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Most healthcare organizations that take up Lean see real early progress. Value stream mapping produces visible improvements. Kaizen events deliver measurable results. Daily management systems get installed. Project boards fill with completed work. And then, somewhere between the third and fifth year, the momentum begins to fade. The improvements that mattered most start to erode. The leaders who championed the work find themselves explaining to the next generation why this work was important.
The diagnosis Kim Barnas and John Toussaint offer, drawn from coaching hundreds of healthcare executives across the United States, Canada, Europe, Brazil, and South Africa, is consistent. The pattern isn't about insufficient training or weak methodology. It's about a leadership gap that the Lean tools themselves cannot close.
Organizations don't change until leaders do. The transformation has to happen at the personal level first, in the actual behaviors leaders practice every day, before any organizational transformation can hold.
This session previews the framework Kim and John developed in their book Becoming the Change: Leadership Behavior Strategies for Continuous Improvement in Healthcare, published shortly after this webinar. The framework rests on two tools: a Leadership Self-Assessment Radar Chart that measures five essential leadership traits with their observable reinforcing behaviors, and a Personal A3 process that applies A3 thinking to one's own leadership development. Both tools are practical, downloadable, and grounded in years of experience coaching executives through real transformations.
Kim Barnas is CEO of Catalysis. Prior to her current role, she served as Senior Vice President of ThedaCare and President of both Appleton Medical Center and Theda Clark Medical Center, where she led two of the original ThedaCare Improvement System value streams (OB and cancer services) starting in 2003. She authored Beyond Heroes: A Lean Management System for Healthcare in 2014, drawing on that work.
John Toussaint, MD, is Chairman of Catalysis, which he founded in 2008. An internist and former healthcare CEO, he is one of the most prominent figures globally in the adoption of organizational excellence principles in healthcare. He has written three books that have each received the Shingo Research and Publication Award: On the Mend, Potent Medicine, and Management on the Mend.
The session is hosted by Mark Graban, Senior Advisor at KaiNexus and the author of Lean Hospitals, Healthcare Kaizen, Measures of Success, and The Mistakes That Make Us.
The diagnostic claim Kim opens with is worth pausing on. She and John spent decades working with healthcare organizations through Lean transformations. They watched organizations make significant initial progress. They watched many of those organizations fail to sustain it. When they finally stepped back and looked at what was happening across hundreds of leaders and dozens of health systems, the pattern they identified was specific.
The problem wasn't methodology. The Lean tools, the value stream maps, the daily management systems, the Shingo Model behavioral framework -- all of these were genuinely useful, and organizations that applied them well saw real results. The problem was the gap between conceptual knowledge and personal practice. Leaders understood Lean. They could explain it. They could even teach it. But they had not actually changed how they themselves operated day to day. They were still doing the work themselves rather than coaching others to do it. They were still solving problems rather than developing problem-solvers. They were still telling rather than asking.
This personal gap turned out to be the variable that determined whether transformations sustained or faded. Organizations whose leaders went through a genuine personal change continued improving. Organizations whose leaders treated transformation as something to delegate or manage did not. The methodology was identical; the outcomes diverged because the leaders did.
The Personal A3 work and the Leadership Self-Assessment that the session walks through are designed to address this gap specifically. They give leaders structured tools for the personal change that organizational change requires.
The first tool Kim presents is the Leadership Self-Assessment Radar Chart, developed by John Toussaint and Carla Hoover, building on the Shingo Institute's work on cultural enablers. The radar chart measures five leadership traits or dimensions, each with specific observable behaviors that reinforce it. Each trait is rated on a one-to-five scale: rare or underdeveloped (1), some awareness and irregular use (2), fairly frequent use (3), consistent use (4), or unconscious and mature use (5).
