Ask Us Anything, Episode 10: Start with Why, Spread a Pilot Without Steamrolling, and Find the Right Leading Indicators

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KaiNexus CEO and co-founder Greg Jacobson joins host Mark Graban for the tenth episode of the Ask Us Anything series, the recurring session built around questions from webinar attendees. This batch keeps coming back to the same instinct: when you want to change how people work, you do not start with the tools. You start with why. The conversation moves from how to introduce process improvement to high school students, through getting old-guard leaders to take Lean seriously, to spreading a successful pilot across a system without bulldozing the rest of the hospitals.

Here is what the episode covers and the thinking behind each answer.

Talking about improvement with high school students

Mark opened with a story. That morning he had spoken to high school juniors at the Alamo Academies Health Professions Academy in San Antonio about their future in healthcare. Greg's reaction was that the act itself, exposing students to process improvement at that stage, is the news. He went through high school, college, medical school, and residency without ever hearing the term. He had also been at a Lean Construction Institute conference the prior week and watched an industry he had not thought of as a natural fit for Lean discovering exactly that. The optimistic read: when the old guard says healthcare is not what it used to be and warns young people away, those are precisely the reasons to go in. There is good to be done.

What struck Mark in the classroom was the students' intuition. He cued up parts of the Toast Kaizen video, then asked what they expected would happen if they wrote an idea on a slip and dropped it in a suggestion box. They laughed. Someone guessed five percent of suggestions get approved. Another said two percent. They were close to the well-known Robinson and Schroeder figure, roughly two percent. They had not worked in places with suggestion boxes, and still it seemed obviously dumb to them to put an idea in a locked box. Mark used Karen Kiel-Rosser at Mary Greeley Medical Center as the alternative: a workplace where everyone has two jobs, doing the work and improving the work.

Getting the old guard to take Lean seriously

A question asked why it is so hard for an old industrialist to see the benefits of Lean and agile methods, and Mark's reframe was that selling benefits is not the real barrier. The barrier is that a leader with decades of experience has to change their own management practices and behaviors, not just train others or preach the principles. That is the hard part.

Greg said start with why. In any conflict resolution, you begin with shared interests. Nobody disagrees with higher quality at lower cost. Build from the why to the how, and only then to the what, the tools. The trap Lean practitioners fall into is leading with the what, because the tools are interesting and they want to pull out the fishbone diagram and the A3. Start there and you trip up. Start with why and the hearts and minds question becomes more manageable.

A second, related question came from an attendee whose improvement work had gotten bureaucratic, with leadership wanting one person to solve everything. Greg returned to the frame he uses often: leadership, methodology, and technology, with leadership doing three things in particular. They commit to the work and talk about it consistently, not in every spare moment but in nearly every conversation in some form. They hold people accountable to it. And they put resources behind it, whether time, training, or money. Improvement cannot be delegated. It requires leadership participation.

Capturing the work without slowing it down

An attendee wrote in about a real tension. He loves the engagement that comes from a team building a process map together on butcher paper and sticky notes, but that approach does a poor job of preserving lessons learned and the details of the process for future work. How do you find time to document, either during the session or after?

Greg made the case for capturing the work in the moment. KaiNexus customers often have laptops open while they work the wall. As opportunities and countermeasures surface on the butcher paper, someone enters them straight into the system, owners are assigned, timeframes are agreed, and a photograph of the wall gets attached to the project. The alternative is asking someone to play secretary afterward, which is non-value-added work nobody enjoys. Mark drew the medical parallel: physicians charting as they go rather than batching documentation at the end of the day. The same logic applies to process documentation. He added the second part of the answer, which is the standard one for any time-related complaint about improvement work. If it matters, make the time, and if barriers are eating the time, use your improvement methods on the barriers.

Finding the right leading indicators

A live question asked how to identify leading indicators, the daily measures at the gemba, that connect to the lagging indicators reported monthly or quarterly. Mark recommended a strategy deployment approach, brainstorming with people across the organization, "catchball" style, around what daily process measures actually drive the longer-term results. The trap is measuring what is easy rather than what is right. He pointed to Pascal Dennis's "Getting the Right Things Done" and Karen Martin's "The Outstanding Organization" as useful references. No twelve-step flowchart, but a structured way to think about it.

