"Empowering staff can’t be just lip service": Interview with Dr. Greg Jacobson

Editor’s note: This is a transcript of a podcast interview and has been edited for readability. Listen to the original interview here.

PEX Network: You're an emergency medicine doctor by training, how did you get interested in Kaizen and continuous improvement?

Greg Jacobson: As you mentioned, I finished my Emergency Medicine training at Vanderbilt University in Nashville and joined the faculty. I was one of the residents that was always asking, why don't we do it this way? Wouldn't it be better if we did it that way?

Then I was handed a book by Masaaki Imai, called Kaizen, I don't know if you're familiar with the book or not or if the listeners are. If you're not familiar with the book, I highly recommend reading it and I was really just blown away that there was this whole body of knowledge that really describes proven improvement principles. I immediately realized that it doesn't matter what system you apply these to, when they’re applied they will really help to improve that system and engage people. That's how I started to get really interested in process improvement in healthcare.

PEX Network: What did you do, then, in terms of your work in actually implementing Kaizen to the ER at Vanderbilt University Medical Center? How did you get started? What were some of the key areas for you to focus on?

Greg Jacobson: I was mostly attracted to the concept that the individual worker is the expert in what they do and that people intrinsically want to do whatever they're doing better. If they can be empowered to improve and make change in their workplace, they'll naturally do that. If you teach them just a little bit about identifying opportunities for improvement, they really can identify dozens, hundreds, thousands, to make that system better.

The initial impetus was an academic research project. It was the residents taking basic process improvement principles that they applied to start making the Emergency Department better. That's really where this all started.

PEX Network: That actually follows up nicely on another question I wanted to ask, which is that it's often said that engaging staff is one of the critical factors when it comes to achieving success with Lean. It sounds like that was one of the areas of interest for you as well. What sort of tactics did you find actually helped in engaging staff and ensuring that people felt empowered to come up with ideas for improvement?

Greg Jacobson: I think that's the key here: people need to feel empowered, but it can't be just lip service. It has to go that extra step, where people recognize and see that they are empowered.

Interestingly enough, I was an all night ER doctor. While I really preferred working at night and being an all night person, you tend to be disconnected from all of the inter-workings of the hospital that are occurring from nine to five, Monday through Friday. So, I was naturally drawn towards communicating via the web because I realized that I'm not going to be able to call up my supervisor or boss at two o'clock in the morning with observations and suggestions and an e-mail is just not a very good way to communicate these sorts of ideas.

So we started a web-based program that just made it very easy and that's the beginning of it. It made it very easy for front-line people to make a suggestion or an observation. Instead of having some paper-based system, where you had to go and find the form in one spot – which would have been difficult because we even had two Emergency Departments – we just made it really, really simple and easy for people to engage. The more cumbersome it is for someone to engage in improvement work, the less likely they are to do so.

PEX Network: Take me through how this web-based system worked.

Greg Jacobson: I think it's funny that we're talking about it because of the way people now use Facebook and LinkedIn and communicate and collaborate so effortlessly on the internet and on the web. But this was a little bit more novel ten years ago. We certainly weren't inventing anything new, we just focus on the concept of making a productivity environment really easy.

It initially started out as really simple, it almost looked like an electronic suggestion box. Then we quickly realized that, in order for this to create a lot of value, we started to learn, if an electronic system is going to help people do engagement and continuous improvement work, it needs to have a couple of different things.

For instance, it needs to have visibility. It needed to be really transparent. It needed to be searchable. You need to have active notifications that go out, to let people know when things are happening. One of the most important things we need to do is, being able to recognize successes and broadcast information out.

After a two to three year period, we realized we were onto something, that we can get people engaged in this type of work fairly easily, using the web and if designed right, it can really make this type of work a lot easier. And so that actually was the basis for founding KaiNexus. Could we build a system that any organization could take off the shelf and start doing their own improvement work with.

PEX Network: Let’s take it back to some of those Lean concepts and the healthcare setting. Which type of Lean concepts did you find most applicable within the healthcare context?

