Greg Jacobson

Continuous improvement for a digital workplace

16 Aug 2020   |   Leadership Technology

Greg Jacobson

Continuous improvement for a digital workplace

16 Aug 2020   |   Leadership Technology

Greg Jacobson is an ER doctor on the side.

That is, he is a co-founder and the CEO of KaiNexus full time, but still manages to get in a couple of ER shifts a month.

But his main passion is now continuous improvement. KaiNexus helps healthcare (and other) organizations find ways to get better all the time. However, as companies step further into the digital workplace, even improvement has to find a way to take advantage of the new world.

On this call is also former guest Mark Graban, who helped us understand the importance of metrics in a digital world.

How should digital workplaces approach continuous improvement?

Greg and Mark agreed that anytime you approach continuous improvement, it’s best to start small. Pick one site, one department, one team. Teach them the fundamentals and let them experiment. This is even possible (and even more important) with distributed teams.

What’s the connection between continuous improvement and the technology you use?

The mindset of continuous improvement and the technology grow hand in hand. You can do continuous improvement with some cards up on a bulletin board, but you will hit a wall eventually. As your understanding of continuous improvement expands on your digital team, you’ll also need to improve the digital tools you use to support it.

Greg said there are three prongs to continuous improvement:

  • Leadership behaviors
  • Improvement methodology
  • Technology

All of these need to be in line to make your efforts a success.

How has KaiNexus transitioned to a digital workplace?

KaiNexus has used 1 ream of paper in 10 years, and there’s always been an element of remote work involved. However, going completely digital has presented some new challenges.

The hardest part about the transition to digital work is the loss of the small group conversation and checking in randomly with people.

They used to have a biannual meeting in Austin where everyone gets together. They tried a virtual one in July and it was ok, but definitely fell flat.

On the call, Mark and Greg discussed how they could have added more asynchronous options and spent more time focused on the debrief and discussion rather than the presentations. Greg also mentioned that even a small amount of latency discourages people from speaking exactly when they want to.

Might this be the end of polished presentations?


Daniel Pink – Drive

James Clear – Atomic Habits + podcast


Today we have a special guest. We have a group call going on. We have Mark Graban and Greg Jacobson. Hi, guys. How are you, both you?



Doing well. Thanks, Neil.



Great to be here.



Mark’s an old friend of the show. He’s been on before. He has a big Lean proponent. If you know Lean, you know Mark. He’s been out there doing a lot of things. So Mark, introduce everyone to Greg and how you guys are connected.



Sure. So, my career in a nutshell was that an engineer with an MBA, who thought he was going to do continuous improvement and leadership roles and manufacturing companies for my whole career. In 2005, I had a chance opportunity to pivot into healthcare, applying Lean and continuous improvement ideas in hospitals and healthcare organizations. And then in 2011, there was another chance introduction. So it was actually a mutual connection of ours, reached out to me and said, hey, there’s this guy. He’s a doctor who’s really into continuous improvement. He’s got a software company. He’s Greg Jacobson. You should meet up with him. And I did. And a couple months later, we started working together and nine years later, it’s been exciting to see how Greg, as a cofounder and CEO, has really grown KaiNexus. So I’m thrilled to still be a part of that effort.



Greg, why don’t you introduce yourself, too?



Yeah, thank you so much for the introduction, Mark. So my name is Greg Jacobson. I’m an ER doctor. finished my residency in ’04, got really interested in continuous improvement, was introduced to Masaaki Imai’s book “Kaizen.” If anyone wants a good introduction to the topic, I think it’s a great place to start. It was the first time someone had conceptualized that improvement could be a science, it could have a discipline, and really could be applied to any system. And so one thing led to another, I realized pretty quickly, there was no way to do improvement work in a methodologic manner without there being a digital platform. It just never crossed my mind to use pen and paper and bulletin boards. And so it started out with email and realize that email and email folders was a complete cluster, I’ll just say, and then I thought, oh, well, software can’t be that difficult to develop. And so that began the journey of developing KaiNexus and doing a prototype in an emergency department for about three, four years. And then in 2011 we had to form the company and raise money. And as Mark said, we had our first customer. And so it’s all been history since. We initially were all in healthcare. And as we’ve iterated over the years, we had, I would say, a minor pivot. And now we are helping companies in pretty much every industry you can think of.



