Most continuous improvement programs in healthcare have a familiar trajectory. A team forms. Projects launch. Results emerge. Then, six or eight months later, someone goes back to look at the process and finds the gains have quietly disappeared. The countermeasures are still on paper. The standard work might still be posted on a wall somewhere. But the day-to-day work has drifted back to where it was before the project began.
Mike McGowan has watched this pattern play out several times in his work at Marietta Memorial Hospital, part of the Memorial Health System in southeastern Ohio. His response has been to systematically build the structure of training, leadership behavior, and embedded coaching that gives improvements a better chance of holding. The system he describes in this session isn't perfect, and Mike is unusually direct about what hasn't worked yet. But the framework is one of the most thought-through approaches to building a community-hospital CI culture available in webinar form.
Memorial Health System has a distinctive operational profile. The system is in southeastern Ohio, geographically isolated from major medical centers by roughly a two-hour drive to anywhere larger. The system includes two hospitals, three emergency departments, and urgent care centers. The organization is independent and aspires to remain so. Its core mission is captured in the phrase "keep care local" -- the geographic isolation makes the work of providing comprehensive local care a strategic imperative rather than a marketing slogan. The CI journey began formally in 2013, when the organization commissioned a team of continuous improvement specialists.
Mike McGowan is Director of Process Excellence at Marietta Memorial Hospital. He came up through hospital laboratory work, having started his career as a medical technologist after earning a BS in Zoology from Ohio University. Over 35 years in healthcare, he has served as a chemistry supervisor, laboratory director, and senior director of ancillary services before moving into his current role. He is a Lean Six Sigma Black Belt and a 2014 graduate of The Ohio State University's Master of Business Operational Excellence program, where Mark Graban served as his project mentor.
The session is hosted by Mark Graban, then VP of Improvement and Innovation Services at KaiNexus and the author of Lean Hospitals, Healthcare Kaizen, Measures of Success, and The Mistakes That Make Us.
Marietta Memorial's CI journey began in 2013 with a project-based model. A team of continuous improvement specialists worked through targeted improvements in different areas of the health system. The model produced wins. Countermeasures got implemented. Metrics improved.
Then the team went back six or eight months later and discovered the gains had eroded. They watched this happen two or three different times across different projects. The pattern wasn't accidental. It pointed to a structural issue with project-based CI that no amount of project execution discipline could fix.
The diagnosis Mike's team arrived at: when the CI team leaves, the gains leave with them. The team had been doing good work, but the work depended on their continued attention. The frontline staff and the leaders responsible for the improved processes weren't equipped to sustain the gains themselves. Once attention shifted to the next project, the previous improvement quietly drifted back to the pre-project state.
The shift Mike describes is from project-based CI toward what might be called culture-based CI -- an approach that aims to embed the disciplines of improvement into how the organization operates day to day rather than treating improvement as something done by a specialized team. The infrastructure for this shift is the five-role belt structure Mike walked through in the session.
The model Marietta Memorial built has five distinct roles, each with specific training expectations and operational responsibilities. The deliberate visual ordering Mike emphasized in the session puts white belts first -- the frontline staff -- because everyone else exists to support them. This isn't a top-down hierarchy. The frontline is where improvement actually happens, and the other roles exist to make that improvement possible.
White Belt: Frontline Staff. The goal is to train 2,000 of the system's 2,500 frontline staff as white belts. The training is a two-hour workshop covering basic Lean and Six Sigma structure, vocabulary, and goals. White belts are expected to enter opportunities for improvement into KaiNexus when they see them, and to participate on project improvement teams when their department is working on a value stream. The training ends with a 10-question quiz to confirm understanding.
Yellow Belt: Department Directors and Leaders. Two-day in-person workshop covering basic Lean concepts and tools. Yellow belts are expected to complete a project that incorporates specific tools -- a value stream map, graphs, KPIs -- and pass a 50-question certification exam. They participate on teams, lead teams, and assist with white belt training as the structure matures. The workshop includes a Kanban demonstration and a flow simulation to keep the training interactive across the two days.
