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Sam Phillips was a record producer who worked with Elvis Presley, Johnny Cash, BB King, and many others during the emergence of rock and roll. He was known not for pursuing technical perfection but for the question he asked when a session ended: when the record stops playing, do they want to play it again?
Dr. Lisa Yerian opens this session with that question because she believes it captures the real test of improvement work -- not whether the process was followed correctly, not whether the metrics moved, but how people felt when the work was done. Did they want to do it again?
After more than a decade as Chief Improvement Officer at Cleveland Clinic, leading a team that has engaged over 20,000 caregivers in improvement efforts across 77,000-person organization, she has a specific answer to what makes people want to play the record again. It isn't more tools. It isn't better training. It isn't a CEO mandate. It's three things: purpose, reflection with integrity, and empathy. This session is her account of how she learned that -- and what it looked like when it worked, and when it didn't.
Lisa opens with a story that has nothing to do with lean methodology. A friend arrived late to a Zoom call, his face flushed, his eyes wet. His daughter had depression. She had become suicidal. The soonest appointment he could get was six weeks out. He apologized for interrupting and went back to the phone to keep calling.
She doesn't tell the story to make the audience feel bad. She tells it because it's why she got into this work, and because it's the honest standard against which she measures improvement efforts. One in five families report difficulty accessing care even when seriously ill. An estimated 42 million people worldwide are harmed in hospitals every year. More than 3 million of those are in the United States, where life expectancy is declining at rates not seen since the 1920s. Caregiver burnout is rampant.
The CI community has been working on these problems for decades. Smart, committed people with good tools and good intentions. And the honest assessment is: we've made process improvements, we've moved metrics, but we haven't created the deep, sustained cultural transformation the problems require. That kind of change -- the kind that carries on and grows beyond any individual leader or initiative -- is still rare. Still mostly aspirational.
Lisa's argument is that this isn't a knowledge problem or a tool problem. It's a problem with how we try to create cultural change. And improving that requires CI professionals to have the courage to examine their own practice honestly.
When Lisa was given the job of building a CI culture across Cleveland Clinic, she faced three conditions that might have seemed like disadvantages.
No roadmap. Nobody had reliably done this in healthcare. There were stories of lean transformations that seemed incredible and later completely unraveled. There were activity-based programs and certification initiatives that nobody thought would produce lasting culture change.
No precedent. She had seen lean methods applied to processes. She had never done a lean transformation herself, and neither had most of her team.
No CEO mandate. Many people at the time believed a mandate from the top was essential to this kind of work. Cleveland Clinic didn't have one.
Looking back, she thinks the absence of a mandate was actually an advantage. Mandates make people feel like victims of change rather than participants in it. Mandates can compel attendance at huddles and completion of cards, but they can't mandate trust, psychological safety, creativity, or courage -- the things that make improvement culture actually work. And mandates eliminate the choice: they remove the opportunity for people to decide, which removes the power that comes from making that decision.
Cleveland Clinic still doesn't have a CEO mandate for CI. Lisa has never asked for one. She has asked for a great deal from leaders, but not that.
The most memorable question in the session comes from Lisa's colleague Nate Hurle. A team from another health system flew in to see Cleveland Clinic's tiered daily huddles. They were excited, detailed, enthusiastic -- they had kickoff plans and training schedules and posters and slogans. At the end of dinner, after describing all of it, they paused and asked Lisa's team what they thought. Nate asked: what is the purpose of your transformation?
There was a pause. That is a great question, they said. We should think about that.
They were planning a transformation without a purpose. Extensive thought about the what, essentially no thought about the why.
The moment that crystallized the importance of purpose for Lisa was simpler than that. When she got the job, she called Mark Reich, an experienced lean leader from Toyota. Excited, probably hoping he would hand her the playbook. He didn't. He said: sounds like you need to do an A3 on that.
She had heard of A3 thinking but never done one. She got a book and a large piece of paper and started. The A3 she produced was messy and clear at the same time -- very different from the polished PowerPoint presentations that moved through Cleveland Clinic's culture. It was visible thinking rather than finished conclusions. When she sat with people and made notes in different colored pens, she could see them lean in as they watched their words appear on the page. Their contribution was visible and real in a way that a feedback box at the end of a slide deck never produces.
The value of the A3 in this context wasn't just the problem-solving structure. It was that it kept the purpose of the transformation in front of everyone all the time. It prevented the drift toward activity -- toward doing things because they were on the roadmap, because they were the next chapter in the lean playbook -- rather than because they were solving a specific identified problem.
Lisa's challenge to the audience, stated plainly: do CI professionals actually use their own best problem-solving methods for their own work? In her experience, it's uncommon. People will say they think that way -- it's just in their heads, they're not writing it down. But what would happen if they did?
Cleveland Clinic's purpose, held for a decade and unchanged: every caregiver capable, empowered, and expected to make improvements every day. Each word deliberate. Capable means genuinely capable -- not just trained, but able to see problems, speak about them openly, and solve them to root cause. Empowered doesn't just mean permitted -- it means a clear, viable path exists and actually works. Expected means improvement isn't optional. And every means all of it, not just clinicians or leaders or CI specialists. Every caregiver, every day.
