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Welcome to Episode #18 of Habitual Excellence, presented by Value Capture.

Our guest today is Didier Rabino, a client advisor with Value Capture.

Today, host Mark Graban asks Didier to share his experience with the “three systems” — work system, improvement system, and management system. How do those systems work together to form an interconnected operations system? Didier shares his experiences from manufacturing and from healthcare in this episode.

Didier is co-presenting a free webinar on Tuesday, September 15th, called “Leading with Respect: Standard Work for Frontline Leaders” — register here. Thanks to KaiNexus for hosting this event.

Also, check out a white paper co-authored by Didier about some of the experiences at Sutter Health, titled “Pursuing Habitual Excellence” (free registration required).

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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):
Hi everybody. Welcome to Habitual Excellence. I'm Mark Graban, and we're joined today by Didier Rabino. He's a client advisor with Value Capture. Didier, how are you?

Didier Rabino (47s):
Good. Thank you, Mark. Nice to see you.

Mark Graban (49s):
Yeah, it's good to see you. And it's great to have you here. Can you tell the listeners a little bit about your background, you know, your education, you've worked in a lot of different interesting industries.

Didier Rabino (1m 1s):
Yeah, in fact, it's interesting, I started as a cabinet maker, so nothing to do with healthcare. And one day I looked at my 10 fingers and I decided that I wanted to keep them, so I studied engineering. And, and after that I joined Steelcase in England first and after working in France and in '99, my family and I moved to the States to Grand Rapids, Michigan also, we have Steelcase. And after working in office furniture, I worked with Andersen Windows and in 2012, I joined HealthEast in Minnesota working with in health care.

Didier Rabino (1m 48s):
So I started my lean journey in manufacturing in, in France, in the mid '90s and, and moved on from leading operations to supporting operations. And I've done that a couple of times and a year ago in March I joined Value Capture.

Mark Graban (2m 14s):
Yeah. And, and as we explore, you know, we're talking about this main topic today of this idea of three different work systems in an organization. And maybe we can, we can go back and have you share examples from not just healthcare, but, but back in manufacturing. And what were some of the differences in these settings?

Didier Rabino (2m 32s):
Absolutely. Yes. Yeah. Many. And I can start, I'm not talking about the topic, but we talk about systemic thinking and, you know, we, in the, I remember in the nineties, this was late eighties, mid nineties. We, we talked about the tools and, and there are a lot of stories about North American and European companies going to benchmark to your time, coming back with tools and, and always thinking that they were copying the, the silver bullet and the, some of the tools doesn't make necessarily a system.

Didier Rabino (3m 13s):
Right. And I think now it's only over the past, maybe five to 10 years, that the notion of systems thinking really evolved and the penetrating industries, especially in manufacturing. And so the idea of a system is the quality of all of the parts, doesn't mean that you have a quality of the whole. The quality of the system is more dependent on the quality of the internet connection or the paths of the tools, more than the, the quality of each tool. It's like, you know, the example of a car, you may have a best parts, you know, to make a car that doesn't make mean, but you have a car.

Didier Rabino (3m 59s):
If I put the V8 engine on my CRV, I don't even have a car anymore, it doesn't work. So, so we have to understand the connectivity of all of these systems. And what we believe is that we have a three main systems in operations, manufacturing, healthcare, or service industries, or one of the systems is the work system, which is all of everything that we do in order to add value to the customer. So that is okay, how do we standardize the work? How do we connect the each work? Or it's a standardize work? How do we work together? How do we flow the work? And another system is the implement system, which is okay, what do we do in order to get better, to develop the pole, to improve our processes, to be better at anything we do. And the management system is a, the third, a big system.

Didier Rabino (4m 59s):
How do we support on an ongoing basis, both the work system and the implementing system, and how do we provide the alignment in direction in order to, to improve and to support these systems? So that's, in a nutshell, this is the understanding that these three systems need to, they need a help from each other and they need to be interconnected. So they make a bigger system, which is maybe what we call the operation system.

Mark Graban (5m 26s):
Hmm. So if we think about, let's talk about work, the work system for a time about the improvement system and the management system. And like I said, this is all interconnected, but the work system would include maybe from a lean methods perspective, the standard work, the training that, you know, whether you're using TWI training within the industry, other methods for how do we design, document, train, execute. Yeah. Work. Can you elaborate on, on story?

