Parable of the Non-Visionary Leader

Many years ago, in the early 21st-century, were two people who ran medium-sized companies that competed against each other.

It was a day of simpler times—when PowerPoint was the de facto corporate communication tool and LinkedIn managed your professional network.

This was in the age before artificial intelligence created all revenue projections. It was long before corneal projection technology. The ubiquitous smartphone owned the most timeshare of anything a professional owned.

The first executive was setting his strategic priorities to achieve blowout performance by the year 2020. Income projections looked exactly like what his board expected, a fast rising slope that easily outpaced GDP. They should expect triple their current revenue over the next several years.

The second executive was also setting her goals, and while they weren’t as aggressive as the first’s, they had an impressive trajectory. It was an excellent growth rate for a business of their size and was ahead of what the industry growth rate was.

Revenue projections are usually based on what executives want to achieve, what they think is expected of them, and what their bonus structure enables. Unfortunately, the disconnect usually begins there. They fail to have strategy trickle down to tactics that achievef financial goals.

Executive one had climbed the ranks through sheer force. He knew the company’s service well but wasn’t the strongest leader. The exec struggled to succinctly develop and convey a game plan to achieve growth. He was an operational specialist, and this always seemed easy before he was in the top position. The words to describe his growth plan were plenty and his explanation plausible but his associates were skeptical. After a couple years of rocky performance, he was returning to the strategy and tactics of the glory years, a time of unprecedented growth for his company. It was based on what his predecessor had done many moons ago.

Executive two had a difficult climb to her position. This was years before gender equality had been achieved but still she had made it. Her number one trait was that she was visionary. She knew the world was changing fast and her company had to adapt. She made bold moves, quickly changing the strategy to align with the reality of the market. It was a gamble but one she knew she had to take.

2020 arrived. Executive one came nowhere near his projections. In fact, his company was slowly whittled down to a fraction of what they had been and was bought for pennies on the dollar.

Executive two beat her projections. Her gamble paid off. Her choice to restructure and refocus had impeccable timing. Their stock value had skyrocketed.

Stuck in the past or a visionary? The early 21st century taught us one thing. That successful CEOs were always the latter. Anything else and you’re company descended along the glide path to obsolescence.

Cancer Center Sterilization

This prominent Los Angeles-area cancer hospital was one of my first exposures to healthcare delivery as a consultant. By the time I got there, my firm had thoroughly indoctrinated me on Lean principles. Of course, I had spent a career in innovating solutions. I now had a portfolio of experience that included both the operations and design worlds. Previously, I had worked at a medical device company, and now I was where the nurses, doctors, and surgeons were doing their job. Ready, set, go!

Our operations consulting delivery model was to place a consultant at a client with a team, in a conference room for an entire week. I shared in the Navy A.D.D. moment that the first three days can be quite difficult, typically because we uncover a significant amount of procedural waste. Despite the fact that employees can feel the pain, some leaders have trouble admitting their existing process needs to change and that they weren’t leading the team in the optimal direction.

The task here seemed simple: redesign the area and the process used to sterilize the surgical equipment. Things did not go smoothly. The amount of push back we received from the new department manager and the “sterilization expert” was so high that they tried to cancel the engagement after just one day. As consultants, this experience isn’t out of the ordinary. We have to have an escalation path. In this case, it was the Chief Nursing Officer. Magically the new manager and team aligned with our method and findings.

As we were digging into the details of what was currently occurring with sterilization, the main problem became readily apparent. Each surgeon had their own set of requirements, based on what procedure they were doing. However, the department providing the surgical instruments wanted to have a standard kit for all surgeons. As you can imagine, we were re-sterilizing many instruments that surgery didn’t use. In fact, about 70,000 a year that were never used were re-sterilized. Each had been exposed to the atmosphere of the surgical suite, thus contaminating them.

