Archive for category: Leadership Practices

Leader Standardized Work

Standardized work is not only designed to guide line staff; it works equally well—and is equally important—for leaders, too. Standardized work for leaders consists of developing routines for rounding with purpose (going to the gemba) and other activities where you check in on the status of current tactical and strategic goals.

A purposeful, daily stand-up meeting is a good start to standardized work. It should consist of sharing census changes, resident concerns, staffing issues, safety incidents, future events and successes to be celebrated. Once you have started building a culture of continuous improvement, consider adding a minute of reflection. Ask the team, “How did yesterday go?” and “What can we do better today?” The idea of building upon each day keeps work from being routine and helps staff to engage in the process of making small improvements all the time. A stand-up meeting should start on time consistently and last no more than 10 or 15 minutes. For issues that require more than a minute or two of discussion, have a smaller group break off afterwards to discuss rather than occupying everyone’s time.

Developing a daily checklist that incorporates current goals is another way to standardize oversight and accountability. A daily checklist helps to reinforce priorities, communicate the intended direction of the organization, and connect to the drivers that will lead to the desired goals. The questions need to be customized to your current goals and priorities to be effective. Generally, improving resident quality and experience are top concerns of most organizations, as are employee staffing and performance issues. If there is significant construction, reorganization or major initiatives rolling out, these items should be integrated into the daily checklist.

Here are two examples of daily check sheets for an administrator and DON:

Administrator Daily Check List




Sometimes, questions may seem formulaic or unnatural. Don’t worry. If staff know that they can count on a response, they will be happy to share struggles and challenges. Also, by asking questions like, “Have there been any falls in the last 24 hours?” or “Are all assessments up to date?” staff will understand the importance of these items to your work and to the organization’s overall success. Questions should change over time as priorities and goals do. The important thing is to develop a daily routine that can help keep your organization on track.

Root cause analysis in The Toyota Way to Lean Leadership

In Jeffrey Liker and Gary Convis’ book, The Toyota Way to Lean Leadership, Gary recounts the story of a young Toyota manager, Yuri Rodrigues, learning the lessons of root cause analysis while working at a Toyota plant in Brazil. A quality problem in the trim department was traced to the wrong torque being applied by technicians. Yuri suggested the plant purchase modern wrenches that would stop automatically when the right torque was applied. His leader replied, “Do you want me to buy new $400 wrenches for everyone in the plant? Because if you’re telling me that is your solution for the problem, that’s what I’ll have to do. I suggest you go back and observe the team members to really understand this problem.” Upon further research, Yuri discovered the ultimate root causes to be poor training and a lack of preventative maintenance.

I like this story for a couple of really important reasons:

Root cause analysis is hard

Purchasing modern wrenches would have been an easy solution, but another quality problem caused by the same lack of training and preventative maintenance would have occurred shortly down the line. In long-term care, fixes are commonly applied to a surface issue, but there is little work on the root causes, and the daily work is filled with a prioritization of firefighting activities.

Ultimately, a lot of unnecessary waste could be eliminated by uncovering the common root causes for many of the problems that plague the industry and addressing those instead of continuing to manage crises. Unfortunately, finding root causes takes tenacity, insight, and an engaged workforce that can critically examine work practices.

Error-proofing is not always the right (or only) solution

Error-proofing is an important part of building quality into processes, but it’s not always the best approach to a problem. In this case, an automatically-stopping wrench might make it easier to use for untrained technicians, but it would just push the problem into another area of the work. Creating “idiot-proof” systems rarely leads to sustainable quality. Rather, error-proofing goes hand-in-hand with expertise and fully-trained employees.

In contrast, solutions in long-term care oftentimes perpetuate the root causes of poor training and a lack of employee engagement by trying to make it difficult for line staff to influence the process. These bottom-line focused solutions might solve one issue, but the core cause is still there.

Problems are rarely caused by a single issue

When Rodriguez went back to the line to study the problem, he discovered not only the wrong torque being applied to the trim, but also that the preventative maintenance program was missing. This example demonstrates one of the most important– and sometimes overlooked– benefits of a rigorous root cause analysis process: the identification of multiple causes, each of which might need a different countermeasure.