Didier Rabino (6m 1s):
Sorry. So the work system, sure. So the work system will be all of the tasks, all of the activities, all of the connections. And that will say all of the pathways, all of the various streams that enable value to move from a supplier to a customer. So this is no, in a, when I was at CKS, make making a case cabinet and <inaudible> sees, how do we partner the sides together and the tops of the cabinet and the suspension sets into, in order to make a final product, which is a cabinet. So it's understanding what are these, value added operations, what are the components that we put together, and how do we put them together and how do we connect with our internal or external suppliers?

Didier Rabino (6m 48s):
So this is really focused on the value added work. When I think about the training, because it is if the training would be necessary to, to get, to provide the capacity for someone to do the work. If it, if we think about the, the training to improve a capability or to develop a cross training, but would be cutting back more to, to implement improvements. And because of that, we be connected to making something better. So instead of having one person knows how to do the job, if we need to have four or five, that could be part of improvement system.

Didier Rabino (7m 28s):
This systems is like a Venn diagram, are they connect? Okay? And I there's sometimes a blurry zone between these, the systems, but they are totally the keys to interconnect these systems. They need each other. So that will be the work system for primary care setting, to be all of the activities that we, we need to do in order to, to provide, to meet the customer needs to, conduct preventive care. So this is really to understand what is going to add value to meet the needs and the wants of a patient.

Mark Graban (8m 15s):
So when you come into an organization, the work is already happening.

Didier Rabino (8m 22s):

Mark Graban (8m 23s):
What makes it a work system, or how do you start? Is it a matter of formalizing or is it a matter of stepping back and asking to your point about value? Do we really understand customer needs or are we just doing it the way we've always done it?

Didier Rabino (8m 39s):
Yeah, exactly. So the systems exist because our customer needs are being met, but the systems may not be like you say, formalized. So the formalization of the system will be in terms of identifying, what is the purpose of the system? How do we measure the performance of the system? What is the standardized work of the system? How do we report on the system? So these are some of the tools or some of the components of the system. So usually it's a question of formalizing and we know that systems drive behaviors, drive what, how people are going to act.

Didier Rabino (9m 24s):
But if we don't formalize the systems, we have accident or how say behaviors, defacto behavior. So if we want to really manage the culture and the sum of collective behaviors, we have to really understand that and have the systems and formalize them to survive. We control, or we manage our systems in software systems managing us. So that, yeah. So say that again, or we may, are we managing the system or is the system managing us? That's an interesting thought, right?Yeah. So very, you know, very often you see, we have a behavior in organizations that are not the behaviors that we like to see.

Didier Rabino (10m 8s):
They are just the, the de facto behaviors. And I have, I'm going to take an example. So I used to work for a manufacturing company and there was a system which is a budget setting. Okay. So all of the companies have a budget or forecast city. I knew everybody knew that the budget is done in three phases and that each phase management, we want to reduce the budget by 5%. So if you want to be in the green at the end of a year, you are going to plan for your budget to be reduced by 5%, twice. So you are going to what we call sandbag and 10% of reserve in order to end up where you should be.

Didier Rabino (10m 57s):
So that's not a normal, a good behavior. That's so this is the system is managing a behavior that is not acceptable, but no, this is not because we have bad people. It's just, the system is not designed the right way. So I don't know why when I devout in the one, one, one example that comes to mind, but no, where I was totally, I had to play the game.

Mark Graban (11m 23s):
Right. So, well, I mean, I think of dysfunctional behaviors, you know, I'm thinking back to my days of manufacturing, people literally hiding and covering up quality problems. The people doing that are not bad people, unethical people who don't care about quality, they were being driven to do that by, I would say the management system, the culture of the organization, sadly.

Didier Rabino (11m 49s):
Yeah. Yeah. Oh, I know that example in healthcare, a healthcare organization where, you know, we have these messages online, the health care organization, right respond to the patients. So you don't need to make a call, or if you make a call the computer system is going to manage that. And this organization pay the $5 per response in order to incite the physicians to, to respond. Well, that behavior led to very, very challenging discussion when we started to new <inaudible> leveling the wall, because some of the messages were just, okay, thank you.