Reflection is something CI organizations say they value. Lisa's question is whether they actually practice it as rigorously as they practice everything else.
A story about a CEO: Lisa got a call from an improvement team leader at another health system who wanted help articulating the value of tiered daily huddles. She agreed. She gets on the call and discovers she's talking to the CEO, not the improvement team leader. The CEO asks why she should add tiered daily huddles to her team's already full plates -- they already have safety briefings, operational calls, and regular problem discussions. When Lisa asked her why she was considering it, the CEO said: my improvement team told me to. And when I didn't see the value they asked me to call you.
Lisa's point, carefully stated: she is not arguing that tiered daily huddles aren't valuable. Cleveland Clinic does them and they are valuable. Her point is that the CEO's improvement team was trying to sell a solution to a leader who hadn't first been engaged in identifying the problem it solves. The solution was on the roadmap. The purpose wasn't clear to the person who needed to commit to it.
The reflection practice Lisa describes is specific. Every week, in the first team she worked with, she and the director would do two things: remind everyone of the purpose -- what problem were they trying to solve -- and then ask honestly how things were going. What was working. What wasn't. How they could do better. This wasn't feedback theater. It was genuine inquiry, sustained over time, producing enough trust that people eventually felt safe enough to be candid.
That candor was what drove the actual development of the CI systems Cleveland Clinic now uses. The kaizen system came from teams articulating that they needed a better way to identify and prioritize the problems they were now seeing. The alignment system came from teams asking for help deciding which problems mattered most. Each system was introduced when the teams actually understood they needed it -- because they had said so -- not because it was the next item on the lean implementation checklist.
The contrast she draws: in most organizations, the roadmap is the guide. You do 5S, then standard work, then visual management, in a sequence defined by the playbook. In Cleveland Clinic's experience, that sequence misses the real requirement: the team has to understand the problem the tool solves before it can use the tool well. That understanding can only come from honest reflection.
The hardest part of the session, and the part most CI leaders will recognize as the most uncomfortable, is this: what do you do when people don't want what you're offering?
Some of Cleveland Clinic's managers actively resisted the move toward empowering their teams. Lisa spent time trying to understand why, and what she found changed her approach. These managers didn't see their role as Sheila did -- as someone who elevates and empowers a team toward better care. They saw themselves as heroes. Their identity and their sense of value were built around rescuing their team from problems. That's how they had been rewarded, that's how they had risen, and that's what being a good manager meant to them.
When improvement culture asks those managers to let their teams solve problems themselves, it's threatening in a way that's deeper than professional inconvenience. It's an identity threat. What does it mean about me if I'm not needed for this? Where does my value go?
The response Lisa identifies as wrong: getting frustrated. Judging people for not seeing things the way she sees them. Feeling like a victim because there aren't more Sheilas in the organization.
The response she identifies as right: empathy. Not sympathy -- sympathy is looking down into the pit and feeling sorry for the person in it. Empathy is going into the pit. It means connecting to something in yourself that knows what that feeling is like.
Lisa names hers directly. In CI work, people who love improvement get called for the most important, most complex, most vexing problems. They get to solve them. That role -- that hero role -- is something many CI professionals are attached to. She was attached to it. Whenever her own role or work was questioned, she felt the threat of losing it. She knows what it feels like to be in that pit. And naming that experience was what allowed her to have genuinely useful conversations with the managers who were struggling, rather than performatively tolerating their resistance.
Her ask of the audience at this point in the session: write down one or two words. What takes you into the pit? What experience or memory knows what it's like to feel threatened, frightened, overwhelmed in this work? The next time you feel annoyed or frustrated or victimized by someone's resistance to change, pull out that word. Use it to go into the pit with them rather than watching from above.
The reason this matters practically: the hero identity problem isn't rare. It's a structural issue in how management is understood in most hierarchical organizations. CI professionals who want to scale empowerment culture will encounter it repeatedly. Approaching it with genuine empathy rather than exasperation is the only approach that actually changes the dynamic.
Sheila is a nurse manager in an inpatient dialysis unit. Her team reduced delays in treating patients, eliminated mandatory overtime, and reduced patient codes -- the events where a patient stops breathing and their heart stops -- by 83 percent. When Lisa asked what kept her committed to the work, Sheila said: because I want the whole team to know, no matter who we are or what role we're in, we all have the ability to impact and make a difference.
For Sheila, the CI culture wasn't a program imposed on her team. It was the mechanism that let her be more of what she came to healthcare to be. She could engage her team fully. She could elevate them. She could make care better for patients in ways that one person, however heroic, never could have done alone.
Lisa describes the transformation she's seen in people who engage with improvement work this way: it can fundamentally change a person's sense of who they are and what they're capable of. She expected that this work would improve care for patients. She had no idea what it would mean for the people doing the work.