Greg split the question in two. There are leading indicators of the industry-specific work the organization does, and there are leading indicators of the improvement process itself. The latter, the measures of whether your improvement culture is actually getting healthier, are still being figured out. Are people logging in? Submitting ideas? Completing improvements? Changing the impact they generate? Some of those are leading, some are lagging, and untangling them is its own conversation. The deeper rule, though, is one KaiNexus repeats often: if it is not benefiting the organization, it is probably not improvement work. Every idea, every A3, every project needs a clear line of sight to a benefit the organization cares about.

Getting an organization out of the red

A broad question asked what methodology would help an organization get back to the black financially. Mark resisted jumping to tools. Use a Lean A3 approach to the problem itself. Why is the organization losing money? Is it a revenue problem or a cost problem? Where exactly? Profitability as a whole is too broad a problem to solve, so the work is to narrow it. He named the trap: under financial pressure people skip diagnosis and rush to solutions, and the urgency is real, but acting fast on the wrong problem is the most expensive kind of waste.

Greg extended it to method selection. The problem you find determines the approach. A need for a new product in a new market is a top-down, high-risk, high-cost effort. Crippling staff turnover and disengagement is largely a bottom-up culture problem. Their rough split is that about twenty percent of an organization's improvement potential lives in top-down efforts and about eighty percent lives in bottom-up work. The mix matters. A weightlifter trying to lift more weight focuses differently than someone trying to be a generally better athlete. Mark connected the eighty percent figure to ThedaCare's experience over more than a decade of Lean practice, where rapid improvement events and bigger initiatives are a relatively small share of total impact compared to staff-driven improvement, and to the Robinson and Schroeder research showing the same pyramid pattern. The old habit of "hire one savior, run one big project" is exactly the habit the old guard tends to default to, and exactly the one to break.

Spreading a pilot without steamrolling

A health system leader wrote in with a careful question. She was leading a system-wide medication reconciliation improvement, designing standard work and running experiments at one pilot site, and it was going well. How do you roll out to the other five hospitals without the rollout feeling like a steamroller? People at the non-pilot sites were anxious, and she wanted to communicate that some things are non-negotiable while expecting sites to improve on the pilot's workflow.

Mark thought she was already on the right path. People do not want a rollout to be a rollover. He pointed to ThedaCare and to Ron Smith at Mary Greeley, who has talked about this in a KaiNexus webinar. You roll out an approach, but you do not copy it exactly. You take what was learned, hand it to the next site, and let them adopt, tweak, and improve. Standardization does not have to mean identical. Distinguish what is non-negotiable from what is open to local adaptation, and you preserve both the integrity of the work and the autonomy of the site.

Greg added a sequencing point about going from pockets of excellence to a tipping point. Early on, pull beats push. Spread first to the sites and leaders that already lean in, because the energy is there and you do not have to overcome cold resistance to change every person, department, and unit at once. As that wave builds, the pull broadens. Eventually, for the hardest pockets, you do shift into more active change management. Cite the model cell pattern. Cite Lee Health, which at the time of the recording was driving an organization-wide Lean push by working through the leadership line before going department by department for tens of thousands of people. Mark closed the segment with an analogy from a forgettable movie. A character explains his transformation: anyone can do it, six hours a day in the gym, every day, for twenty years. Anyone can do continuous improvement. The question is who has the discipline to make it a daily habit. Greg's qualifier: at the microscopic, day-to-day level, none of this looks clean. Three steps forward, two back, one forward, half a step back. The clean line only appears in the rearview mirror. The work is messy, and messy is fine.

Key takeaways

• Start with why. Selling the tools is what trips practitioners up. Lead with the shared interest, then move to how, and only then to the what.
• Improvement cannot be delegated. Leaders commit verbally, hold people accountable, and put resources behind it, including their own time.
• Capture process documentation in the moment, not after the fact. The same logic that puts physicians charting as they go applies to mapping work.
• Measure both the work and the improvement culture. If an idea has no line of sight to organizational benefit, ask why you are doing it.
• Roughly eighty percent of improvement potential is bottom-up. Big projects matter, but they are not the engine.
• Spread by pull before push. Start with the people who already lean in, let pockets of excellence build a wave, and reserve active change management for the cold pockets at the end.

About this series

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.

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