Green Belt: Operational Leaders. A more demanding extension of yellow belt. Green belts complete three additional A3 projects under the coaching of a black belt, beyond the original yellow belt project. They're expected to be significant leaders in driving improvement entry into the system and supporting department-level training. As of the webinar, no one had completed the green belt requirement yet -- one person had completed one A3, but the three-A3 standard had proven hard to reach. The honest framing Mike offered: leaders are busy doing their jobs and see problem-solving as something extra. Part of the work is shifting that perception so that problem-solving is the job, not an add-on.
Black Belt: The CI Team. Six black belts on staff at the time of the webinar, with the original plan calling for ten, then revised to eight, and paused at six due to financial constraints. The team is led by Mike. All black belts are MoreSteam-trained through their online program with coaching. Black belts work with leaders to identify gaps and select improvement projects, coach and teach throughout the system, and run most of the training for green, yellow, and white belts.
Champion: Executive Sponsors. Usually a vice president or executive leader who helps select strategic priorities, removes barriers, and supports the cultural change as it develops. Champions don't run improvements directly. They create the conditions in which improvements can succeed.
One operational decision Mike highlighted is worth pulling out separately. Marietta Memorial standardized on MoreSteam's online black belt training program as the certification standard for the CI team. The reasoning: when LinkedIn and other channels make it clear how variable "black belt" credentials can be, having a defined external standard provides confidence that everyone on the team has been trained to comparable depth.
The hiring approach reinforces this. The team hires internally rather than recruiting external black belts, and pays for MoreSteam training during the first six to eight months of the new black belt's tenure. The training includes two projects, so by the time the new black belt completes the certification, they've already done improvement work in the Marietta context. If someone came in already MoreSteam-certified, they'd be considered good to go. Otherwise, the organization pays for the training to bring them to the same standard.
This kind of explicit external standard for black belt training is one of the more practical pieces of the model. Many organizations train their own black belts internally without a defined external benchmark, which makes the consistency of the certification harder to maintain as the team grows. The MoreSteam approach gives Marietta Memorial a defined floor for black belt capability that's portable, documented, and externally validated.
The most ambitious element of the system Mike described is the embedded black belt dyad model. The strategic plan called for, by 2021, a black belt working in dyad with the director of each of the more high-profile departments -- pharmacy, surgery, imaging, lab, nursing, and materials -- with the black belt embedded in the department rather than working from a central CI team.
The dyad concept comes from healthcare leadership practice. Two roles paired together, each bringing complementary expertise. In Marietta's design, the director continues to handle the operational responsibilities of running the department. The black belt provides the coaching and methodology depth that the director doesn't have time to provide directly, working with frontline staff to identify and solve problems on an ongoing basis. The black belt becomes, as Mike put it, an arm of the director -- not a replacement for leadership, but an extension of it.
So far, the dyad model has been implemented successfully in one department: pharmacy. Mike walked through a specific example. The pharmacy team had been receiving IV medications back from patient floors -- medications that had been prepared but not used, often because the patient had been discharged. The pharmacy was processing these returned medications in one large daily batch, with all the inefficiency and rework that single-batch processing implies. The embedded black belt worked with the team to shift to three smaller batches throughout the day. The result was a substantial reduction in the volume of medications that had to be reprocessed at all, plus simpler workflow for the team handling the returns.
The broader implementation has paused. Financial pressures led the organization to delay the expansion of the black belt team from six to eight or ten, which made the dyad expansion impossible to complete on the original timeline. The pause is honest, and Mike's willingness to discuss it openly in the session is unusual. Most CI presentations gloss over resource constraints. This one names them directly.
The specific worked example Mike walked through was an IV stop time documentation improvement led by one of his black belts. The metric was an error rate -- the percentage of IV documentation that had downstream problems requiring rework or causing billing issues.
The starting state: three emergency departments with error rates well above the 10% goal. One site was averaging around 75% error rate. The other two were in similar territory. The downstream consequences included rework throughout the documentation chain and billing complications that affected the organization's revenue cycle.
The black belt project worked with frontline staff and IT to identify the root causes of the documentation errors and implement system-level changes that addressed the errors at the source. The result, visible in the run charts Mike shared: all three sites brought down to consistent error rates under 10%, with the improvement sustained over time.