The five traits:
Willingness. The disposition to change and to learn. Most leaders rate themselves a three or four here because they're looking at new programs and want to improve. The harder question is the reinforcing behavior: do you actually use reflection as a tool? Reflection in the shower or on the drive home doesn't count. The question is whether you have time on your calendar dedicated to reflection -- substantial, consistent, reproducible -- and whether you have specific questions to reflect on. Two questions Kim and John recommend as a starting point: what did I do today to unleash the creativity of my people, and what did I do that got in their way?
Humility. The trait that gets misunderstood most often. Kim's diagnostic: if you rate yourself a five on humility, you're not. Humility isn't a lifestyle claim. It's a set of observable behaviors. The reinforcing behavior is go and see, listen, and learn. What do you do when you go to the gemba? What questions do you ask? Are they open-ended questions that let people teach you, or are they yes/no questions that don't surface anything? Do you interrupt? Do you listen? Can you reiterate something you learned each time you go? The behaviors are what others can observe, and what they observe is what matters.
Curiosity. Genuine interest in what people do, how they think, and how their work affects the organization. The reinforcing behaviors include going to the gemba with intent, asking good questions that begin with "what" and "how" rather than "who" and "why," using A3 thinking (not the template -- the underlying mode of inquiry) in conversations, and being an effective listener rather than someone waiting to speak. Curiosity that's genuine produces different conversations than curiosity that's performed. The team can tell which one is happening.
Perseverance. The capacity to stay with the work through inevitable failure. Two reinforcing behaviors are particularly important here. The first is having a buddy or partner who can give honest reflection on what they're observing -- someone with enough trust in the relationship to say "when you went to the gemba today, your presence helped, but when you started telling them what to do, you shut down the learning." The second is having a coach -- a more formal relationship with someone who understands what you're working on and can push your development forward.
Self-discipline. The trait most leaders rate themselves lowest on. Self-discipline shows up as leader standard work. Writing down what you intend to practice. Adding to it as you learn. Putting reflection time on the calendar -- twice a week for fifteen minutes, with a journal -- and treating that time as real. Saying "I'm going to demonstrate humility by going to the gemba on these two days, looking for these specific things, with this purpose." Standard work is what turns intentions into reliable practice.
The radar chart's value isn't in the precise numerical scoring. It's in the act of self-assessment itself, which surfaces the gap between what leaders aspire to and what they actually do. The visible gap becomes the starting point for the Personal A3 work that follows.
A practical note Kim adds: when you start practicing these new behaviors, tell people you're practicing. If leaders suddenly change how they show up at the gemba without explaining why, the team often interprets the change as something about them -- as if leadership is now scrutinizing their work more closely. Naming the practice as your own learning takes the threat out of it. The team can support you rather than defend against you.
The second tool is the Personal A3, developed by Margie Hagene, who Kim credits as the groundbreaker on this work. The Personal A3 applies A3 thinking -- the structured improvement methodology Lean practitioners use for organizational problems -- to one's own leadership development.
The template has familiar A3 elements, with modifications for personal use. There's a background section (why should I improve myself), a current state (the leadership habits I have now), an opportunity statement (not a problem statement -- this is a development tool, not a deficit diagnosis), a target condition or goal, an analysis section (why do my current behaviors exist), an experiments section (what will I try), a plan, and follow-up. The radar chart fits naturally into the current state, providing the structured assessment of where the leader is starting from.
The discipline of using the Personal A3 well requires some specific commitments.
It's a dynamic document. Like any A3, it gets revisited and updated as the work progresses. Many leaders who start with the Personal A3 end up reworking it through multiple iterations -- not because the original was wrong, but because the work of self-reflection reveals new things to address.
It's focused on the individual, not the organization. A common failure mode is leaders filling in the Personal A3 with organizational issues -- the team's problems, the system's problems, the structural problems the leader could fix if they had more resources. The Personal A3 isn't for those problems. It's for the behaviors and actions of the leader as an individual.
It frames opportunities, not problems. The language is deliberate. A problem statement implies something is wrong with you. An opportunity statement implies there's a better version of your leadership that's available to develop into. The framing matters because it shapes how the leader engages with the work.
