SI_Playbook

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Strategy
Implementation
Playbook
St. Joseph Health
By Ken Flaherty
Executive Director, St. Joseph Way
2012

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Table of Contents
PREFACE ................................................................................................................................................................ 4
Executive Summary .......................................................................................................................................... 4
Introduction to strategy implementation .......................................................................................................... 4
Historical Development of Strategy Implementation ....................................................................................... 4
Foundations of Strategy Implementation ......................................................................................................... 5
Daily Management System ............................................................................................................................... 6
Visual Management.......................................................................................................................................... 7
Aligning OPERATIONS WITH Strategies........................................................................................................ 7
PREFIX .................................................................................................................................................................... 9
Terms and Definitions ...................................................................................................................................... 9
SECTION 1: STRATEGIC IMPLEMENTATION PLAN ................................................................................ 10
1.1 Pupose ..................................................................................................................................................... 10
1.2 Process – Catchball (REFER TO FIGURES F1 AND F2) ..................................................................... 11
1.3 SI Tool ..................................................................................................................................................... 13
1.4 Processes Used to Inform People............................................................................................................ 15
1.5 Development (REFER TO FIGURES F3 AND F6)................................................................................. 16
1.6 SI Tracking (REFER TO FIGURE F7) ................................................................................................... 17
1.7 Action Plan (REFER TO FIGURE F8) .................................................................................................. 18
1.8 SI Review Notes...................................................................................................................................... 19
1.9 Review and Reporting Process................................................................................................................ 20
1.10 Monthly Tracking Info will Be Four Weeks Old Once it Reaches the Health System........................... 20
1.11 Root Cause(s) and Countermeasures .................................................................................................... 21
1.12 CASCADMENT, ROLL UP AND REPORTING (Health System Example).......................................... 24
SECTION 2: NO MEETING ZONE ................................................................................................................... 25
2.1 Purpose.................................................................................................................................................... 25
Section 3: Visual Management............................................................................................................................. 26
3.1 Visual Management of Performance for Daily/Weekly Reviews.............................................................. 26
3.2 Defining the Driver Metric at the Point of Impact .................................................................................. 28
SECTION 4: Daily Reviews.................................................................................................................................. 32
4.1 Performance Huddles and Rounds......................................................................................................... 32
4.2 Tier 4 Executive Team or Initiative Team Huddles and Rounds with Director ...................................... 33
4.3 Tier 3 Director Rounds with Manager ..................................................................................................... 36
4.4 Tier 2 Manager Rounds with Supervisor/Team Leader .......................................................................... 38
4.5 Tier 1 Supervisor/Team Leader Huddles With Staff................................................................................ 38
SECTION 5: COACHING ................................................................................................................................... 39
5.1 Guiding Principles ................................................................................................................................... 39
5.2 Coaching Cycle for Improvement............................................................................................................. 39
SECTION 6: A3 THINKING.............................................................................................................................. 41
6.1 OVERVIEW OF A3 THINKING.............................................................................................................. 41
6.2 Strategy A3 Overview............................................................................................................................. 42
BOX 1: Reason for Action ................................................................................................................ 43
BOX 2: Initial State........................................................................................................................... 43
BOX 3: Analyze and Justify Future Activity .................................................................................... 44
BOX 4: Breakthrough Targets .......................................................................................................... 44
BOX 5: Confirmed State ................................................................................................................... 45
BOX 6: Insights................................................................................................................................. 45
Ongoing Review of Strategy A3 Through Completion..................................................................... 45
6.3 The Nine Boxes of A3 Thinking ............................................................................................................... 46
Box 1: Reason for Action.................................................................................................................. 46
Box 2: Initial State............................................................................................................................. 46
Box 3: Target State............................................................................................................................ 46

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Box 4: Gap Analysis.......................................................................................................................... 47
Box 5: Solution Approach................................................................................................................. 47
Box 6: Rapid Experiments ................................................................................................................ 47
Box 7: Completion Plan .................................................................................................................... 48
Box 8: Confirmed State..................................................................................................................... 48
Box 9: Insights................................................................................................................................... 48

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PREFACE
Executive Summary
Within Saint Joseph Health, our St. Joseph Management System (SJMS) is comprised of six primary
sub-systems: Strategy Implementation System, Improvement System (St. Joseph Way), Daily
Management System, Visual Management System, Suggestion System, and a Recognition & Reward
System. Each system encapsulates our intent to develop and establish a comprehensive, system-wide,
strategic and tactical-level Continuous Process Improvement (CPI) approach. We will capitalize on
using knowledge from each other as well from other organizations and disciplines to improve every
business process within Saint Joseph Health. With SJMS, we are challenging all of our valued staff
to examine processes and eliminate steps in primary care and business processes that add little to no
value. In other words, the aim is to take our high performing organization to the next level, by
reviewing how we maximize value and eliminate waste in all of our environments – operational,
support, and otherwise; and fully integrate Continuous Process Improvement across the Saint Joseph
Health.
Introduction to strategy implementation
Organizations that win in the long term “plan their work and work their plan.” Realization of strategy –
the long-term vision of an organization is achieved by a disciplined approach to setting direction and
then executing that direction through the effective use of an organization’s resources. In Japan this
method is called Hoshin Kanri (Strategy Implementation) – the secret weapon in the Japanese
management system. Strategy Implementation is the strategic direction setting methodology used to
identify business goals as well as, formulate and deploy major change management projects throughout
an organization. It describes how strategy cascades from vision to execution in the workplace through a
collaborative engagement process that also includes implementation details like performance self-
assessment and management review. This paper describes the relationship between strategy
development and the organization’s daily imperative to measure and manage its operations using a
system that aligns the actions of its people to produce collaboration among the various business
functions and processes to produce requirements for customers.
Historical Development of Strategy Implementation
What were the circumstances under which Strategy Implementation originated? Interest in strategy,
market focus, and long-term, balanced planning were generated by visits of Dr. Peter F. Drucker to
Japan in the early 1950s. i
As a result of his teaching, “Policy and planning” was added to the Deming
Prize checklist in 1958. Bridgestone Tire Corporation first used hoshin kanri, the Japanese term for
Strategy Implementation, in 1965. In 1976 Dr. Yoji Akao and Dr. Shigeru Mizuno were involved in the
Yokagawa Hewlett-Packard (YHP) implementation of hoshin kanri as part of its pursuit of the Deming
Prize. By 1982 YHP had used hoshin to manage a strategic change that moved it from the least
profitable Hewlett-Packard division to the most profitable. In 1985 this hoshin methodology was
introduced to the rest of Hewlett-Packard as a lesson learned from the YHP Deming Prize journey.
From HP this methodology was transferred to other leading companies including: Proctor & Gamble,
Ford, Xerox and Florida Power & Light, involving several advisors and councilors of the Union of
Japanese Scientists and Engineers (JUSE). The work of the GOAL/QPC Research Committee also
extended the managerial technology of Strategy Implementation and was a key ingredient in introducing
Strategy Implementation across North America and, through multi-national companies, into the world. ii

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Foundations of Strategy Implementation
Mizuno defined hoshin kanri as the process for “deploying and sharing the direction, goals and
approaches of corporate management from top management to employees, and for each unit of the
organization to conduct work according to the plan.” Hoshin Kanri is a comprehensive, closed loop
management planning, objectives deployment, and operational review process that coordinates activities
to achieve desired strategic objectives. The word ‘hoshin’ refers to the long-range strategic direction
that anticipates competitive developments while the word ‘kanri’ refers to a control system for
managing the process. iii
Hoshin does not encourage random business improvement, but rather focuses the organization on
projects that move it toward its strategic direction. It builds strength from its relationship with the daily
management system that is focused on kaizen – continuous improvement. Hoshin seeks breakthrough
improvement in business processes by allocating strategic business resources (both financial and human
resources) to projects that balance short-term business performance to sustain improvement toward its
long-term objectives. In a Strategy Implementation management system this two-pronged approach
integrates operational excellence in the daily management system with architectural design of its long-
term future. This planning process contains two objectives: hoshin – the long-range planning objectives
for strategic change that allows an organization to achieve its vision, and nichijo kanri – the daily,
routine management control system (or daily management system) that translates the strategic
objectives into the work that must be accomplished for an organization to fulfill its mission. The
blending of these two elements into a consensus management process to achieve a shared purpose is the
key to success for the Strategy Implementation process. In a hoshin planning system, strategy is
observed through the persistence of its vision – how it is deployed across cycles of learning in project
improvement projects that move the performance of the organization’s daily management system
toward its direction of desired progress.
The fundamental premise of the Strategy Implementation is that the best way to obtain the desired result
for an organization is for all employees to understand the long-range direction and participate in
designing the practical steps to achieve the results. This form of participative management evolved and
was influenced by the Japanese refinement of Drucker’s Management by Objectives (MBO) through the
birth and growth of the quality circle movement. In order for workers to manage their workplace
effectively, they must have measures of their processes and monitor these measures to assure that they
are contributing to continuous improvement as well as closing the gap toward the strategic targets.
Strategy Implementation became the tool that Japanese business leaders used to align the work of their
front-line organizations to the strategic direction of their firm. When HP first implemented hoshin
planning, many of its business leaders explained how it worked by calling it ‘turbo-MBO.’
Strategy Implementation links breakthrough projects that deliver the long-term strategic direction to
achieve sustainable business strength while, at the same time, delivering an operating plan to achieve
short-term performance. The methods of Strategy Implementation anticipate long-term requirements by
focusing on annual plans and actions that must be met each year to accumulate into long-term strength.
Strategy Implementation processes begin when senior management identifies the key issues or
statements of vulnerability, where improvement will have its greatest impact on business performance.
This perspective is an essential starting point for Strategy Implementation. As Dr. Noriaki Kano of the
Tokyo Science University points out, without direction “the ship would be rudder-less.” The
communication of the focus area or theme for improvement provides a cohesive direction to assure
alignment of the entire organization and to build consensus among the management team on business
priorities.
Hoshin helps to create the type of organization that William McKnight, former CEO of 3M, expressed
as his desire: “an organization that would continually self-mutate from within, impelled forward by
employees exercising their individual initiative.” iv
In short, an organization where creativity is

