Stuck in the Middle Of a Lean Leap – Part 2

This is Part II of a two part series – part 1 here

Robert P. Thames, FACHE, FHFMA, President and CEO, Northern Arizona Healthcare


“You are here” and the Gretzky factor[i]

To assist in gaining perspective on ‘where are we now?’ in the context of an organization’s improvement or lean journey, a framework is offered as a combination GPS – Gauging (your) Performance System – and compass (‘where is true north?’) tool; see tables: Gauging Performance System (GPS) Evolution and GPS Illustration. Four stages of improvement evolution are delineated below.

Stuck GPS - Gauge Perf System Table 1-page-001Stage 1: Me Too

An initial step on the improvement journey is often marked by training of some staff in various tools. Because we have some tools, training and projects, the feeling is that “We are doing lean.” A few may be committed to it, but many/most are still in the ‘wait and see’ camp. Wide variation among senior leaders is common. These first steps are the easiest.

Stage 2: Whoa

In this next stage, acknowledgement and growing awareness that there is much more to this path and an early sense of greater potential is realized. The desire to tap that potential leads to a deeper, more serious commitment. However, leaders begin to learn that true personal change is required; it is not for everyone. The SLT needs to do things differently. There is an appreciation that now “We’re learning to learn” and perhaps that “We have only just begun.” This is steep, uphill work.

Stage 3: WOW!

At this point, an established discipline, reflected in a cadence, and significant, undisputed evidence of progress becomes self-perpetuating and motivating. The realization that “Hey, this really works” is followed by recognition that “We are serious improvers.” The earlier variation among the senior leader team significantly reduces as a natural selection process evolves. Many/most mid-managers are engaged. The SLT feels that it flirts with, or is frequently in, a ‘zone’ or what is described as “flow[ii].” This sense of being in full stride is engaging – exciting in a focused yet calm way.

Stage 4: Huh?

The most advanced stage is marked by a natural, sustainable rhythm that is perceived internally as simply “How we do it here.” For staff, the environment is like water to fish: most staff are hardly aware of the infrastructure to support the improvement; they reflexively do things this way because their behavior has been deliberately encultured. Leadership is characterized as adaptive [iii] and the accountability current flows up [iv]. The scope of efforts involves and engages patients, families and suppliers on a regular basis.  Leaders have the humility to understand that some of their SLT, including themselves, and at least parts of their organization will variously cycle back and through stages three and even two. Staff and managers often self-correct; if not, leaders identify this behavior and have the ability to coach or otherwise address it appropriately.

Along with the stages of improvement evolution, eight factors examine different facets of the organization’s improvement maturation in four categories: Senior Leadership, Change Management, Focus, and People Development (see tables).

Stuck GPS - Illustration Table 2-page-001


Organizations that begin a lean/improvement initiative more often than not first develop their Process Focus, Measurement and Resources/training (Factors 5-7). Emphasis is on tools, analysis and discovery. Many get stuck here and do not adequately address the first four factors. However, evidence suggests that what distinguishes quantum improvers from non-starters are an Accountable Change Model, a high level prioritization process, and a “speed to execution” culture of accountability inherent in the Leadership and Change Management categories (Factors 1-4)[v]. These areas emphasize implementation and dealing with resistance to change. This is consistent with Schilling’s assertion that a common stuck point is when local area leaders do not understand or embrace three things: 1) true leader alignment and prioritization, 2) the need to develop the capacity to improve, and 3) capability to execute using ‘rapid iteration cycles’.

A SLT’s discovery that striking the right balance between achieving performance and developing the capability to perform is critical to sustainability of results. The rate at which such discoveries are collectively made determines how long a SLT remains stuck.

What else can a senior leader team do to develop “unstuck capability?” A starter list includes:

  1. Anticipate common stuck points – maintain a healthy paranoia and periodically identify ‘we are here’ using the GPS tool
  2. Encourage courage – support calling a “the-King-has-no-clothes” time out to gain perspective; use an outside view and be coachable. Take the long view.
  3. Unify leadership commitment – expect personal change and SLT ownership of non-delegable factors. Warning: if this isn’t hard, you are not doing it.
  4. Learn from others – Be curious and practice humility. “It takes a wise man to learn from his mistakes and an even wiser man to learn from others’ mistakes” – Zen proverb

The changes required for improvement today are increasingly immune to past approaches. Greater senior leader team emphasis on learning to unlearn, getting comfortable being uncomfortable (leading without answers vs. ‘never in doubt’), and self-organizing (organic chaos vs. mechanistic order) is advised. The inconvenient truth is that such emphases are counter-intuitive, often counter-cultural, and require personal change. Which is why ‘unstuck capability’ is required for organizational improvement.

[i] Hockey great Wayne Gretzky is credited with the notion: “Most players go to where the puck is; I go to where the puck is going.”

[ii] Csikszentmihalyi, Mihaly 1990, Flow: The Psychology of Optimal Experience, New York, Harper & Row, Publishers, Inc.

[iii] Heifitz, Ronald, 1994, Leading without Easy Answers, Cambridge, Belknap/Harvard University Press

When dealing with “technical change,” where the problem is clearly defined and the solution is relatively straight forward, the traditional approach may be sufficient. However, because we are dealing with increasingly more “adaptive change,” where the problems are not clearly defined and new learning is required to address them, a different leadership approach is needed.

[iv] Connors, R. and Smith, T., 2011, Change the Culture, Change the Game, New York, Penguin Group, Inc.

[v] Caldwell, Butler & Poston, “Cost Reduction in Health Systems: Lessons from an Analysis of $200 Million Saved by Top-Performing Organizations,” Frontiers of Health Services Management 27:2



Robert P. Thames is a progressive healthcare industry leader with over 25 years of strong results in both operations and consulting within matrixed, multi-site/multi-function environments. Excels in strategy execution, physician partnerships, care system operations, performance acceleration, and managed care.

Passion for leading complex healthcare organizational change and helping leadership team accelerate pursuit of operational excellence and world class performance.

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