The current discussion Mike's team is having is about goal-setting on a project that has met its initial target. The current goal of 10% is being met. The aspirational goal of zero -- the place where the team would actually want to be -- requires another round of focused work. The team's framing is to set the aspiration at zero but use 10% as the threshold for action, with attention reactivated if the rate climbs above 10%. This is the kind of post-target-met conversation that distinguishes mature improvement work from project-based work that ends when the project ends.
One of the strongest features of this session is Mike's directness about where the program isn't yet doing well. Most webinars highlight successes. This one weights successes and limitations roughly equally, which makes the credible parts more credible.
What's working:
Executive leadership has been supportive. Anything the CI team has requested has been approved. They've been able to add team members. They have autonomy to design their own training. Leadership doesn't get in the way.
Improvements have been completed across a wide variety of departments -- revenue cycle, finance, clinics, pharmacy, emergency department, and others. The reach is broad, not just concentrated in one area.
Leaders are increasingly coached as part of the model. The CI team works with directors on their own problem-solving rather than just running projects in their departments.
The KaiNexus platform has been implemented and is being used to manage the volume of improvement work.
What needs to be better:
Executive leaders need more direct involvement. Only two of them have attended yellow belt training to understand what the CI work actually involves. The executives support the program from a distance but aren't actively leading with it.
Leaders still rush to solutions. The cultural pattern in healthcare -- nurses and physicians wanting to be the hero and fix things immediately -- is hard to interrupt. The discipline of fully defining a problem before jumping to countermeasures is still the work in progress.
The CI team needs to do better coaching internally. Mike asked his team what they could do better, and the team identified coaching within the team as an untapped resource. The team that coaches everyone else hasn't been fully coaching itself.
User updates need to be more timely. As the platform configuration evolves, communicating the changes to the user base requires discipline that the team hasn't yet built consistently.
The process for resourcing the CI team needed clearer structure. The team had been bouncing between project-based work and consultative work without a clear framework for prioritizing across the system. The Value Enhancement Program (described below) was designed in part to address this.
The most recent operational shift Mike described is the Value Enhancement Program, which administration introduced in response to financial pressures. Directors are tasked with three 90-day workout cycles every four months, focused on either reducing cost per unit of service or growing the business. The CI team coaches directors through these projects.
The scale of the program is substantial. At the time of the webinar, 260 total projects had been registered across the system, with about 75 categorized as "no value" projects -- attempts that didn't work out as expected. The total proposed enhancements across all the projects was around 32 million dollars, with substantial upside if the improvements sustain.
Two aspects of the program are distinctive. First, the "no value" projects are celebrated as learning, not treated as failures. Mike was direct that the team tries to make sure people feel good about trying something that didn't pan out -- because the alternative is a culture where people only attempt things they're confident will succeed, which produces conservative and uninteresting improvement work. Second, the program uses a priority tool to rank the 200+ active projects so that administration can decide where to deploy CI specialists for direct support. The higher the priority score, the more important the project is determined to be based on a set of criteria the team developed.
The model implements something many organizations talk about but few actually execute: a coordinated relationship between distributed improvement work happening at the director level and centralized CI capability that can be deployed to where it provides the most leverage. The Value Enhancement Program is the connective tissue between executive prioritization and frontline improvement activity.
One operational distinction worth pulling out from the discussion: many of the improvements in the Value Enhancement Program are what Mike called JDIs -- Just Do Its. The director already knows what to do. They don't need a black belt to facilitate a structured improvement project. They just need to do the thing.
The CI team's response to JDI work is to recognize it, count it, celebrate it, and stay out of the way. The principle Mike articulated: if you already know what you're going to do, go do it. The CI team's leverage is on problems people don't yet know how to solve -- the ones that benefit from structured methodology because the path forward isn't obvious. JDIs are valuable to the organization, but they don't need facilitation. The CI team's coaching time is best spent on the harder problems.
This is a practical version of the conventional Lean wisdom that you shouldn't train people in tools and then send them to find problems the tools might solve. You should identify the problems first, then deploy the methodology where it adds value. The JDI category formalizes this distinction operationally.
