Most healthcare organizations that pursue continuous improvement start with the methodology. They train belts, run Kaizen events, deploy Lean tools, and hope the cultural change follows.
Mary Greeley Medical Center started somewhere else. They started with leadership.
The 220-bed acute care hospital in Ames, Iowa launched their continuous improvement journey in 2009 with a foundational commitment from the top -- not just the executive team, but the city-elected five-member Board of Trustees that governs the organization. That board sat through a Lean training exercise themselves before the broader rollout began. Once the board, the senior leaders, and the management team were aligned around a common vocabulary and a shared philosophy, the rest of the work became possible.
The result, six years in at the time of this session: a hospital where leadership behaviors, a structured improvement methodology, and a daily improvement system engaging 1,300 employees all reinforce each other rather than working at cross purposes. Hard cost savings from a 100-day workout exceeded $722,000. Implementation rates on daily improvements ran 60-65%. More than 70% of employees had logged into the improvement system. The journey was still ongoing -- Mary Greeley's leaders are explicit that the work isn't done -- but the trajectory was unmistakable.
This webinar is the story of how that happened, told by two people who lived it. Karen Kiel-Rosser, then Vice President and Chief Quality Officer, covers the leadership journey from 2009 onward and the systematic approach that organized the work. Ron Smith, then Process Improvement Coordinator, covers the methodology of spreading daily improvements across the organization and the coaching practices that made it stick.
The host is Mark Graban, then VP of Customer Success at KaiNexus and the author of Lean Hospitals and co-author of Healthcare Kaizen. Mark worked with Mary Greeley during the rollout of their daily improvements program and references that engagement in the session.
Mary Greeley Medical Center serves Central Iowa from Ames. The organization is governed by a five-member Board of Trustees elected by the city -- an unusual governance structure that puts community accountability into the formal organizational design rather than treating it as an aspiration.
The strategic plan is organized around four indicators of excellence: culture of quality, safety, and service; operational performance; access to care and services; and regional relationships. At the center of all four is patient-centered care, which Karen describes not as a slogan but as the operational test for every decision about where to focus improvement effort.
The improvement philosophy is captured in a single line that Karen says runs through every level of the organization: "Two jobs for every employee at Mary Greeley -- do your work and improve your work."
That formulation is more consequential than it sounds. The traditional model of improvement work assumes that improvement is a side activity, separate from "real" work, performed by specialists or championed during events. The two-jobs framing treats improvement as part of the job description for everyone. Nurses, pharmacy technicians, physicians, support staff, and leaders all share the same operational expectation: do your work, and improve your work. The expectation lives in employee orientation. It shapes how managers coach. It defines what counts as success in any role.
The first deliberate move in the journey was getting senior leaders and the board aligned around a common vocabulary and a shared philosophy before launching any operational improvement work.
This isn't the order most organizations follow. Most start with a pilot project, see early results, and try to scale from there. Mary Greeley's choice was the opposite: invest the early time in leadership alignment, even though it produces no visible operational results during the alignment work itself.
The board education involved an exercise that Karen describes as the "penny exercise" -- a quasi-assembly-line simulation where board members moved pennies between locations and experienced firsthand how process design affects waste and risk. The exercise wasn't about pennies. It was about giving the board a tangible, embodied understanding of what Lean principles meant in practice before they signed off on rolling out those principles across the organization.
The board emerged from the exercise confident that the philosophy could work in their hospital. That confidence translated into governance support for the entire subsequent journey. Without that early board commitment, the management work that followed would have been more fragile -- vulnerable to questions about resource allocation, strategic priority, and patience for slow results.
The objectives Karen names from that early phase are deliberately framed: develop a common vocabulary, develop a supportive system to ensure accountability, and ultimately build a culture where every one of 1,300 employees is engaged in improving their work. The third objective is the long arc. The first two are the operational prerequisites.
After board alignment, the next move was leadership training. All 60 leaders attended a two-and-a-half-day Yellow Belt training program that covered the Toyota way, rules in use, 6S, visual management, and the core Lean toolkit. The training was the same for every leader, which is significant -- the consistency of the curriculum was deliberate, intended to build a shared vocabulary across the management team rather than letting different departments develop divergent vocabularies.
