When a group of us from KaiNexus attended the Lean Healthcare Transformation Summit in June, one of our favorite presentations was given by Cinnamon Dixon of the Cleveland Clinic. Through her talk (and a fun exercise), she explained and illustrated how powerful the "Daily Tiered Huddles" are as a part of their approach to Lean.

We asked Cinnamon to share some of their approach and we recorded it as a podcast. You can listen or read the full transcript below. Thanks to Cinnamon and Cleveland Clinic for being so open in sharing their approach!! Scroll down to see the transcript after the embedded player...

Transcript:

Mark Graban: Hi, this is Mark Graban from KaiNexus. I want to welcome you to our podcast series. Today we have a conversation with Cinnamon Dixon, the director of continuous improvement at the Cleveland Clinic. She has over 15 years of experience in organizational effectiveness and continuous improvement. Cinnamon started her career at the Cleveland Clinic as an organizational effectiveness consultant. In that role, she led the development of teams and leaders.

Her work included leading system-wide initiatives, such as the implementation of the employee engagement survey, which focuses on how to create and sustain an engaged culture. She was also instrumental in developing and facilitating the Cleveland Clinic experience, which was an interactive exploration for over 50,000 caregivers on how each person contributes to the mission and values of the organization.

During this time, her curiosity for continuous improvement grew. She shifted her focus toward creating and sustaining systems that support the great behaviors that we want to see in our leaders and teams. This led her to join the continuous improvement team.

In her current role, she leads a dedicated group of continuous improvement specialists who execute projects, programs, and apply the Lean methodology as they work to advance the foundation for a continuous improvement culture enterprise-wide.

Cinnamon is also an adjunct professor for Tri-C Corporate College in Cleveland, Ohio. There, she teaches a variety of courses centered on organizational effectiveness and continuous improvement. Cinnamon earned her MA in Diversity Management Psychology at Cleveland State University, with an emphasis on leadership development, group processes, and adult learning. Now, here's our conversation.

Cinnamon: My name is Cinnamon Dixon, and I'm the Director of Continuous Improvement here at the Cleveland Clinic for our main campus central team.

My background is actually industrial psychology. I have a bachelor's and master's in psychology with a focus in industrial organizational psychology. My love and passion is around studying how we think and behave in the workplace.

Mark: When did you first get introduced to continuous improvement? Was it under the banner of Lean? Everyone always has a different path into this, I've found.

Cinnamon: I think I do have kind of a unique path. I've been with the Clinic for about 12 years. I first started out as an organizational effectiveness consultant. I love my work, and my work was truly around leadership and team development and running large-scale projects across the enterprise.

Along the way, one of the things that always stood out to me is there's only so much the leader in a team can do. It was actually a Deming quote that steered me in the direction of continuous improvement.

Eighty-five percent of the reasons for failure are deficiencies in the systems and process rather than the employee. The role of management is to change the process rather than badgering individuals to do better.

- W. Edwards Deming

I would see that come up over and over again, and say to myself, "This isn't the leader" or "This isn't the employee. There's something more to this. Let's take a look at what are the systems and processes that are really keeping the team from being at their best."

It was around that same time that our continuous improvement team and department at the clinic was forming. They started a couple of years before I started at the clinic, so it was fairly new. It then that I joined the continuous improvement department. I do have a background in Lean Six Sigma as well, but we really are on the Lean journey here at the clinic.

Mark: You mentioned one of my favorite people, Dr. Deming. I chuckle sometimes about how he often gets labeled as a statistician, but he's always said psychology is the most important thing for managers to understand. What can we learn about psychology that would be helpful for people whose background is say engineering or nursing or business? Are there some key lessons that you keep coming back to?

Cinnamon: Yes, it comes up all the time. The number one tip that I always give is, first look at yourself and start with yourself. What would cause YOU to change? What would cause you to do something differently? How do you respond to things? If you understand yourself better, that will help you understand others better. That's my number one tip - to start with yourself.