One of the Q&A questions asked which methodology Marietta Memorial trained to. Mike's answer was direct and a useful operational position to capture.
He prefers DMAIC personally because the named steps -- Define, Measure, Analyze, Improve, Control -- make the framework clearer to teach and easier to remember. He admitted candidly that he doesn't fully understand what each letter in PDCA stands for, which is the kind of honest admission most CI leaders don't make publicly.
But his broader position was framework-agnostic. The methodology you use matters less than the discipline of using a scientific method to solve problems. If you're going through a structured process -- define the problem, measure the current state, analyze the causes, test a solution, and control the gain -- it doesn't fundamentally matter whether you call those steps DMAIC, PDCA, or anything else. The discipline of structured problem-solving is what produces results. The label is secondary.
The position is worth honoring because it cuts through a lot of unproductive debate in the CI community. Different organizations standardize on different frameworks for different historical and cultural reasons. The choice matters far less than whether the methodology actually gets used.
The KaiNexus platform is integrated throughout the Marietta Memorial model, and Mike's discussion of how the platform supports the work is specific.
White belts enter their opportunities for improvement into the platform when they see them in their daily work. The platform routes the ideas to the appropriate leader, tracks the status, and ensures that ideas don't disappear into a void without acknowledgment or response.
Each vice president can see all the projects running under their area of responsibility through a dashboard view of the platform. The visibility lets executives manage their portfolio of improvement work, identify projects that are stalling, and coach directors through their improvement cycles.
The priority tool that ranks Value Enhancement Program projects lives in the platform. As directors enter projects, the system applies the prioritization criteria the team developed, producing a rank-ordered view of where CI specialist time should be deployed.
The badging functionality is being used to recognize white belt completion and other improvement milestones. Mike's team was working on extending the badge system so that leaders could award badges directly, creating a recognition pathway that doesn't depend on central administration to issue every acknowledgment.
The platform's standard work and root cause analysis functionality is being extended to support the quality program. Marietta Memorial was, at the time of the webinar, working with KaiNexus to build root cause analysis forms specifically for their quality team and to extend the platform to hold quality collaborative teams' work.
Mike was clear about what the platform doesn't do. It doesn't create the engagement. It doesn't replace leadership behaviors. It doesn't substitute for the cultural work of training, coaching, and developing problem-solvers. What it does is hold the infrastructure on which those practices operate. Without it, the volume of improvement work an engaged frontline workforce generates -- hundreds of opportunities, dozens of active projects, thousands of staff members at different belt levels -- would be impossible to track and sustain.
Mike McGowan is Director of Process Excellence at Marietta Memorial Hospital, part of the Memorial Health System in southeastern Ohio. He earned a BS in Zoology from Ohio University and has worked in healthcare for 35 years, most of that time at Marietta Memorial, in roles including medical technologist, chemistry supervisor, laboratory director, and senior director of ancillary services. He is a Lean Six Sigma Black Belt and a 2014 graduate of The Ohio State University's Master of Business Operational Excellence program. He leads a team of six black belts responsible for the Memorial Health System's continuous improvement work.
Why does Marietta Memorial use a five-role belt structure?
To build a sustained capability across the organization rather than depending on a small specialist team. The five roles -- White Belt (frontline staff), Yellow Belt (department leaders), Green Belt (operational leaders), Black Belt (CI team), and Champion (executive sponsor) -- each have defined training expectations and operational responsibilities. The visual ordering puts white belts first because everyone else exists to support them. The structure recognizes that improvement actually happens at the frontline, and the other roles exist to make frontline improvement possible.
Why doesn't project-based CI sustain over time?
Because when the CI team's attention moves to the next project, the previous improvement quietly drifts back to its pre-project state. The frontline staff and leaders responsible for the improved process aren't equipped to sustain the gains themselves. Marietta Memorial watched this happen two or three times before concluding that project-based work alone wouldn't produce a sustainable culture. The response was to invest in building distributed capability through the belt structure, so that the people doing the work day-to-day have the skills and authority to sustain the gains themselves.
What is the embedded black belt dyad model?
