pivot that very quickly and people were like suddenly leaning into huddles, much more heavily because now it was sort of, you know, have to know there's so much urgency around COVID, you know, sections that are at stake lives were believed to be at stake and in some cases were, so there was this sort of clinging to the system that we had kind of celebration something that, you know, in the prior couple of years had been built, but really hadn't had that urgency around it. So I'd say one is the tiered huddle system. We had also built the problem solving systems. Again, they were typically systems around which teams would huddle once a week or every couple of weeks, they would huddle at their Kaizen board and talk about what were the problems in front of us.

Dr. Lisa Yerian (18m 16s):
And in A3, I shared this at the summit. Also A3 would, in some cases, be done through a collaborative, A3 problem solving program where we would spend a lot of time teaching people how to do a root cause analysis or how to analyze their data. And that was basically a three month program. And so we had kind of unwittingly created this expectation that it takes three months to solve a problem. Now, we had this urgency, which enabled us to really pivot to say, no, no, we don't need three months. Like in fact, there's no way we can take three months to set up a testing site.

Dr. Lisa Yerian (18m 56s):
You know, we're going to do this within, I think we did it in four or five days, but then you can use that methodology. What was good that we had in place was an acceptance of the methodology. So folks didn't folks believed for the most part, believed in the methodology is an effective way to problem to problem solve. They didn't see how agile it could be, how rapid we could have, how rapidly we could apply it. And so COVID really gave us an opportunity to say, okay, and we can use it very acute with these very acute problems we can use it really quickly. Those would be, I would say the two main ones, the two most important ones.

Dr. Lisa Yerian (19m 39s):
And then the idea of PDCA as part of the problem solving methodology, this, you know, we're not going to have time to perfect anything, or to your point, wait for somebody else to develop a best practice or go search the literature. We just have to try something. And then when we see how it works, make it better. And so throughout all the problem solving activity, we were trying to make her performance visible, leverage standard where do PDCA so that we could continue to improve the way that we were doing it. But I think having that found those foundational pieces in place meant that we didn't have to spend a lot of time talking about how were we going to share information?

Dr. Lisa Yerian (20m 21s):
How were we going to identify problems? How were we going to solve these problems? It was really our core method. And it was, how do we adapt these to solve these types of problems at this pace? Which is we mostly hadn't had to in the past.

Mark Graban (20m 36s):
Yeah. So what I hear you saying, I hear you talking about two key things, importance and urgency, right? So the, of having to solve problems quickly, having to iterate quickly, having to move forward, even if we think, well, it's not perfect, but we have to do something and we can iterate our way through anything that comes up, you know, urgency. But then on importance, if I'm remembering correctly, one thing that you said in your discussion with John Toussaint and John Shook at the summit, I'm paraphrasing, but I remember you saying, correct me if I'm wrong or elaborate on this, that something of the fact of, you know, if, if you're giving people a counter-measure, that's not really a countermeasure to a problem that they care about, the adoption of that countermeasure might not be as enthusiastic to your point earlier, nobody speaks up and says, Hey, we want to lean management system.

Mark Graban (21m 35s):
They might not all, you know, they might also not ask for a countermeasure like daily tiered huddles, but it sounds like, you know, the importance of those huddles during COVID times would peak people's attention. And if they didn't already believe it, I'm sure there are people who did believe it through their existing practice to say, well, these huddles are now critically important. We're all in on participating and making the most of it fair to say.

Dr. Lisa Yerian (22m 3s):
Yeah, fair to say. I appreciate that. You brought forth my comment. I've seen that over and over again. And I think some of us who are in the business of change, kind of wonder around asking why isn't anybody interested in my fantastic countermeasure and your countermeasure might be fantastic, but you, in some cases, people need to feel like they have a problem. And they actually used to talk a lot about this book, that it was called something like the little red book of sales that he loved. And I have a Xerox copy to the Xerox because he wanted me to read it over and over again. And it's really about like, understanding what is the customer's need or what is the customer's problem.

