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Episode Synopsis:

Welcome to Episode #14 of Habitual Excellence, presented by Value Capture.

Joining us today is Paul Pejsa, he is the director of the Catalysis Healthcare Value Network, based in Appleton, Wisconsin. Today, Paul talks with host Mark Graban and shares examples of health systems that are members of the CHVN who have done really outstanding work during the Covid-19 pandemic. Note, this episode was recorded in late May.

Organizations mentioned here include  Bryan Health (Nebraska), Nebraska Methodist Health System, UMass Memorial Healthcare, Integris Health (Oklahoma), Torrence Memorial Medical Center (California), and Children's Mercy Hospital in Kansas City. How did they use daily huddles, A3 problem solving, and other Lean Management System practices? Listen to find out… (or watch)…

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Intro (2s):
Welcome to Habitual Excellence presented by Value Capture. This podcast and our firm is all about helping you and your organization achieve habitual excellence via one unifying focus, one value based structure and one performance system. In other words, it's about helping you capture dramatically more value through achieving perfect care and perfect safety for patients and staff. To learn more about value capture and our services visit

Mark Graban (36s):
Welcome to Habitual Excellence. I'm Mark Graban from Value Capture and our guest today is Paul Pejsa. He is network director of the Catalysis Healthcare Value Network. Paul, how are you today?

Paul Pejsa (49s):
I'm doing great Mark. And thank you for the opportunity to share today. I appreciate getting some of the word out on what we've learned through this crisis and Lean management systems.

Mark Graban (60s):
Yeah, well, I'm glad you can share that with us today. And you know, before we dive into that, can you maybe first introduce yourself and Catalysis and the Healthcare Value Network with those are for context?

Paul Pejsa (1m 12s):
Sure. Can do Mark. So a little bit about my background. I've got 30 plus years of experience across various industrial sectors service sectors. And about the last 10 in healthcare, about half of my career has been in a variety of process improvement roles. So it went through a six Sigma with GE as a master black belt, and then with Toyota and some of the Shingijitsu group learned the basic elements of lean and currently in Catalysis under the leadership of Dr. John Toussaint and Kim Barnas, I've been fortunate enough to be exposed to the real details of a Lean management system and how that gets deployed in this very complex industry of healthcare.

Paul Pejsa (2m 2s):
Leading the Catalysis Healthcare Value Network, which is a peer to peer learning network of 70 members, anywhere from small clinics to academic medical centers, to very large regional medical centers we've been able to see the maturation of management systems. And most recently we've been able to see how those have reacted and responded to this very unfortunate COVID-19 crisis that we find ourselves in.

Mark Graban (2m 36s):
Yeah. And before we dive into that, I'd also mentioned to the listeners, you know, Catalysis is a not-for-profit educational Institute, and if you want to learn more about them, their website is if you want to learn more about what they're doing, Healthcare Value Network and otherwise. But Paul, you know, in your role, you have the role to talk to many health systems. What are some of the examples as, as you were sort of teeing up for examples of health systems that are more successfully managing this COVID-19?

Paul Pejsa (3m 13s):
Sure, what we're finding Mark is that the length and breadth of their Lean transformation seems to be a strong indicator of their success in responding to this crisis. A couple of examples of that, where I see organizations that have a fully developed set of tiered huddles anywhere from frontline staff to executive level, the communications in this crisis seems to have flowed more quickly, both up the chain for removing barriers or highlighting our urgent, very urgent issues. As you know, we've experienced through COVID and also to flow down key communications to staff when there are, you know, immediate changes.

Paul Pejsa (4m 0s):
And certainly all of us have seen whether it's through the government or regulatory bodies almost hour by hour, the responses and the advice on how to manage this crisis are changing. Those can flow very quickly if you've got a fully developed, and active tiered management system that truly engages both the staff and the executive. And we're finding in those cases, that levels of staff stress can be lower. And the executives response to immediate issues seems to be more measured.

Mark Graban (4m 42s):
And, and before, you know, looking at some of the specific examples, can you elaborate a little bit for listeners who might not know what you mean by a Lean Management System or what these health systems mean by Lean management?