So give us an example about how a company, you can start with a healthcare company, but how do they actually use KaiNexus to do continuous improvement?



We have people that come to us, either maybe 10% or 15% of them are saying, we would like to do continuous improvement work, and we don’t know how to start. And we realize that we want to get maybe 1000 or 5000 people doing this type of work. And so they immediately realize that there’s a need for technology to help support that. And then we have maybe 85% or 90% of people that come to us and and show us their work documents and their Excel spreadsheets and their emails and their bulletin boards, and it’s just an organizational nightmare. Really the system is just so hard to keep up with that they’re not able to do things like do improvement work. And so initially, if you would have asked the question, I would have just said, oh, it’s all bottom up. You go to the frontline, I’ll use ER as an example. You go to the doctors, you go to the nurses, you go to the transport folks, you go to the janitorial people, you go to the registration people and you say, what’s frustrating you about your workplace? What can we do to make it easier? And you implement low cost, low risk change. And so, in a world without an electronic system to do that, you would write that on pen and paper, but in a world of KaiNexus, you pull out your phone, you put in your opportunity for improvement, if you will, and we can call it whatever you want, your idea. Let’s just use non Lean terms. You have an idea on how to take 10 seconds or 15 seconds off of a process or just make something simpler, or just make it really much nicer for a staff member or a patient. You put it in the system, and then it gets routed to your manager. And then a little project can get built up around that. Sometimes you can configure it however you want. And then other organizations are coming to us to do larger scale Kaizen events or value stream maps or more of the traditional larger top down Lean efforts. And then KPI visualization. And so we have organizations doing and putting all their KPIs in KaiNexus and then linking it to their improvement work. And then finally, we have a lot of organizations that are doing strategy deployment work, or Hoshin Kanri. And so, they’re putting all of the information related to that also in KaiNexus. That’s maybe a two minute overview of how people are using KaiNexus.



It’s great. I think you’ve done a good job of demonstrating the big gulf that exists between what most of us think of. I got to get this better. So here are a bunch of documents I wrote up. Maybe I got to the level of making a spreadsheet. We send some emails around. But then we look across that chasm and see, oh, my goodness, there’s all this really complicated software that I need to install to get things going. So Mark, I’ll throw this question to you. If somebody’s standing on that side of that canyon and says, I don’t know, like, what’s the first thing? Greg used the word system, like, how does the leader build that foundational system that can actually take advantage of something like continuous improvement?



In a lot of cases, it starts with the first step, building a culture of continuous improvement in an organization and really having that become the default. It takes time. It’s not like flipping a light switch and a leader giving one magical speech and saying, okay, poof, we’re now a continuous improvement culture. So I’ve seen organizations be really successful by starting small. If we want to transform the entire organization, let’s start with one site. Let’s start with one department. Let’s start with one team. Practice the behaviors and from leaders and the methodologies and improve it out and refine it and continuously improve your own approach to continuous improvement, and then branch out from there. So if that initial pilot project with continuous improvement has gone well, that creates pull in the rest of the organization, where others are hearing great things of how continuous improvement has benefited employees and customers and leaders. And then you can help spread that through the organization. I think that approach of starting small, starting modest, and then building on early successes is more successful than a big bang company wide launch.



So I’m hearing from you that really it’s implementing that culture and that mindset first before the technology comes in.



I think it can go hand in hand. I mean, Greg probably has some examples of people using KaiNexus to really help get that started, even if they were starting in part of the organization. I think the behaviors and the technology can go hand in hand.



Let’s bring Greg in for this. Talk about that, as technology advances, then the culture advances and they push each other in that. What’s been your experience in it?