Dr. Lisa Yerian (22m 44s):
And sometimes when people are interested in our countermeasure, you think about in some way, pretty much everything that we offer or sell as a countermeasure to something we default trying to tell people how wonderful the countermeasure is. And, you know, if I don't, if I'm not experiencing a problem, then I don't really care like a countermeasure. All of our counter-measures though costs. Even if you have your internal team, they cost your time, your energy, your focus, those are, those are finite resources and particularly in a healthcare environment and particularly to the day.

Dr. Lisa Yerian (23m 25s):
So even if you're going to help as a CI person that leader's got, or that manager, that caregiver's got an invest, something you're much better off to understand what are the problems they are facing. And then when you can attach that countermeasure to a problem, they experience that's when it really becomes something that's attractive to them.

Mark Graban (23m 47s):
Yeah. And I, I found the book here. I'll put a link in the show notes, The Little Red Book of Selling: 12.5 Principles of Sales Greatness. That makes me care. That's a good subtitle. It makes me curious. Why is it 12.5?

Dr. Lisa Yerian (24m 2s):
You should read it. Nate would be thrilled.

Mark Graban (24m 6s):
But yeah, I mean, gaining acceptance, you know, to change is a complex process to, to, to help people work through, you know, going back to maybe kind of what you said earlier about going back to 2012. Like I could, I could hear the thinking you described this a three of a, you know, a culture of improvement. I appreciate that you started with a description of the current state and then a future state, then that gap kind of helps then influence what, what do we work on or how do we break down that problem and start making progress? You know, I hear people all the time, we'll talk about a future state or they'll have sort of a vague goal of, we need to transform the culture.

Mark Graban (24m 53s):
I'm like, all right, from what to what? And then they might articulate the, the future. So my, my question for you, Lisa, is, you know, is it, can it be, was it painful at all to describe the current state good, bad, or otherwise like to try to get consensus around? What is the current state?

Dr. Lisa Yerian (25m 15s):
Yes, yes. It was difficult. So there were multiple challenges. One of our challenges was a sense that we were doing pretty well. Right? So you could arguably point to evidence, the Cleveland Clinic is doing well enough. So why should we build this culture? What does a culture of improvement even mean when you already kind of have a culture of excellence? Right. I don't think many folks would say we have a culture of complacency at Cleveland Clinic. So we have a culture of excellence, sort of what do I mean by a culture of improvement, how it different.

Dr. Lisa Yerian (25m 55s):
And then there are also, I would say, competing interests in what is the method or the how, or the, what we need to create a culture of improvement in my mind now took me a long time to think through this, but now I think it's really about the method. So if I think about culture of excellence, you know, I reflect on my own tendencies. I was always, you know, somebody who was trying to achieve and make things better, make myself better perform better, whatever. But my method was to try hard as an independent agent, as an individual, I might call on others for help.

Dr. Lisa Yerian (26m 38s):
But oftentimes my play is try harder and I think can actually happens a lot in healthcare. If I'm a nurse tech rather than fix the system to make it work better for everyone all the time. I figured out my own way. So that if you talk to people, a lot of them say, well, this is the way I do it because it works a little better. This is the way I do it because it works a little better, or I always do this or whatever people are exhausted.

Mark Graban (27m 1s):
What would I hear is this works. This works for me.

Dr. Lisa Yerian (27m 4s):
There you go.

Mark Graban (27m 5s):
Is that, is that the key criteria now?

Dr. Lisa Yerian (27m 8s):
Right? And like, if you have nothing else, then what works for you? You know, if you have no other options, right? You have no method to figure out what works best or most consistently for everyone. Then that's what it ends up being. So it's a culture of improvement. That's based on developing a method that's going to be better consistently or is going to consistently deliver better out. I think there was also a component of, we're not getting better fast enough, and we're not going to be able to improve as quickly as we need to. So, you know, even though we have a strong brand reputation, we perform well in some things, we certainly have very real opportunities in some of our safety, quality patient experience metrics.