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managed through a combination of self-initiated continuous improvement projects with engaged teams
that combine individual capabilities to achieve strategic projects that make a difference on the larger
organizational scale. How does this change management process work at the front line where these
strategic St. Joseph Way projects engage the routine work processes of the organization? [Typically,
Strategy Implementation is coupled with a measurement system (either a customer dashboard (tracker)
or balanced scorecard).]
Perhaps the reason hoshin kanri took hold within Hewlett-Packard is that this methodology
demonstrated its ability to translate qualitative, directional or strategic goals of an organization into
quantitative, achievable actions that focus on fundamental business priorities achieving significant
competitive breakthroughs – in short, the leaders at HP recognized hoshin kanri as MBO done right! v
The extension of this methodology beyond HP to other leading firms came about because HP was
recognized as possessing a best practice for linking its strategic direction with its operational
management systems.
Daily Management System
Strategy Implementation uses a systems approach to manage organization-wide improvement of key
business processes. It combines the efforts of focused teams on breakthrough projects with the efforts
of intact work groups who continuously improve the performance of their work processes. All change
occurs in projects that accomplish those changes necessary to achieve stretch business objectives that
assure sustained success for the organization. Strategy Implementation systematically plans ways to
link strategic direction with those business fundamentals that are required to run the business routine
successfully. Strategy Implementation allows management to commission change projects for
implementation and to review the implementation of a system of projects and thereby to manage
change. It seeks opportunities disguised as problems – and elevates those high-priority changes
required for the improvement of the daily management system and work processes into business change
objectives that are accomplished as St. Joseph Way projects.
Routine operation of the daily management system requires a foundation in management by fact, or the
combination of business measurement with statistical analysis and graphical reports that illustrates the
current state of performance, historical trends, and is able to extrapolate trends through statistical
inference. A key ingredient is the business fundamentals measurement system that includes the set of
basic process results measures that are monitored at control points within the organization where the
flow of its throughput can be managed based on the requirements that are driven (using a pull-system)
by the customer requirements. This measurement system should include both predictive and diagnostic
capabilities.
Hewlett-Packard embedded its daily management system into a work process measurement system that
they initially called “Business Fundamentals Tables.” Other companies refer to the set of measures that
translate strategic goals into operational measures of work (in units such as quality, cost and time) as
either a customer dashboard or a balanced scorecard. These systems are used to monitor the daily
operations of a business and to report management on the progress in the process for developing and
delivering value to customers. This measurement process must operate in close to real-time to permit
process owners to take appropriate corrective action that will limit the “escapes” of defects, errors, or
mistakes to external customers. Such measures of core work processes are called “business
fundamentals” because they must operate under control for the business to achieve its fundamental
performance objectives.
These measures must also be captured at the point where control may be exercised by process operators
in order to adjust the real-time operation of the process and assure meeting the customer’s performance
requirements on a continuing basis. As the great Dutch architect Miles van der Rohe once observed:

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“God is in the details” and it is in these details that business must effectively operate. A daily
management system defines the details of an organization’s operations. Thus, the measurement and the
point at which it is both monitored and controlled are parts of the daily management system and at this
point they must be related to their contribution to deliver organizational performance objectives. In the
language of Six Sigma a “Business Y” (such as ‘profitable growth’) that must be achieved is the
strategic goal, while a “Process X” (such as ‘creditworthy customers’) delivers this performance in the
transfer function Y = f (X) and is therefore a business fundamentals measure in the daily management
system.
Collins and Porras point out that leading companies stimulate progress through evolutionary progress.
Where the word “evolutionary” describes progress that resembles how organic species evolve and adapt
to their natural environments. Evolutionary progress differs from the Big Hairy Audacious Goals
(BHAG) of strategic progress in two ways. First, whereas BHAG progress involves clear and
unambiguous goals (“We are going to climb that mountain”), evolutionary progress involves ambiguity
(“By trying lots of different approaches, we’re bound to stumble onto something that works; we just
don’t know ahead of time what it will be.”) Second, whereas a BHAG involves bold discontinuous
leaps, evolutionary progress begins with small incremental steps or mutations, often in the form of
quickly seizing unexpected opportunities that eventually grow into major – and often unanticipated –
strategic shifts. Evolutionary progress represents a means to take advantage of unplanned opportunities
for improvement that are observed at the point of application – the daily management system. The
accumulation of many evolutionary improvements results in what looks like part of a brilliant overall
strategic plan. vi
Both types of change are needed to stimulate the organic growth of an enterprise. If an
organization can make improvements in the ‘right X’s’ then it will improve its performance on the
critical Business Y.
Visual Management
At the place of work (gemba) where value is being created for our patients, abnormalities of all sorts
arise every day. Only two possible situations exist in the gemba: Either the process is under control, or
is out of control. The former situation means smooth operations; the later spells trouble. The practice of
visual management involves the clear display of gembutsu (the actual product, as well as performance
boards, so that both management and staff are continually reminded of all of the elements that make
quality, stewardship, and delivery successful-from a display of the link to the over-arching strategies, to
patient status, to a list of the latest employee suggestions. Thus visual management constitutes and
integral part of the St. Joseph management system.
Aligning OPERATIONS WITH Strategies
A critical challenge for organizations is to align their strategic direction with their daily work systems
so that they work in concert to achieve the desired state. Alignment must include linking cultural
practices, strategies, tactics, organization systems, structure, pay and incentive systems, building layout,
accounting systems, job design and measurement systems – everything. In short, alignment means that
all elements of the company work together much like an orchestra leader integrates the various
instruments to conduct a coordinated symphony. Organizations that apply the most mature aspects of
Strategy Implementation do not put in place any random mechanisms or processes, but they make
careful, reasoned strategic choices that reinforce each other and achieve synergy. These organizations
will “obliterate misalignments.” If you evaluate your company’s systems, you can probably identify at
some specific items that misaligned with its vision and that impede progress. These “inappropriate”
practices have been maintained over time and have not been abandoned when they no longer align with
the organizational purpose. “Does the incentive system reward behaviors inconsistent with your core
values? Does the organization’s structure get in the way of progress? Do goals and strategies drive the

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company away from its basic purpose? Do corporate policies inhibit change and improvement? Does
the office and building layout stifle progress? Attaining alignment is not just a process of adding new
things; it is also a never-ending process of identifying and doggedly correcting misalignments that push
a company away from its core ideology or impede progress.” vii
1
Peter F. Drucker, Keynote Address, 56th
Annual Quality Congress, May 20, 2002.
1
Yoji Akao, editor, Hoshin Kanri: Strategy Implementation for Successful TQM (Portland, OR: Productivity
Press, 1991), pp. XXX.
1
Akao, Op. Cit., p. XXX.
1
James C. Collins and Jerry I. Porras, Built to Last: Successful Habits of Visionary Companies (New York:
HarperBusiness, 1994), p. 156.
1
It must be noted that Peter F. Drucker initially discussed MBO in Japan in the mid-1950s. Drucker taught
management concepts to the Japanese along with Dr. Joseph M. Juran and Dr. W. Edwards Deming. At that time
Dr. Juran and Dr. Deming worked in the graduate management school of New York University under the
supervision of Dr. Drucker.
1
Collins and Porras, , Op. Cit., p. 146.
1
Collins and Porras, , Op. Cit., p. 215.

