Most Kaizen programs do not fail because the methodology is wrong. They fail because the coaching is missing. Ideas get submitted into a process where leaders aren't sure what to do with them. Managers default to either rejecting ideas as impractical or taking the work onto their own to-do list, which means they're now doing the improvement instead of developing the person who brought it forward. Six months later, the ideas slow down, the leaders are exhausted, and the program is quietly declared "not the right fit for our culture."
This session is built around the alternative. Joe Swartz spent close to a decade running continuous improvement at Franciscan St. Francis Health in Indianapolis, where the program reached more than 25,000 documented improvements, roughly 40 percent annual staff participation, and over $6 million in validated hard cost savings -- with quality, safety, and patient satisfaction gains on top of that. The lesson he and his team kept arriving at across that work is that the multiplier on a Kaizen program is the quality of the coaching that supports it.
Joe's five fundamentals of Kaizen coaching, developed for supervisors coaching their direct reports, are the spine of the session: develop yourself and others through cycles of learning, demonstrate love and respect, focus on process, start small, and follow up until the skill becomes standard. None of those are abstract principles. Each one comes with worked examples from real units at Franciscan -- the respiratory therapy supply coordinator who reorganized her department once she saw it through her customer's eyes, the NICU manager who unlocked her team's participation by being publicly willing to fail, the nurse whose three-day fix-and-spread on a Yes/NPO sign would have taken three to six months earlier in the journey.
Mark closes the session with a parallel framework for coaching senior leaders, which works on a different set of behaviors -- jumping to solutions, blaming individuals, staying in the office, and treating gemba walks as judgment rather than celebration. Senior leaders need coaching too. They just rarely get it.
Joe Swartz was Director of Business Transformation at Franciscan St. Francis Health in Indianapolis. He is co-author of "Healthcare Kaizen" and "The Executive Guide to Healthcare Kaizen" with Mark Graban, and co-author of "Seeing David in the Stone: Finding and Seizing Great Opportunities" with his father. He studied Electrical Engineering at Cleveland State University and Management at Purdue University, where he graduated as a Krannert Scholar for academic excellence in the master's program. Earlier in his career, he worked as a consultant in automotive engineering at General Motors and in semiconductor manufacturing, pharmaceuticals, and aerospace assembly, including time at Honeywell where he was trained as a Six Sigma Black Belt.
Mark Graban was then VP of Customer Success at KaiNexus. He is author of "Lean Hospitals," a Shingo Research Award recipient, and co-author with Joe Swartz of "Healthcare Kaizen" and "The Executive Guide to Healthcare Kaizen." He earned a BS in Industrial Engineering from Northwestern University and an MS in Mechanical Engineering and an MBA from the MIT Sloan Leaders for Global Operations Program.
Before Joe took over the bulk of the session, Mark set up the framing. Most people, when they say "Kaizen," mean a structured multi-day event with a cross-functional team. Those events are useful. But they're only one of three levels of Kaizen, and arguably the least important for cultural change.
The illustration Franciscan uses puts large Kaizen at the top -- the bed tower, the EMR implementation, the multi-million-dollar capital projects. Medium-sized Kaizen sits in the middle: Six Sigma projects, A3 work, multi-day Lean events. Small or daily Kaizen lives at the bottom, where most of the volume actually happens: the supply rearrangement, the laminated sign, the changed workflow that saves a nurse half her time. The point is not to pick a level. It's to do all three, with the understanding that the bottom level is where culture lives.
Franciscan's history makes this concrete. They started in 2007 with Six Sigma projects that took nine to twelve months and engaged 15 to 20 people each. Joe did the math: at ten projects per year, engaging the entire 4,000-person workforce that way would have taken 25 years. The shift to daily Kaizen wasn't ideological. It was the only way to reach the rest of the building before everyone retired.
