GA 269 | Establishing a Standard Behavior with Skip Steward

I am convinced that every human being is creative. God the Creator, has made humans, the creation, very creative. Every person is very creative. So they've got ideas. They want to improve their world.

Around an hour ago, I sat down in our recording studio, put my headphones on, and prepared myself to record the 269th Gemba Academy podcast with my good friend Skip Stewart. Now, as you'll soon hear, Skip is one of the smartest, most caring and passionate people you'll ever meet. In fact, every time I run into Skip, I get excited, since I know my spirit's about to be elevated. Anyhow, once Skip and I started the interview, I was overcome with a deep sense of gratitude for knowing Skip. I also felt a deep sense of gratitude for the incredible opportunity I have to talk to so many wonderful people each and every week on this podcast. And I most definitely felt a deep sense of gratitude for each and every listener of this podcast. Now, today's episode is a little longer than normal, so please listen in chunks if you need to. Skip and I cover a ton of ground, but the main emphasis of the show is how Skip and the amazing folks at Baptist Memorial have learned to leverage Toyota Kata and TWI into what I believe to be an incredible management system we can all learn from no matter where we work. Show notes for this episode can be found over@gembapodcast.com just look for episode 269. You can also check out Gemba Academy's Lean Learning System, which includes comprehensive courses on Toyota Kata, twi, job instruction, job relations, and job methods. Simply go to gemba academy.com to learn more. Okay, enough from me. Let's get to the show. All right, Skip, welcome to the show. How's it going?

What's going? Great. Thank you so much for having me on.

Well, I know you're a frequent listener to the show. Normally you're running on a treadmill, so it might be kind of weird for.

You to be in every show. Every show I listen to, and I'm sincere about that. I love every single one of your shows.

Well, thank you for that. I really appreciate that, Skip. So I looked it up before we started recording and you and Brandon came on. Gosh, this was a few TWI Katacon summits ago when used to combine them. It was episode 150.

I think we were in San Diego, if I remember.

That's right. We sat outside. Remember, we're sitting outside. Beautiful day.

That's right. People were kind of cutting through our setting. They didn't really realize we had a Camera going. Oh, yeah, that's right.

We were. We did.

We videoed it.

Oh, my gosh.

Yeah.

That was so fun. So fun. Yeah. So we'll link to that in the show notes so folks can go back and listen to that one. And you know what funniest thing I remember about that? You were with some joke about how, you know, normally you guys dress pretty nicely, you know, at your office, I think, and you were talking about how you didn't have a tie on or something.

That's right.

And Brandon, I think, did.

Yeah, Brandon had a tie, and I didn't have a tie, which was very different than what the normal setting is like.

Oh, good stuff. Good stuff. All right, well, hey, Skip, you know the drill. We like to begin all of our shows with our guests sharing a quote. So do you have one that you'd like to share?

I sure do. I actually kind of have two, but.

Okay, that's fine.

The first quote. The first quote's the same one I gave you on that first episode back in San Diego. And it comes out of the Bible, out of the book of James, and it says, quick to hear and slow to speak. Or sometimes it might say, quick to listen and slow to speak. And there's Another proverb in 17 that says, Even a fool who keeps silent is considered wise. When he closes his lips, he is deemed intelligent. And so I think about both of those quotes often. Both of our friend Brandon is the best listener I've ever been around. And even though that verse about quick to listen and slow to speak is speaking about something very specific within context, I still use that and reflect on that about. I can learn so much more if I learn to listen. If I want to be more interested in what the person is saying than me wanting to talk.

Why do you think it's so hard to listen?

Well, I think there's probably a lot of things at play. I think that one is that we probably have good intentions of wanting to share some good information. We might be wanting to share our story. We might be wanting to share something we've learned. And many times we don't realize that sometimes we talk over people, we interrupt people, and. And we don't even realize that sometimes that person, as they were talking, they became silent. And we may not even realize they never ended up sharing their information. And so I have by no means arrived, nor would I want to act that way, but I'm just continuing to learn as I get older that if I will learn to listen more, I can learn more. And so one of the techniques I'll even use sometimes is I'll be sitting there with my fingers over my mouth and some folks think that's some kind of a. That I'm kind of intellectually thinking about something. I'm actually just holding my mouth shut. And so, so I want to learn to listen a lot better. And, and I know, like I said, our friend Brandon, many times I was talking to him yesterday and, and I even at one point said, hey, Brandon, you still on? He goes, yeah, I'm still here. And I said, okay. I wasn't sure, but because he's just an amazing listener.

He is. I remember, I don't know if it was on a podcast or just chatting with him one day. He was just talking about just being okay with silence. And in this world, this fast paced world that we're living in and these podcasts and these audiobooks and this and that, we're just, we fill our lives with, with noise, you know, and sometimes, you know, being still is super important. Well, good, good, good. Well, we got to keep talking because it's a podcast and people are wanting to hear something, so. So Skip, why don't you open up a little bit with your, your background, your personal background, particular how you first came to learn about all this continuous improvement stuff and then, and then definitely tell folks what you're up to these days.