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PREFIX
Terms and Definitions
Action Plans: Specific method or process to achieve the results called for by one or more objectives.
Action Themes: Groupings of objectives with a common underlying purpose.
Actions: Communicate the Team’s intent of meeting the Action Themes.
Catchball: Continuous give-and-take between levels around chosen targets and organizational
capabilities.
Goal: A broad statement describing a desired future condition or achievement without being
specific about how much and when.
Objectives: Articulate the actionable components of our strategy.
Corrective Actions: Action taken to eliminate the cause of a nonconformance that has occurred,
and prevent recurrence of the nonconformance.
Initiatives: Close the gap between our current and desired performance.
Metrics: A measurement, taken over a period of time that communicates vital information about a
process or activity. A metric should drive appropriate leadership or management action.
SI Alignment Tool: This is a one page diagram that begins with the over arching Strategic Goal and
cascades the goal into focused Team Actions, Metrics and goals for each metric. (Productivity, Cost,
Inventory, Quality & Safety)
RALFI: Results, Accomplishments, Lessons Learned, Future Plans, Issues. Summary of the
Months activities for the area in review.
Root Cause: Original reason for nonconformance within a process. When the root cause is removed
or corrected, the nonconformance will be eliminated.
Tracker: One Page Chart that documents the Business Result Metrics.
Vision Statement: A powerful, short phrase to point the organization in a direction for the future.

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SECTION 1: STRATEGIC IMPLEMENTATION PLAN
1.1 Pupose
Strategic Implementation is the method used to ensure everyone in the St. Joseph Health System is
working effectively towards the same goals identified by senior leadership. Cascading this method to
the appropriate level requires clear communication of the SI process to all who are involved in its
execution. The goals and objectives are to be measured and therefore must be written in clear,
understandable language. A point of contact will be identified at the appropriate level of responsibility
to monitor the process and flow of informationup to the System Office.
Successful SI requires effective communication throughout the Health System. Validation can only
occur when the SI process is c a s c a d e d to the lowest level and tracking and reporting of metrics
begin. Senior leadership’s responsibility is to clearly state goals and objectives, and cascade the process
to the next level and review monthly tracking.
SI is designed to:
a. Align the Health System to achieve the goals and objectives impacting the entire
organization.
b. Provide a common/standard methodology to cascade metrics and action plans
throughout the Health System.
c. Communicate HealthSystem CEO’s intent relative to goals, objectives, metrics and action
plans.
d. Assign accountability and responsibility at all levels.
e. Ensure alignment throughout the organization.
f. Concentrate the organization on high-leverage outputs.
g. Form a disparate group of individuals into a team with a common goal.
Critical components of SI:
a. SI Tool(tools). This sheet identifies Health System -wide goals; objectives which
support the implementation of the goal; key metrics and action themes to support
objectives; and shows linkage from goal to action themes.
b. Tracker. This sheet is used to show monthly status of progress toward objectives.
c. Action Plans. One action plan is developed per objective. This is the detailed plan of
action or project plan for meeting the objective. The plan will outline the strategies,
milestones, measures and exit criteria.
d. SI Countermeasures and Review Notes. This sheet is used to capture monthly notes
relating to actions.

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1.2 Process – Catchball (REFER TO FIGURES F1 AND F2)
Catch-ball is the continuous give-and-take between levels around chosen targets and organizational
capabilities.
Using the goals and objectives developed at the higher organizational level (e.g. Health System level 0)
the process is cascaded to sub-organizations (e.g. Regions). Regions then start the process at their level
and further cascade to their (e.g. Ministry) who will further cascade down to the next level, if
necessary going to the lowest level possible.
The St. Joseph System Office will provide a certified trainer (Regional Sensei) who will:
a. Meet with the appropriate leader and provide them a review on:
- The SI process and how it needs to occur.
- The SI flow and format.
b. Conduct a team meeting with the Regional EVP and his staff (Ministry CEO’s
and selected staff) to complete the Regional level SI action plan and develop the next
level actions. The process will then be cascaded to the next level, as required. The
Regional Sensei will explain the process, as required, to various teams during
organizational planning stages. At the team meeting the Regional EVP will:
- Set the stage and expectations for the meeting by reviewing the
outcome of the Health System ’ off site to include the Health System -
wide Goal set by the Health System CEO.
- Review the Health System level Objectives. Discuss how the Regions intend to
meet the Health System-wide Objectives. The CEO’s, at the next level, then
meet and discuss how they intend to meet the objectives.
- Review the Health System Level Action Themes that were developed for each
Top Level Objective and the Team Actions which are to be cascaded to the
next level. As the process is cascaded, specific actions will be identified to
support these themes.
- Review the Key Metrics and Targets, these are the tools used to measure
objectives and Action Themes and identify anticipated results.
At each Team meeting, the entire team will determine if there are any additional actions that need to be
added. As the process is cascaded, the next level will develop their specific Actions and related Metrics
and Targets for how they intend to meet each of the previous level’s Action Themes.
Catch-ball ensures that targets set at a higher level are passed down to the next level to ascertain their
feasibility. The leaders will review, with the entire team, their specific Actions, Metrics, Targets
and Periodic reviews. The team will either concur or discuss to insure these are correct and aligned with
the Action Themes. This give-and-take activity is performed between different levels of the
organization to make sure that critical information on goals and objectives as well as feedback is
passed back and forth. Catch-ball is vital to the process as it helps to show linkage among Health
System Office/Health System Regions/Ministry Executive Team/Ministry Departments.

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Figure F1 - Cascade the Process (Health System example)
SI
Ali
Health
System
Tactical
Action
Plans
System
Region Ministry

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Figure F2 – Catch-ball Process
1.3 SI Tool
The SI matrix (refer to Figure F3) is composed of linked areas of information which show the flow
from Health System Goal to Team Actions and provides a measuring tool which can be used at each
level. The matrix areas below are in the logical order they should be completed.
Area A. The Health System Goal as stated by the S J H S C E O . This area does not change as the
process is cascaded.
Area B. Three Health System Objectives are developed to support the Goal. This area does not change
as the process is cascaded.
Area C. Key Metrics, identified by the Health System , are the main areas the Health System
is interested in tracking. These Metrics are directly linked to the Objectives. As the process is
cascaded, each level will place their metrics in this area.
Area D. Action Themes/OPR states how the Goal and Objectives are to be accomplished and
identifies the OPR for each theme. The Health System Level matrix shows the Health System Level
Themes. As this is cascaded, each level will place their specific Themes in this area.
Leadership Team
• Defines Metrics
• Sets Goals to provide capabilities
• Allocates goals through team
network
• Indentifies actions to attain goals
Address and resolve
barriers
Pass the ball to
the next level…
are goals
attainable?
Has the Action
Plan task
catchball
identified?
Review with the
organization/function
Identify Organization
OPR/POC or contact
change manager
Goals
attainable or
new goals
agreed to?
Final results reviewed
with leadership team
IMPLEMENT and measure
Yes
Yes
Yes
No
No
No

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Area E. This area has several parts:
1. “Actions for Team” reflect the Actions to be taken by the next level in order to
meet the Action Themes in Area D. When cascaded to the next level down, these
Team Actions become the Action Themes (Area D) at the next level.
2. “OPR” is the person responsible or the go-to person that has the authority to make it
happen and follow thru with the action required.
3. “Key Metrics” are how the action will be measured.
4. “Target” reflects the anticipated result reached upon completion of the metric.
5. The team actions will move to Area D and C, respectively, as the process is
cascaded to the next level.
Area F. This area provides linkage to ensure focus and alignment from Goal to Team Actions in order
to support capabilities.
Area G. These blocks are to be color coded to show strong alignment (blue), indirect alignment
(yellow), or no alignment (white) between upper level Action Theme and next level Action Themes.
When filled in this will provide a visual of where resources may need to be realigned to meet
objectives.
Figure F3 - Strategic Implementation Alignment Tool
Strategic Alignment and Implementation
(SA&I) Matrix
Organization Time Frame
Date
Oragnization-Wide Goal
Key
Metrics
Targ
et
Action Themes for
Organization
OP
R
1
1
2
2
RELENTLESSLY
PURSUING CABABILITY
MISSIO
N 3
3
4
4
5
5
6
6
7
7
Oragniztion-wide OBJECTIVES
Initiativ
es OPR KEY METRICS TARGET 1 2 3 4 5 6 7
Legend
Strong Alignment
- Blue
Indirect Alignment -
Yellow

