KaiNexus CEO and co-founder Greg Jacobson joins host Mark Graban for the eighteenth episode of the Ask Us Anything series, the recurring session built around questions from webinar attendees. The questions in this batch share a useful tension. The instinct in Lean work is to want clarity: clear gemba walk protocols, clear metrics, clear credentials. The honest answer in each case is messier than that, because the work is about people, and people respond better to invitation than to mandate. The conversation moves through how to start gemba walks that observe work rather than interrogate staff, how to set local metrics that align with high-level goals without dictating them, and whether the belt-certification system in Six Sigma is necessary for someone serious about practicing Lean.
Here is what the episode covers and the thinking behind each answer.
Tom, a leader at a children's hospital two years into a Lean journey, wrote in with a careful question. His executives were doing what he called walk-arounds, focused on asking staff open-ended questions, but he wanted to shift the activity closer to the spirit of a real gemba visit, which involves actually observing the work. He worried that being observed would be uncomfortable for both leaders and staff in an organization at that stage, and asked how to start and at what granularity, including whether to begin with patient-facing or non-patient-facing work.
Mark agreed with Tom's read. A gemba visit is not a hallway Q&A or a huddle drop-in. The substance of it is observation. He has coached executives to stand at a nurse's station for half an hour and just watch. Setup matters. Communicate why the executive is there, frame it as looking for waste in the systems rather than evaluating individuals, and recognize that early on there will be some friction. The friction eases as people see leaders observing problems, asking questions, behaving as servant leaders, and following through. Over time the observation becomes a positive presence rather than a threatening one.
Greg's reframe was about how to roll the change out. The hospital is not introducing something new; it is taking a slightly different flavor on something it already does. Pitching it as a variation rather than a new program lowers the activation energy. He also suggested a simple practical aid: shoot a couple of minutes of phone video showing what the new style of walk looks like, send it around with a quick explanation, and let people see what they're being asked to host before it shows up at their workstation.
On granularity, Greg had a direct answer from his own perspective as a practicing emergency physician. Even with more than a decade of practice behind him, he would be nervous if his leader walked in while he was in the middle of a direct patient interaction. He would be much more comfortable being observed during the support work around the patient encounter, in the workstation areas, around the medication dispensing unit, in resident-attending interactions, the rooms with the computers. Once trust is built in those settings, the harder, more sensitive observation can follow. Starting at the patient encounter itself is the wrong place to begin.
Mark added that there are times when observing inside the patient room is never appropriate. Confidentiality, sensitivity, privacy, and dignity have to be respected, and early on the strongest improvement opportunities are usually in the support processes around the encounter anyway. The delays in getting the patient to the right place, getting supplies and equipment to the caregiver, and removing waste from the steps that lead up to and away from the encounter. Caregivers feel supported by that kind of work, and over time they're often the ones who start leading the improvement that touches the patient encounter directly. Greg added one more practical thought, drawn from how academic medicine handles patient interactions. Bringing one observer into a room is usually fine; bringing five formalizes the interaction in a way that changes it. The same principle applies in a hospital gemba walk. Pair the leader with at most one CI expert who can coach them on the walk afterward.
An attendee asked for guidance on identifying local metrics that align with high-level metrics in strategy deployment. The questioner had run into people who felt true quality indicators were subjective or beyond measure, or who were already measuring other things and reluctant to change.
Mark's answer was catchball: the back-and-forth conversation that creates alignment around metrics without dictating them. Hoshin kanri usually starts with True North categories, and an organization might track something like patient harm across inpatient and outpatient settings, where each part of the organization has different specifics. Dictating a single measure (everyone tracks falls) usually fails because patient falls are not the most critical safety measure in every setting. The right pattern is to propose, listen for pushback, treat the pushback as a real position rather than as resistance, and keep the conversation going until alignment emerges.
Greg made the same point from inside the question. As a physician, he is acutely aware of metrics that have been "shoved down our throats," in his words, with no relationship to the work he actually does. He pointed to the volume and variable quality of CMS metrics as the case in point. His instinct as a leader is the opposite. Let the departments propose the metrics, but make them justify why those metrics ladder up to the higher-level goals. People defend metrics they helped define. They tolerate metrics that were defined for them. At KaiNexus, as the team grew, he stopped picking sales metrics himself and started the same back-and-forth with the sales team, treating it as an ongoing conversation about whether the right things are being measured, whether the goals are challenging enough, and whether they are SMART rather than impossible.