Paul Pejsa (4m 56s):
Yeah, absolutely. So when we think about a Lean Management System, there are a number of key elements that go into that. And some of the very basics would include, do you have a huddle? Do you gather your team together? Whether it's at the frontline staff or the director level or at the executive level, are you coming together on a regular basis with some sort of a structured 10 or 15 minutes stand up? Do the managers and directors and executives have some sort of a status sheet where they do a one on one check-in on key issues. When we think about what gets discussed in a huddle, do they have performance metrics and are they leading metrics or are they simply looking at lagging metrics like CLABSI or CAUTI rates or 30 day readmissions?

Paul Pejsa (5m 48s):
And have those metrics been developed with the frontline staff? Do those metrics get discussed in some sort of a review session, on a regular basis. And if you do have performance reviews with those metrics, is the leadership team engaged? Are they asking good questions? And in order to ask good questions, of course they have to have some sort of leader standard work that would take them into Gemba to go see, because you can't ask good questions if you don't understand the operation and following onto that, do they have countermeasures? So if a metric goes red, a mature lean management system would treat that as an opportunity.

Paul Pejsa (6m 34s):
The team that's managing that metric would develop countermeasures and the leadership team that's listening to that review would be offering help at the very fundamental level in a Lean management system, you would find A3 thinking broadly deployed. So independent of what you call that A3 tool. Is there a true PDSA thinking? Do I think about the left side of A3 and what's the background? Do I think about the right side of the A3? What are my actions in that A3. And then like most Lean systems that you and I Mark would see in many organizations, are they using the fundamental tools and do they have standard work that actually tells them how to operate on a day to day basis?

Paul Pejsa (7m 23s):
If you put all those pieces together and they're all functioning, I would call that a very mature Lean Management System.

Mark Graban (7m 31s):
And, and you mentioned PDSA: Plan Do Study Adjust. I mean, I think that mindset has been critically important for organizations I've talked to because there has been so much change, so many new requirements and new ways of providing care and protecting people that idea of, of rapidly putting together a plan and then doing our testing. I think it is more beneficial when people then close the loop to actually study the effectiveness of what we're trying, all of these new practices to see if it's really effective so that we can adjust as needed without feeling the pressure to say, Oh, well, we, we put together a new process.

Mark Graban (8m 14s):
It must be perfect. Let's move on as if it is that, that, that experimental mindset I think is really important. You're probably hearing a lot about that.

Paul Pejsa (8m 24s):
Yeah, absolutely. Mark. And, and here's the difference if you're really doing PDSA then even in a crisis, when you make a change, as you stated, you take the time to study and adjust, even if it's, you know, hour by hour or day by day, you're still closing that loop. What happens in a less mature organization, that either has a very young Lean management system or doesn't have one at all, is we tend to fall back into firefighting, which as we both know, is the legacy of healthcare problem solving. It's what we call small P, big P, I make a little plan. I go do a bunch of stuff.

Paul Pejsa (9m 4s):
I don't circle back. I try something else and you can see that in a crisis, if I'm just going through PD cycles. I may never really get to the root cause of, of what's driving this element of the crisis. And that could be, you know, failure to acquire or clean my PPE. It could be a bed allocation. It could be testing. If you're not closing that loop, then you will miss key lessons that will prevent you from successfully getting through a crisis, whether it's COVID or any other. Yeah.

Mark Graban (9m 39s):
Yeah. So I know you've got some specific examples of some organizations on that you can share with us today. What's the first example you can tell us about?

Paul Pejsa (9m 49s):
Sure. The one I'd like to share that I think is perhaps the most important, one of our network members is Bryan Health in one of my favorite cities in the Midwest: Lincoln, Nebraska, because they have a very well deployed and mature management system that ties back to fundamental principles, which is something we haven't covered yet. But I want to touch on briefly. Now, if you've got only management system, part of the bedrock of their management system are some of the principles that guide our behavior, especially as leaders. Two of the most fundamental principles that go back to the Shingo Model that we're all familiar with as respect for the individual and leadership with humility, those two principles have been deeply embraced by Bryan Health during this whole COVID-19 crisis.

Paul Pejsa (10m 44s):
And the behavior led them to was a commitment to no layoffs and a commitment to the staff, having exactly the PPE they needed in the condition they needed it, where they needed it, in adequate supply. And as a result through this COVID-19 crisis through their Lean management system, Mark, they actually saw employee satisfaction increase, which if you think about the crisis and what you and I see on the news every day, or read in the paper, awful lot of stress and having a spouse who is a primary care provider, I can tell you that there's an incredible amount of stress and apprehension.