Didier Rabino (12m 38s):
And that was $5. And so some providers didn't necessarily want to give away these five bucks. So it was, so again, that's not the behavior. And so the continuous improvement was, you know, was in challenging because of this compensation system.

Mark Graban (12m 58s):
Yeah, yeah, no, they're yeah. Compensation systems will drive behaviors. It's not, shouldn't be surprising even if it gets dysfunctional. So let's talk in the curious, you know, if we can talk about improvement systems, what's the difference between an organization saying, Oh, wait, we do improvement. Or we have, you know, our organizations have a statement on their website or on the wall that says we are a culture of continuous improvement. What makes it an improvement system?

Didier Rabino (13m 28s):
Yeah. The improvement system will be, we will have a system of continuous improvement when we have a connection. Again, it's a question of connection between what are the, the objective or the target of the organization. How do these targets get cascaded down to, down to the frontline? So how is this alignment of goals? Our, the goals have the frontline meaningful, meaning for example, dollar hours are not usually a good metric at the frontline. So, so something that they can measure, it's something that they can measure and can see in a, almost in real time.

Didier Rabino (14m 14s):
And very often we see teams that don't even have a scoreboard. Okay. So I don't know if you've ever been to a basketball game with auto scoreboard, but I haven't been to one that must be really boring because you don't even know if you have, if your team is winning or losing and how many times, you know, we have teams work and don't even know at the end of the day they won or they lost the game. So, so that's this connection of targets, of goals, but these are meaningful, purposeful, and the connection to the activities via hypothesis and the experiments that teams are making.

Didier Rabino (14m 57s):
So that is, you know, all of these connections. So it's not change. It's really improvement with a purpose.

Mark Graban (-):

Didier Rabino (15m 3s):
In our doctor to make tomorrow a better day. So if I do this thing, my expectation is that tomorrow will be a better day. I will have less issues are my customers will be more satisfied or her, I will have less pain to do my work, these types of things. So that will be the connection of the true systems, sort of just a tool.

Mark Graban (15m 24s):
And, you know, I mean, so yeah, there's risks that organizations, I have seen this happen, an unheard of risk where a healthcare organization goes and visits and other healthcare organization, they see the tools that are used. They see a board of a certain format and they take pictures and they take home copies of cards or an 83 template. Copying those tools back to what you said earlier, having all of those tools, doesn't make it the same improvement system. What can we do about that?

Didier Rabino (15m 58s):
Yes, exactly. And this is what, you know, in a, in architecture, this is what we are in sociology, we call <inaudible> diffusion. So we see something and it's diffused to another situation and we lose your sense of what this was made or developed for. So organizations have different, you know, my former boss used the term of baskets. Like if you watch chop on TV, you know, the cooking show and every organization has different components or in their baskets, you know, they have different products, different culture, different history. And you have to understand what you have in your basket in order to make your system.

Didier Rabino (16m 41s):
Or so two organizations are going to have two ways to approach <inaudible> Their design, you cannot be cut and paste. So it's a very, we need to move beyond the tools. I think we have a common friend who said, you know, when tools leave the fools follow, and this is not working out the tools, but the purpose that the tools in our meet provide. So it's understanding its purpose and try to maybe, maybe these, the purpose of a specific tool, maybe a copy of the tool itself, it is very dangerous to, to call people to, in fact, now I remember one, a friend of mine, I coached her who was a value stream manager, went to benchmark another plant and came back and copied the signs to identify the part in the shop and had a path A in, a path B in, and so the signs all had in, the law without understanding, but the plant, he benchmarked had five full lanes with in and out, which was not the case of his.

Didier Rabino (17m 54s):
So it's, it's a again, but that is a good example of the fusion, moving something without really understanding the principles about the two need.

Mark Graban (18m 3s):
Yeah. So before we talk about management system, yeah. You've already talked about systems and behaviors, and we think about tools copying a tool without sharing some of the underlying principles can be counterproductive if not dangerous. You know what you said a minute ago reminded me. I watched Hamilton over the weekend and Alexander Hamilton tells Aaron Burr, if you stand for nothing, you'll fall for anything, I think is the, the quote. So why, why is it important to stand for certain principles to help make sure that say for example, an improvement system is helpful and productive?