Dr. Lisa Yerian (27m 56s):
And so, you know, highlighting some of those gaps, which some folks are not real comfortable with somebody running around, highlighting with her a three and you know, and so, and then there were also folks who'd been, who had been working to, I would say, foster continuous improvement or quality improvement in some way in the organization since 2006. And so me showing up and saying, okay, let's, you know, I'm gonna, you know, I'm holding a pencil around, how do we do this? Really could make other folks feel threatened that the way they were doing it or working to solve that problem or close that gap wasn't enough or wasn't good enough.

Dr. Lisa Yerian (28m 47s):
And so here I am, you know, champ trying to highlight a problem that really is, you know, the current state, you got to talk about the problems. Sometimes people felt sensitive about people didn't feel good about, but I actually found that the three and I, and I got the advice to do the eighty-three from a friend mark Reich who was working at the lean enterprise Institute used to work at Toyota. He's well versed in lean. I didn't come up with this on my head. So having a good friend coach incredibly important, but having a piece of paper is, you know, a way to deescalate pretty quickly and easily, right? So it's not, you know, I'm showing up in a boardroom or a high stakes space with a fancy PowerPoint that feels done and polished.

Dr. Lisa Yerian (29m 36s):
You know, it's sitting down with Lisa, this piece of paper, that's very messy and watching her write and take notes and revise the thinking or the story as you're talking with her. And I found out this trick that, and I've talked about this before, too, that if I'm talking with you, I would pick up a different color pen. And I know that, you know, the classical lean thing is to use a pencil. But if I use the pen in a different color, it would help you see where your thinking had filled in and you could see however much green or blue was getting added to the piece of paper, how much you were influencing, what the story or the narrative was for this change.

Dr. Lisa Yerian (30m 23s):
So I think it was, I think it was, it was, it was a good enough thing to get us started. It most certainly could have been better, but that's probably the advice I give most folks. I had dinner with an organization. Similarly wanted to tell me much, like you described, like we're going to start this transformation. And we, you know, they had logos and boards and posters and all these countermeasures, right? All these solutions that they had developed. And they were very excited about it. And I listened and then as they were wrapping it up, I want to know what I thought. And I said, what is, what is the purpose of this transformation that you're planning? And they just paused and looked at each other, it's spend more time and developing countermeasures that really understanding what is the purpose.

Dr. Lisa Yerian (31m 10s):
And what COVID did I think was give us this very clear, urgency and purpose. At that point, we didn't spend any time convincing people that we needed to do it. And then again, what's your method. Everybody's going to be solving problems. Are we going to use a tried proven method where not only do we know that it's effective or more effective than trying hard or more effective than whatever other method we would use, we all have a common method. So as we move in and out of project teams, which we were doing a lot, we all had a common set of tools, a common language, a common approach. We could rely on some core principles that really I think was powerful.

Mark Graban (31m 56s):
And w when you mentioned purpose, I mean, that's really getting to the upper left corner of the left hand side of the eight three, before we even dive into describing the current real reality, whether that's processes or, you know, facts or mindsets that exist. I mean, it's probably easier to get our head wrapped around a physical process with physical flow. The flow is specimens through a pathology process can be observed more directly than these elements of culture and principles and in mindsets. So that's a good reminder too, to even start there. Why are we talking about this? Why is this important to gain clarity around that?

Mark Graban (32m 40s):
I was going to say, back to your A3. I'm not a stickler on doing it in pencil or electronically or whatever. Cause I think it's the thinking, but maybe we'll, we'll, we'll try to find you a set of colored pencils that are also erasable or, you know, there's a there's erasable ink we could use. I love those little clicky for color pens, but I don't know if there's gotta be a version that's erasable.

