5
UNLOCK THE GENIUS AT THE BEDSIDE (OR AT THE FRONT LINE)
Take—and implement—suggestions for improvement from your workforce.
The last two chapters have described how leaders can lay the groundwork for massive change by reshaping their organizations. But how, practically speaking, do established organizations actually unleash possibility? What’s the secret to a company that doesn’t simply talk about supercharging its performance, revolutionizing its industry, or saving the world, but actually gets the job done?
The best way I can think to answer this question is to tell you about a tiny newborn named Maci, born 17 weeks prematurely at one of Intermountain’s hospitals in 2009 and weighing in at just over a pound. Her young life hung in the balance—babies born so early have less than a 50 percent chance of survival. Even the slightest error on the part of caregivers could have proved fatal. Given her fragile state, you would presume that caregivers would have taken care to keep interventions of all kinds to the absolute minimum. In fact, throughout her stay in our neonatal intensive care unit (NICU), Maci experienced in excess of 1,200 pokes in the form of lab tests, intravenous catheter placements and manipulations, and other procedures, many of which were painful or noxious.1
To be sure, we weren’t the only ones who were poking newborns a lot. At most hospitals, it remains standard practice for caregivers to subject newborns to frequent needle jabs in order to run various blood tests. That’s a lot of pain, and newborns feel it. As studies have found, receiving more than about 70 pokes can injure the brains of babies, resulting in developmental issues that show up by the time these children are in grade school. Frequent pokes also subject babies to increased risk of infection.2
As it turns out, a large percentage of these pokes aren’t even necessary for the care of babies like Maci. Rather, they result from processes and procedures that have been adopted and become routine over time. In a NICU, caregivers might have established a process to conduct a certain kind of blood test on newborns each Monday. They might have given this test to all patients, not ascertaining for each individual case whether a baby really needed it. Or doctors might be ordering tests that are nice to run but aren’t strictly necessary, without considering just how many pokes other caregivers might have to make to obtain necessary blood samples.
A great deal of care happens by force of habit. Caregivers perform tests and other interventions because they were trained to do so, without stopping to ask whether the science really backs up their actions. “We find that vast amounts of care is happening behind the scenes that may or may not actually benefit the patient,” observes Dr. R. Erick Ridout, a neonatologist at Intermountain’s St. George Regional Hospital. “But if we don’t know about it, we can’t actually figure that out.”3
Determined to improve how we care for infants, Ridout in 2008 created a database and an ecosystem of care called POKE (an acronym for “preventing pain and organisms from skin and catheter entry”) that allowed team members at his NICU to track every decision they made while caring for patients.4 For the first time ever, caregivers would have a sense of what care felt like from the patient’s perspective, empowering babies who otherwise lacked a voice. Mapping out each step in a care process that included multiple caregivers, they would know the sum total of pokes infants experienced. With that information, they would be able to question existing protocols and devise new ones that, by rendering care simpler and more efficient, minimized pokes.
Analyzing the data, caregivers in Ridout’s unit found, in his words, that “the vast majority of things that were occurring in our NICU were not adding value. It wasn’t that we were providing bad care. We just were providing care in established ways, and we started questioning it and found that we could eliminate a tremendous amount of it.” Little by little, Ridout and his colleagues worked on improving protocols to eliminate unnecessary tests and other procedures and to make care safer. “Each day we tried to get a little bit better, a little bit better, identifying what didn’t add value.” Success led to more success—a flywheel effect that continues to this day.
Relentlessly assessing whether every care decision added value to each patient resulted in massive reductions in the number of pokes babies experienced—Ridout’s NICU eliminated roughly 11,000 per year. Were Maci to come to Ridout’s NICU today, she would experience about 1,000 fewer pokes with no adverse effects on her treatment. This more efficient and humane care is also safer. To take but one example, bloodstream infections from central lines are extremely dangerous and almost entirely avoidable. Many NICUs around the country are happy if they go a month without seeing one such infection. Thanks to process improvements made as part of POKE, Ridout’s NICU has gone more than 13 years without a single infection as of this writing. Eliminating care that doesn’t add value also lowers cost. Over a little more than a decade, reducing pokes at Ridout’s NICU saved our system almost $3 million.5
Maci was one of the first babies whose care experience was tracked so caregivers could aggregate the number of pokes she’d experienced. Today, she’s thriving and has come back to visit with Ridout annually at the NICU’s Reunion.6 POKE, meanwhile, has been so successful that we’ve rolled it out to all of our NICUs. In just a single year, our NICU babies experienced 150,000 fewer pokes. That’s a far more compassionate way to care for babies who are already facing challenging health problems. Of course, eliminating so much care that doesn’t add value also means forgoing the revenue it would bring in—about $50 million each year once implemented across the Intermountain System.7 But we decided we simply had to introduce POKE in our other NICUs—it was the right thing to do for patients.