Too often, we stop after identifying the first problem and miss other contributory factors, which only leads us back to quality issue. In most cases, we need to focus on root causes, not just root cause.

Workers are not the problem

An easy answer to the problem would have been to tell workers to stop over-tightening the bolts. Lean thinking, however, teaches us that this is mostly a wasted effort, and will have little lasting impact on quality. Instead, the point that lean makes over and over is that workers are not the source of problems in most organizations, systems and processes are. The lean value of respect for people demonstrates that with fair treatment and proper tools and resources, employees can actually solve most of the challenges confronting an organization– they just need to be unshackled from dubious mandates and ill-conceived systems.

Too often, line staff in long term care are blamed for poor performance and quality problems. Broad inservicing and rampant memos take the place of thoughtful training and effective communication, and the disciplinary process is quick to engage staff unlucky enough to be singled out by management. To drive sustained results, we need instead focused root cause analysis and a culture that supports long-term quality improvement and value creation.


How Scrum Can Improve Stand-Up Meetings

In many nursing homes, one of the first items on every day’s agenda is the daily stand-up. Some communities have these quick check-ins down: organized, routine, and efficient, highlighting admissions, needed assessments, and any issues from the 24-hour report. I’ve also seen these meeting sprawl for 20 or 30 minutes, or divert into side discussions that occupy everyone’s time to solve an issue between two departments.

Scrum is a software development methodology based on a flexible, iterative model of team collaboration. When implemented effectively, scrum has helped software developers improve productivity by up to 500% by staying focused on the most important challenges, collaborating as a team, and responding quickly to new challenges. You might think scrum is a funny word for a development strategy, but it has a very important background. In rugby, scrum is the way that play is restarted, similar to a tip-off in basketball. Instead of being an individual effort, like the tip-off, however, scrum involves the whole team working together to gain control of the ball. While individual strength and skill is important, no team can compete effectively unless they work flawlessly together. The same idea has been applied to software teams. (And has something to teach healthcare teams.)

While there is a lot to scrum, one of the key features is the daily stand-up meeting that involves each person on a cross-functional development team meeting briefly. What’s involved in the daily scrum meeting?

  1. All members come to the meeting prepared. In post-acute care, this means accurate information about admissions, discharges, assessments and any resident issues.
  2. The meeting starts at the same time each day. Some communities do this well already, though oftentimes I’ve seen meetings delayed until the administrator or DNS arrives. In a scrum daily meeting, the meeting starts, even if someone isn’t present, and it’s the missing person’s responsibility to learn the information missed.
  3. The meeting is timeboxed. Timeboxing is an important project management tool that limits a meeting to a specific length of time. This keeps issues focused and means that issues are prioritized or dealt with in separate (and usually more efficient) ways. For a 100- 150 resident nursing community, 15 minutes should be plenty of time for a stand-up.
  4. Anyone is welcome to attend (though typically only involved core roles speak), and meetings are oftentimes held in hallways or corridors to emphasize the open component. This is an important commitment to openness that allows other staff to stay abreast of development efforts throughout the organization. With an open stand-up, CNAs, cooks, and housekeepers could see some of the nursing home “machinery” that is critical to the day-to-day work.
  5. The meeting consists of each core person answering three questions: what did I do yesterday? what am I planning to do today? Am I experiencing any stumbling blocks or impediments to getting my work done? The “team lead” (scrum master) documents any challenges, but no discussion occurs during the stand-up. Rather, issues are dealt with in smaller groups, involving only those people required to resolve the situation.

What I love most about the scrum meeting is the focus on what’s happening and whether there are any roadblocks to people completing their work. This approach fits well with Lean philosophy (along with servant leadership, which is eminently vogue in LTC right now), and emphases the role of the team lead as an enabler: their primary role is to ensure the team is able to do its work. This person is responsible to remove identified roadblocks, keep the team on track, and prevent outside distractions (in long-term care, think regulatory issues, corporate initiatives not related to the work, interpersonal challenges between department staff, etc.) from interfering with completing necessary work.