Sure. So the majority of my 26, 27 year career was in manufacturing. That was with a wonderful company, Climate Technologies, which is the largest subsidiary of Emerson Electric. And I came up originally through the industrial engineering, quality engineering ranks, got into operations, really enjoyed that very much. So I eventually gravitated into the private equity world and that's where I was introduced to health care. And then at the end of 2012, I got to know my boss, Dr. Paul DePriest. We spent about six months getting to know each other. He was heavily influenced by Georgetown, Kentucky, the Toyota facility. He was a renowned physician out of the University of Kentucky. And then he asked what I consider coming on to Baptist. And we started developing what we call the Baptist Management system. Some people might use the word lean or lean Six Sigma or operational excellence. And there's nothing wrong with any of those terms. But a lot of times we tend to create straw mans of what we think we're talking about when it comes to those terms. So it was just a lot easier to call what we call the Baptist Management system. So we've been in the process of developing that at least six years come June there at Baptist Memorial Healthcare, which is headquartered in Memphis, Tennessee.

So let's talk a little bit about your journey there at Baptist. You kind of talked about the origins there, but let's talk about just the evolution. How did you guys get started? Maybe the first few years. And then obviously you guys are strong, strong practitioners of. Of scientific thinking, Toyota Kata, as we call it, and TWI training industry. So why don't you talk about just that evolution?

Yeah. So we started off, you know, six years ago when we started thinking about putting together the Baptist management system. There was a lot of unknowns for me particularly, and I didn't know how well people in the healthcare world would embrace certain language. And so at first, the first several months of my time at Baptist, I spent a lot of time going around meeting people. And what became very clear within the healthcare industry was it was going to be all about interpersonal skills and how could I serve the people that were doing the real work. And. And so they weren't necessarily going to grasp onto a word like lean, or at least not in our industry. And so I really realized that that interpersonal skills was really important. But I wanted to experiment to see if they would be willing to open up to some new language. Ultimately, I had the desire to introduce Toyota Kata, but I was a little concerned coming out of the gates with that. So I did a very small workshop with John Shook's book, Managing to Learn and introduce them to the A3. But make no mistake about it, I had the Toyota Kata language woven all through the literature and the document. You know, things like current condition, target condition, obstacles, countermeasures, experiments, pdsa. Were they going to be willing to embrace these? And to my surprise and encouragement, they were very hungry for it, very engaged in it. Then we had a hospital in Northeast Arkansas that's one of 22 hospitals we have. We have about 22 hospitals, around 180 clinics, and a lot of other things that make up Baptist. But we had one hospital that we wanted to test as the Model Hospital. Dr. John Toussaint talks a lot about that. And so we started investing there. And it was just a perfect scenario because the CEO and administrator there, Brad Parsons, he embraced this work even to this day. I couldn't give him books fast enough and he wouldn't read it. And so I asked him, I said, would you be willing to take some experiments with me to run some. Take a step of faith. One of the very first things that we actually did after we did some initial job instructions is we introduced TWI training within industry job instructions, and they really embraced that. And I was really encouraged. And we worked a lot with the TWI Institute and we still do today. And then I think the next step at that particular hospital, Skip and I.

Would talk over you. I don't want to talk over you. Sorry, the rules already not listening. Good.

That's okay.

But I want to just, I want to maybe explore JI a little bit there.

Yeah, yeah.

So talk about how did you start that particular process? Did you pick a process and do a job, A jib on that, a breakdown and just like a model area within the hospital or what did you, what was your approach?

Yeah, so what we did was we picked, you know, a model area in the er, in the emergency room and we asked for a specific group of people. There's only 10 people in the workshop. And we asked for Brad and some of the executives to sit back and observe. But we said, let's run a test here. Let's train these folks from the CER area. And I think there was er, maybe the lab. We said, let's train them in the 10 hour course and then let's break down some jobs and let's see if we can experiment with this. And we also brought in Patrick Grop, a master trainer and he helped us break down some really difficult jobs. And it took off very nicely. Now there were some people at first that, for example, one of the jobs that we broke down was how to do blood draws. Now at first there were some, you know, nurses that had been nurses for quite a time and they said, listen, don't you know, don't you think I know how to draw blood? But we had a high contamination rate and we had a high number of people that were doing redo. So you come in, you have your blood drawn, it goes to the lab and they're saying, now we got to redo this and now you're getting stuck with a needle again. So we grabbed the people that the data showed that they weren't having to do rarely any redos. And we worked with them to try to understand the key points, the things inside of the important steps that make or break the job, injure the worker or make it easier to do. And we worked out all those things. And then at the end of the day, you know, Patrick likes to use the word road testing, which is another way for experimenting. We had a beautiful breakdown that we all were invested into. We thought it was good, but at the end of the day we didn't really know. So we had to road test it, we had to experiment with it. And sure enough There was a couple tweaks we had to make to it, but then there were very small tweaks. And then we started rolling that particular job instruction out in the er and we drove the redo, the redo of blood draw to almost zero. And it was a double digit percentage before that. And so we saw a significant impact with that. That particular event at that particular hospital kind of had a huge effect on people hearing about that. And that's created a pull within the hospital.

So to geek out a little bit on the breakdown for that blood process, did you go through all of the phases as far as the important steps, the key points and the reasons for the key points?

Oh, goodness, yeah, absolutely. So, you know, we, we did it exactly like it's laid out. You know, we once we had all the important steps, we had the key points and we had the reasons for the key points and we minimized it down to very few words, just the right words. We had, we had the, you know, the person doing the training, we had them doing it three times then, and then we had the learner doing it four times. And then we had, then we had a follow up process and we kind of stole that idea from Virginia Mason. We had a random number of five follow ups. So, for example, if I were to train you and you seem to demonstrate it really well, I would say, great, Ron, here's our training timetable, which is an area that gets overlooked a lot of times in twi. So here's our training timetable and Ron, we're going to be following back up with you. Let's say it was, you know, two days from now or a week from now, but we would go through five iterations until we said, you know what, Ron knows this. He is drawing blood exactly the way that the JIB or the job instruction breakdown calls for it to be drawn. So, yeah, we followed the recipe exactly like it's done with TWI job instructions.