Didier Rabino (18m 45s):
Yeah. Yeah. So, so I think in terms of a fully implemented system, I like to think about two different perspectives for the improvement. One is what do we need to do in order to go back to standard? And that is really tight connection with a work system. So when we, we have standardized work is a hypothesis that should be validated every time that you follow the standardized work. And if this hypothesis is not validated at a given time, what is the idea? How do we identify with the effect of a process defect? So that is the connection between the implant system and the work system, one of the connections.

Didier Rabino (19m 27s):
So what we stand for is that we have a hypothesis that we are going to enable the team members to be successful 100% of the time at following their standardized work, which is expected to be the best way we know to do the work. So that is directionally we want to be, to provide the ability, the capacity to always be successful at following standardized work, if we are not what happened.? And can we learn from that, so we minimize the chances from that to happen again? So that's going back to standard. The other side of the price descent is how do we improve the standard?

Didier Rabino (20m 8s):
So how do we raise the bar? So instead of doing the work, that requires 12 motions, can we get down to 11 or 10?

Mark Graban (20m 17s):

Didier Rabino (20m 17s):
So minimize the work content so that we'll be getting better. So these are the two different perspective, at least two, two of the multiple perspectives. So that, that is not connecting the improvement is connected to the walk system and we need to make this connection very, very tight.

Mark Graban (20m 35s):
And I mean, I really like what you said there, there's this principle. I, it reminds me of something on Darryl Wilburn who was with Toyota, and Kentucky and Texas for a long time for him say, you know, "it's the leader's responsibility to create a system in which people can be successful." And that, you know what you said reminded me of that, where it's not, we don't have a principle that says, well, if people aren't following the standard work, we're going to just blame them for it, as opposed to looking at why was it not possible that that's a very different mindset, right?

Didier Rabino (21m 13s):
Yeah. And it's really thinking about the responsibility of the leaders in all taking responsibility, for, everything goes wrong. So are we providing the workers, the employees, with a system that makes a very difficult to do the wrong thing and very easy to do the right thing. So that is designing systems that are going to minimize the number of decisions, for example. So the more decisions we have to make, we are people, so the more chances who are going to have to make a mistake. So it's really the responsibility of a leader to provide a safe, you know, system.

Mark Graban (21m 57s):
And what you said there about the leader being responsible for everything that happens. That's something that Paul O'Neill talked about quite a bit. And he took that very seriously. I admire leaders who share that perspective because it's easy or, or, you know, often leaders seem to delegate responsibility instead of maintaining responsibility for the outcomes. They may delegate responsibility and maybe this brings it back to management system. The CEO is not the only manager, the CEO sets the standard for the culture and behaviors, but I'm always glad when somebody reminds me of mr.

Mark Graban (22m 46s):
O'Neill talking about the leaders, the leader being responsible. That doesn't mean they have to do it all, right?

Didier Rabino (22m 53s):
No, it takes a lot of humility to say I am responsible for that.

Mark Graban (22m 57s):

Didier Rabino (22m 57s):
And we don't always find this level of humility. Yes.

Mark Graban (23m 4s):
So, you know, we're talking about leaders, so maybe tell us more about the management system. So we have the work system, the improvement system and the management system. Tell us more about that last one.

Didier Rabino (23m 15s):
Yeah. So the management system is we'll be providing the direction, the alignment and the support of these two systems. The employment system, and the work system cannot sustain and improve on their own. So if I take the example, a famous example of the assembly line, and I can take apart, maybe have a pilot with health care, but you have a work system thinking of a progressive line with fat, usually five people in our, in car manufacturing. And I have the same in making fight cabinets or windows. And we designed the walk system so that we can see when problems happen.

Didier Rabino (24m 1s):
When problems happen, the improvement system, which is to go back to normal kicks in automatically, because if it doesn't kick in the work system is going to stop, the flow is going to stop. The management system is there in terms of structure with where we have one team leader for five, in this case, frontline employees. And we have a structure of response. We've a responsibility of the team leader, of the group leader, you know, all of us on. So we have a structure that is in place in this case, it's a five, four, one or a one, four, five in order to support both the work and the implement system.

