From the LEI senior executive series on Lean Leadership
As part of our continuing series on leading lean transformations, the Lean Enterprise Institute interviews executives from a variety of organizations to explore the challenges lean transformations present to senior managers. Lisa Yerian, MD, discusses engaging people, doctors and senior leaders, healthcare reform’s impact, where to start a lean transformation, why she took on responsibility for continuous improvement, and much more.
Lisa Yerian, MD, is director of Hepatobiliary Pathology and medical director of continuous improvement within the Division of Clinical Transformation at the Cleveland Clinic. She joined the staff of the Cleveland Clinic in 2004, became Section Head of Surgical Pathology in 2009, and was elected to the Board of Governors in 2013. Through her work in surgical pathology she first developed an interest in using process improvement tools and principles in the laboratory. An article* published in the American Journal of Clinical Pathology, which Dr. Yerian co-authored, describes how they applied lean principles to improve workflow during the design phase of the Cleveland Clinic’s new pathology lab.
LEI: What motivated you to take on the continuous improvement (CI) and lean leadership role?
Dr. Yerian: When I first heard about lean I was immediately intrigued by its power and simplicity. I come from a blue-collar background. Respect for the worker resonates deeply with me. As an optimist I always see room for improvement, and I love the collaborative nature of the CI work. Once I began to do lean and see people become transformed by the realization of what they could do, I was hooked.
LEI: As I recall, you have some more personal motivations as well.Many families, including my own, didn’t always have healthcare … I see lean as the only way to address these problems and really begin to provide high quality, safe, affordable and compassionate care to all people, everywhere.
Dr. Yerian: I grew up in rural southeastern Ohio. Many families, including my own, didn’t always have healthcare. That always seemed so wrong. Close friends and family members of mine have suffered from poor quality healthcare or no access to healthcare. I see lean as the only way to address these problems and really begin to provide high quality, safe, affordable and compassionate care to all people, everywhere.
LEI: How important is it to have a physician communicating the continuous improvement (CI) message?
Dr. Yerian: I think it depends on the problem you’re trying to solve! The Cleveland Clinic is a physician-led organization; so here, it means a lot. But every organization is different. I think a good place to start for any leader who intends to pursue lean is by doing their own A3. They need to understand what the problem is in the context of their own organization. Our solutions at the Cleveland Clinic won’t solve someone else’s problems.
LEI: The Cleveland Clinic has a distinct leadership structure that carries over to the Department of Continuous Improvement. Could you describe it?
Dr. Yerian: As a physician-led organization the standard leadership structure pairs a physician leader with an administrative leader. Our CEO is a world-renowned cardiac surgeon, and is supported by an executive administrator. Most of our physician leaders retain active clinical practices, exhibiting great expertise in their clinical fields. Similarly, in CI we have a physician leader (myself) who is supported by an administrative lead. Pairing physicians with administrative leaders enables the physicians to guide the strategic direction of a department while maintaining their clinical practice and their administrative partners manage day-to-day operations.
LEI: How did you develop a vision of what a cultural transformation would look like?
Dr. Yerian: Very, very gradually, through many conversations, questions, reflections, learning, mistakes, more reflections, and more learning. I am grateful for the opportunities I’ve had to talk with [LEI CEO] John Shook and other lean leaders. John’s emphasis on “What problem are you trying to solve?” always reminds me to get back to basics. He taught me the most important criterion of a model area: “It has to work!”
I’ve never seen a lean implementation in healthcare that I was overly impressed by, so I’ve had to look to other places. I’ve seen some good examples of visual management tools, and a daily management system, but nothing that really pulled it all together. A lot of people on our CI team do have that vision and experience from Toyota and other places that they’ve worked. They have a pretty clear idea of where we could go. When we’ve been stuck, they’ve generally said we need to get back to the basics.
LEI: Are there any ways that you’ve found to successfully engage people in the CI effort?
Dr. Yerian: Stories are a really good way to engage people. Caregivers want to believe in what’s possible, but their past experiences often make them wary. If you can tell a really compelling story, and show how it benefitted the patient, that’s always good. You have to point out what’s possible: delivering better on our promises, making the care we deliver the kind of care we want it to be. And then highlight successes.