Talk about the emotional journey that those nurses and those professionals, as you said, very seasoned people who are, I'm sure, very, very good at their job. But talk about that emotional journey through, you know, humility or whatever is the word right, of, of possibly going back and changing the way that you've done this work for a long, long time.

Well, you know, we've had, we've had a really good response from the majority, I'm not going to say 100%, but from the majority of the people, because instead of giving them, you know, a standard operating procedure or giving them some kind of a procedure that comes from up high from corporate or from some department that's really not living on the Gemba. We're working with the real people that do the real work. And yes, we're finding people that have evidence that they seem to be very successful at that particular task, whether it's drawing blood or whether it's putting a catheter in someone's heart. And we've done a tremendous, we've done some really, really difficult jobs. But one part of them is they recognize in the class when you start to talk about, you know, the frustration that every the way I like to say it is, every Tom, Dick and Harry is doing a task completely different, all the heads will start nodding. They recognize that. They know that that's existing. We. One of the phrases I like to sarcastically joke about is that there's what I call the dirty little secret of healthcare, that a lot of people went to college and they learned knowledge. But knowledge and skills are two different things. And many times they haven't gotten to practice the skill as much. Like one of the questions, you can do it with nurses that you know, if you ask a nurse that you know, off the record, hey, is there ever a task that you have to do maybe once a year, maybe once every 18 months, only because the opportunity didn't come up every day or every month. But if you don't do it, it's important. Every time they'll tell you, absolutely. And I'll say, then, I'll say, then what do you do? And if, you know, privately, they may say something that sounds like fake it till I make it. Well, that's not good. That's not good at all. And so we don't want folks to fake it till they make it. We want folks to have a standard behavior. You know, Ron, that's one of the things that people in the lean community we like to talk about a lot, rightfully so, is the importance of standards. But. And you know, Tichi Ohno had some kind of saying something to the effect of without standards we have no hope of improvement. Right? But the real question is how do we get to the standard behavior? How do we get from words on the piece of paper to a standard behavior? Because the folks that are coming to work every day, they're good people with good intentions and they're wanting to do a good job. But how do we get from a best known practice or a standard to a standard behavior? I believe that TWI job instructions does that because it works the neural paths of the brain to create a behavior so that we do it that way every, every single time. Just like when we all drive a car to work and we drive home. Most of us don't even remember the drive because it's in our brain. That neuropath is work there. I remember we did one TWI job instruction on a very difficult job. It's called counting in the or. And that's a very normal practice in surgery across the world to make sure that nothing gets left inside of you like a sponge or something of that nature. And that was a very difficult job. And I remember after we finished it, I saw one of the scrub techs at a Starbucks a month later, and I asked her kind of timidly, I said, hey, how's that TWI job instruction going? And she said, she had a coffee yet? Or. Well, she was getting her coffee, you know, and she said, well, it's going really good, Which I don't know what that means. So I said, well, can you, can you expound a little bit? And she goes, well, Skip, I've been, I've been, you know, in this type of discipline, in this role for 25 years. And I always had my way of doing it. But now when I go into surgery, it's like this new approach kicks in. And I was like, awesome. That's exactly what we wanted to happen. We wanted a new, new behavior to kick in, you know, because we were. That's what we're trying to do is create a new neural pathway, a new behavior, that this is the best way that we're going to do it.

Wow. Okay, so JI is in place while you did a pilot. And I'm. Am I right to assume that we then spread JI across the, the organization?

I would say that we spread the JI across the organization. And I'd also say we're still spreading because in health care, healthcare is getting bigger and bigger. So we've bought some hospitals over the last year and a half and some of them are just in the process of getting introduced to ji. But then the other thing is around sustainment, is that we are learning new lessons around sustainment. And so every year we have a internal TWI summit, the Baptist TWI Summit. And we basically have different people come and they have 20 minute windows and they share, you know, things that they're learning. Good, bad. And I think, I think that I may be wrong, Ron. I think it's called yokatan or something like that.

Horizontal. Yep.

Yeah. And so we attempt to do that. We try to share what's going well, what isn't going well. We have some elements that help people do some assessments. For example, if someone says they're doing TWI job instructions, my first comment is going to be, well, that's great, that's encouraging. But eventually I'm going to get into some questions that ask how do they connect that, how is it connected ultimately to their strategic initiatives of that particular facility. I'm going to ask questions about how do they validate. So for example, if I train Ron, Ron goes through the 10 hour class and then let's say Ron specifically is going to be putting in a Foley catheter in the ICU. Okay, great. Ron did great in the 10 hour class. But now how do I know that Ron's really going to be training people in the ICU the TWI way? And so we have a validation process that we are trying to encourage people to use. Because what you'll see sometimes is people do great in class and because skills feel awkward at first when they get out there, they don't want to follow the TWI way of them doing it three times and the learner doing it four times, they might just hand them the jib and say, hey, why don't you look over this and call me if you have any questions. Yeah, well that's not twi. Right. So we're going to talk about validation. We're also probably going to get into verification. So let's say that Ron trained Jane Doe and how to put in that folder catheter. How do I know that Jane Doe is putting in that Foley catheter that way a month from now, six months from now, a year from now? So we're doing a lot of experimentation around that. So yes, we are spreading horizontally, but then we're also going vertically deep in different places trying to understand how this work is connected to the strategic deployment and alignment of those particular hospitals. And how do we think about things like validation and verification?