Dr. Lisa Yerian (33m 5s):
Yeah, I would expect, so I don't know. I'm not, so I'm not so worried about it. I'm not a stickler pencils, and I'm also, as you heard of at Catalysis, not a stickler for a literal translation of the word gemba,

Mark Graban (33m 21s):
But one other element of the culture. And, and I'll put a link to this in the show notes. One other conversation that Lisa and I had was back in episode seven of a different podcast series that habitual excellence podcast series through value capture. You know, one thing that's very noticeable, not because it says things on the walls when I've had the chance to visit Cleveland Clinic sites. But there, there does seem to be a really strong culture of patients first, which seems like one of those pieces of culture, existing culture, current state culture, that you would want to be strengthening through any of this work that you're doing to improve the culture. Can you share a little bit more about how you orient, how do you stay grounded maybe in, in the improvement work that you're doing to make sure that it remains to that patient's first principle?

Dr. Lisa Yerian (34m 11s):
Yeah, that's a great question. So if we think back to the A3, you know, w one of the suggestions that mark Greg had made was to think about the analysis in terms of what's helping or what's supporting or enabling the culture, your desire, your target condition, and what's working against you. And so very quickly that patients first culture became, you know, and enabling element. And when I'd heard and visited other heard about and visited other organizations who were pursuing lead, it felt like that value that that emphasis on the customer was a little bit harder to create and capture in their improvement work for us, that patient's first emphasis was already in place, which was great.

Dr. Lisa Yerian (35m 6s):
I didn't have to convince people to improve. So for example, you know, I visited places or been asked by others, how do we get people to engage in improvement work, or to want to improve? And I was like, what do you mean? And they like, you know, and they were like, well, how do you get doctors for instance, how do you doctors to participate? And I would be, and I was like, well, we just asked them, you know, of course they look at me like I have three heads are totally like, right. And I really not because, you know, it depends on what I'm asking them. If I say, like take, you know, hours and hours out of your day, did you something that doesn't feel value added because I'm calling it lean or a Kaizen event? Yes. I would not be able to get people to be involved, but if I say, Hey, we're trying to, you know, make something better for patients.

Dr. Lisa Yerian (35m 49s):
Can we get your input? Can we get this? You know, what's the support people really have no problem engaging. I think the limitation that we face in patients first is that we're so focused on identifying with the needs of the patient. We're very focused on, or we try to be focused on empathy. That, again, it enables trying harder. It enables hero is which is not, you know, a reliable, structured improvement methodology. That's going to enable us to consistently deliver better for the patient. I think that what we had to do and continue to work to do is make sure that when we believe in what to be doing, what's best for patients, that we actually have some data and evidence of what that really is.

Dr. Lisa Yerian (36m 38s):
So, you know, sometimes we get caught up in imagining or believing what we think is best for patients. And sometimes we challenged that need to challenge that to say, well, have we actually asked them, what's your evidence, what's your data. And then we also have, in some cases developed some countermeasures. One of them is a panel of patients that we ask for input and, you know, opinions and to help us develop processes, which is great, but there's a tremendous amount of bias that can be introduced by a panel of people who actually have the time interest and investment to be serving on this type of panel for the Cleveland Clinic that may not be representative of the, you know, millions of people that we see every day, every year.

Dr. Lisa Yerian (37m 31s):
And so pushing on even that to say, okay, is that really the best way to get really, you know, diverse, comprehensive quality information about what our patients want and meet?

Mark Graban (37m 44s):
Yeah. Yeah. There's a, there's another trap that I've seen of, you know, that patient role being filled by somebody who's also a staff member. I was working with the children's hospitals with probably a decade ago. And we talked about getting parent representation in, in this work we were doing. And so while, you know, the, the civil so-and-so over here, their child had been a patient here at the hospital and we had a lot of discussion around, well, yes, you're a parent, but you also know a little too much about how things work here. That's different than somebody that's a purely external, fresh eyes perspective, perhaps.