Mark added a relevance test worth keeping. The question is not only whether the metric is meaningful, but whether the person being measured against it can actually influence it. If your work has no plausible connection to the number you're being judged on, the metric is not relevant to you, regardless of how well it ladders up. Greg connected this to a principle he draws from the Spurs. Coach Popovich's teams emphasize process because process can be controlled where outcome often cannot. A door-to-doctor time in an ED is process-driven and within the team's influence. Patient satisfaction scores are influenced by far more than the team's behavior. Both matter, but coaching people on the right metric depends on whether the metric is one they can actually move.
An attendee in Canada asked what role state or national organizations might play in advancing Lean healthcare, and whether nursing organizations or unions might be playing a role being overlooked. Mark answered honestly about the United States picture, including one state nursing association whose published content had been openly critical of Lean. His read was that the criticism reflected a longer history of mistrust between nurses and hospital management; anything proposed by management, Lean included, was reacted to skeptically. He has also seen unions become genuine proponents of Lean when conditions allowed, because the things unions exist to protect — job security, working conditions, the ability to provide high-quality care — align with what Lean done well actually delivers. The NUMMI plant, the joint venture between GM and Toyota in California, was a UAW facility and ran one of the strongest Lean cultures in the U.S. auto industry.
Greg pointed at AHRQ, the Agency for Healthcare Research and Quality, and at the Baldrige framework as examples of government-adjacent organizations that have supported Lean ideas. His more useful contribution was about how to motivate organizations to lean in. Daniel Pink's "Drive" is usually applied to individuals, but the same logic works on organizations. Carrot-and-stick incentives produce limited engagement; recognition for organizations doing good work produces more, and storytelling about those organizations propagates the practice better than any policy mandate.
He closed the segment with a comparison to evidence-based medicine. When he started medical school in the mid-90s, evidence-based medicine was a relatively new idea that required its own curriculum. Today it is so embedded in how medicine is taught and practiced that it no longer needs to be named separately. Lean will have to make that same leap. At some point Lean stops being "the Lean program" and becomes how the organization does its work. The label fades, the practice stays.
A short question asked what color belt the hosts hold, in the Six Sigma sense. Neither has one. Mark went through Six Sigma green belt training at Dell two decades earlier without certifying, and later went through a Lean-equivalent program at Honeywell that the company called "lean expert," a term he dislikes. Most of what he knows about Lean came from books, video, conversation, and practice. Greg has done the same, with no formal belt at all.
Their point was not that the belt system is bad. Greg made the case for what it does well: a belt communicates a level of expertise, which builds a useful baseline of trust when you're working with someone you don't know. The point is that belt certification is not required to practice Lean the way medical school is required to practice medicine. Lean does not have, and never had, a tradition of mandatory belt certification. Toyota itself does not run a belt system. People hired out of Toyota carry credentials in something called Toyota Business Practices, the A3 methodology, but not belts. The belt structure exists in parallel with Lean rather than as a gating credential for it.
The last question asked how to take 5S from a basic auditing posture to something more effective, with better buy-in from production workers and supervisors. Mark's answer was less creative than proven: focus on whether 5S is actually helping people do their jobs. If 5S looks like an initiative about putting tape around things rather than about making work easier, the resistance is reasonable. Pushback is a signal to study and adjust, not to force compliance. If people say it seems silly, that is worth taking seriously.
Greg added that 5S only sells itself when the people involved already see waste in their workspace. If they believe the workplace is already efficient, no 5S program will convince them. Two practical moves help. Find the leaders who do see the waste and start there. And for workplaces that would benefit but cannot see it yet, bring in a testimonial from a comparable workplace that recently did 5S and found real value. Peer testimony lands better than internal advocacy.
Ask Us Anything is a recurring series of short sessions answering questions from KaiNexus webinar attendees. It is hosted by Mark Graban, VP of Improvement and Innovation Services at KaiNexus, with Greg Jacobson, the company's CEO and co-founder.
See every episode in the series on the Ask Us Anything main page. Earlier episodes are also available on the KaiNexus YouTube channel and in the KaiNexus podcast archive.
See KaiNexus in action and see how KaiNexus helps organizations capture ideas, coach improvement, and connect daily work to strategy.
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