Where do you store or I don't know what the. I'm going to use the word archive. I don't know if it's the right word. Your jibs.

Yeah. So we have a SharePoint site. We have a SharePoint site that's for the whole company that we got a couple hundred of jibs in there that people share. But to be perfectly transparent, that doesn't always go real well because with 22 hospitals and all these clinics, people don't always remember to send them in. So almost every hospital will also have their own local SharePoint site. And that's important because one of the things that sometimes People misunderstand about TWI jobs instructions is their intentions are good, but they sometimes think that, well, every job instructions for a particular job should look exactly the same for all 22 hospitals. That's not necessarily true. So, for example, as you know, the jib is nothing more than notes from myself to myself. Right. And so I may have, I may have a policy that says when you're doing a central line dressing change, you must always use alcohol and chlorhexidine because it's health, it's evidence based, it's best practice. And so, yes, you would want that in every single jib. But in deep, deep Mississippi, they might say something like, we're taking people to the potty. And in certain parts of Arkansas, they might say we're taking them to the bathroom. And certain parts of Tennessee, they say we're taking them to the restroom. Right, yeah, exactly. And so it's all, you know, it's all. The jib is still the same. They still say alcohol and chlorhexidine, to use that example. But the language might be a little different and that's okay.

Now talk about then, like the example earlier about the blood work. Let's say you do create, you know, that one best way after, through experimentation and learning. And are you, are you going to try to share that horizontally across all of the hospitals that do that same work using appropriate language as such? But you know what I'm saying.

Yeah, we make every attempt to share that because a lot of times you'll see similar challenges, from healthcare situation to healthcare. It's not exactly the same challenges, but very sometimes similar challenges. So, yeah, we do every attempt to share that. I'll be very transparent in that sharing horizontally is very, very tough. But we make every attempt, whether it be with the summit or whether it be other traditional avenues of email or other traditional avenues of settings, we attempt to do, do that. Yeah.

Well, I've even heard from, you know, Toyota veterans that, you know, the way they do it and, you know, one place may not be exactly the way they do it in the other place. And they're the exemplars of our, of our movement. Right, so.

Exactly, exactly.

Yeah. So, all right, so let's move beyond ji. What was. And I don't want to get in your way. I want you to tell the story. So what was the, the next move for Baptist?

So for Baptist, as far as the Baptist management system, we then started, I had the CEO experimenting with me, with Toyota Kata, and we worked with our good friend Mark Rosenthal, and we've worked with Brandon Brown and Beth Carrington and others. And once again, we started at that Northeast Arkansas facility with Brad Parsons, and it exploded in a very good way. What ended up happening with all of the elements of the Baptist management system, whether it be twi, job instructions, job relations, job methods, cada, strategic deployment, Regardless of the element, what ended up happening is that one hospital in Northeast Arkansas created what I like to refer to, referred to as a macro pull. And so our other hospitals, when they started hearing about what their counterpart in Northeast Arkansas was doing and the success that they were having, it started creating a really big pull. And let's just say my tires were really warm for driving to a lot of places. And so kata, we've had tremendous, tremendous success with the improvement kata coaching kata through. I think. I think it does exist in. I can't think of a hospital. We have it in our hospitals. We have it in our College of Health Science. We have it in many of our clinics. We have it in different places at Corporate. Now, that. That doesn't mean that we have it on every department, on every shift and every, you know, we don't want to imply that, but in every hospital, I can't think of one that we don't have it in where they're not experimenting their way forward and learning unique lessons to their culture, but similar structure. So it expanded with the kata, and then that started creating a pretty large macro pull for the whole organization.

Okay, so talk a little bit then. I know you guys also are big into. Into many words for this policy deployment. You know, Ocean Conry, however you want to call it, with this strategic vision. So are we using this to kind of set the challenge in Kato speak or talk about that?

Great question. So, yeah, a mentor of mine from my manufacturing days, Pascal Dennis, he. He wrote a great book called Getting the right things Done. And he was so kind to actually endorse a book of ours that I'll talk about in a minute that's coming out this summer. But so, yeah, you'll see almost at every hospital what we call strategic A3s. And we have some videos of people want to go to the Baptist management system on YouTube. We'll link to that in the show notes. Yeah, you can. You can see those. But yeah, they'll have a strategic gap there now at every single hospital, if you go anywhere in Baptist and start this sentence, someone will finish it. We want to make sure that we provide the right care at the right time, at the right place, at the right cost. So the true north is Right care, right time, right place, right cost. Now, trying to find a balance between those areas of right care, right time, right place and right cost is very difficult. But under that true north strategic theme, every single hospital has those people will have strategic A3s. So for example, under right care, they might have two or three. They might have one A strategic A3 that has a gap that they're dealing. When it comes to coordinates quality, they may have another strategic A3 under that same right care theme that deals with patient satisfaction, so on and so forth. So every hospital is going to have their strategic A3s that deal with the strategic gaps that they're dealing with. Now they are encouraged and influenced by the corporate strategic A3s, which is in the back of my office at Corporate Corporate. But when I say influenced, every site still has their unique issues that they're dealing with also, but they're influenced with those high arching corporate strategic A3s also. Then from the local sites strategic A3 they might go down to a huddle board where the tactical A3 is, which is the same structure as the strategic A3. It's just at a lower level within a department. And from there it might get connected to a kata to a CADA challenge. Now, depending on the hospital, how big they are, depending on the issue, it might go straight from the strategic A3 to A challenge on the storyboard where Toyota Kata is being practiced. Does that help?