The strongest illustration in the session is John's walk-through of a real Personal A3 from Al Pilong, then a chief operating officer at a Michigan health system (now CEO of Novant Health). Al permitted John to share his Personal A3 publicly, and the example illustrates every box of the template with real content from a real leader.
Title and date. "My Personal Leadership Development Journey," version three. The version number signals that this is iterative work; Al had already revised the A3 twice by the time John captured it.
Background. Personal change is critical to changing behavior. Organizations don't change until leaders do. The Personal A3 is the self-reflection mechanism for that to happen. In Al's case, the burning platform was the scale of change his organization needed to navigate -- change that required alignment up and down the organization, which required developing problem-solvers at every level, which required Al himself to operate differently than he was operating.
Current state. Al's honest assessment: "I'd rather do things than coach others to do." Frankly, it was easier to just do things himself. He liked the positive personal feedback that came from solving problems directly. He had no standard for coaching. He'd never been taught how. The frustration this was producing in his work -- everyone bringing problems to his office, him solving them, the cycle repeating without organizational learning -- was reaching the point of personal burnout.
Opportunity statement. "My comfort with doing the improvement myself versus aligning and enabling others to do the improvement is resulting in little organizational change." The framing is honest without being self-flagellating. It identifies the specific behavior pattern and its specific organizational consequence.
Target condition. More focus on developing and coaching others through the transformation. The shift from being the person who solved problems to being the person who developed problem-solvers.
Analysis. Why do these behaviors exist? Al's analysis traced his pattern back to his clinical training as a pharmacist. Scientific training rewards individual problem-solving. The transition into management positions where the work is creating systems and behaviors that allow others to solve problems is a transition many clinically-trained leaders struggle with. The positive feedback loop -- patients improving when you make good decisions -- becomes harder to replicate when your role is two or three steps removed from the actual care. The analysis identified specific belief structures, not just behaviors: there was no standard for coaching, no executive culture that included coaching as part of the leader's work, and a tendency for difficult conversations about people development to get avoided.
Experiments. Al committed to three:
Develop and implement a standard template for his one-on-ones with direct reports, focused on coaching rather than status updates.
Get to the gemba with each of his roughly 20-25 direct reports quarterly, treating those visits as coaching opportunities rather than oversight.
Create a structured reflection process -- a journal, a regular practice -- to capture what was working and what wasn't in his coaching attempts.
Plan. Specific actions, owners, and timelines. Develop the template. Schedule the one-on-ones. Block the reflection time on the calendar. Work with his assistant to set up the gemba visits across the geography his reports were spread across.
Follow-up. How would Al know he was improving? Three sources: feedback from his direct reports (which John notes was harder to get than expected, because power distance makes honest upward feedback difficult), his own reflection (the journaling practice), and feedback from his boss and his coach. The combination of sources triangulated what self-reflection alone might have missed.
The Al Pilong example is valuable not because it's perfect but because it's specific. The opportunity is named clearly. The analysis goes deeper than "I should coach more." The experiments are concrete and testable. The follow-up has named sources. The whole thing is dated and versioned and treated as ongoing work rather than as a one-time exercise. That's what makes the Personal A3 operational rather than aspirational.
One of the most powerful applications of the Personal A3 surfaces in the Q&A. When Susan Ehrlich was leading San Francisco General Hospital, she posted her Personal A3 and Radar Chart on her office door. The decision was deliberate. It modeled the practice for everyone walking past. Within months, every other leader at the hospital had done the same thing.
At Charlotte Maxeke Hospital in Johannesburg, Gray Dubé posted his Personal A3 publicly as part of his accountability to the work, not just as transparency. He then taught the methodology to his direct reports, who taught it to their directors. Visitors to the hospital now see Personal A3s and Radar Charts throughout the facility, alongside the leader standard work that develops out of them.