Paul Pejsa (11m 33s):
And yet this healthcare system actually increased employee satisfaction during this crisis, which hit the Midwest, perhaps not as hard as the coasts, but certainly causing a lot of stress within the staff and within the providers.

Mark Graban (11m 52s):
Yeah, well, there's, there's that stress or there's that anxiety of not knowing what's coming and feeling supported from a safety perspective and from a financial perspective. I mean, that's all right at the base of, you know, Maslow's hierarchy of needs to, to help eliminate that stress allows people to shine and excel in patient care and everything else they do. Yeah,

Paul Pejsa (12m 16s):
Absolutely. And if the provider feels comfortable, then certainly that translates over to the patient. In another case, in a pediatric case, our friends at Children's Mercy Hospital in Kansas City, they have a rapidly matured their management system in particular, the communications that flow through five tiers of huddles. They have a total of 300 huddles deployed within their main hospital in Kansas City. And due to the crisis, they took one third of them, 100 and turned them into virtual huddles.

Paul Pejsa (12m 57s):
So because of the necessity of, of distancing and the way that care is being provided and to keep their providers safe, a hundred of those huddles became virtual. And because the system was mature, they didn't miss a beat in communications. And what the employees are reporting is that they feel well communicated to by the executive team led by CEO, Paul Kempinski and the executive team feels like they understand on a day to day basis, what are the key barriers? And they've defined the levels of escalation in such a way that the right problems are being solved at the right level.

Paul Pejsa (13m 39s):
And that's another fundamental piece of a Lean management system. You want to drive problem solving down the lowest level possible, but you and I both know we can't solve every problem at the frontline. There are barriers that are must be removed at different levels. So piece of their rapid maturation was to devise a process by which they would determine what gets solved at staff level, what gets solved by the managers, what gets solved by directors and what goes all the way up to the CEO huddle to be solved. And they're finding that things get solved rapidly as a result.

Mark Graban (14m 16s):
Yeah. Yeah. And that's interesting hearing about that balance. You, you mentioned earlier, Dr. John Toussaint is a founder of Catalysis, you know, we've, we've both heard John talk about, you know, the shift in his own leadership style when he was the CEO and what he teaches others is the leaders can't be all knowing and all powerful having all the answers. And so there's this balance like you were, you're saying frontline leaders have a really important role to be supportive, but they can't delegate everything. Like you were saying. There are some problems that frontline staff is perfectly positionted to address, and some things are more systemic, bigger picture issues that the executives or middle management leaders need to really be directly involved.

Paul Pejsa (15m 2s):
Yeah, absolutely. And let me give another example because as you and I both know, and have taught and advocated for many years, a standard work is part of the foundation of Lean. You know, if there's no standard work, there is no improvement, it's all variation. So when one of our network members Nebraska Methodist Health System in Omaha, as part of their COVID-19 response, they spend time with their improvement team to create an operational readiness plan that not only creates the standards to manage the crisis, but created with a mindset towards the next crisis.

Paul Pejsa (15m 43s):
Because you and I both know there will be another pandemic. There will be another crisis, it's simply a matter of time. So with an eye towards that, the Nebraska Methodist Improvement Team created a full operational readiness plan that has them thinking about what happens the next time. How do we better manage so that we can be more efficient, more effective and more Lean when the next crisis hits? And because we've got this peer to peer learning network, they have very graciously shared that across the full network so that others can learn. And, you know, really, that's another piece of these Lean management systems that we advocate as that, you know, when you learn about practice, share it.

Paul Pejsa (16m 31s):
If you've got a lesson learned where you've stubbed your toe, share that as well. Cause sometimes we learn as much from the failures as we do from the successes. Yeah,

Mark Graban (16m 40s):
Yeah, yeah. That's very true. And you know, I think there at least one other example you had, but I, you know, along these lines, but you mentioned Bryan Health and, you know, respect for people and not laying people off. I see the headlines flow through every day from some of the healthcare publications and their news summaries. And you see a lot of headlines about layoffs and furloughs, but it's great to see not just Bryan Health, but one other that I had heard about and, you know, personally want to give some recognition to is on UMass Memorial Healthcare, where their CEO, Dr.