In 2017, inspired by POKE and other local improvement initiatives underway at Intermountain, we introduced a standard, system-wide process for improving how we work as part of our restructuring efforts. Now all of our teams could help to improve how they cared for patients. This initiative, which began under my predecessor, has played a huge role in producing our systemwide gains in quality, safety, and patient experience I described earlier. And since we’ve set specific goals related to the adoption of value-based care and population health, our improvement process has allowed us to move much more aggressively toward a disruptive business model than we would have otherwise. Hearing of our success, organizations from over a dozen countries have visited Intermountain to learn about our system for organizing improvement efforts for our people.8
As we’ve learned, the secret to affecting radical change in an organization is not a particular technology or strategy. It’s something far simpler: empowering everyone to make small strides forward each day. As leaders, we should enable frontline teams to reflect constantly on what they’re doing, to make incremental changes, and to take responsibility for their results. We must set clear goals, measure performance, and implement a way to improve operations.
Reflecting on POKE, Dr. Ridout notes that, “We’re not doing anything novel. We’re just doing it. That’s the difference.” It is indeed. Most leaders in healthcare and beyond know about continuous improvement, and they also know about specific methods like lean, Six Sigma, or the Toyota Production System that originated in industrial settings. This all sounds like fancy business school or corporate lingo that can make eyes roll. But the heart of it is simple. How do we do better together? Many leaders don’t embed such methods as deeply as they might in their own companies—a failure that is also a significant opportunity.
If you haven’t made continuous improvement a central focus in your organization, I hope you will. Organizations that are constantly striving to improve are simply better places—nimbler, more energetic, more innovative—because they’ve unlocked their greatest resource, the genius and passion of their people.
REVOLUTIONIZE THE CULTURE
As we’ve seen, an emphasis on improvement unleashes workforces in the first instance by embedding a strong culture of improvement. Rather than take for granted how work gets done, people learn to spot flaws, look for root causes, and make changes. They develop a critical perspective regarding improvement as a core part of what they do, the pathway to potentially massive accomplishments over the long term. They come to feel more comfortable speaking up and welcoming the contributions of their peers.
This was certainly the case with POKE. As Dr. Ridout relates, the essence of the program wasn’t the database. It was the practice of “evaluating every single decision we make, action we take, resource we utilize from a patient’s perspective, and if it doesn’t add value, then we’re going to stop it.”9 Embedded in this practice was a shift in cultural values, with a new emphasis on putting patients first, tracking performance, probing for failures rather than ignoring them, feeling deep respect for frontline caregivers and their contributions (more on this in a moment), cultivating an atmosphere of psychological safety so caregivers and family members can raise issues, and striving for excellence.
Similar values have marked the culture of improvement at Intermountain generally. As Guido Bergomi, executive director of our Office of Patient Experience, remarks, teams at Intermountain increasingly have begun to move away from a culture of competitiveness and ego toward one of “caring and learning.” They are aiming to reach “a much better place of talking about our processes and what could or did go wrong, asking how do we prevent it from going wrong again.”10 Dr. Mike Woodruff, an emergency room physician and senior medical director for our Office of Patient Experience, agrees, describing our emerging culture as one of “Ownership, accountability, and transparency, with the vulnerability and the curiosity to say, ‘What are we doing wrong here? And what can we learn to get better?’”11
Instilling an improvement-focused culture and all that comes with that is not easy, whether in healthcare or other domains of performance. Wes Johnson, veteran coach and the US Olympic Committee’s 2019 Paralympic Coach of the Year, finds that his elite athletes do much better when they focus not on some big performance goal but rather on making small tweaks to what they do on an ongoing basis. And yet, he notes that some athletes don’t like the incremental approach. Rather than starting small and chipping away at a challenge, they want to charge in and tackle what they perceive as their biggest challenges.