The pattern Kim observes: when leaders share their Personal A3s publicly, the team's learning accelerates dramatically. The vulnerability of admitting what you're working on -- not as a confession of weakness but as a commitment to development -- creates conditions where everyone can do the same work. The Personal A3 stops being a private exercise and becomes part of the visible operating system of the organization.
This isn't appropriate for every organization or every leader. It requires a certain level of cultural readiness. But the leaders who do this consistently report that the transparency itself drives organizational change in ways the private version cannot.
A second story from the Q&A illustrates a related move. Eric Dickson, CEO of UMass Memorial Health, is a trauma physician by training. His clinical work taught him a particular mode of operating in crisis -- command and control, fast decisions, clear directions. The mode is appropriate in a trauma bay. It's not appropriate in most executive meetings.
Eric reflected on this and made an explicit commitment to his leadership team: when they saw him moving into command-and-control mode in a meeting, they should call him on it. They had explicit permission to interrupt and name what they were observing. And when they did, he committed to thanking them publicly for the interruption.
The pattern that developed: when Eric started to slip into trauma mode in a meeting, members of his team would use the agreed-upon signal. Eric would stop, recognize what was happening, thank them by name, and reset. Over time, the frequency of the slip decreased. But the practice continued, because the value wasn't only in the interruptions -- it was in the continuous reinforcement that this kind of honesty was wanted and rewarded.
The story illustrates two principles together. First, leaders can identify and name their own patterns through reflection, which is the Personal A3 work in action. Second, leaders can create explicit permission and reward structures that allow their teams to support the development they're trying to do. The combination is more powerful than either piece alone.
The session is fundamentally about human leadership work that no platform can perform. Personal A3 reflection happens in the leader's head, on a piece of paper, in conversations with a coach or a buddy, in journal entries at the end of the day. The work is relational, not technological.
That said, the platform supports the surrounding system that makes Personal A3 work sustainable.
Leader standard work that includes reflection time, gemba time, and coaching time can be structured and tracked in the platform. The discipline of "is this on the calendar" can be operationalized through routine reminders and visible commitments. The Personal A3 itself can live in the platform alongside organizational A3s, creating a visible record of the leader's own development work that the leader can return to over time.
The cross-organizational visibility the platform provides supports the kind of public Personal A3 work Susan Ehrlich and Mr. Dubé practice. When a leader's commitments are visible to the team, the team can support them. When the team's improvement work is visible to the leader, the leader can identify coaching opportunities they would otherwise miss. The mutual visibility is what makes the system work as a whole rather than as a collection of disconnected practices.
The platform also supports the broader organizational infrastructure that leader development depends on -- the daily management system, the strategy deployment work, the improvement project tracking, the spread of learning across the organization. Without that infrastructure, the leader who has developed coaching skills has no system to coach within. The platform doesn't create the leadership behaviors, but it creates the conditions in which the behaviors produce sustained organizational outcomes.
None of this substitutes for the personal work Kim and John describe. Becoming the change is fundamentally an internal process. The external tools support the internal work. The internal work is what changes the organization.
Kim Barnas is CEO of Catalysis. Prior to her current role, she served as Senior Vice President of ThedaCare and President of both Appleton Medical Center and Theda Clark Medical Center, where she led two of the initial value streams of the ThedaCare Improvement System (OB and cancer services) starting in 2003. She authored Beyond Heroes: A Lean Management System for Healthcare in 2014. She holds a Master of Science degree in Health Care Administration.
John Toussaint, MD is Chairman of Catalysis, the nonprofit education institute he founded in 2008. An internist and former healthcare CEO, he is one of the foremost figures globally in the adoption of organizational excellence principles in healthcare. Catalysis has launched peer-to-peer learning networks, developed in-depth workshops, and created many products. John has written three books that have each received the Shingo Research and Publication Award: On the Mend, Potent Medicine, and Management on the Mend. His most recent book with Kim Barnas is Becoming the Change: Leadership Behavior Strategies for Continuous Improvement in Healthcare.