Probably the first place to start to think about this is to understand, what do we mean about when we use the term culture. So I love Seth Godin’s definition of culture, which is people like us do things like this. And so there’s this recognition that you can’t go by culture. You can’t just all sit around and say, this is culture. This is the definition of our culture. But culture really is a manifestation of all the collective behaviors that an organization is doing. So to me, there’s really three prongs to developing a culture of continuous improvement, which when we say that we mean, an organization that allows every person, and not only that allows, but almost expects every person to help improve the organization every day. What one point and one prong is, is leadership behaviors. Another prong is improvement methodology. And then the final prong is a technology. And the leadership behaviors, we can talk about that. That could probably occupy multiple podcasts. Improving methodology, if we’re talking about trying to get the vast majority of people engaged in this, it has to be simple and it has to be very accessible. And then technology, a lot of people say, well, wait, hold on. This technology thing, I don’t really see why we need that. I’d like for people to think for a second that paper didn’t exist 500 years ago in the way it exists today. So even paper and pen is a technology. So anything that you’re going to do that’s not an oral history is technology. And so I would ask you, if you’re going to train for a marathon, should you just go get any pair of shoes out of the closet? Or what is probably the best that you get the right shoes out of the closet and get some running shoes. So does that mean you need to get custom fitted and built running shoes that cost $25,000 or something because they’re going to be unique for you? No, probably just a regular, reasonable pair of running shoes will do the trick. And so I think Mark’s absolutely right, that this isn’t a situation where, the guidance you would need some kind of technology to do it. So I do think that they go hand in hand but just purchasing the technology or implementing the technology is going to fail unless there is a methodology and unless there are behaviors around it as well.



Let’s bring everything into our core topic of the digital workplace. A lot of companies where we’re now over six months nearly into this pandemic, a lot of companies had to make that first jump from what we call level one to level two digital workplace where the office is no longer the center, they’re trying to figure out how to use these digital tools. How do you feel like, when it comes to a topic like continuous improvement, if a company was already had continuous improvement as part of its culture, and something that they cared about, and now everyone’s distributed, they’re working in remote environments, how can they bridge that gap? Mark, why don’t you take this one for us?



The first things that come to mind these days are healthcare organizations that I’ve worked with, and these organizations have been thrown into completely new ways of working where a lot of the healthcare delivery is still by nature physical work delivered in person in an emergency room or a clinic or what have you. A lot of the process improvement people have been told, and so it’s a somewhat insulting phrase, you’re non essential personnel. And the organization doesn’t really literally mean that when they have a culture of continuous improvement. But my point is the internal process improvement coaches and facilitators have been thrust into this new mode of where they have to work from home. And they are now trying to support and work with and do projects and develop new workflows with people who are in the physical workplace, but they’re remote. So, people are using video conferencing technologies. In the Lean methodology, we talk a lot about getting out of your office or the conference room and going out into the real workplace. People are using FaceTime video calls to do that in ways, as long as they can do so without jeopardizing patient privacy or confidentiality. So, people are having to adapt to new ways of work. And that includes I think KaiNexus customers that are continuing to use the same methodology, the same technology, the same leadership behaviors, but now they’re layering on top of that, this additional virtualization or distance to what they’re doing. When that foundation has been strong, I think people have been able to build upon that. I’ve talked to people have said because of their work on building this culture of continuous improvement over the last two years, they would say, hey, we’re not at the destination yet. But we’ve made great strides in the culture that their organizations have been more adaptive, for one, to the new demands and fears and risks of COVID-19, but secondly, being more adaptable to increase virtualization.



Greg, what’s been your experience as companies have made a big shift to digital workplaces? What are some of the unique opportunities they’ve seen, both some of your clients and even in your own company?