Yes, it does. Okay, so we have a challenge on our Kata storyboard and obviously, you know, 2C current condition, we're gonna go and assess the current condition, then we're gonna set that short term target condition. Am I right? Do you typically set your target conditions out a week or two or talk about that?

Yeah, we pretty much. So across the the system, there's a lot of similarities to this. Almost everyone will set their target conditions for two to three weeks out. The challenge will be set for 52 weeks out. We even say it that way. We, we intentionally don't say it's a year from now, we say it's 52 weeks. You can kind of see what we're doing there. Right. And so then once we set our current condition in light of that 52 week challenge, then we're going to have target conditions that are two to three weeks out. And one of the things that we did from day one that pretty much everyone's bought into, I don't know that anyone's really ever fought us on this, is we asked people to take their titles and put them to the side. And to humble themselves. And so you might be a director that has 500 people reporting to you, a nurse director. And I'm thinking of one right now. Her name is Jackie, and she had 500 people that reported to her. And we said, jackie, I know that you're a director. I know that, you know, you're an important position, but as we get started with this, would you. We need you to start off as the learner, and we're going to have one of your people play the coach, and we're going to. We're going to eventually get you to that second coach's position, but we need you to work with us, and we ask you to stay here for five target conditions, which we would be 10 weeks. But in that particular scenario, Jackie didn't stay there for 10 weeks. She stayed. She chose to stay there for six months. Wow. And when she rotated into the coach's role, I was there that day, and she looked at me and she said, skip, this is. And I said, jackie, I agree it is hard, but can you elaborate on what you mean? And she goes, well, I've never thought about myself being a commander and control person, but I've just come to the realization today that it's easier to give an order, a directive, a command than it is to coach someone. And so then Jackie stayed as a coach for six months, and then Jackie's as a second coach right now. Now, most people will ask them the 10 week. But we asked people to do that because she would have never been able to be a really good coach. And for sure, not a second coach had to. She not felt what it was like to be a learner first.

Yeah. And back to the humility that we talked about earlier.

Right, that's right. That's right. That's exactly right.

What a wonderful version.

Exactly right.

So, okay, so we've got these target conditions. We identify, then, I'm assuming, some obstacles keeping us from that target condition. Then am I right to assume that this might be where we might wield some ji, some jm, some jr?

Absolutely. So, yes, you are correct. So we. We try to spend a lot of time. And we even have a video out there. And once again, Brandon Brown's the best that I know at this. But we try to spend extra time helping people. Right. Obstacles. Because what we've discovered is that most people are vague about everything. And when you're vague about everything, you're always happy with whatever you get. That's what my friend Mark Rosenthalo says. And. And there's a lot of truth to that. And so, for example, when people first start off in healthcare, we always see the top three vague obstacles. The first most popular one is the doctor, which I have no idea what that means. What is it about the doctor? What do you need from the doctor? The second one's the nurses and the third one technically can't even be an obstacle. It'll say time. So we have to help people write obstacles and teach them how to run those experiments. But yes, ji, JR and JM will start to come in. Because what you'll see inevitably as you're trying to experiment your way toward that two to three week target condition is you'll discover many times that every Tom, Dick and Harry is doing a task completely different good intentioned people. But as a result of that, that variation is causing mistakes and errors. And so that's where JI can come in to help create that standard behavior to help you move forward. Not that it's the only thing and not that it's a magic wand, but it can help you move forward towards that target condition.

Yeah, we use a lot of acronyms in case folks aren't familiar with twi. So JI we've talked a lot about is job instruction kind of the skill and instructing JR Raise job relations, maybe skill and leading skip. Is that a good way?

That's great. That's a very good way. I would actually, you know, you don't always roll things out. You know, we like to, I like to say we like to experiment our way forward versus implement our way forward. And things aren't always rolled out. You know, hindsight's always 20 20, but I get asked quite often, you know, when it comes to twi, if you had to do it all over again, where would you, where would you start? And I don't even blink an eye. My first response is JR job relations. Yes. And the way I like to say it is that job relations is the best way that I know to operationalize respect for every individual. And Ron, I've been around JR for like five years. I'm a certified train the trainer in ji, JR and jm. But it's gotten to where it's daily, if not weekly. Now every time I see a problem, maybe someone's struggling doing improvement kata or coaching kata, maybe someone's struggling with strategic deployment or whatever it may be, it almost is always connected to job relations. So job relations is how do I get people to follow my leadership and when there is a person problem, how do I deal with that? Because at the end of the Day. Everything we're trying to do is through people. And one of the things that's quite encouraging is that when people go through jr, they'll pull you aside. And they've done this to me and Pat and others multiple times and they almost want to give you a confession. And it's something to the effect of, hey, I've been a manager for 20 plus years. I wish I would have had JR 20 plus years ago because I didn't realize I needed to have a relationship with these people. I thought my job was, was just to basically watch over folks and if they stepped outside the rules and policies, I was to write them up, you know, and job relations is powerful. We had a nurse manager and then I'll leave her nameless. But she, she's went 18 months without any nurse turnover, which is unheard of, right. In healthcare. And I asked her, I said, can you tell me how you did that? She said, skip, I went to, to school to be a nurse. And one day I woke up and I was a manager. I didn't know what I was doing. J.R. gave me that standard, how to relate to people, how to have relationships with people, how to get people to follow my lead, and then how to deal with folks when we do have an issue. So I'm a huge believer in jr, not just for the improvement kata coaching kata, but just for the everyday interaction. Not just the vertical interaction, but the horizontal interactions. I had one guy recently say, hey, Skip, this JR stuff is wonderful, but it doesn't really apply to me. I said, oh, can you tell me some more? And he said, well, I've got five all Stars. I don't have any problems. I said, okay. I said, do you ever have any issues or concerns with your counterparts that you work with? Oh, yeah, that materials department. Let me tell you about them. I said, okay, then let's practice Junior, you know, so big believer in Junior.