Mark Graban (17m 20s):
Eric Dickson, who is really committed to, you know, he really used Lean management system as a turnaround mechanism for the health system when he came in and took that job. But I'm looking at a news story from May 13th, UMass Memorial CEO commits to avoiding layoffs and furloughs. And, you know, even though it says, yes, they've had a financial hit, you know, they, they feel like they're doing the right thing for the longterm perspective. And like, to me, that that's an important element of Lean thinking if you, you know, for people are familiar with the book, the Toyota way that lays out 14 principles of, of Toyota, or, you know, we can call it lean thinking.

Mark Graban (18m 0s):
Principle number one is focusing on the longterm, even at the expense of the short term. So I admire when leaders and organizations are willing to do what they think is best for their people and best for the organization in the longterm.

Paul Pejsa (18m 16s):
Sure, and I think, you know, one of the aspects of Dr. Dickson's behavior that he talks about very honestly, is, is his need to practice leadership with humility, to go to Gemba, to learn the real situation, which is what we should do as leaders before we act we should go learn. And I think some of that humble leadership is what you see reflected in the actions that he and his executive team took at UMass Memorial that they want to preserve their staff. They're looking for the long term. You know, if you think back to the very origins of the Toyota production system that like are covers in his books, it was originally called the Respect for People System, because what Toyota understood very deeply was that if we're not respecting our people, we won't engage them in problem solving.

Paul Pejsa (19m 6s):
If we don't engage them in problem solving, then almost by definition, we don't have Kaizen. We don't have that day to day improvement.

Mark Graban (19m 13s):
Yeah. And I think, you know, people's commitment to organizations like UMass Memorial and others that are finding alternatives to lay off some furloughs that, that, that that's going to help reduce turnover and improve performance. And a lot of other, a lot of other dimensions. But if you've got a couple of other examples that, that you're able to share with us here as well, right?

Paul Pejsa (19m 41s):
I do. I want to highlight our friends over at Integris Health in Oklahoma City. So under the leadership of CEO, Tim Pearson, using some of the skills that he honed when he was leaving North division at Intermountain Health, they rapidly created a Lean management system about a year and a half ago. And one of the bedrocks of that is the creation of standard work. So their vice president for continuous improvement, Lisa Olenski, at the very start of the crisis, worked with their medical leadership to create standard clinical guidelines for treating COVID-19 patients.

Paul Pejsa (20m 22s):
So fairly large document that they almost literally created overnight and then shared very broadly across all of their 13 hospitals, and then went ahead and shared it across our entire healthcare value network system that gave very detailed standard work on how to manage these very new challenges of COVID-19, and they adjust that standard work on a daily basis through their continuous improvement team. So it, it really highlights the need to first develop standard work. And then through the process of a kamishibai or audit of standard work, to interrogate it on a regular basis to understand is the standard work still giving us what we need or do we need to adjust it?

Paul Pejsa (21m 13s):
And so under Lisa's leadership, they have processes to very rapidly adapt that standard work as the crisis unfolds and, and frankly continues to unfold throughout our country and across the world.

Mark Graban (21m 29s):
And then I'm going to another part of the country. You had an example from California as well, right?

Paul Pejsa (21m 35s):
Sure. So a really fantastic example, our friend, Jeremiah Hargrave at Torrence Memorial Medical Center and Dr. Toussaint is actually writing about this as we speak. They had a shortage of PPE. They had a number of engineers on a Jeremiah's improvement team, and they were able to use a 3D printing techniques to create some of the face shields that were required also using, you know, simple things like a clear plastic dividers to help create the PPE. Either people needed rapidly deploy it and essentially create a little factory within a hospital to first create that PPE.

Paul Pejsa (22m 23s):
And then on a day to day basis, increase production using, no surprise Lean techniques to interrogate the process and improve the process. So, you know, a real success story responding to the need. We need PPE smart people on the improvement team that had the skills to actually stand up a process, understand how it flowed and then improve it so that, you know, on a day to day basis, they are improving their output of quality PPE, tenfold, a really an amazing, story,

Mark Graban (22m 56s):
Yeah, that's great. And you know, you've got these examples and I was wondering if you could talk a little bit more about the Catalysis healthcare value network. When, when I, you know, it's been going on more than 10 years and I was there and involved a little bit in some of the early days when the network was smaller and just getting started, but I know one of the guiding principles has already always been this idea of sharing and collaborating across organizational boundaries. So I was wondering if you could just sort of touch on that a little bit more, you've got all these great examples and it's great that you're sharing them publicly here, but can you talk a little bit more about the learning and sharing dynamic within that network?