The Franciscan definition of a Kaizen has stayed simple across the years. There's measurably better performance against something that matters -- safety, quality, time, cost, morale. The idea has been implemented, not just brainstormed. And if the idea fails, that still counts as a Kaizen, because the learning produced a better next iteration. That last clause is doing more work than it appears to.
Joe's first fundamental is the one most leaders find hardest to internalize: the purpose of Kaizen is to develop the people doing the work, not to fix the work itself. Improvements are the visible output. The improvers are the actual product.
The bulletin board image he showed -- the one that won an internal contest at Franciscan -- has petals labeled with individual Kaizens, ideas raining down from above as input, nutrients running up through the roots. But the center of the flower, the part that propagates the system, is people. The team that designed that board understood something most CI functions only learn after several years: if the people aren't developed, no amount of process improvement will scale.
This reframing changes what coaching looks like in practice. A leader whose mental model is "I need to solve problems" naturally takes the improvement off the employee's plate and adds it to their own to-do list. A leader whose mental model is "I need to develop improvers" leaves the idea in the originator's hands and coaches them through the implementation. Joe's example was a new manager who told him Kaizen was taking her a day a week and asked whether that was normal. It wasn't. She was implementing every idea herself instead of coaching the people who brought them forward. A month after he reframed her role, she reported Kaizen was taking her about an hour a week -- because her staff was doing the work and she was coaching them through it.
The shift sounds straightforward. It is one of the hardest behavior changes in CI work to actually make stick, because the immediate gratification of solving a problem yourself is real, and the longer payoff of developing someone else is delayed and partly invisible.
The second fundamental is the one that produces the most measurable behavioral target in the entire session: get to a 90 percent yes rate on employee-driven ideas.
The benchmark matters because it is so far from where most organizations naturally land. Joe cited industry data showing leaders say yes to roughly a third of employee ideas. At that rate, a Kaizen program is dying before it has a chance to grow. The average employee gives up after three or four rejections and quietly stops participating. The system fills up with employees who clock in, do their work, and never offer the institutional knowledge they actually have.
Franciscan's pharmacy department -- one of the most patient-safety-sensitive environments in any health system -- was running at an 89 percent yes rate at the time of the webinar. The 11 percent that gets a "not yet" almost always involves a specific patient safety constraint that the staff member, with coaching, can usually resolve in a modified version of the idea.
The mechanism Joe described for getting to a 90 percent yes rate is not lowering the bar. It's changing what "yes" means. Saying yes to a Kaizen doesn't mean implementing the idea as submitted. It means finding the underlying problem the idea is trying to solve and committing to test something. The classic example from his coaching is the parking garage. An employee says they want a parking garage. The literal idea is a multi-million-dollar capital project. But what's actually underneath the idea? They want to get out of the rain. So the yes is something testable: a covered walkway, a closer parking space, an umbrella program. The structure of "yes, and let's figure out what we can actually test" is what gets a 90 percent rate without compromising operational reality.
Joe was emphatic that the analytical instinct most CI practitioners have -- to pick problems apart and identify weaknesses -- has to be paired with leaving the person feeling cared for at the end of the conversation. He quoted John Wooden: "They won't care how much you know until they know how much you care." Some coaching sessions can leave staff feeling personally picked apart instead of helped. The best coaches Joe has observed leave people feeling, in his words, like they were just loved on.
Practical operating notes from this section: open with permission to coach ("I saw your Kaizen idea -- would you like some coaching on it?" lands very differently from "we need to talk"). Acknowledge the idea before digging into it. Share back what you heard to confirm you understood. Shift from autocratic to Socratic, asking questions rather than giving answers. Stay open even when the idea sounds crazy on first hearing -- staff can tell when a leader has mentally closed the door, and they stop sharing.
The example that anchored the second fundamental was the respiratory therapy supply room. Maggie Reid, the supply coordinator, was proud of how she'd organized the area. Joe wasn't there to do a project -- he had no charter to be in respiratory therapy supplies -- but he started noticing a pattern as therapists came down to grab what they needed. He asked Maggie if she could spend a week categorizing what each therapist was actually picking up: parts or systems (ventilator, CPAP, BiPAP setups). She agreed.