We defined the challenge as “putting the correct instrument in the surgeon’s hand when asked for during the procedure.” From there, we were able to come up with a process to do just that. As a result, we drastically reduced the number of instruments in a kit as each surgeon got their own custom kit. It required a bit more coordination on the sterilization department, but it saved the hospital a lot of money. Annually, tens of thousands of instruments avoided the destructive process of repeated sterilization-without-use. There were savings in both the process and purchase budget. That savings could fund treatment for the patient instead of repeat sterilization of an unused instrument.

USN Ordnance Team

In my previous post, I mentioned I wanted to be a fighter pilot. As a child of the ‘80s, I was captivated by Top Gun. I researched anything military, whether it was bombers, ICBMs, nuclear-powered submarines or aircraft carriers. As a military brat, I visited Navy stations, Army bases and Air Force runways just to catch a glimpse of an aircraft, but it was almost always from afar. The closest I got was during air shows. Sometimes I was part of a crowd surrounding stunning, military jets or part of a group of onlookers as we gazed into a roped-off hangar further away.

When I got to work with the US Navy, I was up close and personal with fighter planes. It wasn’t cockpit-close like the F-15, but these jets were on an active runway and in use. When the F-18 Super Hornets took off, you could wait and hear the faded booming of distant bombs falling on the desert range to the east, pounding the ground with 500 lb. of explosives on each drop.

My job was helping the naval ordnance team to be more efficient in the entire process from bunker to fighter and return. I worked with a small group of E2s to E4s, with an E6 to keep them in line. Their language was enough to make a sailor blush. Oh wait, they were sailors. Enough to make me blush. They pushed each other hard, they didn’t let any mistake remain unfixed or poor performance not be corrected, and they called each other out on anything and everything that kept them from achieving top level results.  I loved it.

The process I apply at clients can be very demanding. We pull aside a team of about ten people for a full business week to drive significant improvements immediately. Every day can be draining. They have nicknames for each hard day: Margarita Monday, Tequila Tuesday, and Whiskey Wednesday. By Thursdays, the team has made it past the tough part and has to implement the defined work.

These soldiers did a fantastic job. Their Chief had created a team that could perform under difficulty. I pushed them hard too. They came together, fought, talked it out, argued, cursed and came up with a great new process that improved mission readiness and performance. They were proud of their motto and shouted it with pride: IYAOYAS!

USAF Medical Clinic Redesign

My mission, if I should choose to accept it: Design a new, medical clinic that will keep the airmen mission-ready for decades into the future. The medical group commander responsible for the project was a full Colonel that wanted the best for her troops but insisted on the optimum use of the designated funds for the project. The Lieutenant Colonel (Lt Col) that she assigned the work to wanted to do it the typical Air Force way. We began the work and quickly identified they could reduce the new clinic’s footprint by fifty percent. We were still meeting demand, working faster, and meeting the target of having no waiting rooms. The Lt Col didn’t believe it could be done.

As always, there was some pushback. The Lt Col became an active resistor to the new possibility. We pushed with data. Ultimately, it was a compromise between our capability and their comfort level with the approach. Although they ended up adding some space back for their peace of mind and comfort, it was a great result. The output thrilled the Colonel. I earned a commander’s coin for that work. That clinic now serves as a model for the Air Force. What happened with the Lt Col? He was unceremoniously pushed on to his next role.

I loved this project, not because we were achieving our mission to improve the accomplishment of their mission, but because it was a base with fighter jets. In junior high, I had dreams of becoming a fighter pilot. I wanted to fly the F-15 Eagle. It was the premier fighter jet during the ‘80s. I had models of it, drew pictures of it, and stood in awe at its performance at the annual air show. However, my dreams died when I got glasses to correct my nearsightedness. Although, the F-22 replaced the F-15 and the F-35 is replacing the F-22, there were still some F-15s around on this base.

During my training runs in the evening, there was a road next to the airstrip that the F-15s would use. One run allowed me to “race” an F-15 as it taxied down the runway. I shared my story with the Colonel and the next day I was standing in a hangar, climbing into the cockpit of my childhood dream. We didn’t go out for a flight, but I was sitting in the jet, looking at gauges and controls of this once-elite fighter. I loved it.