Athletes can also struggle with the idea that improvement isn’t always a linear process. “On the quest for progress, there’re a lot of hard days,” Johnson says. “We’re just very up front with athletes about that and making sure that they understand that that’s part of the process, that it’s not going to be easy, and there are going to be some failures along the way.”12 Athletes must begin to see failures in a more positive light—as opportunities for growth. They must learn to trust the process, understanding that if they stick with it, small improvements really will deliver big results in the end. Some athletes can’t make this shift, and in those cases, Johnson has had to let them go. But many can and do.
The bottom line is simple. We want to create a culture where people are curious to learn more, have the tenacity to do better, and grow from failure.
I first discovered the strains and stresses that come with embracing an improvement-focused culture during the early 2000s when I introduced an improvement initiative at Cleveland Clinic. Many doctors resisted, perceiving it as both overly bureaucratic and a challenge to their status as experts. They protested that we were a health system, not a factory, so we shouldn’t import industrial process improvement methods and expect them to work.
The name “continuous improvement” does sound somewhat formulaic and cold—especially in a setting that is all about caring for people. Further, improvement methods go against the grain of medical education. During their training, most young doctors serve as apprentices to established physicians in their field, doing the grunt work in exchange for a chance to learn under a master practitioner’s watchful eye. Young doctors usually don’t learn how to troubleshoot a system that isn’t working well—the emphasis isn’t on challenging existing practice and improving it but on respecting one’s elders and copying what they do.
More recently, the introduction of continuous improvement at Intermountain prompted resistance from some administrators at our local facilities who felt that we were imposing a way of working upon them. Protective of their autonomy, they didn’t like that we were going to closely measure performance and hold them accountable for achieving specific goals.
There is no shortcut to dealing with such resistance. We must push through as compassionately as we can. My team and I have done that, preaching the gospel of continuous improvement as well as its underlying goal, providing the safest, highest quality care to patients at the lowest appropriate cost. To remedy gaps in medical education, we’ve invested heavily in training physician leaders throughout Intermountain to nurture improvement efforts by staying alert to problems, staying humble, and driving toward relentless forward progress.
This ongoing effort has paid off. Over time, resistance has receded, and our desired culture has taken hold. In general, leaders and teams across Intermountain have learned to treat failures as learning opportunities and work together every day to make incremental process changes. When queried, individuals on most of our teams report feeling safer than they had in the past to bring issues to light. The shift in mindset has been, in Woodruff’s estimation, nothing less than “a revolution for Intermountain.”
AN ORGANIZATION OF PLAYERS, NOT TOURISTS
What were you doing at the age of 17? Hanging out with your friends? Working at a minimum wage job? Bain & Company chair-woman Orit Gadiesh was watching senior military and political offi-cials wage war in one of the world’s most volatile regions. Reporting for mandatory military service in her native Israel, she was assigned to assist the deputy to the chief of staff of the Israeli Defense Forces (IDF). In this capacity, she attended meetings of the country’s top brass in their war bunker during Israel’s so-called “War of Attrition” with Egypt and other Arab countries during the late 1960s. Her job duties were menial: serving coffee and passing out documents. But the opportunity to observe the country’s most senior military and political officials in action was invaluable.
As she recounts, one leadership lesson she learned stands out above the rest: the importance of consulting with frontline soldiers and understanding their reality when making operational decisions. Senior leaders, including the IDF’s chief of staff and minister of defense, huddled often with frontline soldiers to exchange ideas. Officials also led troops themselves on the front lines rather than staying sequestered in their bunkers. “People always say that that’s the way armies should operate,” she relates. The Israeli Army actually did so, and it gave them an operational advantage. It was also “one of the reasons that so many high-ranked officers have been killed in the various wars. They really are up on the front lines.”13
In gleaning knowledge from frontline soldiers, the leaders Gadeish observed weren’t micromanaging. Although they expressed their opinions and gave advice, they let the frontline commanders make final operational decisions, even though these commanders ranked much lower than they did in the chain of command. “That’s a lesson you never forget,” Gadeish says. “I learned this pragmatism. It’s not about lofty things. It’s about doing what really needs to get done in order to be successful in the next thing we have to do.” To help an organization execute well, leaders must check their egos at the door and trust the judgment of frontline personnel. They might weigh in, but they must give the front line a certain amount of autonomy to adapt strategies to the operational realities on the ground.