A week later, the answer was that 80 percent of the time, therapists were assembling a system, not picking up an isolated part. Maggie had organized her supply room alphabetically by part name -- because that was her view of the work. Her customers' view was entirely different. They needed to assemble a ventilator setup or a BiPAP setup, which meant hunting through a dozen alphabetical locations to gather pieces.
She reorganized the room around systems. The respiratory therapists cut their supply-gathering time roughly in half. Maggie became, in Joe's framing, the unit's hero.
The point of the story for coaching isn't the result. It's the mechanism. Joe didn't tell Maggie her organization was wrong. He didn't even tell her what to look for. He gave her a question to answer with data over a week, and let her see the gap between her view of the work and her customer's view. The whole reorganization followed automatically once she could see what her customers actually needed. As Joe put it: "All I did was help her see her world from another perspective. Once she could see her world from that perspective, everything else changed."
That's coaching by question, not by answer. It's slower than telling. It produces a problem-solver, not a solved problem.
The third fundamental is about process in two senses: the work process being improved, and the Kaizen process itself. Joe described Franciscan's culture of putting before-and-after states side by side and showcasing hundreds of them to staff. Over time, the visual repetition teaches people that the current state is not the only possible state. There can be an after. The staff member can have a hand in shaping it.
But the process discipline that mattered most in this section was the operating norm that it has to be safe to fail. Joe's example was Paula Stanfield, the NICU manager. She had been doing Kaizen herself for about six months and struggling to get her staff engaged. One of her early improvements -- replacing a manual paper towel dispenser with an automated one -- turned out to make noise that disturbed babies in the nearby isolettes. The nurses came to her and asked to go back to the manual dispenser. She tried to insist on a longer trial. The nurses brought in engineering with a noise meter, documented a 50-decibel sound every time the dispenser fired, and made the case clearly enough that Paula reversed the decision.
Paula thought she had failed. The Kaizens in her unit started increasing within weeks.
When she asked her staff what had changed, they told her: "You showed us it was okay to fail. If we fail, we just go back. We're just trying stuff." The visible reversal -- the manager publicly trying something, hearing concerns, and changing course without making it anyone's fault -- was the single most engaging moment in her unit's improvement culture to that point. The failure was the unlock.
This pattern repeats consistently in healthy improvement cultures and is consistently missing in unhealthy ones. Staff calibrate their willingness to try against what they observe happening to people who fail. If failure is punished, ridiculed, or quietly held against people in performance reviews, participation collapses. If failure is treated as a learning event the team works through together, participation grows.
The fourth fundamental is the one most CI books mention and most leaders still get wrong. Improvements should start small -- small enough that staff can succeed and feel that success, small enough that the cycle from idea to implementation is short, small enough that confidence compounds before the work gets ambitious.
Joe's worked example was a nurse who had been doing Kaizen for about three years and had built a reputation for clean, small, replicable improvements. She wanted a way to indicate clearly whether a patient could have food by mouth or was NPO. She had built a relationship with the print shop through earlier Kaizens. She called them, sent over a PowerPoint slide, and received laminated signs colored green for yes and red for no, mounted with Velcro so they could be flipped.
The manager came to Joe afterward and said: "Joe, this would have taken three to six months three years ago when we first started Kaizen. She implemented it in three days across all thirty rooms in our unit."
That delta -- three to six months down to three days -- is what starting small produces over time. Not because the improvements get smaller, but because the people doing them have built enough confidence and enough relationships across the organization that execution gets faster. The first hundred small Kaizens are the apprenticeship. The hundred-and-first is fast.