A structure where a black belt works in dyad partnership with the director of a high-profile department -- pharmacy, surgery, imaging, lab, nursing, materials -- rather than working from a central CI team. The director continues to handle the operational responsibilities of running the department. The black belt provides ongoing coaching and methodology depth, working with frontline staff to identify and solve problems on a continuous basis. The model has been successfully implemented in pharmacy at Marietta Memorial, with substantial results including a shift from one large daily batch of returned IV medications to three smaller batches that dramatically reduced rework volume.
How does Marietta Memorial decide how many black belts to have on the CI team?
The decision evolved over time. The team started with three black belts plus a director. A fourth was added out of necessity when project volume exceeded capacity. The strategic plan called for ten total to support the full dyad model across all high-profile departments. The plan was revised to eight, and currently sits at six due to financial constraints that paused team expansion. The principle: the right number depends on the scope of the dyad model the organization wants to support and the financial conditions that constrain hiring. There's no universal right answer.
Why does Marietta Memorial use MoreSteam for black belt training?
Because external certification provides a defined standard for black belt capability that's portable, documented, and externally validated. The variability of "black belt" credentials in the broader market makes internal-only training harder to verify and harder to sustain as the team grows. MoreSteam's online program with coaching gives Marietta Memorial a consistent floor for black belt capability. The hiring approach is to hire internally and pay for MoreSteam certification during the first six to eight months of the new black belt's tenure, including two real projects as part of the certification work.
What is the Value Enhancement Program?
A structured cost-and-value improvement program where directors are tasked with three 90-day workout cycles every four months, focused on either reducing cost per unit of service or growing the business. The CI team coaches directors through these projects. At the time of the webinar, the program had 260 total projects registered with about 32 million dollars in proposed enhancements. The program uses a priority tool to rank projects so administration can decide where to deploy CI specialists for direct support. Projects that don't pan out are categorized as "no value" projects and celebrated as learning experiences rather than treated as failures.
What's a JDI and why does it matter operationally?
A Just Do It -- an improvement the director already knows how to make. JDIs don't need facilitation from the CI team. They just need to be done. Marietta Memorial's principle is that CI team coaching time should be spent on problems people don't yet know how to solve, not on improvements people are already capable of executing. Recognizing the distinction operationally lets the CI team's leverage land where it produces the most value. The JDI category formalizes the conventional Lean wisdom that you should identify problems first and deploy methodology where it adds genuine value, rather than applying tools indiscriminately.
DMAIC or PDCA -- which methodology should you use?
Mike's position is that the choice matters less than the discipline. DMAIC's named steps -- Define, Measure, Analyze, Improve, Control -- make it easier to teach and remember. PDCA has its own logic. As long as you're going through a structured scientific process to solve problems, the specific framework you label it with is secondary. The discipline of structured problem-solving is what produces results, not the brand of methodology. Different organizations standardize on different frameworks for legitimate historical and cultural reasons. Pick one and use it.
How do you sustain frontline engagement over time once the initial excitement fades?
It comes back to leadership behavior. When frontline staff bring forward ideas and leaders listen, respond, and act, the engagement continues. When ideas disappear into a void without acknowledgment or response, people stop bringing them forward. Mike was direct that the secret isn't any specific tool or technique -- it's whether leaders are actually engaging with what frontline staff bring to them. Marietta Memorial supports this through training, badging, and platform infrastructure that makes ideas visible and tracked, but the underlying engagement depends on leadership response.
How does Marietta Memorial think about recognition and incentives?
The team explicitly favors recognition over financial incentives. Completion of training is recognized through colored badge holders that signal yellow belt or white belt status, and platform badging is being extended. The team has discussed financial incentives but consciously stepped back from them. The reasoning: large financial rewards introduce arguments about what an improvement is really worth and produce distractions from the work itself. Recognition -- a thank-you note from the CEO, public acknowledgment at a department meeting, a manager taking time to say "great job" -- has more durable motivational value than a $10 gift card. The intrinsic motivation of making your own work better is the strongest reward.
Bonus Webinar:
.svg)
Copyright © 2026
Privacy Policy