Teams can’t always see the impact of their work; they’re too much in the middle of it. I spend a ton of time in the gemba with our workgroups and I can see the impact of their work. If I can describe that in a compelling way, the teams are inspired. During a transformation people go through the whole cycle from, ‘We’re never going to be able to do this!’ to ‘We can actually do this!’ That’s very powerful.
I am often asked how to engage physicians in CI efforts. I don’t see engaging physicians as any different from engaging other caregivers. There are no universal solutions; the work must address problems they experience in delivering value to their customers: the patients.
LEI: How do you engage senior leaders in continuous improvement work?The organizational leaders need to see, when you’re improving things, that you’re improving the things that are most important to them … It’s not about how engaged people are, or how much time you save here and there, but how the improvement work impacts the most important priorities of the organization.
Dr. Yerian: The organizational leaders need to see, when you’re improving things, that you’re improving the things that are most important to them. We haven’t always been as good as we needed to be at documenting the benefits of our lean transformation work in a way that enabled leaders to see how it supports their priorities.
If anything that you’re working on isn’t a priority, you shouldn’t be working on it. It’s not about how engaged people are, or how much time you save here and there, but how the improvement work impacts the most important priorities of the organization. We’re still working on articulating and sharing the impact of our transformation work.
LEI: Do you have any advice for leaders in other healthcare organizations on where they should start and how to set priorities?
Dr. Yerian: In the very early days our CI strategy was simply to work with the willing. When we started our lean cultural improvement work I went to a conference and asked a number of the speakers exactly that question. Everyone I asked had a different answer. The person teaching value-stream mapping suggested we start by mapping out value streams. The person teaching visual management indicated we should start by putting up visual management boards. The daily improvement speaker said to start by building a daily improvement board.
My advice would be to create an A3 and focus on the problem you’re trying to solve. Then go from there.
LEI: How does the Cleveland Clinic Experience support and mesh with your CI efforts?
Dr. Yerian: “Patients First” is an important element of our culture. The Cleveland Clinic Experience introduced and reinforced an understanding that everyone is a caregiver. What each one of us does every day impacts the patient’s experience.
What we’re doing now is piggy-backing on some of this culture work to say, “Not only do you have a part to play in this patient’s experience, you also have a part to play in making sure that they receive high quality, compassionate, affordable and safe care. You have a responsibility to improve the value we bring to our patients.”
LEI: Has the rollout of the Affordable Care Act had an impact on the Cleveland Clinic’s improvement efforts?Healthcare reform is really the greatest factor that’s driving the call to build a culture of improvement across our entire organization. There’s an awareness that 30 or so CI people aren’t going to be able to do enough. We really need everybody …
Dr. Yerian: It’s huge. It provides a burning platform for us because we expect revenues to fall, and there are increasing expectations and transparency around quality and the patient experience. Healthcare reform is really the greatest factor that’s driving the call to build a culture of improvement across our entire organization. There’s an awareness that 30 or so CI people aren’t going to be able to do enough. We really need everybody thinking this way, and working on it, and have the tools and the skills to improve care. That’s why our CFO and the CMO are asking us, “How do we transform the culture?”
LEI: What’s your vision of where the Cleveland Clinic’s CI organization is going to be five years from now?
Dr. Yerian: In my ideal future state vision we are a leader in continuous improvement, in healthcare and beyond. CI will be practiced daily at every level in every part of our organization. We’ve made a lot of progress, but we have 40,000-plus people.
I think that we will be providing more value to our patients. I think we’ll still have project work for things that are complex or that cross disciplines, but there will be a much higher proportion of improvement work and problem-solving that’s done every day by leaders, managers and front-line caregivers. Five years may be ambitious, but I think the Cleveland Clinic has an amazing ability to move quickly. We already have a culture of excellence after all!
Links with relevant information:
- * “A Collaborative Approach to Lean Laboratory Workstation Design Reduces Wasted Technologist Travel,” Lisa M. Yerian, MD, Joseph A. Seestadt, Erron R. Gomez and Kandice K. Marchant, MD, PhD, American Journal of Clinical Pathology, 138 (2012), 273-280.
- Read the case study: Transforming Healthcare: What Matters Most? How the Cleveland Clinic Is Cultivating a Problem-Solving Mindset and Building a Culture of Improvement.
- Get helpful candid advice from lean-thinking executives in a variety of industries. Go to LEI’s Lean Leadership executive series.