Yeah. The thing about, the thing about Junior that, that I can. Confession time that I always have to improve on and just even with, just at home with my children and everything is number step one, get the facts. You know, I mean, it sounds so simple. It's three words, get the facts. But how can I even tell you how many times I don't have the facts and I'm flying off the handle or, you know, getting emotional, try to be all stoic, but it doesn't work, you know, because just that alone. Get the facts.

Well, well, and here's the thing, if you think about it, this was created in the 40s. If you look at it, it follows a very similar, what I like to call a meta routine, like the Toyota Coda, for example, Toyota Kata. What's the first thing we know is we start off with a challenge, right? Well, J.R. says determine the objective, different words. The next thing is, it says, grasp the current condition. And to your point, the next step for JR is get the facts, get the feelings, the opinions, and it goes through that same thing. But one of the things that we're seeing is if we can spend more time in the preventive approach of the foundations for good relations, we can avoid a lot of the problems that do occur. So if we can spend more time letting each worker know how he or she is doing, giving credit when credit's due, and pretty simple things, but profound pieces that we don't really do very well. Here's the other thing. Maybe we don't always avoid all the problems with people, but the problem is structured different because most of the problems are what we call people problems or what we call running into. We would rather be tipped off or be able to frame up a problem versus having it come running into you like a freight train. And so if it isn't obvious, I am very passionate about Junior. Yeah, I. I just think it's so important. Yeah. And so it comes into play. And then the third piece that plays with CADA and plays with a lot of things that I think gets overlooked and unappreciated enough is job methods. And so we worked with the TWI Institute to Healthcare Rise, specifically JR and jm. They already had a healthcare version of jihad. And so we had to change a couple words, because at first when I was talking to nurses and I was using words like jigs and fixtures, they about wanted to rip my head off. You know, we don't use jigs and fixtures. And I was like, well, you actually do. So we had to change them to words like devices and holders. But the reason I'm such a huge believer in job methods is from multiple reasons. But what happens is job methods, you are forced to work with the real people that do the real work, and to get the details. The devil's in the details. And to get the details, and you're asking questions in a certain order for a certain purpose. And so I'm dissecting every detail with why is that necessary and what is the purpose? I'm trying to see if I can eliminate it, and if I can't eliminate it, I'm going to be asking, where should it be done, when should it be done, who is the best qualified to do it. I'm trying to see if I can combine or rearrange or I'm going to say how is the best way to do it? Because they have ideas, they work 10, 12 hours a day. But what we do, Ron, specifically with kata, is a lot of times in the world of kata, you know, we talk about three things in the current condition. When we talk about the pattern of work, we talk about process metrics and we talk about result metrics. Right. And well, a lot of times when it comes to the pattern of work, we'll use things like a value stream map, which is powerful, or we might use what we call a block diagram. And that's very powerful. I don't want to ever underestimate that because those are really good tools. But what job methods does. I can do some of that work like a, like a block diagram. I can do it sitting in an office. JM forces me to the front lines where the real people do the real work to dissect. And what I call it is it rips open the veil and it lets you see the hidden factory that's going on. So we did some and it really, really let you understand the current condition. So then once you question all those ideas in the job methods approach, you end up having a proposed methodology which ends up going into your target condition, which it ends up being nothing more than a hypothesis. I don't know if it's going to work, so we have to road test it. So big believer in job methods because I'm able to get a lot of people involved and they may not even know what the Baptist management system or CADA or anything else is, but they know their work because they do their job every day. That's right. So I love job methods.

How do you find? You know, we talked about combining rearranging so the E eliminate. How does that work? You know, when you're potentially eliminating some of the stuff steps or some of the. Some of the work folks may have been doing for many years.

Yeah, it actually works really good because, you know, a lot of times I used to say this was just the South. I used to say here down the South, a lot of people will smile and nod our head, but that doesn't mean we agree with you. It just means we're being polite. Right. And but I'm finding that's true in life, period. And so I remember doing job methods and a triage of emergency room and we went into that area and we said, can you tell us how you do your job. And they kept saying, well, we just get it done. And I said, well, I don't really know what that means. Is it okay if we. If we watch you? We had a small group of people and they said, yeah, and we told them what we were doing. And so we just wrote down every single detail. And then we started getting them involved. You know, things like, hey, I know I missed some details. I'm sure I did. I just don't know where I missed them. Can you help me out? And sure enough, they pointed out a couple details. We got all the details written out. We provided any comments, like how far they had to walk or what were some of the characteristics of how they were doing it. And then we actually worked with them to question every detail, and we would ask that question. So, you know, why is that detail right there necessary? And one of the things I've learned a lot from Patrick Grop is to let that question breathe for a second. In other words, don't be too ready just to put a check and keep moving. And because sometimes the person will say, well, eventually they'll say something that sounds like, well, we've always done it that way. Now they might say, no, we have to do that. That's protocol. That's, you know, that's legally. Or that's what the Joint Commission calls for. And then we back away. We don't even come close to. To that. But if there's any hesitation on their part, if they say, well, you know, we've always done it that way. Okay, so then that second question, as you know, Ron, is a check question for the why question. Well, what's the purpose? You know? You know, well, I really don't know what the purpose is, you know, and so we're looking, we're. We're sniffing around to see if we can eliminate it. We have not had a lot of pushback of people saying, no, you can't eliminate that and not giving a logical reason because they're getting involved in the process. Most people, because all humans are creative, they want to make their world better. And so they're pretty open to the ideas of what we're doing. It's pretty magical when you see JM being worked. It's amazing to watch people that have done a job 10, 20 years, like we were doing one recently on a orthopedic inpatient clinic. And this little older lady that was kind of quiet, she eventually spoke up, she goes, yeah, we used to never do it that way. Meaning that the detail didn't even exist. And someone so we stopped and we said, well, tell us more about that. It took her a couple hours before she got comfortable speaking up. Right. But we said, tell us more about that. And she went on to tell us about how an executive that no longer works for the company, it was their idea, that one idea. Well, ideas have consequences. Right? And so those willing workers did what they were told to do, even though they knew that that idea was having a real negative effect on other pieces of the process. We were able to eliminate that detail. It wasn't even necessary. And so we haven't really had a lot of pushback of people, you know, kind of taking it personal. Yeah, because we're trying, because, because we're trying to practice our junior.