Methods for improving how work gets done also empower front-line employees, another way that they unleash workforces to execute big changes. In driving improvement programs, leaders set their egos aside, respecting the judgment and expertise of frontline personnel and truly listening to them, just like the Israeli generals did. Rather than micromanaging changes to how work gets done, they adopt a servant-oriented mindset, seeking to support improvement processes in which employees themselves generate the solutions.
In Dr. Ridout’s words, leaders under the POKE approach “massively invest” in frontline caregivers “every single day by valuing what they say, empowering them, and oftentimes implementing the care they recommend.” They also give caregivers the tools they need to capture the voice of patients, such as the POKE database. There is “genius that exists at every bedside across our organization,” Ridout says. With continuous improvement, leaders seek to leverage and unleash that intellectual power.
Since 2017, Intermountain’s systemwide improvement efforts have served to unleash the genius of frontline caregivers as well. To engage caregivers in daily improvement, we’ve instituted a system of morning frontline huddles across our organization. These are quick, 15-minute meetings in which caregivers report data from the past 24 hours and alert their colleagues to problems that have arisen, bearing on safety, quality, access to care, and our stewardship of resources. If a local team can resolve a problem on its own by making an operational change, great. Otherwise, the local team escalates the issue to managers and leaders.
Every day, we hold more than 3,100 huddles of frontline employees across Intermountain. These quick meetings are highly productive, generating tens of thousands of ideas for improvement each year. Our teams and organizational leaders don’t just sit on these ideas. They take action. When caregivers think they know how to solve a problem they’ve identified, they enter them into an online ideas system. Then they think through their idea with their teams. If the idea has merit, they work to implement it on an experimental basis. Once ideas are proven to work, we share them across Intermountain.
We implement more than 50,000 ideas from our caregivers each year.14 Some of these are relatively minor process changes to remedy problems such as medication errors, delays admitting patients, or even just an exit sign that’s hard for patients to see. Other ideas are bigger process changes that improve how caregivers across our system do their work. For example, physicians might suggest ideas for changing how medications are administered or how we treat patients with particular ailments.
It’s tempting to focus on the bigger, higher-impact ideas, but the much more numerous smaller changes implemented year after year are really what drive progress the most. Every now and then, a breakthrough idea will emerge, and of course we run with those. But as our vice president of continuous improvement Dr. Matt Pollard notes, the whole point of our huddles and idea collection system is to “aggregate all of the collective intellect, energy, and heart and soul of our employees in this system. That’s the magic.”15 Pollard would “rather have a million small improvements than one massive one,” and so would I (although the massive ones are nice, too).
In cascading daily huddles across Intermountain, I had hoped that caregivers would come away feeling more respected, empowered, and happier with their jobs, since they would have more of a voice in how they deliver care. Consultations with people across our organization and our own data so far suggests that they do. As one of our analyses found, Intermountain teams that implemented more ideas tended to have higher engagement scores than those that implemented fewer ideas. Observing the sheer number of ideas we generate systemwide each year, Pollard surmises that “not only are our caregivers excited about improving the work, but they want to improve the work for their patients, they see the benefit of coming together as teams and rooting out the waste in their processes, and solving it themselves instead of someone else coming in and telling them exactly how to solve their problems.”16
Empowering frontline teams to improve how they work ties back to the cultural change described earlier, as it fosters greater openness to bigger changes organizations might be attempting. When Frans van Houten, CEO of the Dutch multinational Philips since 2011, set about to turn around the ailing company, he realized that he had to invest in improvement as part of the company’s shift from a lumbering conglomerate to a more customer-focused provider of comprehensive healthcare solutions.17 Philips had a long tradition of innovation, but it lacked the discipline to actually execute in ways that wowed customers. Implementation of continuous improvement across the organization would allow Philips to “be very disciplined in perfecting execution, as opposed to inventing the next thing.”18
Critically, continuous improvement would also allow Philips to rally its workforce behind the company’s transformation. As van Houten notes, leaders often struggle to galvanize employees behind big changes, with many preferring to stand by passively rather than help push change along. They become “tourists” who are along for the ride or even “prisoners” who are dragged against their will, not active players in the company’s future success.