For a coach, the discipline is to keep breaking big ideas into smaller ones. When someone proposes a parking garage, the conversation is "what's the smallest test we could run this week to see if covered access addresses your real problem?" When someone proposes new shelving in every patient bathroom, the conversation is "let's pile it in one room first and see how it works for two weeks." The smaller the test, the faster the learning, and the cheaper the mistakes.
The fifth fundamental is the one most coaches forget about because it lives after the visible work is done. The Kaizen is implemented. The improvement is real. The coach moves on to the next person. The skill they were trying to build in the staff member never quite becomes habit, because nobody followed up.
Joe's example was his son and parallel parking. He used job instruction training to walk his son through the process, demonstrated it once, and let his son try. His son did it once and announced he had it. Joe asked for a few more reps, explained that parallel parking is a skill rather than knowledge -- the situation is different every time, the geometry varies, the cars in front and behind vary. His son humored him, did three more reps, and again declared he had it.
His son failed the parallel parking portion of his driving test the next week.
The car ride home was quiet. Eventually Joe asked: "What did you learn?" His son's answer: "You were right. It's a skill."
Kaizen is the same. It's a skill that has to be practiced through repetition, with feedback, in different conditions. The first few attempts won't go well. The coach's job is to be there for the tenth and the twentieth and the thirtieth attempt, helping the staff member see what they learned, helping them connect the work to the benefit it produced, and confirming that they did the work. Joe was clear on this last point: the staff member needs to know they did it. The coach's job is to keep the credit and the ownership where it belongs.
When staff members tangibly experience the benefits of their improvements -- to themselves, to their patients, to their families, to their colleagues -- they engage more. When they don't see the benefits, participation stagnates. The follow-up that closes that loop is what turns a one-time Kaizen into a habit.
Mark took the back portion of the session to talk about coaching senior leaders, where the dynamics are different but the underlying principles are the same. Senior leaders need coaching too. They almost never get it. And the tone they set cascades through every layer of the organization beneath them.
Several specific habits Mark called out as worth coaching against:
Jumping to solutions before understanding the problem. Senior leaders, by the structure of their careers, have usually been rewarded for being action-oriented. The instinct to provide an answer is deeply trained. The coaching move is to gently model the pause -- "wait a minute, do we actually understand the problem yet?" -- and watch the senior leader start asking that question of their own direct reports.
Blaming individuals instead of looking at the system. When something goes wrong, the default question in most organizations is "who did this?" In a healthy improvement culture, the question is "what about the process allowed this?" The fear of being blamed kills the willingness to surface problems, and the absence of surfaced problems kills the improvement program.
Staying in the office. When a problem comes up, the senior leader's habit is often to discuss it in a conference room. The Lean discipline is to go see the actual work being done -- the floor, the unit, the line, the gemba. Mark mentioned the structural barrier some health systems have where executive offices are in a separate building from the hospital itself. Some senior leaders address this by maintaining an auxiliary office in the main facility and gradually shifting more of their work there.
Treating gemba walks as judgment. A senior leader visiting a unit and asking "why didn't you also consider X?" might be sincerely curious. To the staff member on the receiving end, the question often lands as criticism, simply because of who's asking. Senior leaders typically need a coach shadowing them to surface this in a private moment afterward -- "the way you asked that question came across as judgmental, not curious."
The framing Mark closed with is one of the most useful in the session. Common excuses for not starting Kaizen -- no time, no budget, staff don't have ideas, the culture isn't ready -- are problems to solve, not stop signs. Apply Kaizen thinking to the Kaizen rollout itself. If staff fear layoffs will result from improvements that eliminate waste, the senior leader needs to make and honor a no-layoffs-due-to-Kaizen pledge. If staff don't trust that pledge, the next problem is rebuilding trust. Each barrier dissolves when treated as a problem to work through with the same patience and rigor as any other improvement target.
A question came in about whether Franciscan recognizes Kaizens based on the size of the savings. Joe's answer was direct: they don't, and they don't recommend it.