Didier Rabino (24m 45s):
So, so in any, it could be, no, the management system is also the set of policies of process ideas. You know, what is going to give us the alignment? <inaudible> all of these, you know, structure and systems, how they have to support both the improvement of the work system. Because at the end of the day, we see is what do we do? We do the work and improve a work and measurement system should be there to support these two things. What else is there to do no. So yeah,

Mark Graban (25m 12s):
Supporting the people, having the right systems in place to help drive the results that we need or that we want?

Didier Rabino (25m 21s):
And improve this result continuously, and not every level in the organization, it could be the frontline team level or it could be at the organization level to understand, okay, how are we, how are we going to differentiate yourself in the market in three to five years, which is another type of improvement system. Yeah. But every employee is connected to the work system and the <inadubile> just a different scale, a different zone.

Mark Graban (25m 49s):
Hmm. So one of the things we wanted to mention here today, we've had some announcements at the beginning of other episodes, but, you know, Didier, you played a big role in developing a white paper, not just the writing, but being involved in this excellent work at Sutter Health. And so there's a white paper that's been published. People can find it at What are your kind of your main, we can do a whole episode about the white paper, but you know, at a high level, what was unique, what's compelling about the work that Sutter for you that, that would, you know, that others should go read about?

Didier Rabino (26m 31s):
This is, you know, this, this is something that I always, always amazes me is not only the transformation of processes and are achieving absolutely fantastic results, but it's for transformation of the people. And it's how people grow in terms of respect for each other, between leadership and frontline employees, how they think as a team, how they see things, it's like getting them a new pair of glasses and suddenly they see things and they cannot forget these things.

Didier Rabino (27m 13s):
And you know that in one year, five years, 10 years, they will still have this pair of glasses and they will continuously think and see differently. That's what, and, and you have, you know, sometimes you see tears, okay, that's people realizing things I need emotional side is so powerful. So, so I think there are a lot of things that this team did, that is very impressive. I must say, imagine, for example, eliminating patient wait time in a primary care, which is what we're able to demonstrate as a possibility.

Didier Rabino (27m 54s):
Eliminate, meeting 1% of patient needs. So that was, you know, getting to the ideal. We strive for the ideal. We implemented the attack time-based flow. So every 10 minutes a new patient comes and we synchronize all of the flows of patient flows, the location flows, the medical assistance rules. So, so it's how we, we can really apply some of the concepts from manufacturing to, to primary care and to healthcare in general. So this is possible eliminating, and we know that, you know, patients are different.

Didier Rabino (28m 36s):
Okay, that's what we hear a lot, but still you can manage these variation in terms of patients without adding artificial variations, and we can flow. We can have one piece flow in healthcare.

Mark Graban (28m 47s):
Takes a lot of work.

Didier Rabino (28m 50s):
It takes a lot of work. Yeah. But it's not because things are difficult, but we do not dare, it's because we do not dare because they are difficult.

Mark Graban (28m 58s):
So the paper really does a great job of laying out what was done there and, and how everybody went about it. The full title of the paper is Pursuing Habitual Excellence, sort of health designs and new primary care process and encourages learning experimentation and continuous improvement. So thank you for that work and for helping share it. Didier.

Didier Rabino (29m 24s):
Thank you, Mark.

Mark Graban (29m 24s):
And thank you for sharing here on, on the podcast, time flies. When we get our guests talking about interesting topics that they care about. So we'll, hopefully we'll get to do another one of these sometime soon.

Didier Rabino (29m 41s):
Sounds good. Thank you. Nice talking to you.

Mark Graban (29m 42s):
And it's good talking to you. Well, again, our guest has been Didier Rabino. He is a client advisor for Value Capture. So thanks to everybody for tuning in and listening. Thanks again, Didier.

OUTRO (29m 54s):
Thanks for listening to Habitual Excellence presented by Value Capture. We hope you'll subscribe to the podcast and please also rate and review it in your favorite podcast, directory or app to learn more about Value Capture and how we can help your organization on this journey to habitual excellence, visit our website



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