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Dr. Scott Kelley (Host): Hello. My name is Scott Kelly, and I'm the Director of Mission Integration at Loyola University Medical Center. I'm here with Tad Gomez, who is the President of Loyola University Medical Center. Welcome Tad.

Tad Gomez, RPh, MS, FASHP (Guest): Thank you, Scott.

Host: Could you tell us a little bit your professional journey and your current responsibilities?

Tad: Sure. I am a pharmacist by training. came up through the ranks of pharmacy as a Pharmacy Manager and then Pharmacy Director and then, I guess I kind of reached a point in my career where I decided I wanted to venture outside of pharmacy. And so, I, accepted additional responsibilities in imaging and lab, respiratory, rehab services.

in, really I guess, my responsibilities kind of grew from there. I have lived in five different states throughout my professional career, including now, currently in Illinois. guess my current responsibilities of President, I guess, the easiest way to say it is I'm responsible for everything that happens within the four walls of the hospital.

Host: Thinking about the last year, what a, what a time to be a president? lot of challenges and, in our conversations in the past, I've really been struck by sort of the development of two things. One is, our response to COVID, but also our, journey as a lean organization, following the principles of lean management. And this is an area that you have a lot of experience in. Can you give us a brief overview of what lean management is and why it's important for improving performance?

Tad: So, lean management, particularly in healthcare is, modeled like all lean management systems, it's modeled after the production system, which was of course, founded by the, Toyota Auto group in Japan. And at its essence, really what lean is about is, eliminating waste and defects. obviously, you know, manufacturing automobiles is much different than what we do in the hospital. But there are a lot of similarities and certainly, there are things that we try to do, that can provide a better patient experience. So, focusing on our patients, which are our customers, but also trying to eliminate waste.

And obviously we want to minimize, or really our goal is zero safety defects, which is how we term a defect within the hospitals, we're trying to eliminate all, safety related events, whether they happen to our patients or their families, or our own colleagues here at the hospital. So, at a high level. That's really what, lean management is all about in my mind, at least.

Host: So, thinking about our, core value of stewardship, don't know that waste is the first thing that comes to mind for people. Is there an example of how we reduce or eliminate waste and how that improves the patient experience?

Tad: Yeah. So, thinking about it, just from the patient's perspective, you waste comes in a lot of different forms. It's not just, something that is, let's say, end product that doesn't meet, specifications. That's, certainly one type of waste because if something done and isn't produced in the correct way, then obviously it's a defect that by its definition is waste, but looking at it from, a patient experience perspective and thinking about, just how patients move through our hospital. Let's say that someone arrives to our emergency department, via ambulance. And you think about all the steps it takes to provide care to that patient, whether they're admitted to the hospital or not.

And typically, our patients that come to us via ambulance usually do get admitted to the hospital. So, you think about then all the steps it takes to transition them from the emergency department hospital bed, whether that be in an intensive care unit or in, regular, medical or surgical bed. There are a lot of handoffs. There are a lot of processes that go into each one of those steps and thinking about how can we make that as efficient for being able to provide that, care of the patient while at the same time doing all the things that we have to   from an administrative perspective.

So that we, do things like, you know, capture the patient's insurance, if they have insurance, making sure that we have all the correct contact information, making sure that that we've entered it in, into our electronic health record correctly. And is there a double check for that? All of those things are, a process and, thinking about, okay, is a particular step in a particular process value added for the patients? A lot of times, some of those steps that we have to do, particularly the administrative steps, don't add value from a patient's perspective, they add value from our perspective, as a business.

But really, if you think about it from the patient's perspective, at the end of the day, they're seeking care. They want care delivered and they want it delivered in the safest manner as possible. So, if we break down very large processes into smaller processes, we can, create what are called value stream maps that we can really take a look at a very complex break it down into its individual steps, and then make a decision about whether this is value added or not, who it's value added for. And is it even necessary or can it be done in, a way that's different or does it have to be done in the same order that we currently have those processes for lack of a better term mapped out in. So, hope that answered your question.

Host: Yeah. could you paint a little bit of a picture of what operational life was like in hospitals before that focus on, waste reduction and value stream mapping. And what was life like before this?