Paul Pejsa (23m 34s):
Sure. And, you know, frankly, Mark, we've been very blessed. We've got a fantastic members of the network that are willing to share. I think the, the very fundamental thinking is that if we can learn together as peers, we will more rapidly transform this very complicated industry of healthcare that, you know, we've made a big part of, of our lives Mark. So on a, almost a day to day basis, we will get requests coming in from a network member, whether it's during the crisis around PPE or a more general question around standing up the lean management system. And because we have so many people doing experiments across these, you know, 70 or so members within sometimes hours, we can connect say a Children's Mercy Hospital in Kansas City to Seattle Children's Hospital in Seattle to learn a best practice on a huddling with physicians, for example.

Paul Pejsa (24m 34s):
So very, very rapid cycles of learning. And through this crisis on a weekly or even a biweekly basis, we have network members holding up their hands to say, Hey, I've learned something about staff stress or how to redirect on productive behaviors. Southern Illinois Health down in Carbondale, Illinois has given one zoom sharing session on how to reduce staff stress with over 70 individuals, attending that Zoom meeting, asking questions back and forth, Southern Illinois Health sharing their best practices and their presentation.

Paul Pejsa (25m 16s):
And we'll actually do a followup session next week with Southern Illinois health. And we're going to try zoom breakout rooms Mark for the first time to see if we can actually do some training, do a breakout session, then have people come back and report out something that you and I have both seen in life Gemba visits. We're going to try it virtually. We're going to see how the experiment goes. And as the minimal we'll learn something and we can not even adjust, but we think it will be successful. And, you know, we're very thankful that these technologies exist for us, like zoom, that we can actually do things virtually during this crisis that we used to do very comfortably face to face.

Mark Graban (26m 3s):
We're all having to adapt. And I guess so, you know, Plan Do Study Adjust is happening a lot during, During this era. You know, what I I hear you're saying is that there are principles there's leadership, there's diligent effort that there there's no silver bullet or magic beans or instant pudding or whatever phrase you might use when it comes to lean management systems and dealing with a crisis or regular ongoing operations. Right?

Paul Pejsa (26m 35s):
Yeah, that's true. But if there is one, I'll use your phrase. If there is one instant pudding that makes work, I'm going to go back to a name that you shared a few minutes ago. I think a leadership of CEOs like Dr. Eric Dickson, who embrace the principles, not only drive the behaviors in themselves, but expect them out of their direct reports is perhaps the key element. And you and I have both seen where there is executive engagement, especially from the CEO. You know, if, if she or he is out there in front leading it, that transformation can happen both rapidly and it can be sustainable.

Paul Pejsa (27m 21s):
Without that it can be very difficult to sustain. It can revert back to a tool based or project based approach, but you know, where we see network members with the CEO out in front waving the flag, then I think we have a lot of confidence that not only will they transform into a full lean management system, but they will sustain. And in particular, in some of Dr. Toussaint's latest work, if they're engaging the board of directors, so the board clearly understands what, what is meant by a Lean management system and what it takes to lead it. Then we have good hope that when the next CEO is brought into that organization, that he or she will continue that Lean journey.

Paul Pejsa (28m 9s):

Mark Graban (28m 10s):
Yeah. Well said. So Paul, thank you for sharing this good news from a, what, you know, what's happening out there in the health systems you've been talking to our guests again has been Paul Pejsa. He is network director of the Catalysis Healthcare Value Network. And you can learn more at their website As Paul mentioned, there's a lot of great blog posts and white papers, and Catalysis its own podcast called The Lens. There's, there's a lot of great information that's inspiring and educational. So I definitely recommend that to everybody as well.

Mark Graban (28m 53s):
So, Paul, again, thank you. And you'll, hopefully we can, we can talk again sometime. I'm sure there'll be more lessons to be, to be sure down the road.

Paul Pejsa (29m 3s):
Great Mark. Thank you very much for the opportunity to share. I hope our listeners can take something away from this, that they can go experiment themselves and we'll look forward to the opportunity to continue this conversation. Thank you.

Mark Graban (29m 17s):
Thanks again, Paul.

Paul Pejsa (29m 19s):
Bye. Bye.

Outro (29m 20s):
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