VA Cardiology Suite Redesign

The task seemed relatively easy to me: design a new cardiology, surgery suite that can provide world-class care while simultaneously keeping up with future demand for our veterans. This project was at a major, regional VA hospital. I had done similar work before, but not for a government agency. Apparently, it was a big deal. The local press was at the kick-off event for the work. I was partnered with a high-powered, architectural firm. Our goal was to develop and finalize the design to build.

We established a team of stakeholders and subject matter experts. They conducted interviews with patients, surgeons, nurses, and staff. We began the process and analyzed existed demand, procedures and available technology as well as budget. We discovered great information. The government building-requirements binder was as thick as I had ever seen but despite the significant number of rules and regulations and requirements for cardiac surgical suites, we made them work for us.

The team created an optimized layout for the entire department, with specific attention to where clinicians delivered the medical care, the surgical suite. We used a Lean tool known as Process Preparation (2P). For this, we made small-scale, “paper doll” cutouts for everything that might go into a surgical suite. Then we moved things around on an architectural blueprint until we found a good solution for the suite itself and the entire floor. Eventually, we mocked-up an actual suite with surgical tables, full-scale cardboard cutouts, and auxiliary equipment until we finalized a solution that would work for everyone at each stage of use: before, during and after surgery.

We had created the goal. From there, it was figuring out how to make it happen. A team took our work and delivered it. It was a great plan with great teamwork that yielded great results. Our veterans are receiving better care, at a lower cost, because of it.

Solving Children’s Food Insecurity with Innovation

The goal was to help feed the 50,000 children who don’t get meals on a regular basis. Not getting enough to eat is called food insecurity. Police, educators, public policy makers, industry, and nonprofit food pantries would have to partner together. Although I have worked with several federal agencies over the past several years, my first foray into the local public domain was in Indiana. They asked me to play the process expert and facilitator for a project that could have a significant local impact to urban residents. In setting up the team, we included execs from the police, public policy, food pantries, donors, healthcare and local media.

Secondary research indicated 20% or over 50,000 children in the identified area were food insecure. This number was a significant gap, and we needed to understand what, besides food, was necessary to fix the issue. Reporters conducted our primary research by interviewing dozens of food insecure families. The core team visited multiple food pantries. These combined efforts gave our team the necessary information to make informed decisions. After several months of preparation, the team spent a week together thinking about what solutions would be effective. Several great project ideas came out of our session: police delivered food, food pantries at every school, and an app for information. We named project leads for each idea, and the teams began their work.

It took a while to build some momentum. Sometimes, it looked like it was over before it started. There was a great dream but it faced some obstacles. Fortunately, months after the initial session, the effort is making serious progress. They are delivering meals to hungry children across the entire metropolis in new ways not previously imagined. It took a strong realization to get this effort started, continue it through some tough times and start to impact actual lives. The project is positively affecting people’s health and future.

Innovation Methodologies

Lean Startup, Agile, SAFe and Silicon Valley’s impact on development…

A headhunter contacted me in my twelfth year as a design engineer. At the time, I was designing for Honda. He asked me if I knew anything about Lean Product Development and its principles of set-based concurrent engineering, chief engineer, trade-off curves and more. I honestly had no idea what he was talking about and told him so. He wasn’t convinced so he sent me a book, TheToyota Product Development System by James Morgan and Jeffrey Liker. After quickly digesting the book, I realized it described what I did on a daily basis. I had not realized that academia had conducted research and coined terms for our style of development, Lean Product Development.

Design for Six Sigma (DfSS) was an attempt to drive six sigma  principles into the development arena. This methodology was accepted about as well as Lean was in design settings; in other words, not so much. There were, however, a couple of wins in both areas: Lean’s focus on flow and value creation and DfSS’ emphasis on the voice of the customer (VoC) and Design for X, where X could be anything other than technology that considered the impact on manufacturing, service, cost and more. That gave each of those practitioners a solid base from which they could build.