Tad: Yeah. So, I would say for the most part and not just hospitals, but I would healthcare in general, was really more focused, not necessarily focused on the patient, but more focused on the provider or the, site of care. And by provider, I mean, is focused on what's easiest for the physician or what's, easiest for the nurse practitioner that's providing the care. do we make things as easy for them as possible and not necessarily thinking about, the patient's experience or what's easiest for the patients. So, some examples I think of are, I think everyone probably has the, experience of going to a physician's office.

first thing you do is you write your name down on a, registration form that you've, arrived. probably the first thing that, the receptionist would do would hand you a clipboard with a bunch of pieces of paper on it. And, maybe if you, that was your first visit to that provider or that physician, that might've been necessary for them to gather all the pertinent information needed to create your medical record. But if this is your fifth or sixth visit to that same provider, and every time you're filling out the same paperwork, what's being done with that paperwork? Is anybody even looking at that paperwork that you've, now created? and really a lot of instances, what that would turn into is, well, no, we don't really look at it, but it gives the patient something to do while they're waiting for me. And that is a perfect example of a, provider, or a physician centric model I had a mentor that once said, waiting is not a function of healthcare, but we've made it one. it was, trying to get us to be more focused on things from a patient's perspective.

From a patient care perspective and less from what's easiest for us versus, when a patient arrives, why can't we take them straight back into the exam room? Why do we have to have them sitting here? Why couldn't we take that square footage that costs money just like exam rooms do and instead of creating this large waiting room, why don't we create five or six more exam rooms instead? So, then patients don't have to sit and wait in a waiting room.

Host: And so you think about the paperwork example or time and multiply that towards all of the points in the patient care process. And that adds up to significant sums of time and time is money. do you think are the biggest indicators, if, if you are operating by lean and in a very efficient operation, what are the key indicators that tell you that you're doing a good job?

Tad: Well, I think there's several. I think the first thing is that the team providing the care has to have clear metrics for, what they're trying to achieve in a certain amount of time lean, we call it tack time. So, how, much time does each individual step in a process? How much time should it take? if we know the tack time for every process, including the interaction the physician and that's, the one variable that depending on the complexity of the patient or the complexity of the visit can, change from person to person. But most of the steps that go up into that point should be trackable, should be measurable and there should be a standard for that.

So, if you add up all of those steps, then, you know, how long does it patient to, basically complete their office visit and say it's, 25 minutes. Okay. Well, you know, that each patient takes 25 minutes from start to end, and we have X amount of exam rooms, and we know that our operating hours are, Y then we should be able to determine how many patients, what is our capacity for that day to be able to get basically today's work done today.

Meaning we're able to see every patient on the schedule within our allotted time. so that's really what I would focus on. And then as a, forecasting, if you will, way of saying, are we being successful at our throughput metrics? But another metric would be, you know, what are the patient satisfaction or patient experience scores?

are they satisfied with their experience? Are they having their questions answered or do they feel like they're being rushed through the system? So, it's a balance between, what work we need to get done in that particular day versus providing it in a way that is a good experience for the patient as well. So, those would be the two that I would focus on.

Host: And it sounds like it's, so it's not just a question of the stewardship of our resources but also reverence for patients because sitting in a waiting room for an excessive amount of time, people have better things to do with their lives than to sit in a process.

Tad: Exactly. everyone's time is worth something. Correct. I could be at work making X amount per hour, but also, I mean, it doesn't matter whether you have a job or even if you don't have a job or you're retired, the time you spend waiting, there's an opportunity cost to that as well. Cause you could be doing something else that could be more profitable if you will. So, any time that is spent doing something that, you're giving up the opportunity to do something else, then yeah, in my mind, that's, wasted time.

Host: There's another term from lean philosophy that is really intriguing to me. And that's the gemba. So, there's a lot of Japanese terminology in lean, but the idea that there is a space where value is created, the gemba. What is this in healthcare and why is it important for leaders to go there? So you hear this phrase go to the gemba. What does that mean?

Tad: another healthcare organization I worked in, they found that, using the, Japanese terms like Gemba, necessarily resonate with their teams. And so they, they, did a little play on it. And instead of going to gemba, they called, it go and see.

basically what Gemba is, is where the work is done, you know, so go to where the work is done. And this is particularly important for, leaders and managers in healthcare, because the work is done wherever there is care being provided or wherever there are processes being done that allows for care to be provided.

So, I'll take, for example, a sterile processing area. They're not seeing patients there, but they are processing surgical instruments, sterilizing surgical instruments to be used in the operating arena or operating suite. you can imagine a manager over that area, isn't going to be able to, connect with his team or her team and see the work that's actually being done. See the, obstacles that are being faced by their team or the barriers that are keeping their team from being efficient by going to the gonna get the most value by, being in that sterile processing area and observing their teams and listening to their teams when they have ideas about how to, simplify a process or how to make a process more efficient or how to eliminate waste. But also in, working together to solve problems.