Why do continuous improvement programs stall even when the methodology is solid?
Because the methodology can be applied without the leadership behaviors that sustain it. Lean tools, value stream maps, kaizen events, daily management systems -- all of these produce real early results. But sustaining those results requires leaders who have actually changed how they themselves operate, not just leaders who understand Lean conceptually. The personal gap between knowing and practicing is the variable that determines whether transformation holds. Organizations whose leaders close that gap continue improving. Organizations whose leaders treat transformation as something to manage from a distance do not.
What is the Leadership Self-Assessment Radar Chart?
A tool developed by John Toussaint and Carla Hoover, building on the Shingo Institute's cultural enabler work, that measures five leadership traits on a one-to-five scale: willingness, humility, curiosity, perseverance, and self-discipline. Each trait has specific observable reinforcing behaviors that the leader and others can use to assess current practice. The radar chart's purpose isn't precise numerical scoring -- it's structured self-reflection that surfaces the gap between aspiration and practice and feeds the Personal A3 work that follows.
What is the Personal A3?
A tool developed by Margie Hagene that applies A3 thinking to the leader's own development rather than to organizational problems. It has the familiar A3 elements (background, current state, opportunity, target, analysis, experiments, plan, follow-up) adapted for personal use. The framing is opportunity rather than problem, the focus is the individual rather than the organization, and the practice is iterative -- the document gets revised as the leader's development progresses.
How is the Personal A3 different from a personal development plan or a 360 review?
The Personal A3 is structured around A3 thinking, which means it's grounded in specific current-state observation, root-cause analysis of why current behaviors exist, experiments rather than goals, and follow-up that includes both self-reflection and external feedback. It's also visible and iterative. Most personal development plans are written once, filed, and forgotten. The Personal A3 is a dynamic document that gets revisited regularly as the leader learns. The combination of A3 discipline and personal application makes it operationally different from other personal development tools.
Who should leaders share their Personal A3 with?
At minimum, a coach and a buddy or trusted partner who can observe them and give honest feedback. Some leaders go further and share their Personal A3 publicly with their team -- Susan Ehrlich posted hers on her office door at San Francisco General Hospital, and Gray Dubé did the same at Charlotte Maxeke Hospital in Johannesburg. The public version isn't appropriate for every leader or every culture, but where it has been practiced, it has accelerated organizational learning dramatically. The vulnerability of admitting publicly what you're working on creates conditions where everyone can do the same work.
What's the right frequency for executive coaching on this kind of work?
Monthly. Kim and John's coaching practice with executive teams operates on a monthly cadence, with each session starting with a brief review of Personal A3 learning before moving on to other content. The monthly frequency is enough to maintain momentum without overwhelming leaders who are still doing their day jobs. The five to ten minutes of Personal A3 review at the start of each session keeps the personal work alive rather than letting it drift to the background.
How do you measure progress on a Personal A3?
Through observation, not quantification. Personal change isn't a scientific measurement -- it's an observational one. The radar chart's observable reinforcing behaviors are what you watch for. The coach observes you at the gemba and notes whether you're asking how and what questions instead of who and why. The buddy observes you in meetings and notes whether you're listening or interrupting. Self-reflection captures what you can observe about yourself. The combination of internal and external observation produces the assessment. The fact that the measurement is observational doesn't make it soft -- it makes it appropriately fitted to the kind of change being measured.
What if my leaders aren't engaged in this work? How do I influence them?
John's answer: model the way within your span of control. As you change your own behaviors and start producing different results in your area, other leaders notice. The change isn't always quick, but it's more reliable than trying to convince leaders who aren't there yet through argument. Hand them the book. Share articles. But mostly, demonstrate through your own practice what becomes possible when the leadership behaviors change. The leaders who are ready will start paying attention. The ones who aren't may never be -- and that's not a failure of your approach, it's a real limit of what one person can change.
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