That's what Sam Phillips was after. That's what "do they want to play it again?" sounds like in practice.
The session closes with an invitation to audit your own organization's CI culture not through metrics but through experience.
If someone walked into your organization and asked caregivers about your improvement work -- not a specific project, but the overarching cultural effort -- what would they say? Is it something people talk about with energy and enthusiasm? When teams engage with it, does it sustain and grow, or does it slowly fade as the initial excitement passes? When the improvement record stops playing, do your people want to play it again?
The honest version of those questions, asked with integrity, is what Lisa argues produces the direction for improving how you do improvement. Not the next tool or the next training program or the next mandate. The willingness to ask, really ask, and hear what the answer actually is.
A few specific connections to the platform are worth naming.
The kaizen system Cleveland Clinic developed came from listening to what their teams needed. A reliable, visible, responsive place to capture problems and improvement ideas -- and track them through to resolution -- is exactly what KaiNexus provides at scale. The difference between a system where ideas disappear and one where every submission gets acknowledged and tracked is the difference between futility and genuine participation.
The visibility Lisa describes as central to her A3 practice -- the ability to show thinking in progress, to have people see their words incorporated, to make improvement work visible to everyone it touches -- is the same principle that drives the platform's approach to transparency across teams and facilities.
And the empowerment vision Lisa articulates -- every caregiver capable, empowered, and expected to make improvements every day -- is the exact goal KaiNexus is designed to support. Not as a slogan but as a measurable operational state: more people participating, more improvements implemented, more impact tracked, more learning spread across the organization.
Dr. Lisa Yerian, MD is the Chief Improvement Officer at Cleveland Clinic, where she also serves as a pathologist. She joined Cleveland Clinic in 2004 and has held multiple pathology and health system leadership positions. Under her leadership, the Cleveland Clinic Improvement Model was developed, tested, and refined as the organization's roadmap for building improvement culture over more than a decade. Her team has engaged over 20,000 Cleveland Clinic caregivers in improvement efforts. She received her BS from the University of Notre Dame, her medical degree from the University of Chicago Pritzker School of Medicine, and completed residency training in Anatomic Pathology and a fellowship in gastrointestinal and liver pathology at the University of Chicago.
What is the central argument of this session?
Sustained cultural transformation in CI isn't primarily about tools, training programs, or mandates. It's about how people experience the work. When improvement is grounded in clear purpose, supported by honest reflection, and approached with genuine empathy for the people who find it threatening, people want to engage and keep engaging. When it isn't, even technically well-designed improvement systems produce activity without real cultural change.
Why doesn't Lisa recommend seeking a CEO mandate for CI transformation?
Because mandates make people feel like victims of change rather than participants in it. They can compel behavior -- attendance at huddles, completion of cards -- but they can't mandate trust, psychological safety, creativity, or courage, which are what CI culture actually requires. They also eliminate the opportunity for people to choose, which removes the power of choosing. Cleveland Clinic has operated without a CEO mandate for CI for over a decade.
What does "anchoring in purpose" actually mean in practice?
It means being able to answer -- clearly, specifically, and in a way that connects to what the people doing the work care about -- why the transformation effort exists and what problem it's solving. Cleveland Clinic's purpose, held for ten years: every caregiver capable, empowered, and expected to make improvements every day. Tools and systems are introduced when the team has identified the problem those tools solve, not because they're next in the lean playbook.
What is "reflection with integrity" and how is it different from checking the box?
Reflection with integrity means genuinely asking how things are going -- what's working, what isn't, what needs to change -- and actually hearing the answer. It requires sustained practice, enough trust to get honest responses, and the willingness to change direction when the data says you should. Checking the box means asking for feedback and feeling good because you asked, without real engagement with what was actually shared or whether it changed anything.
How do you handle managers who resist empowerment culture?
With empathy, not frustration. Many managers who resist teams solving their own problems are experiencing an identity threat, not just professional inconvenience. Their sense of value and their role are built around being the person who rescues the team from problems. When improvement culture asks them to step back and let the team solve problems, it threatens that identity. Understanding that -- connecting to your own experience of feeling threatened, of being in "the pit" -- is what makes genuinely productive conversations possible.
Does Cleveland Clinic use financial incentives to drive CI participation?
No. Lisa's answer is direct: they don't use financial incentives, she'd be afraid to try it, and they haven't needed it. Seeing and feeling the effect of improvement work on patients and on the team, over and over, has been sufficient motivation. Financial incentives also become complicated quickly. The problem they're designed to solve -- motivation -- hasn't been the actual constraint.
How does Cleveland Clinic manage time for CI work in a clinical environment?
By starting as small as possible. Lisa's emphasis is on the minimal testable unit -- the smallest possible test of any change before wider rollout. She also pushes back on the assumption that effective improvement work requires large time blocks. A well-organized, focused A3 conversation can produce significant learning in ten minutes. The hardest period is the beginning, when teams haven't improved anything yet and are working on faith. Leadership support to create a little space during that period helps. After early results start to appear, the improvement work begins to justify itself.
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