Podcast, The Lens – 26. How Executives Model the Way to Build an Improvement Culture

Posted on by CATALYSIS


John Toussaint, MD, founder of Catalysis and co-author of Becoming the Change, explains why leader behaviors are fundamental to building a culture of improvement.

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Becoming the Change: Leadership Behavior Strategies for Continuous Improvement in Healthcare by John Toussaint and Kim Barnas

Principles and Behaviors of Organizational Excellence on Catalysis Academy

Principles and Behaviors of Organizational Excellence Virtual Workshop

Lean Healthcare Transformation Summit



Peter Mariahazy: Welcome back to The Lens. I'm your host, Peter Mariahazy. Today I’m joined by John Toussaint, founder of Catalysis, and co-author of, Becoming the Change. This new book offers leadership strategies for continuous improvement in healthcare. John, thank you for joining us today.

John Toussaint: Nice to be with you, Peter.

Peter Mariahazy: So, please, tell us a bit about why leaders’ behaviors are so fundamental to beginning an improvement culture.

John Toussaint: Well, we all know that, that culture is really related to behaviors and that leaders actually are the ones who decide what that culture is going to be. And they do that by modeling the behaviors that are, that are expected or that are the what the leaders feel are going to change the organization. And we know that there are specific behaviors that are important from the standpoint of building a continuous improvement culture. And I think that's the, that's the point here. Is that if we, as leaders, are really serious, about building that improvement culture, then we're the ones that actually have to make those changes.

Peter Mariahazy: You know that's tied into a lot of podcasts we've had. So what are what are those most important behaviors you reference for executives to model? To build that culture, to set the standard and, and show the way.

John Toussaint: Well, we've defined five what I would call behavioral traits or behavioral dimensions, but then there are specific observable behaviors but behind each one of those. So let's talk through that. The first one is willingness. And that means willingness to change one's own approach or actions. And one of the ways that we would know whether an executive is actually willing to do that is that we would have specific evidence in their calendars, for example. That they're taking time not in the shower or not driving to work, but actually taking time in their regular work schedules to reflect. And I, and I like to ask you know, two questions. What did I do this week that unleashed the creativity of my team? What did I do this week that shut them down? And if we can reflect on those two questions, and we have that in our calendar, then that's observable. The second key behavioral trait is humility. And so, we know, and there's a lot of good evidence in the literature, that humble leaders actually have better results from an organizational perspective. That's been shown for many years. Actually, Jim Collins wrote about that way back in 2005. So, the question is, what would we observe if we were observing leaders leading with humility? And one of the things we would observe is that, first of all, they go to the place of work where the, or go to the place where, value is created in the work. Go to the front line and ask open ended questions. Not questions related to, you know, that have a have their solutions embedded in them, but questions that that helped people to maybe think differently, and also to learn what's really going on with the gemba. The third, the third key trait here is curiosity and that that's an interesting one that doesn't necessarily show up in leadership books. But we know if you're going to build a continuous improvement culture, you really have to care about what's going on in your organization. And in the way that we would observe. That is, are you as actually asking open ended questions are you empathetically listening, rather than just waiting to talk? And are you using some kind of method. We suggest sort of an A3 Thinking method which is staying on the left side of the A3, not jumping to conclusions but going to the gemba and asking these questions to try to deeply understand really, the current state of any clinic, or department, or any place that you're that you're visiting. The fourth one is perseverance. And the way we might observe this is, “Are you persevering to the point where you have a coach, you're getting some feedback from a buddy?” That's what we suggest is, that there's somebody that's observing you and then giving you direct feedback about how your behaviors are affecting people. And then the fifth one is self-discipline and, of course, this tends to be where a lot of executives have gaps. And so, the question is, you know, can I observe anything that way? And what I would observe is, “do you have leader standard work? Is there anything in your in your calendar which is standard and actually adding value to patients?” So, we do. When I was CEO, I reviewed my calendar for the next week my coach said just ask yourself, “Is anything you're doing actually going to add value to your patients?” And when I looked at my calendar and found that in the whole week the answer was zero. All my meetings, all the activities that I had planned actually, were not going to be value added. So unless you build value added standard work into your calendar, your calendar is going to get filled with non-value-added activities. So, you always have to keep that in mind when you are thinking about this idea of building self-discipline within your day and your week.

Peter Mariahazy: So, with those traits you, one of the hardest things for anybody is self-reflection. And, so how do, how does the team of executives hold each other accountable and keep an eye on each other to help each other in day-to-day to continue that development process?

John Toussaint: One of the most important aspects of this, and this is, I like the word responsible rather than accountable. I hear the word accountable all the time. And to me, that means that you know sort of top-down you're not doing what I told you to do. But if we hold each other responsible that's a different type of way to get work done. And it starts with us agreeing to what are we actually going to. How are we going to treat each other, how and what are those key behaviors that we're going to agree that we all are going to model the way for? And if we've actually established that as a team, then we can call each other out. Whether you're the CEO, or the finance Director, or whatever. You know and that should be part of this discussion at the senior level. Please, you know, if I’m not acting the way that we all have agreed to call me out on it. And I think you know the example that I use is Eric Dickson at UMass Memorial. He's an emergency room physician and the CEO there. And with his team, he basically said, “You know I’m a trauma doctor, so when, when I get in my trauma mode I’m going to direct people. But when I’m in my CEO mode that's not the right way to go, that's not the right behavior to model. So, if I get into the trauma doctor mode during meetings or when I’m, you know, actually in a management situation, you need to call me out on that. Because that's not the right behavior that we expect out of our executive team.”  And so it's really important, and they do and I’ve actually seen them do that to him and it's perfectly fine because you know they've created this space that says, you know, if I’m acting in this way, you are absolutely, not only okay, but I want you to call me out.