Agile wrote its Manifesto  years before but exploded on the scene after 2010. Everybody was scurrying to mimic the software world. Lean met Agile when Eric Reis’ book The Lean Startup gained notoriety for its emphasis on infinitely small design/test cycles. It doesn’t take into account prototype creation time. It assumes an instantaneous build. Outside of publicly distributed software, there simply aren’t industries that can do instant prototypes and the requisite testing. Approaches require a short “waterfall” approach before writing User Stories.

Scaling Agile isn’t easy. A scrum of scrums and SAFe are one person’s take on Agile’s answer to portfolio management. Proceed with caution as I have yet to see a successful implementation of SAFe.

Development teams don’t want structure

Creative teams don’t like process. They bristle under micro-management. They embrace Agile because scrum teams are nearly autonomous in what they work on, what order and by whom. Classic waterfall project management opponents outright reject large Gantt charts, critical paths, associated resources and precise prototypes stages today, and for a good reason, it’s bureaucratic and burdensome.

However, Agile has its limitations too. Because of the brand equity associated with Agile now, executives have little ammunition to dig in and debate the innovation methodology and process. Results seem eerily familiar: projects remain stuck in development, schedules aren’t maintained, and it stretches people beyond their limits.

Development teams must have constraints. You must define the innovation process, while keeping it dynamic. You must also closely monitor autonomy and holacracy. Teams often hide poor performance behind industry accepted development methodologies. Be aware of the advantages and disadvantages of each approach if you are going to implement them. If not, you may create a confused, frustrated team.

Nearsightedness Kills Innovation

This system became famous in its industry for its original implementation of lean in the early 2000’s. Following their heyday, the CEO went on to be quite famous and started a consulting firm helping implement lean in other healthcare organizations. However, they were still not achieving the breakthrough level of performance improvement they needed or wanted. They called me in when they were looking to redesign their care model for their high-risk patient population. By definition, we included the top five percent of these patients. It would require a new way of thinking about things.

Per my typical requirement, they named a leader and set-up a cross-functional team to successfully execute this massive project. We established stretch goals and began work. The team developed an in-house, risk stratification method to define the patient population for the new care model. This patient population was then studied to determine their barriers to care and better health. The insights were staggering. One patient traveled over 5,000 local miles annually to get to all of their appointments. Another patient had 66 physician interactions in one year; more than one per week!
Patients were interviewed, observed at home and brought into focus groups.

We studied their engagement with the healthcare system. Their needs and pain points became evident, and the brainstorming of solutions began. Soon, a new model of care began to coalesce. It was different than anything this healthcare network had done before. Every patient would have an interaction with a patient care team that acted as an extension of the primary care provider. The team included all critical elements determined during research: a pharmacist, a social worker coordinator, a behavioral health counselor and a triage nurse. The experiments began. The team saw multiple successes in medicinal accuracy, blood pressure control, blood sugar reduction, physical activity and patient engagement.

My involvement stopped when they were expanding the patient cohort. It was then the Operational Excellence team swooped in and almost destroyed the efforts. This company struggled the entire length of the project despite years of Lean implementation and associated subject matter expertise. Eventually, the COO disbanded the effort, even though the health outcomes were outperforming even the best physicians in their network. This organization struggled with many of the Becoming Endurance principles outlined in this book and the results have become obvious.

If you talk to the former CEO of this organization, he will say he wonders why they only came up with two “new” things during his tenure. My analysis and involvement made it clear that they were expecting the operational excellence tool kit to innovate. It is unable to do this; you need innovation techniques. Teams can’t innovate when you’re staring at the bottom line every month. Executives have to be 100 percent committed to the project once they decide to do it. The project should keep going until it’s time to stop it altogether. Why? Because nearsightedness kills innovation.