Continuous improvement would allow frontline employees to play an important and active role in pushing Philips forward. With a structured way of working that included daily tracking of performance, problem solving, root-cause analysis, and empowerment to make improvements, members of the rank and file could “actually become a contributor to the overall journey” of the company in line with its larger purpose. “You suddenly start unlocking thousands of people to become part of a journey of improvement and change, as opposed to people standing by and saying, ‘Well, he’s changing the company, and I hate it.’”
Philips trained more than 25,000 members of its 80,000-strong workforce in continuous improvement methods, pulling them out of their ordinary jobs for a week or two at a time. The point was to “get the transformation deep down into the rank and file of the organization to get people involved.” The training itself helped turn employees into advocates for change, as it gave leaders an opportunity to describe and explain the transformation. In van Houten’s opinion, this extensive effort that unfolded during a two- to three-year period made all the difference in rallying the organization behind the transformation. Had he and his team not mobilized the front line, van Houten doubts whether the transformation would have succeeded to the extent it has—Philips is now one of the world’s foremost medical technology firms.19 The company has become an organization of players, and it shows.
Similarly, improvement enables us to move aggressively toward our new models of value-based care and population health. In general, the ongoing process of adopting new best practices from other parts of the organization instills openness in teams. It leaves them, in Dr. Pollard’s words, “always on the lookout for the next best thing that’s coming along that’s going to help us.”20 Our improvement efforts also facilitate numerous operational changes required to keep people well rather than just take care of them when they’re sick.
To take but one example, we know that we can keep elderly patients out of the hospital if we follow up with them on the phone within a week after discharging them, asking them questions about how they’re feeling, whether they’ve filled their prescriptions, and so on. Not long ago, we discovered that we weren’t doing a good job of this. Although we were doing fairly well at preventing patients from having to return to the hospital, even here there was room for improvement. We promptly identified the operational snags, created a metric to track this behavior, and worked to implement changes— all because we have a series of structures and tools in place to improve how we work.
We now are much better at following up with these patients. As a result, fewer of them wind up back in the hospital again. It’s a small bit of progress, but it pushes us that much further along toward our new, disruptive business model.
THE ANTIDOTE TO ENTROPY
In 2017, as teams at Intermountain were beginning to focus on improving how they work, our frontline huddles turned up some problems with our CT scanners. Clinical teams were finding that their patients had to wait way too long to receive CT scans. Imaging teams at multiple hospitals found that their machines were down for long periods of time due to a lack of replacement parts.
In many organizations, problems uncovered by local teams might go unaddressed because senior leaders never hear about them, or because no mechanism exists for ensuring that leaders can spot problems that recur across teams. At Intermountain we struggled with this. Although many frontline teams performed regular huddles, these weren’t connected in any rigorous way. All too often, information about problems stayed with local teams.
As we spread improvement efforts across our system, we didn’t limit huddles to frontline teams. We created a system of tiered, synchronized huddles that ensured that information flowed up and down the system with great speed. Thanks to this system, senior leaders quickly learned about the recurring problems with our CT scanners and were able to investigate. Looking into the root cause of these issues, it appeared that we were having a systemic problem with a large imaging vendor. Because this vendor’s network of warehouses was located primarily in Europe, we had to wait a week or longer for replacement parts.
Once we grasped the problem, we raised it with the vendor, who didn’t even know we had been experiencing issues. Since we were a large customer, this vendor agreed to work with us to change their network of shipping and warehouses so that we could get replacement parts more quickly. In fairly short order, our imaging equipment was staying up and serving patients better, and other US-based health systems working with this vendor saw similar gains. As a bonus, we developed a closer relationship with this vendor because we had a chance to work through the problem together.
Yet another way that focusing on improving how we work can unleash workforces is by allowing for greater alignment across an organization. Many organizations are highly fragmented. Even when they aren’t formally siloed, as we used to be, information doesn’t flow up and down the chain of command. Problems remain buried. Best practices don’t spread. Leaders struggle to communicate strategies. Local teams fail to execute them well. Galvanizing people across an organization to improve how they work can solve this lack of coordination. It can help organizations drive progress by ensuring that everyone is pulling together in the same direction.