From our perspective, the shift from going to in-person to completely virtual is made on almost in a 10-minute conversation with the other cofounder. It was not a difficult decision to make. And the transition actually wasn’t difficult. But I will tell you some of the mistakes that we made as we were doing this, but I’ll also mention one of the reasons why it wasn’t difficult was because KaiNexus at its core started as a virtual company. Initially when Matt Paliulis, my cofounder, and I started KaiNexus, it was a side hustle. We worked on it on nights and weekends and almost for several years we worked on it on nights and weekends and we were in different states. And for periods of time we were in different countries. I was an ER doc, and for about two and a half years, I was traveling and doing travel work. And we’ve always had offices in both Dallas and Austin. And so there’s been a virtual component that’s always existed. And while I actually love paper for lots of things, KaiNexus, we probably have one ream of paper in 10 years that is kept, maybe even less than that. So we’re essentially a paperless company already. But I hate being black and white about things. So there’s a lot I like about paper. I still see patients and write on paper while I’m engaging with someone. I think writing on a computer is much more non engaging with the patient. So, it was an easy transition. But from that perspective, also, our product is digital. So what was easier from that side of things, but some of the things that I think were lost was really the empathy that’s created by all of the small little conversations that are randomly happening. Meetings with more than about three or four people are much more difficult from a collaborative standpoint and a virtual video conference platform. And so that’s something to be mindful of when we’re having larger meetings or work sessions with people. And then the other thing that I think, until last week, I just made a mistake on was, I kept my normal cadence of one on ones where you have a culture at KaiNexus of doing one on ones with people where we just take half an hour or just check in with each other, and sometimes you might not talk about business or KaiNexus for 30 minutes, or sometimes you might take up a lot of time, but making sure you’re making an effort to chat with people in a relaxed manner. I think that’s super important. That is something to keep in mind as you’re transitioning. So I don’t know if that’s exactly what you had in mind for an answer. But those were some of the things that I was thinking about as making the statement, oh, we had a really easy time to do. It doesn’t mean we didn’t make mistakes, and doesn’t mean we didn’t have to change things up. But overall, it’s been extremely enlightening that can certainly not say that we’re less productive, and in many cases, we’re more productive going into this framework.



Mark, what would you add to that in terms of how you’ve seen other customers and clients really say, wow, there’s opportunities here we didn’t even realize that we had in front of us?



That’s a good question. Thinking of the frameworks of these levels of virtual work, I think people are still, maybe just now getting things back to being as good as they had been before. And this next phase, I think, as people realize, this is not a temporary normal, this is a new normal is going to lead to more creativity around being more effective. So, I’ll use an example, and Greg, forgive me, I’m not trying to pick on you, but thinking about like our KaiNexus biannual team meetings with people in different locations, as Greg mentioned, it was really important to get together twice a year to be in Austin, to be all together in the same room. Not just for the work in the room, but for the social time and you really spend most of those couple waking days together. So now with the pandemic, we did that biannual meeting in July as a virtual meeting. And that was still very much, it wasn’t full days, but it was like half days, because I think we realize we have our limits of how much time we can spend on a web meeting. But it was still very much that same format of we got together virtually. It was hard to do as much social stuff, but we were able to conduct business. So the challenge, I’m just going to throw it out there. Greg, I was meaning to talk to you about this. So again, apologize for bringing it up on a podcast.



You might as well do it in front of lots of people.



Thinking ahead, Greg’s fine on transparency. I know he’s not trying to kick me through the computer. Thinking about our next meeting in January. How do we do this in a more asynchronous way? Can people record updates about their part of the company and put those up as private YouTube videos and we tell everyone, hey, by next Tuesday, you need to carve out time at your own convenience to watch all of the present at you updates, and then maybe have a shorter time where we’re all together and we can do virtual team building and discussions and things that are better when they can only be done synchronously.