Priceless Gems

I was standing in a heavily secured room in the diamond district of Manhattan. In the palm of my hand was a large, pink diamond worth hundreds of thousands of dollars. I then held a smaller, yet more valuable, blue diamond worth millions of dollars. The value of those diamonds was legitimate, but their value wasn’t always known. A few decades ago, diamonds were worth whatever a salesperson could get for the diamond, often not even selling an actual one, but a knock-off gem. That doesn’t happen much anymore, or ever if the stone is certified. Why? In the early twentieth century, founders started a non-profit organization with the distinct purpose of protecting consumers from jewelry con artists.

The most, publicly famous output of this non-profit organization was the 4 Cs of a diamond: color, cut, carat, and clarity. Diamonds could now be valued based on criteria established by each of the Cs. This judgment is what determines how much a diamond is worth. Diamond owners can, for a small fee, have their gemstones assessed by expert graders, giving confidence to buyers and sellers about its quality. This organization created criteria not only for diamonds, but also all types of gems as they expanded their protection of consumers. They trusted me to hold the blue diamond in my hand, and they also trusted me to help them on their next part of the journey.

The biggest gap in the jewelry world then became the jewelry itself, not the jewel that goes in it. Most of us don’t think about it, but the shape of prongs has specific best practices that hold and display the stone forever and can be disastrous if done poorly. Cutting, polishing, soldering, casting and many more techniques can be done well or done poorly too.

Ring mold
Mold for platinum ring.

Under the leadership of their VP of Education, they hired a Director of Jewelry Design. He was responsible for growing and teaching tomorrow’s bench jewelers using world-leading, best-in-class techniques. This direction meant a complete overhaul of a specific certification program from the ground up. We recreated the entire program using innovation processes and visual management techniques. We interviewed instructors and students and identified pain points for each. Brainstorming began.

The team gutted the hands-on focused, outdated classrooms so students could easily interact with the instructors during praxis. We threw away the educational, paper-based study material and recreated in an electronic, interactive, tablet format for all classes. The response was overwhelming. Both students and instructors raved about the changes. Attendance grew, and the company was back on track to better protect and inform consumers in another area, jewelry design.

At the same time, I was able to successfully have my wife’s twentieth anniversary ring designed and built. I relied on contacts made while working there. With certified diamonds, the right precious metal, and a recommended bench jeweler, I was confident of what I was getting would last forever. It all came together, and I was able to present her with the ring during our anniversary trip to Alaska. She gets compliments all of the time, and I’m confident in what she wears everyday is worth what I paid.

anniversary ring
Ring I designed for my wife on our 20th anniversary.

Mandatory Steps for Basic Healthcare Reform

W After ten years of driving healthcare reform with healthcare systems, medical device OEMs, and thought leaders, I have an opinion on how we can get it done. I posted this on social media recently:  “There are 2 parts to driving #healthcarereform of reducing cost and improving outcomes: 1) Who gets care and 2) How care is delivered. Both need a radical overhaul.”

Someone replied, “Can you provide more detail around those points? How do you envision rationing who gets care? How would you go about innovating the delivery [for] that care?”

This article is meant to hit the highlights for each of those three questions. To keep it short, I’m not going to include all of the statistics so you will have to research them yourselves.

Who Gets Care

With the discussion of Obamacare and its repeal, the topic of “medically uninsured” is top of mind for many people. Some argue that healthcare is a right and that inequality and disparity of outcomes is unacceptable. Maybe it is, maybe it isn’t. I will leave that to the politicians and social reform.

There is much we can do regardless of where we stand on that topic. There’s a significant amount of healthcare spend and poor outcomes with births, untreated chronic diseases, and end of life.

Babies and their moms

Our babies need to come healthy into the world. Costs can be driven up for their entire life if someone has a poor start in life. Many infant mortalities and complications can be avoided with simple, prenatal care that is unavailable or unused for or by too many people.

The Chronic Diseased

With 45% of Americans having at least one chronic disease, healthcare reform must address this. We have to care for people with chronic diseases before exacerbations. Ultimately, we would like to drive down the rates of diabetes, hypertension, asthma, and others, but we can make a significant improvement in healthcare by offering easier treatment and education plans that are non-hospital, non-clinic based with minimal physician involvement.