Yeah, well, you're trying to make people's lives easier and their jobs, you easier. Remember, struggle, however you want to call it.

Right, that's right. That's exactly right. That's exactly right.

Beautiful.

And what's really neat about that, Ron, is that if you do jm, like just in small bites. Let's say I go out and do 20 minutes a day and 20 minutes at the end of the week, and let's say it takes me a couple weeks to do the jm, what will magically happen is those folks, if they see you, they'll start coming up to you and, and saying, hey, hey, hey, I was thinking about you this weekend. In other words, they're thinking about the job on their own time. And the reason is, and I'm very passionate about this, I am convinced that every human being is creative. God the Creator has made humans, the creation, very creative. Every person is very creative. So they've got ideas. They want to improve their world.

Beautiful. Beautiful. Goodness gracious. We're running out of time. And I have so many other things that I want to, I want to talk to you about, but I think it's important. I, I, I definitely want you to talk about the book that, that, that you guys are about to release here. But before then, you know, someone's listening to this right now, Skip. Who is? Perhaps they're in a, in a hospital. Maybe they're not. I didn't have to be a hospital hospital. It doesn't have to be health care even. But they're, maybe they've, they've approached continuous improvement in the, I don't want to belittle it or make it sound like I'm, I'm, I'm putting it down, but let's call it the Kaizen event approach. You know, where we've, where We've maybe, maybe we have drawn some value stream maps for whatever reason and, and we've identified some areas and we've just, we run some Kaizen events and we make things better, but maybe we're just kind of maybe lack a little direction, lack a little vision and we want to, we just know something's missing. Can you talk to that person in that organization and give them some, some advice, some wisdom?

Yeah, I think that, I think, you know, there's a phrase that, and I may butcher it, but I believe there's a phrase that I've heard people that used to work at Toyota, at least Toyota Georgetown, say it goes something to the effect, effect of some days small steps, someday big step, but every day take a step. And I think that's an important mindset because we tend to all in our life want to batch everything. We always want to eat that elephant in one bite. You know, we didn't start, first of all, we haven't arrived by any stretch of the imagination. And we didn't start with ji, jr, JM and KATA and Strategic Deployment all at the same time. But you've got to start with where your culture is and what they're going to let you start with. So in the ideal scenario, I can't promote enough Toyota Kata and Coaching Kata. And it's not a tool, as you know, Ron, my friend Beth Carrington calls it a meta routine that stays the same regardless of the circumstances. A routine way of acting and thinking. And for me, what Toyota Kata and Coaching Kata did was it created a thinking construct that I can have TWI and everything else work within. So we have a lot of people that are practicing kata, but they're never at a storyboard board. They're having a conversation, right? And they're talking about, well, you know, where do I want to be at in the future and where am I at now and what's in my way and what's my next step. And so even though they may be talking in their strategic A3s, you'll hear the Kata language. They'll talk about countermeasures versus solutions. They'll talk about experimenting versus implementing. So I think KATA is a good place for people to start. I'm a big believer in that because it allows that thinking construct. And then other pieces can come along when the timing is right. But wherever you're at manufacturing healthcare and I have a lot of my manufacturing friends from Emerson that have come and visited me. I've had friends from GE and from Boeing and others come to Baptist not because we've arrived or that we got it going great, but that we're just one learner sharing with another learner what we're learning. Right. I would just say start somewhere. The reason that I'm a big believer in TWI and KATA and strategic deployment isn't because it's my favorite flavor of ice cream. And everything we do within the Baptist management system is based on thinking. So we give everyone away. A little blue stress reliever brain. At the top of the brain it says Baptist Management System. And at the bottom of the brain it says, show me your thinking. We've been giving these away for six years. I'm holding one in my hand right now. So that's kind of our little, our little branding. But outside of just the branding, everything we do in the Baptist management system is based on the science of routines and habits and thinking. So you and I both are big lovers of atomic habit and the power of habits and a lot of that same literature. Well, you think about Jihad, you think about jr, you think about jm. They're all based on skill development, which skill is different than knowledge. They're all based on routines and habits. So is Kata. I mean, that's one of the things with jr. I've been really challenging people. If we're going to call it a skill, then we better find ways for people to practice, which we've been coming up with some cool experiments on that. But regardless, I would tell that person manufacturing healthcare, whatever sector they may be in, take a serious look at TWI and at kata. But I would say take a step. Take a step to move forward. Don't try to eat the elephant in one bite. And then when you've done taking that step and you're ready, take your next.