Dr. Lisa Yerian (38m 21s):
Well, it's totally true. And also sometimes if you work there, you have a different experience because people recognize you. I mean, I, a couple of weeks ago, my father had, was involved in an accident, terrible accident, a tree branch fell and broke his, broke his neck in three places, hit him in the head. And so I, you know, I w you know, they transferred him to you. He lives in the country, they transferred him here, but I, you know, went into the ER to meet the ambulance, wearing my badge. So I know that my experience was for better or for worse, different than what somebody else experiences. The fact that I could even go in is probably, you know, dramatically different from another's experience.

Dr. Lisa Yerian (39m 4s):
And also, you know, I'm an n of one, they may not be the best way to the best way to do it.

Mark Graban (39m 12s):
W w what are the thing I'm curious about is the balance between here's, here's why I would propose, I'm curious to hear your reactions to it. The patients first doesn't mean patients only that with a patient's first perspective, you can also care deeply about the staff of making sure they're not overburdened, that we're not relying on hero culture, workarounds, that we can focus on trying to prevent burnout or help people recover from burnout. If it's happened. I was curious if you could kind of share your thoughts on also kind of addressing, you know, staff needs even in normal times.

Dr. Lisa Yerian (39m 48s):
Yeah. So I'm a, I'm a big believer in respect for people, and that's the patients who have real needs and the caregivers who also have real needs our vision that our CEO brought in. And really I love is that we are the best place to receive care anywhere, anywhere, and the best place to work in healthcare, creating processes or implementing countermeasures that are fantastic for patients, but are bad for caregivers or too overly burdensome, or do not support caregivers. You know, they're, they're, they're, it's, they're unsustainable.

Dr. Lisa Yerian (40m 30s):
First of all, because caregivers are never going to continue to practice them or use those processes. You'll be back to work arounds and, you know, nonstandard processes or ways to deliver things, but taking care of your caregivers is the way to take care of patients, especially in the economy now where, you know, staffing and hiring is difficult. We and others really are struggling to hire enough. People, keep people, retain people, having an, an environment where you're treated with respect is incredibly important and having processes that are not perceived to be, or actually prioritizing the experience to patients really, to the detriment of caregivers.

Dr. Lisa Yerian (41m 18s):
I just think, think that's, that's untenable, it's, it's really, it's really not sustainable. And one of the major benefits that I see to the continuous improvement work is the ability to enable caregivers to improve the care that is the most energizing, transformative, engaging activity I've ever seen. And part of it is the ability to make things better. And, you know, you make things better to know how you made things better, which really, you know, in gender as a sense of agency, part of it is having evidence of the work that you're doing. And some cases before you've even improved anything that can be very rewarding and exciting.

Dr. Lisa Yerian (42m 3s):
I've seen this time and time again, I shared an example at the catalysis meeting. I had, one of my assignments now is access. And I now lead a large team supporting access, access to healthcare, scheduling, things like that. And one of the teams does transplant scheduling. And I got this emailed report of how many patients, where you had transplanted so far this year. And I offered it to the team and they were ecstatic because they'd been scheduling, scheduling, scheduling, but they had no idea how many of those patients actually went on to receive a transplant, which is life saving life changing experience. And so you think about how fun would your fund with this podcast arc of nobody ever posted anything in the chat?

Dr. Lisa Yerian (42m 49s):
You don't know how many people viewed it, nobody ever came up to you and talk to you about it, or asked you about it. It would be, it would be just work. It wouldn't be fun at all. It wouldn't be rewarding, wouldn't be engaging. And it's such a simple idea that you give people evidence of their work as a way to engage and motivate them, but yet in so many ways in places, even those basic things we don't do or haven't done, I don't know if that's a continuous improvement principle or a lean principle. We talked about visual management, but I get the impression we talk about more, about more, because we want to understand performance and identify problems. We want to use it strategically to solve problems.

Dr. Lisa Yerian (43m 31s):
I think it's at least as valuable if not more so to engage people in the work that they're doing to provide meeting and to provide a sense of yeah. Of impact.