But training alone doesn't change behavior. The follow-up move was the warehouse project.
Mary Greeley had a large warehouse that had become a de facto dumping ground -- unused equipment, items needing repair, supplies that someone might need later but were stored without organization. The leadership team turned this warehouse into a training center. They did a 6S project together, hands-on, with all 60 leaders working through the actual practice rather than discussing it in a classroom.
Then, immediately after the group project, Karen and her team applied the "see one, do one, teach one" principle -- a model from medical education. Every leader was challenged to complete a 6S project within their own department within a defined timeframe. They had to use the tools they had just learned, on a project they owned, with their own staff. Six months later, the leadership team toured each other's 6S work and shared best practices.
The pattern is worth pulling out. Training alone produces understanding but not behavior change. Group practice produces shared experience but not departmental application. Individual application produces departmental change but not organizational learning. The four-stage sequence -- classroom training, group hands-on practice, individual departmental project, cross-department sharing tour -- produced all four. Five years later, Karen notes, the 6S improvements from those original projects were still sustained.
After the leadership team was trained and had practical experience, the next structural move was creating the Standard Work Steering Committee -- a multi-disciplinary group that would prioritize where improvement work should focus next.
The reason for the committee was practical. After the initial training and 6S work, leaders were identifying problems in their own departments and the queue of potential projects was piling up. Without a prioritization mechanism, the organization risked working on whatever was loudest rather than whatever mattered most.
The committee did three things. First, they defined what "standard work" actually meant for Mary Greeley -- the documented current best practice for tasks the organization wanted to repeat with accuracy. Second, they identified the 49 distinct work processes that existed across the hospital. Third, they applied a prioritization framework that weighted patient impact, risk of error, and likelihood of improvement success, and narrowed those 49 processes down to a top 10.
Those top 10 work processes became the focus for value stream mapping events, rapid improvement events, and structured projects across 2011 and 2012. The work was organized around the processes that mattered most, not around the departments that asked loudest.
This is where most organizations get stuck. The temptation when running an improvement program is to address whatever leaders bring forward. The Standard Work Steering Committee was Mary Greeley's mechanism for keeping the work focused on systemic priorities rather than departmental preferences. The committee didn't ignore departmental requests, but it ensured that the highest-priority systemic improvements got attention regardless of who was asking.
By 2013, Mary Greeley had multiple value stream mapping events running, more than a dozen rapid improvement events completed, dozens of 6S projects underway, and an expanding catalog of departmental improvement work. The improvement department had two people. The volume of work had outgrown what spreadsheets and email could track.
The team evaluated multiple project management and improvement management platforms. KaiNexus rose to the top because of the simplicity of use, the alignment with the Lean improvement methodology, and the fit with the work they were already doing. They adopted the platform initially for managing structured improvement projects -- value stream mapping events, rapid improvement events, and the larger departmental projects.
The early use was within the improvement department. The leaders running the projects used the platform. The frontline staff and most managers weren't using it yet. That changed in 2014.
The 100-Day Workout was the move that brought the leadership team into the platform and built the foundation for the daily improvements rollout that would follow.
Borrowing from the GE 100-day workout concept, Mary Greeley challenged each of their 60 leaders to identify an improvement project in their area that could be completed in 100 days. The project had to either generate revenue or produce cost savings, and the leader had to use KaiNexus to manage it.
The results exceeded what Karen and her team had projected.
Of the 60 leaders, many completed projects within the 100 days. Some had larger projects that were tracked beyond the workout window. The 54 opportunities for improvement that were completed within the workout period produced over $722,000 in hard cost savings, $675,000 of which was first-year savings, plus $47,000 in revenue generation. The workout also produced 5,200 hours of labor savings -- time that didn't disappear from payroll but was redirected from waste to productive work.
The financial impact was significant. The cultural impact was more important. After the 100-Day Workout, 60 leaders had personal experience with both the platform and the discipline of running an improvement project to completion. The skepticism that would have greeted a top-down daily improvements rollout was now replaced by leaders who understood the work because they had done it themselves.
This is the pattern that runs through Mary Greeley's journey. Every new phase is preceded by hands-on experience for the leaders who will be expected to support it. Board training before management training. Management training before management practice. Management practice before management coaching of staff. Each prerequisite is built before the next stage launches.