Step and then see what you learn. Right?

See what you learn. That's right. That's right. And one of the things I know we didn't get into, but we even use KATA to deploy. Deploy our JI Junior and JM and even our idea generation. So in other words, instead of implementing it, we, we try to experiment our way forward via deployment. So we say with a new hospital, where do we want JR to be @ a year from now? Where is it at today? Where could it be at maybe in three weeks? What's in our way? And so as a result of that, what's happened is we've had facilities, develop some really cool experiments for the further, the furthering of JR and things of that nature.

Yeah, one of the things that I've personally experimented with I wrote a blog article about this recently is we have some folks going through some various certification programs here at Gamba Academy. And part of it is they got to watch some videos, right? I mean, they got to get through it. And so when we're doing our coaching call and all they're doing is watching videos, I said, well, what's your next step like for the next five business days? Because we talk every week. Well, what's your plan? You know? Well, might be that I'm going to watch, you know, get. Goal is 45 minutes per day for the next five business days. All right. What do you think? What do you think's going to happen? I think I'll be okay, except for Wednesday. Skip's coming in. And, you know, when Skip comes in, sometimes we might have the meeting or two. So, you know, okay, cool. Then next week we go through the.

Cool.

What actually happened? What did you learn? I had one gal tell me, she goes, I learned that I cannot watch these videos at my desk. I got to go to a conference room and shut the door. I said, beautiful, you know, But I tell you, since we've started this routine, people are flying through this program, you know, and so I just. I just wish everyone in the world would just do it.

I do, too. And I. And I even practice it with my kids, you know. You know, my son just graduated with an economics degree and a minor in statistics. And ever since he was little and he watched the movie Moneyball, that's what he wants to do. He wants to work in Major League Baseball. So he's getting ready to go to law school. And we were a couple years ago, when he was a sophomore, I think he was telling me how he wanted to get an internship. And I couldn't use the Cotta language because he would have caught on to dad. But we were sitting there, I asked him where he wanted to be at in a year from now, and he told me. I said, waited for a couple innings. I said, where are you at now? And he. He said, what do you mean, dad? I'm not anywhere. And I said, well, where would you like to be at in three weeks? I'm going after that target condition. He said, well, I'd like to at least like to have a resume done and a couple applications. I said, what's in your way of being able to do that? And he said, well, I've never done a resume, dad, and I don't know which teams offer applications. I won't keep going. But you see what I was doing. So where Is he at now? Well, we discovered that teams don't let you even do an internship in the Major League Baseball without having a bachelor's first. But he has talked to every single major league team. He's talked to a couple of the VPs by way of email. He's gotten advice from a couple ex general managers and there's. He's done some scouting, he's written some blogs, but he's so much farther down the road than he was when he was a sophomore in college.

Wow, that's so good. That's so good. I can't wait to have you back on when he. Or maybe him to tell his story once he becomes the next Moneyball. Right?

That'd be great. I'd love it too. That'd make me a proud dad.

That's so good. Oh, Skip, I so love talking to you, man. You're super inspirational to me and to so many people around the world. You know, the healthcare is something that we're all. If we've not been a customer, we're going to be a customer.

We're going to be a customer.

And thank you for the work that you, your team, people like Brandon and Patrick. We're running out of time, but I want you to talk about your book. Maybe we'll have you back on to go into a little deeper, dive into it. But what's the name of that?

Name of the book is. It's on Amazon right now. It doesn't have the COVID We just approved the COVID last night. But the name of the book is called Creating an Effective Management System. And the subtitle is Integrating Policy Deployment, TWI and kata. So it's called Creating an Effective Management System, Integrating Policy Deployment, TWI and kata. The objective of the book is really to encourage people to think about their own management system. And we actually even say several times in the book, if you don't want to do TWI or cada, that's fine, but you still have to think about a management system and how the dots are connected. And so we're encouraging people to really think about their own management system and that management system connected to purpose, people and process. How are those elements connected?

And you co authored this book with Mr. Grop and Parsons?

I guess. Yeah. So Patrick Grop from. From the TWI Institute, myself, and then Brad Parsons, which is a CEO of the Northeast Arkansas Healthcare System. And so Patrick Grot, myself and Brad Parsons were the authors on that. And now when's that release?

Or it's not available right now.

Yeah. No, you can pre order, but it's released on mid July. That's what I was told.

Okay, well, I can't wait to get my hands on it and read it.

Good, good. Look forward to hearing your thoughts.

Yeah. All right, Skip. Well, thanks again. Hey, if people want to connect with you, what's the best way?

Best way is by LinkedIn. I tend to share a lot of things on LinkedIn. I just shared some stuff last night. We had.

Yeah, Mr. Wheeler. Right?

Yeah. My old mentor, Dr. Don Wheeler. He was a big influencer on me 26 years ago. And so we brought him into Baptist and. And we had. We had several people. We had a heart physician sitting in the room. We had several people in the room and learning about variation and how variation impacts their world.

Yeah. Understanding variation. If you're listening to these words and you haven't read that book. Oh, do not relay. Go get it. Understanding variation. Must. Must. Must read.

Yeah, totally agree. Must read. Absolutely agree with you.

Beautiful. All right, Skip, well, thanks again for all you do. Thank you for your friendship. Thank you for being. For just being a great guy and a fantastic continuous improvement practitioner. I look forward to seeing you at the next Katacon and probably Ame and everywhere in between.

Thank you, Ron, so much. I appreciate everything y' all do.

All right, you take care, Skip.

All right. Bye. Bye.

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