Mark Graban (43m 42s):
Yeah. Well, I think it's a powerful example you shared of, of helping remind people of purpose and the close the loop about the impact of their work. You know, that that's, that's really profitable. I mean, I will say, and I've, I've, I've said this for a long time about the podcast, that there is some inherent enjoyment. Like these are kind of like this conversation with you. These are conversations that I enjoy in and of themselves. And the fact that I get to record and share with others is icing on the cake.

Dr. Lisa Yerian (44m 11s):
Well, good. I enjoyed them as well.

Mark Graban (44m 15s):
It, the only enjoyment does not come from looking at the, the podcast statistics. I'm thankful for everybody who takes the time to listen and learn is nice when somebody does come up, though, I appreciate it. When someone comes up and says hi at a place like the katala summit or the AME conference. Well, Hey, listen to your podcasts. Thanks for doing those. That, that helps. I mean, I do appreciate that. I was gonna, you know, share, you know, thought when you talk about best place to receive care or best place to work in healthcare, you know, there's, you know, kind of kindred spirit thoughts. I've heard articulated by the people at UMass Memorial Health, where the way they articulated is best place to give care best place to receive care.

Mark Graban (44m 60s):
So there's those two pieces together. I don't know if it matters, which order you put those in, but I think they, they it's, it's a yin and a yang. They kind of go hand in hand. You know, I had a guest years ago who wrote a book with a fairly provocative title or intentional and provocative, you know, so, you know, patients come second and that's the camp that says, well, if you take care of the staff, they can take care of the patients. And, you know, I don't know a first or second matters with, but both it's not either or

Dr. Lisa Yerian (45m 29s):
Both. Yes. Probably in any business or any organization, you clearly need an emphasis on both. And, you know, can you navigate supporting both? And what's the best way to navigate supporting both. Everybody's going to face problems. Everybody's going to be solving problems. What's the, what's the method that you're going to use to make sure that you can really stay true to both.

Mark Graban (45m 52s):
Yeah. And maybe a final topic here, Lisa, I'm kind of touching on something that your colleague Melissa Vandergriff shared at the Catalysis summit of having a method for creating alignment up and down side to side in the organization. It's not enough just to have this goal. We need better alignment. Okay. What does that mean? And, you know, Melissa shared about an approach. Okay. Ours, which I think people probably more associated with Silicon Valley or, or, or startups, the book, John door's a venture capitalist book measure. What matters that talks about this OKR methodology objectives and key results.

Mark Graban (46m 33s):
And I was wondering if you could share either, you know, in that context or additionally, what are some of the things that the Cleveland is trying to do to, you know, build greater alignment?

Dr. Lisa Yerian (46m 43s):
Yeah. So, so we we've been, I'd say learning and applying OKR pretty broadly across the organization. We started with the CEO creating and sharing objective a set of objectives and key results that spanned our for care priorities, caring for patients, caring for caregivers, caring for community, caring for the organization, and then also research and education. So then after he did that, then we started to work with them at the executive team. So his direct reports, and now we're using them into, you know, deeper into the organization, in our institutes, in our hospitals and our divisions.

Dr. Lisa Yerian (47m 25s):
I use them with my team, for instance, we have, so I've been there for 18 years. I'm not sure that we've ever really had a clearly articulated strategic plan with a real deployment focus. There were killing sprayed spots. They were places where individual leaders valued it, emphasized it and build it. But as an enterprise, there was no kind of clear method that provided clarity on what people could attach to. And so I think what Tom did, our CEO, Dr.

Dr. Lisa Yerian (48m 6s):
Tom Mihaljevic did with OKR is, is he provided his set of goals and priorities for the organization. And then OKR is really became a method that people could use to look at your leaders. OKR is, look right, look left, and then develop, what are those objectives? And then what are the key results? And then, well, there's several things I like about them. One is it's not just activity or key results. It's, what's the objective. Like why did these matter? What is it that I'm really trying to accomplish here? And then it provides, you know, if you use a template or tool, whatever your format is, it developed it, it provides a common construct that we can use to bring our team together, look at them and on a cadence and a repeated way, and look at each other.