Host: It sounds like curiosity is a big part of lean, And

Tad: Yeah. Curiosity is, absolutely critical. And there's also sought it, not just about curiosity, but, inquiring in a way, that is genuine. that really does elicit connecting with frontline staff, managers have to do that in a way that is, that is authentic. it's that authentic curiosity that then drives, big part of lean management, which is okay, well, what's the problem we're trying to solve? Okay. Where are we trying to get to? Where are we now? And what is, holding us back from getting from A, to B and being able to engage with staff with authentic curiosity. another term I like to use is, with humble inquiry, that I think is, really important.

Host: And that seems to connect. When we talk about it's reverence for the people who are doing the work, it's reverence for the space where the work is being done, it's reverence for the process. it seems that that, curiosity, and inquiry is one way that, you know, the value of, reverence seems to be, in our organizational culture.

Tad: Right. I couldn't agree more because reverence, is basically, it's acknowledging that every person has worth. And that is a huge tenet of lean as well, which is really interesting because you think about the Catholic value that we have around reverence, but is so ingrained within lean as well. And it's, honoring, not only the work of people by honoring people and showing respect for people. That is a huge tenet of lean as well. And I think they all fit so well, all of these kind of major tenets within lean, fits so well within our, own values that's what resonates with me.

Host: I want to talk a little bit about our daily management system. And then there's another principle that sort of strikes me as connected with how, we do this work. Could you tell us a little bit about the daily management system? What is it? Why is it important? How does it work?

Tad: our daily management system is really a set of, tiered huddles, occur, just as it would lead you to believe, daily. And it's a way for, colleagues to come together and to communicate in a way that is, structured, yet free flowing enough that it, creates the space to have open and honest communication. It allows the sharing of ideas, the sharing of, issues or, barriers or hurdles that may exist. it's really, probably a better way to think of it these are daily readiness huddles. So, we're trying to do a quick check-in with our various work units or teams.

And we want to create a space for two way communication so that if we have that's occurring, that's going to be a barrier for us to complete the work that we need to do today, during the day, during our normal workday, then we need to raise that up. it's for both communication for visibility, but also if there's an issue that can't be solved by that team, then we have the next tier up, which may be management level that they can then discuss those issues, possibly discuss solutions.

of goes up from there. So, it starts at a staff level. And then however, many layers of management, if you will, until you reach that executive level, that's how many tiers would be, in your, what we call daily stacked huddles or our daily management system or our daily readiness huddle system. but the other things it does, it allows for communication of follow up on issues that have been raised previously. It allows some structured time for the team to focus on what metrics they're trying to work on to improve. And then it also gives an opportunity to make announcements. So, large announcements across the organization.

most importantly, it also gives a time for recognition for a job well done, or someone going above and beyond or someone pitching in extra. And that can be peer to peer. That can be from manager to staff level, it could be from, the next level up of management to, frontline management, so it creates a really nice space to be able to, recognize,

Tad Gomez, RPh, MS, FASHP (Guest): and

Tad: really highlight good work that's being done in a particular area or on a particular team or within an entire organization.

Host: And what strikes me about this philosophy and the way it's implemented in the workplace is how similar it is to a principle in Catholic social thought called subsidiarity. Subsidiarity was really, principle of social philosophy. So, it was trying to understand the relationship between individuals and the state and in between those two entities, there are lots of intermediary institutions, they call it, which are neighborhood associations. You know, all of the organizations that make up civic and social life. So, there's, I want to read a little excerpt and get your thoughts on it, of how it connects to lean. So, this is from, Catholic Social Thought, just as it is gravely wrong to take from individuals what they can accomplish by their own initiative and industry and give it to the community; so also, is it an injustice at the same time, a grave evil and disturbance of right order to assign to a greater and higher association, what lesser and subordinate organizations can do. And it seems that isn't this exactly what lean is trying to do. Or the in the daily manager system is have local problems addressed locally.

Tad: Absolutely. The highest performing organizations typically have the problem solved at the lowest possible level of the organization. Meaning, those frontline staff not only have, a say in what they're doing, but in the way that it's done and they are empowered by their leaders, make changes that can improve organizational performance.

So, this is the, paradox of lean management or it's a paradox of management just overall, because if you think about how most people make their way up the ladder, if you will, is by having particular knowledge or technical skill.