The instinct sounds reasonable. Bigger savings, bigger recognition. The problem is what happens once dollar value drives the reward. People start disputing who came up with the idea, who contributed, who deserves a share of the savings. Suggestion-box systems that paid percentages of savings have a long, well-documented history of breaking down into exactly these disputes, and the disputes are often what kills the system rather than the financial cost.
Franciscan's approach is to recognize the process equally. Every Kaizen submitted and approved earns the same 200 VIP points that staff can use on a merchandise site. A pencil-relocation Kaizen and a thousand-dollar-savings Kaizen earn the same recognition, because both required the same act of seeing a problem and doing something about it.
Beyond the points, recognition is mostly non-monetary. Bulletin boards. Emails to all staff with the originator's name on a notable Kaizen. Star charts. Badge holders that show how many Kaizens a staff member has completed -- one staff member at Franciscan had passed three hundred. The signal is appreciation, not transaction. Mark added that the order matters: it's recognition and rewards, not rewards and recognition. The handshake, the thank you, the public acknowledgment, the helping people see the value of what they did -- those produce more durable participation than any merchandise.
The behavioral work Joe described -- the 90 percent yes rate, the coaching by question, the safety to fail, the starting small, the follow-up until the skill becomes habit -- is not something a platform can do for a leader. It has to come from the leader themselves.
What infrastructure can do is remove the friction that otherwise makes the behavioral work fail. The yes rate matters partly because every "no" without explanation costs an employee's willingness to participate. A system that tracks every submission, surfaces unassigned ideas to the right leader within a day or two, and makes the response visible to the originator is doing for an organization at scale what a manager's good intentions can do for a single team. The "say yes to the underlying problem, not just the literal idea" discipline is easier to coach when the trail of conversations and revisions lives in one place rather than in scattered email threads.
The follow-up discipline that the fifth fundamental depends on is structurally hard. A coach with twenty direct reports cannot hold every Kaizen they've coached in working memory. Visibility into who completed what, what they learned, and whether the next step happened lets the coach actually show up at the tenth and the twentieth attempt, not just the first one. The badge holders and star charts Franciscan uses for recognition map onto the same need -- making the volume of participation visible, both to the staff member and to the leader.
And the spreadability of small improvements that Joe described in the laminated-sign story -- where one nurse implemented across thirty rooms in three days -- depends on relationships and visibility that mature over time. Infrastructure that makes Kaizens searchable and reviewable across departments is what lets a unit see what a neighboring unit has tried and adapt it rather than re-solving the same problem in isolation.
None of this changes the fundamental argument. The coaching is the work. What the infrastructure does is make the coaching scale.
What are the five fundamentals of Kaizen coaching at Franciscan St. Francis Health? Develop yourself and others through cycles of learning. Demonstrate love and respect. Focus on process. Start small. Follow up until the skill becomes standard. The fundamentals were developed specifically for supervisors coaching their direct reports through Kaizen implementation, though the principles apply at every level.
Why does Franciscan target a 90 percent yes rate on employee ideas? Because the alternative produces a slow death for the program. Industry data suggests leaders say yes to roughly a third of ideas, which is fast enough to kill any Kaizen system. Employees give up submitting after a few rejections. At 90 percent yes, the system stays alive. Saying yes does not mean implementing the literal idea -- it means finding the underlying problem the idea is trying to solve and committing to test something. Franciscan's pharmacy department, one of the most patient-safety-sensitive environments in any hospital, runs at 89 percent yes.
What does "starting small" actually look like in a Kaizen? Small enough that the cycle from idea to implementation can finish in days, not months. Small enough that staff experience the success of completing one before they take on the next. The example Joe used was a nurse implementing a laminated NPO sign across thirty rooms in three days -- after three years of building confidence and relationships through smaller Kaizens. Three years earlier, that same improvement would have taken three to six months.