Dr. Lisa Yerian (48m 58s):
So we have a chief of staff, Dr. Beri Ridgeway, all of the clinical institute chairs, reports to her. She asked them to use this common format and methods so that, you know, she has maybe 20 direct reports. She's not looking at 20 different sets of goals, of varying, you know, length format. You know, we're all going to do it the same way so that we can be efficient in understanding what everyone's looking, working on and looking across to see how does it all connect. So it has provided, I think a lot of improvement in our organizational, in our organization in terms of alignment, it's also fairly flexible.

Dr. Lisa Yerian (49m 44s):
I've seen and heard about organizations where they tried to be very, very structured with like straight line goal alignment. One-to-one I don't think that would work well for us. Our organization is very innovative. I think people would feel constraint with a very structured one-to-one. You have to work on exactly a subset of whatever your boss is doing. And I don't think people have the patience to go through, you know, all of the math. So we're all of the kind of detailed work to make sure all those align. And one of the things John Doerr talks about in the book is, you know, it's pretty misalignment stands out. You know, it's pretty easy for me to look at a short set of OKRS and a short of my OKRs.

Dr. Lisa Yerian (50m 28s):
And say, okay, Mark and Lisa working towards the same thing or not. And then let's talk about that without us having to very deliberately write all that out or, or articulate all of that. So it gives us some flexibility. I think we have derived value from it. It's actually, you know, kind of thing where people don't recognize they have a problem and say, I need a, you know, an organizational align the system, but when they start to see it, experience it huddle around it, practice using it. They appreciate the clarity and the focus that it brings their team.

Mark Graban (51m 3s):
And it seemed to me to be very similar conceptually to strategy deployment in terms of what people are trying to accomplish through that. And, you know, one example that comes to mind for me, that sounds like what I think you were talking about in terms of having the alignment, not being too rigid. Like there was an organization I visited where one of their high level goals, objectives was reducing patient harm or eliminating patient harm. And one of the measures they were using was patient falls. Well, they were cascading that measure to every part of the organization. And there are some parts of the organization where patient falls is just not relevant.

Mark Graban (51m 46s):
Or I remember the one example where they learned this was an iteration and an opportunity for learning like the labor and delivery department pushed back and said, we don't think our key patient safety measures should be falls. We should choose something else that rolls up and contributes to a measure of let's say, serious harm incidents. So I appreciated them sharing that example of, you know, maybe the first pass is very strict and then there's feedback. Or if it's too loose, maybe then to your point, you notice it and you can iterate and bring it to closer alignment.

Dr. Lisa Yerian (52m 22s):
Yep. And that takes practice. We talk about catch ball a lot. It takes practice to learn how to, how to do that. You know, we have leaders who, you know, don't want to provide any or want to provide very little, you know, constraint or guidance to their team. We have other leaders who are, you know, heavy, much more heavy handed at that, but you're absolutely right. And falls are a great example, such a central line infection, sepsis mortality, things like that. Like for some or parts of the organization, they have very few central lines or they, you know, sepsis isn't really an issue for their patients. You don't want to, you know, have them have a goal that feels meaningless to them because they don't have the ability to drive it, getting back to our sense of engagement and purpose.

Dr. Lisa Yerian (53m 4s):
You want everybody focused on really what matters most in those areas. It may not be easy to draw a straight line through the entire organization, to the, you know, enterprise okay. Ours for every single one of those things. But that's really the leader's job to say, okay, if I'm managing obstetrics and the emergency department, I need to make sure they're both focused on matter what matters most in their arenas. What's going to be most impactful for their patients and their caregivers. And then how do I pull this together to make sense of it at my level, you know, to align to what my leader does.