Yeah, I love that. What’s interesting, you’re reminding me, Mark, we almost always do a debrief after the annual and mid annual meeting. And I think we just forgot to do that, because we weren’t all together and it wasn’t on the calendar. So I think that’s a great idea. I think we could utilize smaller groups of people when you have 20, 25 people on a single meeting, and even though these video conferences are pretty exceptional, there is some latency there. And so people feel like they’re talking over people, even if it’s just a 0.25 seconds of latency. It can’t completely replicate human speech. And so I think, increasing the number of breakout sessions we do getting it down to three or four people increasing. I mean, really, when you’re talking about with regard to the presentation is I don’t want to say the presentation is the boring part. But the presentation, like you said, is the part that you can consume whenever you want to consume it, that the real magic in that kind of an environment is going to happen when you’re discussing the data that was presented. So yeah, I love that. And you can pick on me anytime you want, Mark.



And I’m hearing the same thing from a lot of other people. A few things. One is that sometimes the best conversations you have that really shape the business plan and the strategy happen after the meeting is over, you’re walking out, maybe you’re catching a meal before your flight out, or you’re walking to the parking lot or you’re with somebody else, and that’s when like those really deep conversations and bonding happen. But we’re set up right now that after the Zoom call is done, you just hang up and you’re done. And you don’t get that connection. And I think, and this is what we call that level four digital workplaces, when time becomes extremely important, because you recognize you can’t spend eight hours on a video call, it’s just not going to be good for you. So, time becomes extremely important. You have to use that time well. So you figure out, well, let’s just let everybody watch the videos first, and then use the time that we have to do the really important stuff, which is while there’s some kind of socialization or some intense discussion about things, really reserved the time that you have for those important things. I like where you guys are going with that.



And I think it’d be important to make sure that you tell people, this isn’t a polished presentation. I mean, I don’t want you to spend time editing. Who cares about any of that? Just go through the presentation. That’s not the important part. The important part is just get the information across. It’ll help facilitate future conversation. I don’t know if we’re going to get into the levels, but I find all these levels super fascinating. So I don’t know if that’s a future question, Neil.



We can get into it more later. We’ll do a follow-up session, because it really is, like you start to realize where everyone is in this. And I think that was something that hit me as I was putting things out together. Everyone thought, okay, yeah, we went through remote work, therefore, we’re all in the future of work. It’s like, no, we’re not. We’re just at home. That’s just like one little step that’s there. So to recognize that there are companies out there that have been doing this for a long time, and have paved that way and shown what the real value is of remote work, of distributed teams, and how they’re overcoming that and they haven’t figured out all the problems, but there’s a lot of things they can get to. Before I leave you guys, I want you to just answer one more question. You guys are both experts in behavior changes because that’s the essence of what continuous improvement is. If you’re talking to CEOs out there who are thinking, yeah, I want to get my team to do some adaptation to adjust to this digital lifestyle, what’s one thing you can leave them with in terms of making these small behavioral changes as they look to make those improvements?



I think continuous improvement and having that culture and growing that culture requires some level of trust. I don’t know how you measure or gauge trust in your organization. There’s probably a spectrum or a bell curve. There’s some minimal level of trust where people realize if the company does well, I also do well. I think that has to be there. People need to feel safe in speaking up and pointing out problems, that they’re not going to be blamed or punished for pointing out opportunities for improvement. You’re making us look bad. And then there’s got to be that trust that as we improve in the organization that people are not going to lose their jobs as a result. So I think that’s one of the really important things to put in place. I want to give a shout out to, he’s another ER doc and a CEO, like Greg, but Dr. Eric Dickson is CEO of UMass Memorial health system. So they’ve been on this journey for maybe seven years of working to create a culture of continuous improvement. Eric leads by example. He’s the cheerleader. He’s the chief culture change person as CEO. And even during the pandemic here, I recently had the chance to interview him about this. They were seeing a 40% reduction in revenue almost immediately, because of the pandemic. And unlike a lot of healthcare systems, they did not furlough anybody, and they did not lay anybody off. Is it because they had money to burn? No, they realized that that was the best decision for the long-term of the organization. And so Eric got his board’s approval. That was a choice that they made to invest in their people in terms of training and continuous improvement and redeploying them in other areas. And I’ll tell you, the loyalty that I would predict that action to engender is going to lead to even more continuous improvement going forward.