Tad Gomez, RPh, MS, FASHP (Guest): And

Tad: The higher you get up in the organization, the less reliance there is on a particular, specific set of knowledge or technical skill and it's, more about, working with your teams to, bring that out. in a traditional model, people get promoted based on proficiency, knowledge and performance, and that they know how to solve the problems and that they have the answers for problems, but the further you get up and management, the further you get away from the gemba or get away from the work, you no longer possess that knowledge, because you're not doing the work on a day-to-day basis. So, you have to rely more on your teams in a lean model versus in a traditional model, it's bring your problems to me. I'm your manager. I'll solve them. So, we flip that on its head and say, no, the best answers come from the frontline staff and the managers need to listen to what the staff is saying, and they need to help the staff implement those solutions, remove barriers so that those solutions can be implemented. So, at the end of the day, we're able to provide care in a safer, higher quality manner and that one that's free from, any kind of defect.

Host: Confronts kind of a caricature that, maybe people have of, of their mind, of what it means to be a hospital president, for example, they imagine, you're sitting in this office with like a NASA dashboard and you've got all these knobs and levers. And if you just twist the right one, magically, some problem will be solved at a local level. And it, it seems like lean just kind of blows that whole concept up.

Tad: Yeah, it does. And, I wish it were that easy, because it's, not, I rely on, my teams, my senior leadership team to, escalate issues and, and give me visibility to what's going on. But at the end of the day, they usually know what the best solution is. And the key is then for them to work with their teams and to filter that down throughout the organization. Now, before we can do all that, we all have to agree on, what is our true north and what are our priorities in terms of what we're trying to, not just accomplish, but also improve.

So, once we have alignment on that and we can all agree, or wouldn't say all agree, but we have consensus around, yes, these are our priorities. These are the things that are going to take us you from A to B, or A to Z in some cases. then it's all about, having that, authentic curiosity and humble inquiry as a leader, to draw those solutions out of your teams, because the strength is in the team, not in the leader, because I've never seen a leader be successful because of what they've done individually. It's always about how they have enabled and encouraged and assisted their team by removing barriers or, whatever the case is, and that allows success to occur.

Host: So, I want to circle back. we started our conversation just kind of noting these parallel tracks. our lean journey as we talk about it, also coincided with addressing challenges of a pandemic. Do you think that our lean journey helped us address those unforeseen challenges that were, surprises that no one could really anticipate?

Tad: And, I'm glad you, mentioned cause lean, it certainly is a journey and we are still at our, in my opinion, at our infancy of this journey. But I do think it helped. I think, we had some basic structures set up like our, daily management system or our daily readiness huddles. I think what that allowed, was we had open lines of communications that didn't necessarily exist before. And it helped particularly at the beginning when we were dealing with so many unknowns. And it seemed like there was a new, issue or a new problem, coming up, not just daily, but sometimes, hour to hour, minute to minute, there'd be a new, problem we needed to solve.

if nothing else, it allowed for visibility of what are the issues. And it created a system that we could have, people that were accountable for either working on a problem themselves, but usually with a team of folks, but we had point people and we're able to keep up with issue resolution in a real time basis do it in a way that was transparent and clear and visible, throughout the organization. that helped. I, think if we didn't have that system, we would have struggled, to say we didn't have our challenges and we didn't have our struggles, but I think it would have made it exponentially worse, honestly. if nothing else, the structure set forth, with our, daily management system gave us a way to at least approach the work. And, have transparent and open communication as well as accountability and responsibility for issue resolution.

Host: So, we've, talked about lean journey and the value that it brings to the organization, how it's aligned with our values and our commitment. Is there any final thoughts that you have for other people maybe earlier in their lean journey? what advice or what, wisdom would you share?

Tad: guess the one piece of wisdom I would share is that, like anything lean is not a panacea. it's not the, solution to all problems. but it structure and it's a process and it's a set of ideals that fully aligned with our values. The thing that makes it so difficult is you have to be relentless in reinforcing on a daily basis, that, this is the system, or this is the process that we're going to use to solve problems. So, this isn't a new way of doing things or this isn't a way of doing things that's separate from how we operate. This is just how we operate. This is how the work is getting done. And I think from a leadership perspective, you have to be relentless in your pursuit and your reinforcement that this is not on top of what we're doing. This isn't in addition to, this is how we do the work.

Host: Thank you for sharing your, insights, your experience, and your reflections Tad. It's been a remarkable journey over the last year, and very grateful for your leadership.

Tad: Well, thank you very much, Scott. I appreciate your leadership as well.