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1.4 Processes Used to Inform People
Figure F4, below, depicts the normal approach to SI. It is the “broadcast” approach. The Health
System CEO develops a policy statement and broadcasts it to the organization.
Figure F4 - The “Broadcasting” of SI policy
System
CEO
Regional
EVP’s
Ministry
CEO’s
Ministry
Department’s
Strategic
Implementation
The evolution of a policy statement as it moves down the system is depicted in the following Figure
F5.
Figure F5 - The evolution of SI policy statement into a specific
plan or strategy for accomplishment
System
CEO
Regional
EVP’s
Ministry
CEO’s
Ministry
Department’s
Strategic
Implementation
What, Why,
How to
measure,
When, Target
(Health System
Goal, Health
System
Objective’s
Actions
Themes)
What, When,
Who, How to
measure, target
(Action Themes
for Team
What,
When, Who, How
to measure, target,
how it might be
done, quality
measures (Key
Metrics, Target)
Plan of attack
or Strategy, What,
Who, Quality
issues, First Steps,
Schedule

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1.5 Development (REFER TO FIGURES F3 AND F6)
SI Tracking (Refer to paragraph 2.6)
The Objective, Key Metric, Target, and Office of Primary Responsibility from the Matrix will
automatically be filled in on the tracker sheet. The sheet will be used to show a monthly status of the
progress of objectives.
Action Plans (Refer to paragraph 2.)
Catch-ball with higher level management and support functions. Catch-ball provides an opportunity for
others to contribute to another unit’s metric with possible linkage and support which would otherwise go
unnoticed.
Figure F6 - Development of Strategic Implementation
“Catch-ball”with
higher level
management and
support groups
Action Plans to
support Objectives
& Business Results
Matrix
Tracker

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1.6 SI Tracking (REFER TO FIGURE F7)
Performance measures to be tracked are automatically filled to this sheet when entered into the Matrix.
Areas from the Matrix which are automatically linked are the Health System Objectives, Key Metrics,
Target, and Office of Primary Responsibility (OPR).
a. Manual monthly tracking is divided into three color coded parts:
b. “Plan” block identifies the monthly goal to reach in order to meet the target.
c. “Actual” block will reflect the number/percentage that was actually met by the end of the month.
e. “ytd+/-“ indicates if the metric is ahead or behind schedule for the year.
Color Codes. The monthly tracking is color coded (see Legend) using the following:
a. Completing target should be indicated by shading blue.
b. On schedule of target should be indicated by shading green.
c. Slightly behind target should be indicated by shading yellow.
d. Not meeting target should be indicated by shading red.
Figure F7 - Example Tracking Progresses of Objectives

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1.7 Action Plan (REFER TO FIGURE F8)
The recipe for accomplishment of our objectives is summarized in individual action plans--one for each
objective. Action plans by nature are just as their name implies--plans of action. Within the structure of
this strategic plan is one action plan for each of our strategic objectives. Each Health System action plan
identifies accountability for objective accomplishment and outlines the achievement strategies,
milestones, performance measures, and exit criteria for objective fulfillment. The specific format for each
action plan is as follows:
a. Objective. This is the Health System Objective identified by the Health System CEO and is
automatically filled in and linked to the Matrix.
b. Events Column. Will be checked if there is an event scheduled/ongoing to accomplish the
specific action.
c. Short Description. Briefly describe the action to be taken.
d. Details and Deliverable. List specific steps to accomplish the objective and action theme.
e. OPR. Identifies the person/unit responsible for this specific action.
f. Plan Dates. The start and finish dates identified for accomplishing achievement strategies.
g. Catch-ball. This column will be checked to identify that there is a link to another unit for
support or action.
h. Comments. Use this area to expand on the Catch-ball or other significant information
related to this action.
i. Status. This block is color coded, in accordance with the Legend, to identify the progress
of the action to completion.
Figure F8 - Actions Plan Sheets

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SI Review Notes Jan 2012
1.8 SI Review Notes
This sheet is used to capture monthly notes relating to the actions. There are several categories identified
to assist with gathering this information. These categories are referred to as RALFIs. (Refer to Figure F9)
 Results - Key results from the metrics for period tracking.
 Accomplishments - For period tracking.
 Lessons Learned - Top two to three key lessons learned.
 Future Plans - Root cause and corrective actions on action items not being met. May use
Root Cause and Countermeasure template if necessary. (Refer to Figure 11)
 Issues with suggestions – Problems, issues. Concerns, barriers that need to be elevated along
with remedy.
Figure F9 - RALFI (Monthly review notes)

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1.9 Review and Reporting Process
Once the SI process has been cascaded down to the action level, the lowest level will begin reporting up
the chain. Only the target areas which were not met are to be reported monthly. Reporting should include
why the target was not met and what is the plan to meet the metric target.
Figure F10 - Metrics Review
1.10 Monthly Tracking Info will Be Four Weeks Old Once it Reaches the Health System
Each Level reviews the Tracker for their Level and then reports up to next level the following week. This
reporting continues up the chain to the Health System Level. The Tracker will indicate which Metric
Target has been met and which has not been obtained. After reviewing each Metric Targets, the Metric
Targets that have not been met are discussed in more detail.
The discussion for the Metric Targets that have not been met will begin with the question of “why”. The
lower level will explain Root Cause, and then provide the counter actions of how and when they intend to
achieve the Metric Target for the next period of review. This process of asking “why”, explaining the
Root Cause, and providing counter actions of how and when to get back on track to meet the Metric target
will repeat for each Metric Target not met.
The Action plans will only be reviewed as part of the Root Cause and Counter Action for the specific
Metric and Target that was not obtained.
WHY
Review Tracker on
monthly basis to
verify achievement
of Metric Targets
WHY
WHY
WHY
WHY
Reporting Level
Explains “Why” target was
not met and shows what
actions were not
accomplished to achieve the
metric target.

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1.11 Root Cause(s) and Countermeasures
Countermeasure Discussion with the Sensei
Countermeasures are the actions taken to reduce or eliminate the root causes of problems that are
preventing you from reaching your goals. In many cases, this is a formal process for a ministry. A
ministry does its strategic planning, which cascades down through the levels of an organization,
creating targets, or Key Performance Indicators (KPIs). When the organization is missing on one
of its KPIs, its leaders should perform countermeasures to make sure they have a plan to get back
on track.
Countermeasures are also done when a problem ‘pops up’. But ensure to look at what metric that
problem links to. You’d be surprised how often these sorts of issues can be tied to the tracker
targets.
At a minimum, the countermeasure should include: a summary of the organization’s performance
toward the goal, a definition of the goal (including how the goal is measured), problem
statement(s), a root cause analysis of each problem (with an understanding of how it contributes
to the shortfall), and an action plan that includes: task, deadline, person responsible, impact on
the goal.
Countermeasures should be maintained for as long as the team is missing on its goals. If you take
the time to set goals (and you certainly should), then you should also invest the time to manage
your business towards meeting those goals.
My observation is that people struggle when doing countermeasures. They look at
countermeasures as a nuisance, and do them in the last few minutes before an operations review
is scheduled. So instead of closely managing how they are doing improvement efforts, they use a
certain amount of faith that improvement efforts are lining up with goals. When that faith is
misguided, the gap between actual performance and the target doesn’t close. That means wasted
effort.
Because the format is in Excel and is math intensive, many people do not have skills that are
refined enough to put together a thorough analysis. They also get so wrapped up in fighting the
daily fires that they have no time left to manage the business. In addition, managers want to make
sure the operations review goes off well, so they do the countermeasures themselves. This
prevents full by-in from their team, and also limits junior leaders’ development.
It takes a lot of practice and effort to really get good at this skill. As a leader, you have to stress to
your team the importance of countermeasures. That means looking at the progress of
improvement efforts with them more than once a month. It means providing training to them
frequently, and coaching them on how to improve their countermeasuring skills. I recommend
doing the coaching in private, as junior leaders and team members are not used to being
scrutinized in public.
Identify a metric that is below its target, and start using countermeasures on it. Once you’ve tried it for a
while, find a sensei or facilitator who can help you answer any questions that come up.
Trying it on your own first will help you get perspective and will help you ask better questions of
your Sensei or facilitator.