Our system of tiered, synchronized huddles has allowed for much greater alignment across Intermountain. The huddles work like this: Every morning, all those frontline meetings I told you about take place at 8:45 a.m. If a local team can resolve a problem on its own by making a process change, great. Otherwise, the local team escalates the issue, and it is reported at a series of 9 a.m. huddles of leaders one level up in the organization. If leaders at this level can resolve the problem, great. Otherwise, they escalate it up another level. This process continues all the way up the organization.
All told, we hold about 3,100 daily huddles across seven managerial levels. By 10:15 a.m. each morning, when my team huddles, we’re in a position to consider problems that might have arisen with the front line and have escalated up the chain of command over the past hour and a quarter. If a significant problem has arisen and leaders at every level can’t address it, we hear about it. And if the same problem has emerged in multiple places across Intermountain, we hear about that, too. Meanwhile, information flows back down—teams at the lower tiers learn about how the organization has handled previous issues that have been escalated and the results of any actions taken.
When our huddles uncover important safety issues, my senior leadership team can quickly identify them as systemwide problems and alert caregivers across the organization. We can keep a closer eye on operations, understanding when we have systemwide shortages of drugs, for instance, or when caregivers require training on a new piece of equipment. Since our local huddles report key metrics relative to safety, we get real-time updates on our safety performance across Intermountain. We can monitor business performance—for instance, whether we’re meeting our goal of keeping our clinics open longer or creating more appointment slots for patients.21
We use our improvement efforts and system of huddles to deploy strategies across our large and expanding network of facilities. And they also enable us to adapt rapidly to unforeseen disruptions as they arise. Consider our response to Covid. When the pandemic erupted, our system of huddles allowed us to react to a fluid situation on the ground and rapidly make a whole slew of operational changes. These huddles morphed seamlessly into Covid-oriented huddles, handling daily operational tasks like establishing testing sites, monitoring our supplies of personal protective equipment, identifying and addressing future drug shortages, monitoring bed capacity across our facilities, and much more. As the pandemic wore on, frontline caregivers surfaced problems and iterated to solve them, tracking their performance and escalating the problems when necessary so that leaders could devise broader, systemwide solutions.
I can’t emphasize enough how important these structured improvement efforts were (and still are) for us in adapting to Covid. If we had not been doing this work for several years already, our efforts would have been well meaning but ultimately uncoordinated and ineffectual. Each individual facility at Intermountain would have been desperately trying to manage the volume of Covid patients. One Intermountain gave us the organizational structure to operate in a synchronized way, and our huddles and improvement methods gave us a common culture and process for taking swift action in a unified way.
The second law of thermodynamics holds that systems tend toward entropy or disorder. That’s true of organizations, too. Leave them to their own devices, and they will devolve into chaos. Convening an entire organization to improve how teams work is an antidote to entropy. It allows leaders to keep a better handle on operations, and it keeps teams aligned around common goals. The pandemic, that great sower of entropy, posed an enormous challenge, but we had a way of pushing back against the chaos and maintaining order.
MAKE IT PERSONAL—AND KEEP IT REAL
During the early 2000s, when I served as a frontline physician and later chairman of the Pediatric Intensive Care Unit at Cleveland Clinic Children’s Hospital, I noticed that the external vendors we were using to transport critically ill children to our facility were underperforming. Because these vendors didn’t know how to care for tiny newborns with congenital heart disease, they couldn’t begin lifesaving interventions en route. When an infant or child is experiencing a cardiac crisis, every minute counts. Children would arrive at our unit much sicker than they had to be, and as a result, they weren’t doing very well.
I felt we needed to do better for these patients, so I took it upon myself to fix the problem. Working with the administrator of our children’s hospital, I created a business plan for bringing the transportation of critically ill babies in-house. When a newborn needed specialized care from us, our own specialists would fly or drive over, pick up the patient, and bring them to us, providing them with the lifesaving care they desperately needed on the way.