Greg Jacobson: In the first couple of years of doing this type of work I really tried to distil most of the Lean concepts that I think are really good for engaging front-line employees.

Those are really found in the body of knowledge on Kaizen. We really tried to pick out a number that would be easy for people to grab onto. The idea wasn't, to make it too cumbersome for people to become expert problem-solvers; the idea was to give them enough knowledge to point them in the right direction. Then, with help from other leaders and more problem-solving experts, they could find good solutions and come up with good improvements.

Some of the things that really resonated in healthcare were to focus on the process and not the people. In healthcare, there is such a culture of sweeping things under the rug because someone's going to get in trouble; there’s this whole medical/legal environment of fear of getting sued. We needed to change the behavior of hiding our little problems and only addressing the really big, obvious problems.

There are tons of near misses that we could learn from, but instead, having a culture of sweeping under the rug, doesn't really help anybody. So healthcare workers really gravitated to that concept. "You mean, I'm not going to get in trouble if I say something? Sure, I'll be happy to engage with that!"

Another concept, for example, was be looking for the non-value-added steps. Healthcare is rife with these. You find them when you start talking to doctors and nurses and techs, transporters, registration folks about all the little work-arounds that they're doing because of broken systems. Instead, we wanted to say "let's find opportunities and make your job better and easier."

PEX Network: So what did you find truly the most challenging aspect of implementing Lean as it must be said that, Lean is a methodology that to all intents and purposes, was, for a long time, thought as something that only manufacturers did. So applying it to an ER, what were some of those challenges?

Greg Jacobson: The first time I was ever exposed to lean manufacturing or improvement in any way I recognized that the principles would work no matter where you applied them. The principles can be applied individually, or really any group or any system.

The one-to-one corollary on some of the principles was the easy part: teaching someone what a non-value-added step is, or describing how to identify problems and avoid work-arounds was the easy part.

The parts that we struggled the most with are probably the same in every industry and, now that I'm engaging with all sorts of companies in all sorts of industries, I'm seeing that the basic issues of, how do you do change management? How do you break bad habits? How do you do things in a disciplined way? I think those are probably the biggest challenges that I found in healthcare and now that I'm seeing it and starting to work with companies in other industries, those are still the exact same problems that they're dealing with.

PEX Network: The final question that I'd like to end on, is quite a big picture question. You said, in an interview last year, that healthcare will look significantly different in say, five to ten years' time, from how it does today. What do you see as that future for healthcare?

Greg Jacobson: First, just to give some perspective: I graduated Medical School in 2001, so I've been involved in healthcare for ten to fifteen years now. I started, for example, at a hospital that had no computers. Everything was done on paper and if you wanted to go and get an x-ray, you had to go down to the file room and pull an x-ray.

Now if I want an x-ray, I go to the nearest x-ray monitor and pull it up. There has been really dramatic change in the last 15 years already and I think, in the next ten to 15 years, there's going to probably even be more change.

So what do I mean by that?

I mean that there's certainly going to be things that are US specific such as payer-provider shifts and things of that nature. But I think, looking at it from a more global perspective, I think healthcare has to date been really focusing on automating current processes. In many cases, they're automating things that maybe shouldn't be automated and there is going to be this radical shift in the way care is provided.

So I think that over the next ten to 15 years, organizations that figure out how to change quicker and how to think more outside the box, are going to be defining what healthcare is going to look like in the future.

Whether that's communication and collaboration within an organization, in figuring how to do things better, or even with other technologies that can connect providers and patients. I'm an ER doctor, imagine doing an ER visit at home, with videoconferencing technology.

There's no reason that we can't start moving in different ways, to really open up our minds in how we can deliver healthcare. Especially in the US, we're really, really bad at this, based on how much we spend on healthcare, but we've been throwing money at this industry for the last 50 years and we're not able to continue to sustain that.

And so for us to have successful health deliveries over the next several decades, there's just going to be some massive changes in the way we think about, what is healthcare and how is that delivered? And what exactly is value? And what are we trying to accomplish?

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