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Questions for leaders to ask when countermeasures are not closing the metric gap
1. Have you identified the real root cause? Show me your supporting A3 and data.
2. Did you uncover the right information to support the analysis?
3. Did you isolate the root causes(s) of the main components of the gap?
4. Did you capture this material in the most clear and concise manner, i.e. one that clarifies true
problems, invites analytic questions, and suggests direct countermeasures?
5. Have you explored every reasonable countermeasure?
6. Cab you show how your proposed actions will address the root causes of the performance
problems?
7. Can you show the gap between the target and the current condition?
8. Have you continued to go to the gemba in gathering new information and countermeasures?
Root Cause(s) and Countermeasures - Health System Example
Start by completing the following:
1. Fill out header and complete Quadrant 1
a. Performance Measure: What metric are you presenting?
b. Complete the header with the objective of the countermeasure, goal of the
countermeasure, owner and month. (use 1-3 words on each line)
c. Historical Trends (Quadrant 1)
d. The graph of the Historical Data in Quadrant 1 should have 6 mo-3 yrs. of data
e. Direction you want to move (up or down) to show improvement
f. Metric title at top of graph
g. Month by month or year by year breakdown
h. Target line to show desired goal
2. Complete (Quadrant 2) which includes the most recent month’s data
a. Stratify Data where possible according to department, patient population, etc.
b. Display each segment of performance where possible
c. Title of the graph has timeframe and metric being measured.
d. Include legend as needed
3. Complete (Quadrant 3) identify top contributors
a. Complete an A4 (done by those closest to the process)
b. Identify and display top contributors in a Pareto diagram or using other visual tool
c. Include legend as needed.
4. Complete (Quadrant 4) by filling out action plan
a. List problem with potential cause and potential solution, owner of each, due date &
status.
b. This is a 30 day action plan describing what will be done in the next 30 days to
improve performance

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Figure F11 – Root Cause and Countermeasure Review

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1.12 CASCADMENT, ROLL UP AND REPORTING (Health System Example)
Week One – Report to Department Heads
Week Two – Department Heads report to ministry CEO
Week Three – CEO report to Regional EVP
Week Four – EVP report to Health System CEO
Figure F11 - Reporting up the chain
Roll-up
Roll-up
Roll-up
Dept. Head
Week 1 Review
EMT
Week 2 Review
Regional/Ministry
Week 3 Review
System/Region
Week 4 Review

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SECTION 2: NO MEETING ZONE
2.1 Purpose
Having a No Meeting Zone enables leadership focus on process improvement and performance within the
work area.
When: (usually at start of day)
8-10 AM Daily Monday through Friday using a structured agenda. Typically 2 hours is needed to allow for all
huddles, rounding, and process observations/audits to occur. When possible the front line start up huddles
should begin before the No Meeting Zone.
 Description of Appropriate No Meeting Zone Activities
 Review and improve performance
 Identify gaps, effectively solve problems and experiment/implement
 Teach, coach and develop staff members
 Engage staff in identifying and resolving issues/problems real-time
 Share news, new/updated policies, processes, practices and mandatory issues
 Recognize and reward employees
 Leaders observe the processes in the Gemba and learn the key elements of their business
while managing adherence to standard work
 Develop teamwork and relationships within the unit/value stream
 Environment of Care observations, staff rounding, patient rounding
Other Activities during this time period
 Response to onsite regulatory bodies
 Monthly staff meeting and monthly team leader meeting
 Meetings with physicians
Activities that do not belong
 Office work including schedules, evaluations, interviews and administrative tasks
 Updating visual boards (should be completed in preparation of Gemba Zone Time)
 Firefighting that can be postponed
Executive Schedule during the “No Meeting Zone”
Executive Team and Initiative Team Huddles should be done at a minimum of once a week on the same day, at
the same time. During the No Meeting Zone the Executives will have a schedule of rotating huddles and rounds
to attend. See Figure F12 Sample Executive Rounding Schedule
The No Meeting Zone is used to:
1. Attend EMT Huddle – 30 min, Ministry Strategy Room
2. Round with Initiative Owner, 30 min, Initiative Team Strategy Room (Round on Initiative that they sponsor
once a week and rotate through other initiatives at least once a week)
3. Round with Director – 30 min, Performance Center in the Gemba (Rotate Gemba daily/weekly as needed)
4. Escalation Meeting (Top Tier) – 30 min, at Daily Escalation Center (note: Escalation Meetings will not be
implemented until later phases of Strategy Implementation)
5. Document notes on observation, feedback needed/corrective actions taken, personal growth, and
opportunities to improve huddles and rounds

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Section 3: Visual Management
3.1 Visual Management of Performance for Daily/Weekly Reviews
Strategy Rooms (See Figures F13 and F14)
Visual Control Center for Executive Team and Initiative Teams
The Executive Management Team and Initiative Teams should use visual controls to facilitate more
meaningful discussions in huddles and review meetings. The content of these visual centers will vary
depending on the scope of authority of the team and the specific improvement activity type. Typically the
conversations in these huddles and meetings are more strategic in nature and these teams often need a place
away from the Gemba, so it is common to create a Strategy Room in the location that these teams meet
regularly.
Figure F13 Sample Executive Team Strategy Room
Figure F14 Sample Initiative Team Strategy Room

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Purpose/Intent
Having a Strategy Room will enable the Executive Team and Initiative Teams to manage the performance and
improvement activities associated with Strategic Goals with a broader perspective. The teams will be able to
see performance trends, systemic problems, barriers to progress, and goals/initiatives needing more attention
or interventions with more transparency and frequency. It allows corrective actions to be taken in a quicker
fashion. This regular attention to performance will drive success. This system closes the gaps between the
improvement activities and strategic and operational goals. Leaders will know if their efforts are impacting the
success of the ministry.
While Strategy Rooms can take on many different designs, there are standard elements when it comes to
content. The visuals should be used to highlight the following information:
1. Link to Strategy – The Strategic Initiative(s) of focus should be explicit and there should be a
clear business case or reason for action
2. Target – Where should we be, what is the goal
3. Actual – Where are we, what is the current state of the performance, the status of the plan, the
actual progress, trends
4. Insights and Adjustments – Where did we vary from the plan, where have we not sustained
and why, what are we learning, how will we improve, what actions are required
5. Improvement Plan – What is the plan for this week, month, quarter, what impact do we
anticipate from the efforts, do we have the appropriate resources
Common information posted in Strategy Rooms:
 SI Matrix
 Metrics Tracker
 Trend Charts for Critical Few Goals
 Schedule of Improvement Activities
 A3s – Future, Planned, In progress
 Action Plans
 Project Charters
 Value Stream Maps – Current and Target State
 Huddle/Rounding Schedules or Standard Work
 Countermeasures
Location and Roles and Responsibilities
Ideally the Strategy Room is a permanent location where these teams regularly meet to discuss performance
and improvement activities. Owners of specific measures/initiatives should have some responsibility in
updating the information in the center and reporting on progress.
Risks
Process v. Results – Since these Visual Centers are more strategic in nature the measures are often not
reported very frequently and the processes that drive performance may not be explicit. The teams should
intentionally find ways to make the information gathered more frequently in rounds explicit in the visual
controls. The team should also take special care to keep the improvement plan as explicit as possible, as some
efforts may be hard to get back on track if there is a deviation from the plan.

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Pontificating v. Go and See – It is easy when meeting with a group of leaders away from the Gemba to make
assumptions and about the actual situation and make decisions for course correction without gathering the
facts through observation, discussion with people who are closer to the work, etc. Teams should be careful to
remember that the Strategy Room is not the Gemba.
Complicated Visuals – The visuals should be as explicit and simple to interpret as possible. There may be
more detailed information available in a folder, etc. but the visuals should give information at a glance. The
teams will go through many iterations of visual tools in the Strategy Center as they try to find the right balance
of simplicity and meaningfulness.
Performance Tracking Centers
Visual Control Center for Executive Team and Initiative Teams (see Figure F15)
There are many different type of visual controls for managing a work area. For the purposes of strategic
implementation the focus in this playbook will be on tools that will facilitate improvement focused on the
goals of the work area and the ministry as a whole. The primary tool for this is a Performance Tracking
Center.
Figure F15
3.2 Defining the Driver Metric at the Point of Impact
Once the “vital few” performance measures have been identified in the strategic implementation process they
are cascaded to the point of impact. At the point of impact the measures are translated to measures that are
understandable, meaningful, and actionable at that level. These metrics should reflect drivers that can be
tracked and reacted to timely:
 Good = respond to weekly
 Better = respond to daily
 Best = respond to in real time, hourly, by instance, etc.
Purpose/Intent
Having a visual management system and standard daily process for reviewing and acting on the performance
information with staff will enable a team to know if they are “winning” or “losing” in real time and take action
immediately. It allows problems to be addressed closer to the time that they happen, and ultimately prevent
them from happening again in the future. This daily attention to performance will drive success. This system
closes the gaps between the daily work and strategic and operational goals. Employees at the point of impact
will understand how the work they do aligns to the success of the ministry.