Streamlining and focusing stand-up can have a big impact on staff’s ability to work effectively throughout the day. If your stand-up wanders, or doesn’t focus on the most crucial info to share, look at whether the scrum daily meeting concepts above might be able to improve this crucial meeting.

Respect For People

At the core of Lean thinking is the concept of Respect for People, and it’s this part– more than continuous improvement and elimination of waste– that makes us believe Lean has so much to offer the long-term and post-acute care environments. Many nursing homes and assisted living communities have already engaged in culture change activities over the past several years, and one of the most crucial elements to success– as well as a benefit in and of itself– is empowering and engaging line staff in the change journey. Lean can complement and strengthen this area, and serves as a link between organizational philosophy and quality improvement activities.

Respect for people is altogether both simple and difficult to understand and implement. For most healthcare organizations, respect means treating employees fairly, providing adequate training and supervision, and providing a safe and stable working environment. In Lean, respect for people is much more involved; it means line staff are understood to be experts of their work areas, supervisors and managers spend time on the floor with line staff, all employees are involved in problem-solving, and errors are generally assumed to be system-induced.

The problem solving process is a key example used in describing respect for people from a Lean perspective, as noted in this e-letter from James Womack, the founder of the Lean Enterprise Institute:

Managers begin by asking employees what the problem is with the way their work is currently being done. Next they challenge the employees’ answer and enter into a dialogue about what the real problem is. (It’s rarely the problem showing on the surface.)


Then they ask what is causing this problem and enter into another dialogue about its root causes. (True dialogue requires the employees to gather evidence on the gemba – the place where value is being created — for joint evaluation.)


Then they ask what should be done about the problem and ask employees why they have proposed one solution instead of another. (This generally requires considering a range of solutions and collecting more evidence.)

Then they ask how they – manager and employees – will know when the problem has been solved, and engage one more time in dialogue on the best indicator.


Finally, after agreement is reached on the most appropriate measure of success, the employees set out to implement the solution.


For many of us that doesn’t sound much like respect for people. The manager after all doesn’t just say “I trust you to solve the problem because I respect you. Do it your way and get on with it.” And the manager isn’t a morale booster, always saying, “Great job!” Instead the manager challenges the employees every step of the way, asking for more thought, more facts, and more discussion, when the employees just want to implement their favored solution.

This back and forth process demonstrates how each person in the organization brings a perspective, and true problem solving means involving and engaging each individual. It’s not in making employees feel good, or in dodging tough issues, but rather actual, committed problem solving that enables each member of the organization to thrive. Indeed, as Mike Rother notes, “respect for people means that it’s disrespectful of people to not utilize their human capability to learn and to grow. That is, each person’s working day would ideally include some challenge, and each person is being taught a systematic way of meeting challenges.”

This is a much different view than is typically practiced in nursing homes. When problems occur, staff are oftentimes blamed for not following a policy (without regard to whether the policy is reasonable or even doable), counseled (to provide documentation that the facility acted on the problem) and scapegoated (often in a demoralizing way as other staff know it could happen to any of them).

Mark Graban shared a video in a recent post on respect for people that highlights a great example of how an organization shifted during an incident to exemplify a respectful problem solving process:

Creating an organization built on respect for people cannot happen overnight, and it can’t be done without the commitment of senior leadership. As we’ve noted in the past, organizations need to evaluate their entire process of problem solving, especially around incident investigations. Organizations must also stop penalizing employees for system failures due to lack of adequate resources, ineffective safety measures, and organizational policies that harm open communication and dialogue.

In Mark’s post, he notes the similarity between respect for people and just culture, and there is certainly a lot of overlap. Implementing a just culture is also a proven risk management strategy, as it leads to fewer errors and more complete problem solving. Examine this diagram from Outcome Engenuity:


Respect for people holds that most errors are not caused recklessly or maliciously, but rather catch people up in a poorly designed or poorly functioning system, and, in order to rectify and prevent these errors from happening again, we must involve everyone in an organization in a thoughtful, purposeful journey of continuous improvement.