In January 2015, Mary Greeley launched their Daily Improvements program -- the rollout that engaged all 1,300 employees in the work they had been building toward for six years.
The methodology Ron Smith walks through in the second half of the session is the operational core of the rollout. Mary Greeley didn't flip a switch and turn on daily improvements for the entire organization. They worked through departments two or three at a time, over a roughly two-and-a-half-week cycle per cohort, with structured coaching sessions for the leaders involved.
The four-meeting cycle per cohort:
The first meeting was a one-hour conference call between the department leaders and the KaiNexus team, covering how the software supports daily improvement management.
The second meeting was a two-hour session covering how to capture ideas. The emphasis was on coaching leaders to coach employees -- not just teaching the software, but teaching the practice of rounding with staff in a way that surfaced real process improvement opportunities rather than the random ideas that suggestion boxes tend to attract.
The third meeting was an implementation session covering how to assign ideas, engage staff in the work, and resist the leader's tendency to solve problems themselves rather than coaching employees to solve them.
The fourth meeting was a two-week followup to check on early results, address any questions, and surface any patterns that needed adjustment.
The rollout strategy is consistent with everything Mary Greeley had done before. Train the leaders, give them experience, support them with coaching, then move to the next cohort. By the time the entire organization was running daily improvements, every department had been through the same structured rollout. The methodology was consistent across the organization not because the central team enforced it, but because every leader had been trained the same way.
The four-stage daily improvements methodology Ron describes maps directly to the practical work of running an improvement program at scale.
Capture. The work of identifying ideas worth pursuing. The crucial discipline here is asking the right questions during rounding. The traditional employee-rounding question -- "What tools and equipment do you need to do your job?" -- is actually asking for solutions. The daily improvements question reframes around problems: "What bugs you?" "What frustrates you?" "What gets in the way of providing excellent patient care?" These questions surface the underlying problems the employee is dealing with, which the team can then work on collaboratively.
The "three-foot radius" framing Ron describes is a practical tool. Tell employees to look at what frustrates them within a three-foot radius of where they actually work. The framing focuses attention on things the employee can influence rather than on the parking ramp, the cafeteria menu, or other items outside their control. The corollary: "There is no somebody who works here." If an idea is addressed to "somebody," it's probably outside the employee's sphere of action and outside the daily improvements scope.
Capture lessons learned include the discipline of generating ideas during the rounding session before showing the employee how to log in. The reverse order -- show them the software first, then ask for ideas -- tends to produce a polite "got it" and no follow-through. Generating ideas first and then showing the employee how to capture them produces submissions in the same session.
Implement. The work of moving an idea from submitted to completed. The crucial discipline is coaching the leader to resist solving the problem themselves. The leader's role is to assign the idea -- usually back to the employee who submitted it, sometimes to a small team that includes other affected staff -- and then to support the employee in doing the work.
The standard assignment workflow Ron describes is simple. The leader thanks the employee for the idea, provides direction on investigating it further, and offers to support questions and roadblocks. The employee owns the implementation. The leader coaches and removes barriers.
The implementation phase grounds itself in PDCA (Plan-Do-Check-Act). The Check step is the one most often skipped -- teams tend to plan and do, plan and do, without verifying whether what they tried actually worked. Mary Greeley's coaching addresses this directly by requiring a feedback loop. At minimum, the leader asks the employee whether the change is in place and working. Where data is available, the data is used. Where data isn't easily available, employee feedback substitutes.
Measure. The work of resolving the idea and capturing its impact. The key metric is the percentage of OIs that result in a change. Mary Greeley was running 60-65% at the time of this recording -- below the KaiNexus customer average of 75-80%, but well above the 1-2% typical of suggestion box systems. Ron is explicit that they want partial improvements over no change. An idea that addresses 30% of a problem still produces a change. Closing an idea with "no change" should be a last resort.
The lesson learned Ron names: distinguishing between hard cost savings and time savings (a soft saving). A change that frees up two hours of an employee's time at $15 an hour doesn't generate a $30 hard cost saving unless that employee is laid off, which generally doesn't happen. The time gets reallocated to other work. Tracking it as "time saved" rather than "money saved" is the more honest categorization.