Why is it important that staff feel safe to fail? Because Kaizen depends on staff being willing to try things. When failures are punished, criticized, or quietly held against people, the willingness collapses. Paula Stanfield's NICU example showed the opposite pattern: she publicly reversed a Kaizen that wasn't working, treated the reversal as routine rather than shameful, and watched her unit's participation rate climb afterward. Staff said directly: "You showed us it was okay to fail."
What's the difference between Kaizen events and daily Kaizen? Kaizen events are structured, time-boxed efforts -- typically three to five days -- where a cross-functional team works intensively on a specific process problem. Daily Kaizen is the practice of identifying and solving small problems continuously as part of regular work. Both are valuable. Most organizations over-rely on events and under-invest in daily Kaizen, which is where the volume of improvement actually lives. The math at Franciscan made this concrete: with 4,000 staff and Six Sigma projects engaging 15 to 20 people each, reaching the full workforce through projects alone would have taken 25 years.
How does Franciscan handle Kaizens that require budget? The Lean principle is "creativity before capital" -- find the smallest test you can run with what you have before committing to spend money. Most Kaizens implement at no cost or under $100. When small spending is required, departments use small discretionary funds or, in nursing, a CNO-level fund that helps. When a Kaizen genuinely requires capital -- buying equipment, remodeling rooms -- it shifts from a Kaizen into a project with a real ROI analysis. The smallest-test discipline applies even there: test in one room before you remodel thirty.
Why doesn't Franciscan recognize Kaizens based on dollar savings? Because dollar-based recognition breaks down into disputes over who deserves what share of the savings. The literature on suggestion-box systems that paid percentages of savings consistently shows the same failure mode. Franciscan recognizes the process equally: every approved Kaizen earns the same 200 VIP points regardless of whether the savings were ten dollars or ten thousand. Beyond the points, recognition is mostly social -- bulletin boards, all-staff emails with the originator's name, badge holders showing Kaizen count.
How should coaches handle a staff member who's about to fail? Joe's framing is that if no one will be harmed, let them try. Failure that doesn't hurt anyone is one of the strongest learning experiences a staff member can have. The discussion that follows a failure, when the staff member is emotionally engaged with what just happened, sticks longer than any classroom lesson. The exception is anything that risks harm to patients, staff, or others -- there the leader has to intervene. The Kaizen process at Franciscan builds in a discussion step with the supervisor before implementation specifically to provide that check without becoming bureaucratic.
What's the difference between coaching and telling? Telling is faster in the short term and trains the staff member to come back to the leader the next time. Coaching is slower in the short term and develops the staff member's capacity to solve future problems themselves. Joe's manager who went from spending a day a week on Kaizen to spending an hour a week made that exact transition: she stopped implementing the ideas herself and started coaching her staff to implement them. The result was more Kaizens done with less of her time invested.
How do you coach senior leaders without making it feel like a critique? Get permission first, the same way you would with staff. Frame the coaching as observation rather than judgment: "I noticed something in that meeting -- would it be useful to talk through it?" Sometimes the most useful coaching is shadowing the leader through a gemba walk and then, in private afterward, pointing out how a sincere-sounding question might have landed as criticism on the staff side. Senior leaders rarely get this kind of feedback, and most of them respond well to it when the relationship is established.
What habits should senior leaders work to break? Jumping to solutions before understanding the problem. Blaming individuals instead of looking at the system. Staying in the office when problems should be observed firsthand. Treating gemba walks as judgment moments rather than celebration moments. Asking questions that sound like criticism because of who's asking. None of these are character flaws. They're trained habits, often reinforced for years before the senior leader started thinking about Kaizen. They take deliberate work to unlearn.
What's the right way to think about barriers to starting Kaizen? As problems to solve, not as stop signs. "We don't have time" can become an excuse or a Kaizen target. "Staff don't have ideas" is usually a culture problem worth investigating, not a fact. "We don't have budget" usually means the first round of improvements should be ones that cost nothing. The same problem-solving discipline that gets applied to clinical processes should apply to the rollout of the Kaizen program itself.
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