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While Performance Tracking Centers can take on many different designs, there are standard elements when it
comes to content. The standard elements are:
Balanced – Driver metrics across balanced dimensions of performance are represented. Categories
may be a mix of “runs the business” operational metrics and “improve the business” strategic
metrics. Common categories include quality, service, stewardship, employee engagement, human
development, growth, and community/mission
Performance Tracking (Fig F16) – A graphical
representation of driver metrics that align to
organizational goals and are meaningful to staff
and actionable on a daily basis. The graphic should
show trending and visualize the goal vs. actual
performance. Anyone who walks into the area
should be able to see at a glance if the performance
goal is being met.
Problem Tracking (Fig F17) – Whenever the goal
is not met the question “why” should be asked.
The problems affecting performance should be
captured and trended, to allow for daily continuous
improvement where there is an opportunity to
examine the actual failure and gain a data /fact
based understanding of top contributors affecting
performance. If top contributors to grow despite
daily problem solving efforts, then there may be a
need for a more detailed problem solving activity
or project.
Figure F17
Figure F16

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Response Tracking (Fig F18) - Potential root causes and potential solutions should be identified by
the team who do the work and solutions should be trialed, tracked, and then standardized if proven
effective in eliminating the problem. This focuses the team on finding root cause, eliminating
repeat concerns, and taking immediate action.
Location and Roles and Responsibilities
Performance Tracking Centers should be located on or adjacent to the work area and maintained throughout
the shift by employees and Team Leaders/Supervisors in the work area. This enables daily review of
performance in tiered huddles and Gemba walks. As a part of their daily/weekly/monthly standard work,
leaders should review the performance centers at different frequencies depending on their level in the
leadership team.
Data Collection and Employee Engagement
Whenever possible the employees doing the work should populate the data in real time, so these graphics are
often done by hand. This often means that the work area will need to create a data collection plan to know
how to capture the data in the real time, as opposed to waiting for a computer generated report that delays
response time. Staff involvement helps drive improvement and changes behavior. As in a sports game, the
employees can see their score and make adjustments if they are losing. When the employees are a part of
creating the information they are more engaged in the meaning of the graphics and their role in helping the
area achieve success.
No Good = computer generated monthly lagging report
Good = Team Leader/Supervisor a couple of times per day
Better = Team Leader/supervisor in real time
Best = Staff in real time
Problem Possible Causes Solution / Corrective Action
Date of
occurrence
Person
responsible
for solution
Expected
completion
date
Actual
completion
date
COUNTERMEASURES
Figure F18

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Risks
Exposure -There are risks to being so transparent about performance. First, leaders and employees
will feel very exposed. Without a non-punitive environment that truly rewards the recognition of
problems not just good results, the data may be skewed, not collected at all, or worse, employees will
create difficult workarounds to ensure they meet goals by any means necessary. The “green is good”
concept must be replaced with “problems are treasures” that should be surfaced. This takes
reinforcement not necessarily of good or bad performance, but of relentless pursuit to understand
why there may be poor performance and a willingness to test solutions.
Results v. Process Focus - It is important to be mindful that the visual center is not the Gemba. So,
to keep an equal focus on the results and process it is important to visit the board often, but also to
observe the processes that drive performance.
Management Control v. Wallpaper – If the visual center is not engaged both in a tactile and
facilitative way it runs the risk of becoming another communication board that nobody reads. Only
this time it is also a board where employees were asked to write down their problems and then
ignored. Leaders must have the discipline to use the boards to facilitate discussion and problem
solving and commit to follow up on improvement action items.

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SECTION 4: Daily Reviews
4.1 Performance Huddles and Rounds
A daily focus on performance and continuous improvement is accomplished through huddles and layered
leadership rounds at the visual centers. Performance Huddles will happen at the Executive, Initiative Team,
and Front Line levels at different intervals. At the beginning of the “No Meeting Zone” all 3 levels will huddle
around their visual controls. Then the Executives, Directors, and Initiative Teams will round at the
Performance Centers at the Point of Impact during the remaining time. Huddles will be used as a way to
review performance, problems, and countermeasures at all levels of the organization. Problems and potential
solutions will be prioritized and assigned at these huddles. When possible problem solving may happen in
these huddles. Problems that require more focus can be addressed in separate Problem Solving Circles used by
management and staff to go deeper into root causes and possible solutions to be experimented. Tiered
Rounding and Problem Solving Circles will be a venue for coaching, modeling, and rewarding expected
behaviors. Huddles and Rounding create transparency and around performance and problems, engage
management and staff in voicing the problems they are experiencing, and empower them to solve them.
 Brevity – Huddles should be under 15 minutes in duration
 Posture – All members of huddles should be standing
 Tone – Non-punitive, Coaching focused more on gaining a deep understanding of the problems
affecting performance and countermeasures than the actual performance itself, 2- way
communication (weighted toward lower tier giving more information than receiving)
 Location – In the work area at the visual center
 Agenda – should be clear and visually posted
The huddles should consist of the following parts:
 Assessment based on visual controls
 Assignment of countermeasures or improvements
 Accountability for having completed assignments on time
 Reward and Recognition for performance and problem solving efforts
The standard work for the huddles reinforces a mental model: Performance – Problems – Responses (See
Figure F19)
Figure F19
Performance
• Are you meeting the goal?
• Are you improving?
• Is the performance stable?
Problems
• What are the top contributors that are negatively affecting performance?
Responses
• What countermeasures have you taken or are you going to take?
• PDCA?
• Employee suggestions, manager decision, root causes and countermeasures, A3/A4
• Can trigger an event, project, or just do it
Managing for Daily Improvement

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4.2 Tier 4 Executive Team or Initiative Team Huddles and Rounds with Director
Executive Team and Initiative Team Huddles
The Executive Team and Initiative Teams should huddle at least once a week. The huddles are meant for
oversight of performance goals and improvement activities to ensure Ministry goals are met. The Huddles
should take place in the Strategy Rooms and should be followed by Rounding with Directors in the Gemba.
These huddles have the same focus on performance, problems, and results as do the huddles at the
Performance Centers in the Gemba. The difference is the level of detail. The scope of the conversation in
these huddles is to understand performance of the Strategy Implementation process almost more so than the
performance of the processes that drives the Strategic Goals. The standard topics for the Executive and
Initiative teams should include:
Are we working on the right stuff?
 Review the planning board and 3 month rolling horizon of improvement activities
 Make decisions for performance improvement efforts by selecting and de-selecting initiatives
for improvement and allocating resources
 Are we moving the right metrics?
 Review the tracker
 Review the results of recent improvement efforts – are they linked and driving the right
metrics?
 Review the 3 month horizon for linkage to metrics
 Are we developing our people? What are they learning?
 Review notes and observations from Performance Rounds
 Review the monthly Action Plan/A3/Project Plan:
 Are we delivering results?
Executive Team and Initiative Team Rounds
The Executive should round with Director at least one time a week and visit each of their work areas at least
one time a month. To achieve this it is likely that the Executive may need to plan time each day in the Gemba.
Refer to the Sample Executive Schedule for Performance Rounds in Figure F20. As with the other
huddles the intent is for Executive to reinforce the mental model and coach the Director to be a problem solver
and a coach and developer of the people who they support. The Core Team of an improvement effort may
need to round weekly in a work area to assess implementation and sustainment of past improvement efforts,
manage change for those affected, and assess and adjust their planned improvement efforts. See Figure F21
Sample Executive/Core Team Gemba Walk Standard Work