Share. The work of making completed improvements visible across the organization. The platform supports this structurally -- improvements can be broadcast and made visible to other departments who might benefit from similar work. Mary Greeley also uses department huddles for recognition and a monthly "first Friday" leadership report-out where 30 minutes is set aside to review notable improvements across the organization.
Sharing is the step most often forgotten. Ron names it explicitly because the value compounds when ideas travel. An improvement in one department becomes a template that another department can adopt or adapt. Sharing also models the culture the organization is building -- it puts the early adopters on a visible pedestal and signals to others what the expected behavior looks like.
By December 2015, the daily improvements program had produced several visible signals of engagement and impact.
More than 72% of employees had logged into the KaiNexus system at least once. 71% had logged in more than once.
1,145 opportunities for improvement had been submitted. 769 had been completed -- an implementation rate in the 60-65% range that Ron names.
The categorization of impact across the four strategic indicators of excellence was being tracked monthly, with departmental breakdowns visible to the central improvement team.
The combination of the earlier 100-Day Workout savings ($722,000+ in hard cost savings, 5,200 hours of labor) and the ongoing daily improvements work was producing financial impact that justified the program to the board and the senior leadership team. The program wasn't a soft engagement initiative being defended on culture grounds. It was producing measurable operational and financial results.
Karen and Ron name several lessons that travel beyond their specific context.
Let the process work. When leaders see a problem, the reflex is to fix it themselves. The discipline is to let the process work -- to coach the employee through the steps rather than short-circuiting the methodology. Solving the problem yourself is faster on any individual problem and dramatically slower over the organizational arc.
Allow habits to form and to change. Improvement initiatives don't pay off immediately. Some changes look like they aren't working until they've had time to settle. The patience to let new patterns take hold is part of the work.
Set clear expectations and audit them. Where standard work exists, it's mandatory. Persistent auditing isn't punitive -- it's the mechanism by which the standard actually becomes standard. Without audits, the standard drifts.
Coach leaders to coach, not to solve. The biggest cultural shift Mary Greeley made was coaching leaders to develop their employees' problem-solving capability rather than treating themselves as the organization's problem solvers. This is the change that scales. When 60 leaders coach their staff to solve problems, the organization has 1,300 problem solvers. When 60 leaders solve problems themselves, the organization has 60 bottlenecks.
Gravitate toward early adopters. Not every department will be ready at the same time. The push approach -- forcing departments to adopt the practice before they're ready -- produces resistance and resentment. The pull approach -- working with departments that volunteer, that have strong leadership, that show readiness -- produces success stories that other departments eventually want to emulate.
Make time for improvement. A leader with 10-15 active OIs in their department needs to schedule 30-60 minutes a week to review them, assign new ones, and check on stuck work. Staff need scheduled time to work on their assigned OIs. The work doesn't fit itself into existing schedules. It has to be planned for.
Recognition over reward. Mary Greeley maintains a small $10-per-implemented-OI recognition payment, but Ron is candid that he'd prefer not to have it. Monetary rewards complicate the intrinsic motivation that drives sustainable improvement. Recognition -- in huddles, in monthly leadership meetings, in visible celebration of work that landed -- does more to sustain engagement than financial incentives do.
Several elements of Mary Greeley's journey are operationally supported by the platform in ways worth naming.
The Standard Work Steering Committee's prioritization of 49 work processes down to a top 10 is the kind of strategic alignment work that the platform supports through strategic initiative tagging. Every improvement can be linked to one of Mary Greeley's four strategic indicators of excellence, which lets the leadership team see at any moment whether the improvement portfolio is balanced across the strategic priorities or skewed toward one.
The 100-Day Workout's structured project management for 60 leaders simultaneously is exactly what the platform was designed to handle. Without that infrastructure, coordinating 60 leaders running parallel projects within a 100-day window would have required dedicated project management staff. With it, two people in the improvement department could oversee the entire workout.
The daily improvements rollout depends on the platform's idea capture, assignment, tracking, and reporting capabilities. The 60-65% implementation rate that Mary Greeley achieves depends on managers being able to see what's stuck in their departments, what's been assigned, what's overdue, and what's been completed. The platform makes that visible without requiring manual tracking.