I wound up presenting this plan to Dr. Floyd Loop, then-CEO of Cleveland Clinic, and his executive team. It was an experience I’ll never forget. Dr. Loop had a huge stack of papers in front of him on the table, and as I made my pitch, he proceeded to read papers, sign them, and shuffle them around. I started to wonder if he was paying any attention, but it turned out that he was. When I finished, he looked up at me and muttered, “Why the f*** haven’t you done this before?” That was it—the only words Dr. Loop ever said to me.
“Well, sir,” I said, “I’ll take that as a yes. I’ll start working on it straight away.” I did, and within a year, our pediatric critical care transport service was a big success, improving quality and helping more babies survive. At the Clinic’s request, I created an in-house critical care transport service for adults, a much larger service that included international transport via jet. This business also succeeded and continues to operate today, transporting some 4,500 patients every year under the mantra, “No patient too sick, no patient too far.”22
Little did I know that this initiative would come to carry deep personal meaning for me. It was this very service that picked up my son Alex in Germany following his devastating brain injury and brought him home to the United States for treatment.
There is no great secret to teams and organizations—or individuals, for that matter—who actually make change happen rather than simply talking about it. We have to work at making change, questioning the status quo and pushing hard every day to improve on it. We all have it in us to make change and improve. At Intermountain, we just wanted to create a way that we could all learn from one another and grow as teams each and every day.
By establishing improvement as an organizational imperative and providing teams with the tools and support they need to speak up about problems, implement solutions, and track progress, leaders lay the groundwork for a true culture of improvement to blossom. By empowering frontline personnel to speak up and make decisions, leaders unleash the genius of their people. And by giving everyone across the organization a common language and practices they can use to drive change, leaders align and unify the organization, enabling it to become a powerhouse of change.
You’ll notice that I haven’t said much about the specific tools we at Intermountain use to structure team discussion in our huddles. That’s because in my view the specific improvement methods you use don’t matter that much. What’s most important is simply that teams have some kind of structure in place that focuses them on iterating over time to improve performance. Our system incorporates a variety of methods, including lean, Six Sigma, Total Productive Maintenance, and the Theory of Constraints (let’s face it, the naming of these methods could use some improvement, too). I encourage you to explore these and other approaches, crafting an improvement process that works best for your organization.
Don’t feel you must have everything figured out before you start. It’s better, I find, to begin somewhere, notch some early wins, and proceed from there. Choose a single project that’s important to the organization and easy to understand, and work on that. At Intermountain, our huddle process and the commitment of our leadership team to listen to what flowed out of it every single day became the foundation upon which our broader improvement efforts took shape. At Cleveland Clinic, our improvement efforts grew out of a specific initiative I started to optimize how we transferred patients into and out of our facilities.
Personal engagement makes all the difference, too. I first came to understand this at Cleveland Clinic while launching our Abu Dhabi operations. We held daily huddles to organize our work, and I saw how meaningful it was that I made a point of showing up. People understood that improving what we did and aligning ourselves around execution were important priorities of mine. And they took the work seriously.
As improvement efforts progress and bear fruit, it’s also important that leaders and our organization retain the purity of intention that hopefully led us to undertake the work in the first place. It can be flattering when, after a period of time, the outside world starts to notice the amazing results we’re generating. Industry awards and the like are great. But if we allow improvement to become a vanity project, we’ll veer off track. Tune out this noise and allow the organization’s animating purpose to continue to power your improvement efforts and your own personal commitment to them.
It might sound corny, but there’s a soulfulness that drives improvement at Intermountain. We care deeply about our patients and really do want to provide them with exceptional care. That’s why we show up at work each day. And it’s why we work each day to get just a little bit better. “In the end,” Dr. Pollard says, “It’s all about making care better for patients. What’s right for the patient? How do we get to that? That’s what this is about. We’re not going to stand still and pat ourselves on the back and say, ‘Intermountain provides the best quality care in the nation.’ If there’s a single sign that we don’t, there’s always room for improvement.”23
My wish for you is that you never stop striving to do better in your own work, and that you instill this mentality of continuous improvement in your organization. Big changes can and sometimes do happen all at once. But most of the time, they happen little by little, day by day, huddle by huddle. Empower your people to drive hard and improve. Help them discover the joy and satisfaction that comes with the ongoing pursuit of mastery. Power your organization forward by tapping its most valuable resource—the genius and energy of employees themselves.