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Figure F21
Sample Executive/Core Team Gemba Walk Standard Work
Gemba Walk – 4th
Tier
Executive or Core Team
Attendance: Gemba Leader and Core Team including Executive Sponsor, Facilitator, Process Owner, and other key players
Frequency: Core Team to Gemba Walk 1 X week for 3 weeks post RIE
EMT to Gemba Walk 1 X a month
# Work Steps Who Time
Team to meet at the visual tracking center EMT Member or Core Team
and Gemba Leader
1 Tracking Center Gemba Leader 5 min
a Performance - Graph
a. What is the metric?
b. What is the goal?
c. Have we achieved the goal?
d. Are we improving?
e. Is performance consistent?
b Top Contributors – Bar Chart
What are the top contributors affecting
performance?
c Responses - Countermeasures Summary Sheet
a. What has been done?
b. What is going to be done?
c. Effectiveness of measures?
2 Questions from Team/EMT
3 Gemba Walk – Go and See Core Team or EMT Member
and Gemba Leader
20
min
a Observe Process in action:
-Visual Management Tools
-6S/Workplace Organization
-Problems Obvious
-Standard Work – right number of people, in sequence,
at planned rate, safely and with 100% quality
b Solicit Feedback:
a. How do you do this work?
b. How do you know you are doing this correctly?
c. How do you know the outcome is free of defects?
d. What do you do if you have a problem?
e. What challenges are you facing with the new process?
f. Is there anything we can do to help the process move forward?
c Thank staff for their efforts, reward success and
recognize opportunities
4 Debrief EMT or Core Team, Gemba
Leaders, Process Owners,
10
min
Discuss:
a. What did we see?
b. What did we learn?
c. What do we want to change?
d. When do we want to make change?
e. How can we support the area?
f. How can we help them develop further?
Go to an area away from the
front line staff
- Remember the Tracking Center is not the Gemba: 5 Minutes checking the scoreboard and the rest of the time watching the game
- EMT and Core Team should provide direction, remove barriers, and coach
- Focus should be on implementation/sustainment, measurement, training, and management issues, being careful not to solve process problems for the

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4.3 Tier 3 Director Rounds with Manager
The Director should round in at least one work area daily and try to hit each of their work areas once a week.
Typically a Director is responsible for multiple Managers and work areas, so while they are rounding daily the
work area should see the Director huddling one time a week. Refer to Figure F22 Sample Director Schedule
for Performance Rounds. The intent is for the Director to coach, remove, barriers, and reward and recognize
performance and problem solving. Most follow up actions from this huddle should focus more on developing
the people in the lower tiers as problem solving not necessarily on the solutions themselves. See Figure F23
Sample Tier 2 and Tier 3 Agenda.
Figure F22

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Figure F23
Sample Tier 2 and Tier 3 Agenda
Performance Huddles – 2nd
and 3rd
Tiers
Attendance: Manager and Supervisor or Director and Manager (Facilitator/Sensei as
needed to coach and facilitate problem solving tools)
Frequency: 1 Time a Day
Go to area where work is performed Director and Manager or
Manager and Supervisor
(Facilitator/Sensei)
1 Observe Process Director/Manager 15
min
Is standard work being followed?
 Right number of people
 Timely – at planned rate
 Safely
 Defect Free
Coaching
 How do you do this work? (written procedures/std
work)
 How do you know you are doing this work correctly?
(control/inspection points)
 How do you know the outcome is free of defects?
(control charts)
 What do you do if you have a problem? (procedures
to follow in case of abnormalities)
2 Meet at Tracking Center Director and Manager or
Manager and Supervisor
10
minAre people trained to the standard work?
Are we tracking performance and problems?
Are we achieving the goal? Consistent? Improving?
Are problems identified?
Are corrective actions planned?
Are corrective actions executed? on and are they
successful?
Are corrective actions successfully solving the
problems?
3 Coach Director/Manager 5 min
How can I help you remove any roadblocks?
What do you need from me?
Assist with problem solving and corrective actions
4 Celebrate Director/Manager
Reward successes
Recognize opportunities
-Huddles should take no longer than 30 minutes
-Remember what gets attention gets improved

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4.4 Tier 2 Manager Rounds with Supervisor/Team Leader
The Manager should round with the Supervisor/Team Leader in each of their work areas at least one time per
day. Since a Manager may lead over multiple areas/shifts they may have more than one a day. The intent is
for the Manager to reinforce the mental model and the focus on understanding performance and testing
solutions. The focus should be less on the details of the actual solution and more on the development of the
Supervisor/Team Leader as a problem solver. See Figure F24 Sample Tier 2 and Tier 3 Agenda.
4.5 Tier 1 Supervisor/Team Leader Huddles With Staff
Ideally problems are solved at the lowest level possible, so it is important to begin huddles with staff so that
they have the opportunity to understand problems affecting performance and plan/take countermeasures
before higher level leadership rounds and reviews. Supervisor/Team Leader should huddle with the staff one
time per shift to facilitate a discussion to communicate performance and request information on problems and
ideas for potential solutions. See Figure X.X for Sample Agenda for the Tier 1Staff Performance Huddle
Figure F24
Sample Tier 1 Agenda
Performance Huddles – 1st
Tier
Attendance: Supervisor/Team Leader and Staff (Facilitator as needed to coach and
facilitate problem solving tools)
Frequency: 1 Time per Shift
Meet at the visual tracking center Supervisor/TL and Staff,
(Facilitator)
1 Standard Work Supervisor/Team Leader 5 min
Has the Team Leader held Daily Huddle and
addressed Process Improvement Topics for the
week?
Is all staff educated to the minimum level of
competency?
Have Kamishibai Audits been performed as
scheduled?
Document any corrective action needed and
implement immediately
Is data current and plotted correctly? Supervisor/Team Leader 5 min
2 Performance - Graph
How did we perform yesterday, or since last
huddle?
Are we achieving the goal?
3 Top Contributors – Bar Chart Supervisor/Team Leader
Are problems captured on the chart?
What problems are affecting our performance?
4 Responses - Countermeasures Summary Sheet Sup/TL?Facilitator - use
appropriate problem solving
tools – A4, 5 Whys, 7 Ways,
Fishbone, etc.
5 min
Involve the people doing the work
Pick one problem
Identify possible root causes
Identify possible solutions
5 Document - A4, Countermeasures Sheet, and Pareto
(Mark line to see if problems continue to grow after
countermeasure implemented)
6 Implement Experiments and track outcomes
-Huddles should take no longer than 10-15 minutes
-Counter Measures do not have to be perfect solutions – try something rather than let the problem
continue to grow
-Make a containment effort or implement an interim solution whenever necessary, but be sure to continue
to root cause problem solving

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SECTION 5: COACHING
5.1 Guiding Principles
When engaging employees at all levels of the organization in performance improvement it is important to
remember the foundational principles of continuous improvement and servant leadership that reflect our
values.
 Respect for People – Employees, Patients, and Community
 Non-Judgmental/Non-Blaming Behavior
 Problems are Treasures (Opportunities for Improvement)
 Process AND Results
 Total Systems Thinking (Enterprise)
Engage People
SJHS Value: Dignity of the person as an inherently valuable member of the human community and as a
unique expression of life.
 Regard the people doing the work as experts and allow the team to work through the problems
(Respect for People)
 Focus on the situation, issue, or behavior, not the person. Maintain the self-confidence and self-
esteem of others (Non-judgmental, Non-blaming)
 Take initiative to make things better. Have a bias for action. Try it don’t debate. (Problems are
Treasures)
 Go and See – watch the processes not just the reports (Process AND Results)
 Be consistent in communication by linking what associates do and how it impacts the Patients,
Doctors, Departments goals which thereby impact the Organization’s goals (Total Systems
Thinking)
5.2 Coaching Cycle for Improvement
To create a culture of problem solvers the people making improvements are asked to repetitively use A3
thinking pattern to create a habit. The role of the coach is to repeat a pattern of questioning that will support
and reinforce the behavior of problem solving. By repeating the same questions the person will learn the
pattern and practice it until it becomes subconscious. This coaching pattern should be used in huddles and
countermeasure review meetings.
 The Coaching Questions are:
 What is the target condition?
 What is the actual condition now?
 What obstacles are now preventing you from reaching the target condition? Which one are you
working on?
 What is your next step (experiment)? What do you expect?
 When can we go and see what we have learned from taking that next step?
Reflect after the experiments
 What was the last experiment?
 What happened?
 What did you learn?
Repeat the Coaching Cycle

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Follow-up
 Recognize when the person does follow through on Action Plan
 Document the conversation
 Recognize when the person does NOT follow through on Action Plan
 Determine next steps
 Document the appropriate step discipline, next Action plan and conversation
Reward and Recognition
 Look for and make specific positive acknowledgements from personal observations
 Recognize those employees who have been identified by leadership and peers for positive
contributions

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SECTION 6: A3 THINKING
6.1 OVERVIEW OF A3 THINKING
A3 is a name of a metric paper size similar to 11x17. A3 is a problem solving method developed my Toyota
based on the Plan, Do, Check Act Cycle also known as PDCA Cycle. When we refer to A3 thinking we are
referring to the scientific method that is built into the boxes of the St. Joseph Way A3. The boxes guide
teams though a simple and disciplined approach is solving problems.
Benefits to promoting A3 thinking:
1. It is organized in a logical progression that helps the team stay focused
2. It is structured in a disciplined fashion that assures that the root cause is uncovered before
moving on to a solution approach.
3. It makes problems visual and transparent.
4. The A3 tells the story.
5. It teaches a shared model for approaching problems so that everyone in the organization can
have a standard way of communicating
Key Points to Achieving A3 thinking:
1. Make the process as team based and as inclusive as possible.
2. Include someone from outside the process as “fresh eyes” whenever possible.
3. Work in team to write out the A3 (as opposed to sitting behind a desk at a computer)
4. Include pictures and drawing to inspire creativity
5. Work step-by-step to build consensus
6. Remember that A3 thinking can be applied at all levels and all types of activities

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6.2 Strategy A3 Overview
The Strategy A3 is a mechanism to translate strategy to action. It is developed from the north box of the top
level Strategy Implementation. The Strategy A3 uses a 6 box format (as opposed the standard 9 box A3
format) which focuses more the on the in-depth data gathering and analysis necessary for effective Strategy
Implementation.
Significant money and resources are often spent on a poorly developed business strategy and even the best
ideas and strategies are worthless unless executed effectively. Strategy creation should be a fundamentally
dynamic and creative process and the Strategy A3 provides the tool in which to successfully navigate this
process.