Mark Graban (53m 39s):
Well, Lisa, thank you for sharing, you know, some of the progress and continued iteration and evolution of your approach, you and everybody there at Cleveland Clinic, you know, remind everybody, look in the show notes, there'll be links to past episodes, including the episode Lisa and I did in the habitual excellence podcast series, encourage people to check that out. And again, as a final reminder here, the AME annual conference here, 2022, October 17th to 20 in Dallas, you can learn more at and maybe a final question for you, Lisa, you know, you, you had an opportunity at the Catalysis Summit to speak to a healthcare audience where it was maybe 98.

Mark Graban (54m 24s):
I've a friend of mine who works in, you know, construction or it's related to healthcare construction, right? So maybe as a healthcare person cut, we'll call it 98% healthcare people at the AME conference. I think in past years, it we'll, we'll call it 20 to 30% healthcare people. What, what do you find on talking about what's the opportunity given, you know, kind of a broader audience of people from all sorts of different industries?

Dr. Lisa Yerian (54m 50s):
Yeah, that's a great question, Mark. I think that I probably need to spend some time with the customer, with people in other industries. You know, some of the, some of the variants that I've had talking to folks in other industries, it's just curiosity about, you know, lean in healthcare. And we, we, we may not all work in healthcare, but we're clearly all users of healthcare. And you know, if I were, although that's a little bit dangerous, but if I were not in healthcare, if I were the customer, what I'd be interested in is like, when is it going to get better? Like we can really expect what we've gotten in other industries, a higher quality outcome at a lower cost, maybe, but higher quality outcome, for sure.

Dr. Lisa Yerian (55m 36s):
When are we going to really see that in healthcare? The airline industry is become more reliable. The automotive industry production has become much more reliable, much safer. When are we going to see these gains in healthcare? And how, how are we gonna get there? What do we need to do to get there? So that's part of what he went to attempt to take suggestions.

Mark Graban (56m 1s):
Well, no, I mean, I think that I agree with you, people have a personal interest in the healthcare system, whether they're a patient or family member is or has been, or they know they will be at some point. So yeah, there, I think there is that deep curiosity and I think there are opportunities to help connect dots about culture leadership, methodology for improvement, not just hopes and dreams of improvement, but methodology there's a lot to learn back across other industries. You know, my wife who you'll have a chance to meet at AME and she's going to be part of a panel there. I've learned a lot from an opportunity.

Mark Graban (56m 41s):
John Toussaint invited her to come visit ThedaCare back in the day. And she learned a lot particularly about strategy deployment. Cause that's, it's a management process, it's a culture. And she was able to bring that back into the manufacturing space. So I know there's a lot of opportunity to learn in all directions,

Dr. Lisa Yerian (57m 1s):
But yeah, hopefully share some good stories, inspire some books, cheer some good, some good learning, but yeah, I really look forward to seeing you and meeting Amy there.

Mark Graban (57m 10s):
Yeah, well, it'll be fun. So again, our guest here today has been Dr. Lisa Yerian, come join us at AME. You can not only hear her speak, but have a chance to ask questions of your own and, and chat about the healthcare system and lessons that you could bring back either to your health system or your own organization, regardless of where you work. So, Lisa, this has been a lot of fun. Let's do this again more frequently than, than every five years. Maybe. How about that?

Dr. Lisa Yerian (57m 38s):
I think we should do the turnabout.

Mark Graban (57m 42s):
We could do that. Lisa had an idea of sort of, she wants to play guest host and ask me questions. Right?

Dr. Lisa Yerian (57m 49s):
I think your audience would love to hear Mark's point of view.

Mark Graban (57m 53s):
Well, hopefully I'll have answers worthy of, of the questions, but okay. Let's let's do, let's do, let's do that.

Dr. Lisa Yerian (57m 60s):
I would love to talk again.

Mark Graban (58m 1s):
Okay. Look forward to that. So thanks again for, for being here on the podcast. Again, Lisa,

Announcer (58m 9s):
Thanks for listening. This has been the lean blog podcast for lean news and commentary updated daily, visit If you have any questions or comments about this podcast, email mark

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