Peter Mariahazy: So, it's an expectation and thank you for that clarification on terminology, because we talked about words matter, right? The difference between accountability and responsibility is very important. So how do the executives learn these behaviors? How do they take it to the next level, and start working on them, and learn them, and go from there?

John Toussaint: Well, this is why one of the reasons we've written this book, Becoming the Change. It gives people examples of others who have actually gone down this path, begun to model, the way for the organization. But, frankly, you know I’ve worked with executive teams all over the world, and many, many, many, many of them, and I’ve really not found any that that could just do it completely on their own. They really required some level of coaching to understand. Really, you know, they didn't know what they didn't know. And that was true for me 20 years ago as well. And so, unless you commit to some kind of coaching process, whether that's internal or external. I think it's really difficult to make these changes. Because it does take perseverance and it does take it does take expertise that you don't have necessarily to make some of these changes happen. And so, you know, we're a big believer that identifying a coach, and then identifying also a mentor, which is different than a coach right, so a mentor is somebody you can cry on their shoulder whereas a coach is actually going to be giving you feedback and helping you down this path of building these, these important behaviors and then learning how to model those behaviors in a way that is going to really cascade throughout the organization.

Peter Mariahazy: And, and that time is to, as you said, the willingness and the humility to accept that and understand that you've got to develop. And so you've mentioned the mentor the coach the peers and the team providing feedback. How else can they get some feedback? I mean, there you've talked about setting aside time for reflection as well.

John Toussaint: I think that, that those that are listening to this podcast that are familiar with A3 Thinking. We actually have built a process. And you can actually download the templates of that from the book, Becoming the Change, on how to use a Personal A3. So we always think about an A3 as problem-solving or strategic. But you can also use it as a personal development activity. And so what it is, is really a self-reflection. It's a, it's a deep self-reflection process. And when we introduce the Personal A3, which is really about your own behavior and habits. It becomes a, you know, living, breathing document for you that you want to revisit every couple months. And you want to reflect in on, what I’ve learned and what is working, what are the experiments that I’ve run, and why am I running those experiments in terms of my own actions and habits and behaviors. And, what have I learned, and then and then, let's try some other things, you know,  if I’m not actually making the progress that I want to make. Now, with a Personal A3, you do need to have some kind of feedback mechanism. And, you know some teams, like Eric Dickson's team, are willing to give him feedback. You know, I’ve certainly worked with other teams, where the executives are not that comfortable with giving the top person feedback, or you know subordinates giving their bosses feedback. So, in that case, which is, I would say most cases, you need another mechanism. And that can be, for example, an internal PI coach. If you give them that power, to give you direct feedback. It can be an external coach, like we talked about. It can be a buddy, so someone that you've anointed who's a trusted colleague. Who can, you know, tell you what they saw. For example, I've seen these trusted colleagues, you know, write down the questions that you ask at the gemba. And then, you know, you can get some reflection from the buddy on the questions you ask. Were they “what” and “how” questions? Or, are they “who” and “why” questions? Obviously we're looking for what and how questions. SO, you have to figure out for yourself, you know what's the best way to get feedback and then you have to build that into your reflection process. And I would suggest the Personal A3 is really the most powerful way to sort of hold yourself responsible for the changes that you've already committed that you want to make.

Peter Mariahazy: Fantastic. John, are there any final thoughts you'd like to share with our listeners on this? It's important self-reflection and development.

John Toussaint: Well, I think one of the things we've learned over this many, many years now that we've been students of the organizational excellence/lean game is that it really starts with behaviors. And, most of us grew up with tools. And the tools are great and you’ve got to learn them and you got to know how to use them. But if we don't have behaviors that are based on a set of principles. So again, we have to identify key principles to our management philosophy. We, of course have been espousing the Shingo principles. All ten of those as a way to get started. But you know, you have to define the principles of your management philosophy. Which then, actually help you to understand what the behaviors are that you're going to need to begin to model. And then you can build systems that reinforce those behaviors and then use tools to get results. But if we don't start with the principles and behaviors first, we just don't sustain the gain and we don't build a culture of continuous improvement.

Peter Mariahazy: Really doesn't become part of the DNA does it? It's not, doesn't stay with you. Right? John, thank you for taking the time to talk to us today.

John Toussaint: My pleasure.

Peter Mariahazy: And thank you all for listening, please visit to learn about the Lean Healthcare Transformation Summit in June, and this book, Becoming the Change. Stay tuned for more episodes designed to help healthcare leaders support their organization on journey to organizational excellence.


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