Those Dying

We need to start talking about end-of-life sooner. When a loved one is in the hospital, it’s too late. I have seen far too many instances of family members trying to extend the life of their loved one for weeks days or even hours however possible. Not only is it uncomfortable for the person dying, it’s outrageously expensive and ultimately ends in death anyway. We should move to having 100% of advance directives in place prior to hospitalization. We should also talk about death with dignity in a non-hospital environment.

How Care is Delivered

Any industry is going to protect the status quo and tradition. It’s easier because it doesn’t require the players to change. Healthcare is no exception. Its employees are the most educated in the world. They have significant incomes and tremendous power. They accept change when legally mandated or when it could negatively impact revenue or personal income. Healthcare reform demands a change in how care is delivered.


Last week, two major academic institutions announced hospital projects. Total spend for two facilities is expected to be $8 billion! Both were claiming to advance medicine and offer the absolute highest level of care for patients. They used fancy words like artificial intelligence and precision medicine. With healthcare spend in the U.S. at nearly 20% of GDP, projects like this are fiscally irresponsible.

Hospitals should only be used for the highest acuity issues, academia should conduct research but everything else should be treated somewhere else. The smaller and more distributed treatment places are, the better. The centralized hospital model continues to drive unprecedented levels of inconvenience, cost, and societal impact. They increase traffic, have poor or expensive parking, require long patient commutes, have acquired infections and more. It also puts people in the worst healing environment: a hospital room.


We have overqualified medical professionals treating patients with simple issues. For many health issues, we don’t need to see an actual doctor. A nurse, nurse practitioner or physician’s assistant is more than sufficient. For other issues, our primary care physician isn’t the best and we should talk to a specialist. We can’t overutilize the high-priced experts, though.

We must use specialists, subspecialists, and super subspecialists only when necessary to return a patient’s health to “normal.”


We can’t continue to require a patient to schedule an appointment at a doctor’s office. It’s overkill. A significant number of appointments don’t require “hands-on” presence of a physician and they can be done via phone call, video conference, email or text. We must kill the office visit unless absolutely necessary.


Having open hours when the majority of dual-income families are working is ridiculous. Opening at 9 AM and closing at 4 PM doesn’t work. Non-acute healthcare, especially primary care, needs to be available before normal working hours and after normal working hours. Finally, we can no longer have providers that reject evidence-based medicine and instead rely solely on their own experience. Too many physicians and offices are clogging their schedules with appointments that are medically unnecessary. This includes everything from annual physicals to how often and how early a woman should get a mammogram.

Innovating Care Delivery

We have to innovate our patient care model to achieve healthcare reform. As much as I would like to think that an existing healthcare system can do this, there is little evidence that they can. There are very few systems that even have an innovation center in place and even fewer that focus on the patient care model. Most want to be a tech incubator for new ideas from the surgeons or physicians. While I applaud those efforts, we can have a significantly higher impact by investing equivalent time and resources into care model changes.

This requires a systematic approach with a dedicated team. A hospital or healthcare system must invest in the minimal number of resources required to develop new care models. It is a skill set not possessed, taught or practiced in any healthcare environment yet we must establish and expand this skill set, everywhere.

We can’t expect corporate mega-conglomerates to come up with the best way to care for patients. They are focused on selling technology and solutions at a high-profit margin. They rarely understand the customer, the entire healthcare process or the people delivering it. You must have an immersive, ethnographic process, such as design thinking, coupled with technology development and change management. It must be internal- healthcare systems know their patients and market best.

Create Healthcare Reform

Now, when I say it only takes two things to impact healthcare reform, they are big things. However, I have personally led and experienced organizations that are taking the right steps. There are companies like CVS which are redefining care delivery.

Reform will happen. Time will determine the winners and the losers. It can’t be the patients. Check out my article on Population Health for a deeper dive.