The cross-departmental sharing of completed improvements is what turns local improvements into organizational learning. The platform makes implemented improvements searchable and discoverable across the organization, supporting the discipline of yokoten -- the lateral spread of improvements -- that Ron names as one of the program's most underused but most valuable elements.
None of this substitutes for the leadership work Karen and Ron describe. The platform amplifies what the leadership practice produces. The platform without the practice produces tracked-but-shallow improvement. The practice without the platform doesn't scale beyond what a small team can personally manage. Together, the practice and the platform produce what Mary Greeley has built.
Karen Kiel-Rosser served as Vice President and Chief Quality Officer at Mary Greeley Medical Center at the time of this recording. She led the organization's Lean transformation efforts and helped align leadership around the systematic improvement framework described in this session.
Ron Smith served as Process Improvement Coordinator at Mary Greeley Medical Center at the time of this recording. He worked directly with department leaders and frontline staff to implement the daily improvement practices and to spread Lean methodology across the organization.
Mary Greeley Medical Center is a 220-bed acute care community hospital in Ames, Iowa, governed by a five-member Board of Trustees elected by the city. The hospital has been recognized for its sustained commitment to operational excellence and quality improvement.
Why start with leadership commitment before launching improvement work?
Because the management system that surrounds improvement work determines whether the work sustains. Organizations that start with a pilot project, see early results, and try to scale from there tend to hit a ceiling when the project ends and the management system reverts to its previous patterns. Mary Greeley's choice to invest in board education, leadership training, and shared vocabulary before launching operational improvement work produced a foundation that could support sustained change. The investment looked like time spent without visible results in 2009. By 2015, it was the reason the daily improvements rollout worked.
What is the Standard Work Steering Committee and what does it do?
A multi-disciplinary committee at Mary Greeley that defines standard work, identifies the organization's key work processes, and prioritizes improvement focus areas. The committee identified 49 work processes across the hospital and narrowed those down to a top 10 based on patient impact, risk of error, and likelihood of improvement success. The committee's role is to keep improvement work focused on systemic priorities rather than departmental preferences. Without that prioritization mechanism, organizations tend to work on whatever is loudest rather than whatever matters most.
What was the 100-Day Workout and what did it accomplish?
A structured leadership challenge where each of Mary Greeley's 60 leaders identified an improvement project in their area that could be completed in 100 days. Projects had to generate revenue or produce cost savings, and leaders had to manage them through KaiNexus. The workout completed 54 opportunities for improvement, producing over $722,000 in hard cost savings (with $675,000 in first-year savings), $47,000 in revenue generation, and 5,200 hours of labor savings. More importantly, the workout built leadership familiarity with the platform and the discipline of running improvement projects to completion, which created the foundation for the daily improvements rollout that followed.
How do you coach leaders to coach instead of solving problems themselves?
By making the coaching the explicit expectation and providing structured support to develop the practice. When an employee submits an idea, the leader's job is to thank the employee, assign the idea back to them (or to a small team that includes them), provide direction on investigation, and offer support. The leader's job is not to take the idea, solve the problem, and report back. The discipline is uncomfortable for leaders who are used to being the problem-solvers. The structured rollout meetings at Mary Greeley addressed this directly by coaching leaders through the practice, surfacing the temptation to solve problems themselves, and helping them resist it.
Why ask "What frustrates you?" instead of "What do you need?"
Because "What do you need?" is asking for solutions, and the daily improvements program is meant to capture problems. The employee who answers "What do you need?" gives you their proposed solution -- which may or may not address the actual underlying issue. The employee who answers "What frustrates you?" or "What gets in the way of good patient care?" describes the problem itself, which opens up a larger solution space and lets the team work on the right thing rather than the first thing.
What's the right balance between recognition and reward?
Recognition matters more than monetary reward. Mary Greeley maintains a small $10-per-implemented-OI recognition payment as a holdover from their previous bright ideas program, but Ron is candid that he'd prefer to phase it out. Monetary rewards tend to complicate the intrinsic motivation that drives sustainable improvement and can produce gaming or honor-roll dynamics where bigger ideas are rewarded more than smaller ones. The healthier pattern is to recognize all implemented improvements equally, celebrate broadly in huddles and leadership meetings, and let intrinsic motivation -- the satisfaction of seeing your idea actually change the work -- be the primary driver.
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