The Importance of Beautiful(ly Thoughtful) Questions

In 1943, Edwin Land, while on vacation with his family, took some photographs of his daughter, Jennifer. Like any good three-year-old, Jennifer wanted to see the results of the picture right away. “Why can’t I?,” Jennifer asked. This simple yet powerful question led Land and his company, Polaroid, to develop products that transformed the experience of photography.


Why, What If, and How

In Warren Berger‘s new book, A More Beautiful Question, Land’s story is one of many used to illustrate the importance of not only questioning (itself a lost art among adults and organizations) but in also asking the right questions (primarily why, what if, and how) as a catalyst to innovation. The power of questioning is already revolutionizing fields from marketing to technology startups, and although Berger’s book has barely been out a month, I suspect it will become one of the top business books of the year.

A More Beautiful Question is particularly timely for aging services, as a confluence of forces– from payment models to demographic needs to disruptive technologies– are bringing fundamental changes quickly into focus and now, more than ever, organizations need to deeply question the core tenants of their organization as a precursor for survival.

The why, what if and how questions form the triad of powerful, leading devices for questioning. For why questions, Berger recommends the following process:

  • Step back.
  • Notice what others miss.
  • Challenge assumptions.
  • Gain a deeper understanding of the situation at hand, through contextual inquiry.
  • Question the questions we’re asking.
  • Take ownership of a particular question.

Many providers today are struggling with declining reimbursement, razor thin operating margins, maintaining quality of care, and meeting the needs and wants of a quickly changing population. Why questions can be incredibly useful in asking, “Why are we providing this service line?”, “Why aren’t we meeting these needs?” and even “Why are we here?”

If why has “penetrative power,” Berger writes, “what if [has] a more expansive effect– allowing us to think without limits or constraints, firing the imagination.” Several organizations have used the what if question to create groundbreaking innovations in aging services already: “What if we stopped building bricks and mortar?” (The CCAH model), “What if we made senior centers as appealing as Starbucks?” (MatherLifeways Cafe Plus), and “What if we combined predictive analytics with remote monitoring? (HealthSense, HealthSignals, CarePredict, and several others).

The final crucial question, how, is where results are created. Berger points to a number of examples that highlight the value of fast prototyping (Eric Reis and the Lean Startup)  and test and learn (referencing Bloomberg’s pilot programs in NYC). Both of these strategies can be incredibly useful to aging services providers, who oftentimes think an idea to death before even launching a trial. For organizations that are able to test out new ideas and programming, it’s important to measure results carefully. Ask the question “Am I failing differently each time?”, Berger writes, drawing on IDEO founder David Kelley’s observations on the subject. This is particularly useful in responding to adverse events, as the lack of learning inevitable leads to policy creep: the tendency to respond to any event by writing a new policy or creating a new form.


Learning Organizations

I’ve heard many providers refer to themselves as “learning organizations,” popularized by Peter Senge, et al., in the book, The Fifth Dsicipline. The reality, however, is that very few actually embark on the journey to implement the disciplines necessary– systems thinking, personal mastery, mental models, shared vision, and team learning– mainly because they aren’t adept at questioning correctly.

One of the biggest reasons I love lean thinking is the emphasis on constant reflection and continuous improvement. Aging services providers, always already trying to do too much good work with too few resources and supports, tend to aggressively justify their current operations, values and faults rather than deeply question their core work. “We’re doing the best we can for our staff,” rather than, “How can we pay our staff a living wage?” “You have to move to assisted living to get services,” instead of “What if we built up services in place by leveraging other offerings?” This is unfortunate, foremost for its detrimental impact on persons served– and will likely be lethal over the coming years to organizations that can’t make the shift. (Polaroid, itself, is a great example of why learning must be constant, going bankrupt in 2001 after underestimating the impact of digital cameras.)



Peter Drucker, considered to be the father of management, famously consulted with organizations not by providing answers but by asking crucial, if sometimes rather obvious, questions. The power of questioning, as Berger lays out so clearly in his book, will indeed be one of the biggest differentiators in the field of aging services moving forward. There is great future need, for sure, but it will no longer be met by senior housing alone. The current explosion into remote monitoring, home and community-based services, and intergenerational communities is only the tip, and providers need to start now to build strong organizations suited for deep questioning.

Ready to get started? So are we!