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BOX 1: Reason for Action
Start your Strategy A3 in Box 1 – Reason for Action. It is important to develop each box fully, one at a time.
The Executive Sponsor and Process Owner will complete this box prior to the event and will review it with the
Strategy A3 team once it has been identified and assembled.
Key Points for completing Box 1:
1. Ensure that there is a direct link to a
strategic initiative
2. Answer the question, “Is there a goal
or objective that we must deliver on?”
3. Document the business case in a
manner that will satisfy customers
and stakeholders
4. Clearly define the scope. What is in
scope, what is out of scope and why.
What is the duration? If it’s a process
what is the trigger and done? Be sure
that the scope big enough to be
“strategic” but small enough to be
actionable
Box 1 is complete when there is approval/consensus from both the Executive Sponsor and Process Owner
BOX 2: Initial State
The Executive Sponsor and Process Owner will gather information needed to complete Box 2. In this box,
you will analyze data to form a true picture of your current state.
1. Ensure that there is enough internal
data to properly assess your capability
to execute the strategy.
2. Answer the question, “Is there enough
external data to form fact based
decisions about the opportunity?”
3. Present that data in a manner so that it
tells the story.
4. Be sure that anyone reading the A3
can logically see how you’ve drawn
the respective conclusions
5. Conduct your analysis using tools
(SWOT, PEST, Pareto, Growth Map,
etc.) then analyze the inputs to create
the hypotheses on what to target and why
6. Try to truly understand the internal and external dynamics

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BOX 3: Analyze and Justify Future Activity
In Box 3, the team will use the conclusions drawn from the data analysis in Box 2 to answer key quesitons to
create and justify a target hypothesis and set evidence based breakthrough targets.
1. Use the tools of 4P (product,
pricing/costs, people,
promotion/marketing analysis), reverse
fishbone, internet research, stakeholder
interviews, impact matrix, and revenue
forecast to justify your target hypothesis
2. Identify key actions that are necessary to
support or achieve each breakthrough
3. Identify the enablers required for success
4. Be sure to prioritize and rank the
breakthroughs and key actions based
upon impact on your growth targets
5. Set evidence based breakthrough targets
6. Ask yourself the following questions:
7. Is it clear what segments you are going after, what you are doing, and what you hope to
achieve?
8. Are the time and resources requested consistent with the level of effort required?
9. Are the actions consistent with the current improvement methodology?
10. When the strategy is executed, will it deliver Box 1?
BOX 4: Breakthrough Targets
In Box 4, the team should deatil breakthrough milestones, in the order they need occur detailing what and how
much needs to be done by when. Additionally, the team should detail the amount of time required to achieve
each breakthough in order to level the workload.
1. List breakthrough milestones that must be achieved to
deliver on the strategy.
2. Define how much progress to the target would be truly
breakthrough. If it’s not a step change in performance
then it is not a breakthrough.
3. Be sure to detail when the targets need to be achieved
and who owns the action.
4. Be sure that actions or outcomes are specific enough
that we can measure the progress monthly in Box 5.
5. Ask the following questions:
6. Will the breakthroughs shift the business, service, or
service line paradigm?
7. Should the breakthroughs targets be process focused or
outcomes focused or a blend of both?
8. Are the breakthroughs specific enough to know what we are doing and what we expect to achieve?
9. Is there clear linkage between the breakthroughs and the expectations outlined in Box 1?

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BOX 5: Confirmed State
In Box 5, the team should detail planned and acutal metrics as well as any variances.
1. Use the following types of metrics
2. Health of process
3. Outcomes
4. Performance to plan
5. Metrics MUST relate to breakthroughs
6. Box 5 should be updated as prep prior to any
reviews.
7. Create a clear Bowler Chart or graphs with
trends to help focus efforts
8. Evaluate if the process or outcome measures
reflect the breakthrough necessary to achieve
the strategy.
BOX 6: Insights
It is critical to review and ask the question, “What’s working and what’s not?” In Box 6, the team should
detail the answers to this question caputuring insights, reflections, reactions and lessons learned.
1. When gathering insights be honest and truly reflect
so that you can make improvements.
2. Check to see if you are truly resolving issues or
just documenting them.
3. Ask the following questions:
4. Can the insights improve the process of the current
strategy?
5. Can the insights improve future strategy
development processes?
6. What other processes must be improved in order
for the strategy to be achieved?
7. Communicate answers to these questions to the EMT or Steering Committee as necessary.
8. Use insights at subsequent reviews. Always check the following:
9. What were the issues from the prior review?
10. What has happened since the last review and how effective has it been?
11. What response to issues was agreed to in the last review?
12. Based on the reflections and the last improvement cycle, what have we learned?
Ongoing Review of Strategy A3 Through Completion
The team should meeting regularly as confirmed state data gathered and completion plan actions are executed.
Progress needs to be reviewed monthly on the Strategy Implementation (Deployment) Action Plan and
reviewed at least quarterly with Executive Management Team or Board. During the meeting with the EMT or
Board, you will need to include a high level summary of progress and next steps.

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6.3 The Nine Boxes of A3 Thinking
Box 1: Reason for Action
This box should describe the “burning platform” or the chief
complaint. There are 3 things that should be called out in
Box 1.
1. Problem Statement. The problem statement should
include why there is a problem and address the chief
complaint.
2. Aim: Define what we looking to accomplish.
3. Scope: Specifically call out what is in scope and
what is out of scope.
Be sure NOT to include potential solutions! This will come
in Box 5.
Box 2: Initial State
This is where the current state is examined. In this box, you should break down the problem as it is occurring
now. This can be done in words, numbers or pictures. Do not list what is “not happening now” or what you
need to happen.
When filling out Box 2, be sure to include the following:
1. What the current process is
2. Where the problem is happening
3. The scale or size of the problem
Use St. Joseph Way tools to process mapping, spaghetti
diagram, pareto chart and other statistical tools to help
identify problem and determine what measures you will use
to determine success. Be sure to use a balance of metrics to
ensure that improvements in one area do not create new
problems.
Box 3: Target State
Describe the attributes of what we want the future state to be.
Create a vision for an improved process without problems.
Use words, numbers and pictures to describe the future state
and set a target for the improvement measures. Typically,
you should aim to set goals that “half the bad” or “double the
good”. For example, “reduce waiting time by 50%” or
“increase quality by 50%”.

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Box 4: Gap Analysis
This is where we analysis root cause by looking at what is missing between current state and future state.
Do this by:
1. Exploring all of the gaps and potential causes
2. Narrow these to the top contributors
3. Find the root causes of the top contributors.
Common tools used in this box are brainstorming, fishbone
diagram, affinity diagram and five whys.
Box 5: Solution Approach
In box 5, you will finally start to move toward solutions by
forming a hypothesis for each root cause. Each hypothesis
will be validated or proven untrue though the experiments in
the next steps.
Box 6: Rapid Experiments
In this step, experiments are planned for each hypothesis,
qualitative and quantitative expected outcomes are defined
before each experiment and assessed and changed after each
trial. It is important to run multiple trials of each experiment
to get the best results for each.

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Box 7: Completion Plan
In this box, you will list that tasks or to-do’s with clear
owners and due dates. This should be reviewed and
updated regularly.
Box 8: Confirmed State
The new standardized process should be described and the
process and performance measures should be reviewed,
updated and recorded through sustainment. Measures from
boxes 2 and 3 are carried over to this box.
Box 9: Insights
This is the final step of the A3. Here you will capture key
learning and reflections. Capture what went well, what did
not and what actions were taken. Be sure to also list what
helped and what hindered. This should be regularly updated
through sustainment in order to tell the whole story.

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