That’s great. That trust has to be there. And for you, Greg, what do you feel like is the essence of if you’re willing to make that behavioral change, what do they need to focus on?



So I’m going to answer in a couple different ways. One, Mark stole the one word I wanted to use, which is trust. So I’m going to insert another word in its place, not in its place, in addition to, which is the act of being really intentional about listening. I think one of the most important things that leaders can do is listen but not listen in a passive way, really listen in an active way. And so when someone tells you something, to repeat it back to them. So what I hear you saying, Mark, is that if leaders have trust in the organization, etc, etc, etc. And so I think that active listening creates a huge amount of connection with people. And so that is a behavior or attribute that leaders really need to do well. I want to put a plug in for two books that I think are really important, and neither of them are continuous improvement or Lean books. One is Daniel Pink’s “Drive.” I think if you don’t have a fundamental understanding of what motivates people today, then you’re going to be lost. So that is a book that if you haven’t read, you should immediately read. And then James Clear’s “Atomic Habits” is the second one because really what we’re talking about is developing habits. Now we’re talking about organizational habits, but organizational habits are manifestations of individual habits. And so the situation that a leader needs to provide is one, the initial spark, the lighting the fire, but then stoking the fire and the follow-up. So the follow-up isn’t holding people accountable. You could certainly try to do that. But I like when Mark talks about that holding people accountable seems like you’re making people in trouble almost for not doing that. So let’s just use a term follow-up. So we’re going to not only develop behaviors that allow people to engage in improvement every day, but then I’m going to follow up as I’m going and touching base and doing my one on ones with all my VPs or divisional leaders or whoever the organization is laid out. But you’re following up. Hey, Mark, how is the idea management system? How is your continuous improvement system? How is KaiNexus? Hopefully, it’s always KaiNexus, but how are those things going and do that in a collaborative way. And I think those are probably some of the biggest things that a leader not only can do, but it’s going to have to do in order to really move the needle on continuous improvement.



Awesome points. I love the listening aspect, because especially right now, there’s no way that one person knows the right thing to do all the time. It’s just impossible. The way the world is, there is no way that one person can do that. So you have to be listening to people because there’s so much new information you’ve never experienced before. And they’re all experiencing it differently. So that’s very important. And I love the two books you mentioned, when we talk about what leadership looks like in that level three, four, five, it’s all about understanding humans. You got to know what drives human, understanding those things at a deep level, you can’t get away with just assuming that you know these things. So that’s really important. And if you guys have any connections to James Clear, please let me know so I can get him on the show because I’m a big fan of his work. Always tweeting his stuff out. Thanks a lot for being on the show, guys. KaiNexus is the product we’ve been talking about. But what other websites, other things that we can be checking you guys out with?



Well, I primarily am going to be found on KaiNexus. We have been really honored to be working with Mark for almost a decade now. So Mark has his pokers in a lot of fires. Mark, you want to add to that?



Yeah, so I can be found online. I’m obnoxiously easy to find online. I can be found is my blog and I have podcasts there. So those are the main places people can find me.



Excellent. Well, thanks, guys for taking your time with us. I really appreciate this conversation. It’s good to see how continuous improvement overlaps with the digital workplace and how people can do that. So thanks a lot for everything you do.



Thank you, Neil.



Thank you very much.


Greg graduated from Washington University in St Louis in 1997 with a BS in Biology. He attended Baylor College of Medicine from 1997 to 2001. From 2001 to 2004, he completed a residency in Emergency Medicine at Vanderbilt University Medical Center where he then stayed on as faculty.

Starting in 2004, it was his observation and research of operational inefficiencies and unrealized continuous improvement opportunities that resulted in the founding of KaiNexus.

Jacobson is co-author of Kaizen: A Method of Process Improvement in the Emergency Department, published in the journal Academic Emergency Medicine.

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