Mark: That's great advice. I've always found that it really helps to have a continuous improvement team with a mix of different backgrounds, professions, and educations. How important would you say that is - that mix and diversity of backgrounds?

Cinnamon: We've definitely found the benefit of having a very diverse team here. I've been with the Clinic for 12 years and with the continuous improvement department for eight, and in that time frame, I've seen the ebbs and flows of us hiring one type of skill set. We've always just gone right back to, "No, let's truly open up and understand what else would help bring value to our team." Now, we have a huge mix of team members. We have a team with MBAs and engineering degrees, myself with psychology, you name it. We do have a wide variety on the team who bring such rich experience to continuous improvement. We appreciate the diversity.

The Cleveland Clinic Improvement Model

Mark: Let's drill a little bit deeper into the The Cleveland Clinic Improvement Model. We're going to spend most of the time here talking about tiered huddles. We'll link to this file in the blog post for the episode.

Mark: How would you describe the Cleveland Clinic Improvement Model at a high level?

Cinnamon: Our Cleveland Clinic Improvement Model, or what we call the CCIM, is our roadmap for how we achieve our goals. This document was put together by multiple disciplines across the enterprise coming together to say, "What matters most for us, and how can we achieve our goals?"

There are four systems that make up the CCIM:

1. Organizational alignment: identifying and communicating what matters most.
   
   
2. Visual management system: managing what matters most.
   
   
3. Problem-solving: improving what matters most.
   
   
4. Standardization: sustaining what matters most (often one of the most difficult parts of improvement).

Those four systems make up the improvement model, and in the model, there's a role for everyone.

There's a role for senior leaders and what's expected of them. Let's just say that for our senior leader, they're working through problem-solving. What does that mean for them? Also, there's a role for managers. For managers, for example, if they're looking at organizational alignment, what's their part of that? What do they have to do to bring that to life?

Then there is a role for all caregivers across the system. We have that broken out, and then we have tools that we recommend our caregivers use. You'll hear me say the word "caregivers" frequently, because we think of everyone, all of our employees, as caregivers, so you'll hear me say that throughout this entire podcast.

Mark: When I've had a chance to visit Cleveland Clinic, that's one thing that stands out -- the idea that everybody is a caregiver. One of the other things that I think really stands out is another great foundation for Lean, is the patients-first philosophy. Can you talk a little bit about how the CCIM aligns and supports that philosophy that's been there at Cleveland Clinic for a while?

Cinnamon: Our patients are wholeheartedly at the center of every single thing we do. When it comes to improvement work, the number one question we ask is always starting out with how does this affect the patient or with the patient in mind and making sure that in every way that we are giving the best possible care.

We like to personalize things. We oftentimes state it at the Clinic, too. If this was your mother or your father or your niece, nephew and then your family member or friend, how would you want them to be treated? What kind of care would you want provided to them? At the heart of every single thing we do, we always have our patient first.

Tiered Huddles

Mark: The second pillar in the model is visual management. Down in the tool section, it says you use tiered huddles to identify, improve, and share issues. Before we get to some of the behaviors at the different levels, can you talk a little bit about maybe what are the tiered huddles and how did that develop there at Cleveland Clinic?

Cinnamon: Sure. The tiered huddles are our way of getting daily insight into our performance. One of our mantras here is every caregiver capable, expected, and empowered to make improvement every day. We do believe that that is achievable, and our daily huddles help us to bring that to life.

With the tiered huddles, every day we're taking a look at what's important to us, what matters to us most, how are we doing with that, are we making improvements, what barriers or hurdles do we need to have removed, and who can help with that.

Our tiered huddles help us solve all of those things together on an every-single-day basis. That's a quick five-second glimpse of the tiered huddles.

Mark: Before we dig a little bit deeper into that, I see behaviors here in the model. All caregivers should huddle often. Even managers, talks about fostering team participations.

Can you talk maybe a little bit about that dynamic? Try to help paint a picture of, let's say, the front-line level huddle. That's where the tiered huddles start each day. Right?

Cinnamon: Right. Let me just say this. When we started our tiered huddle probably about a year and a half -- almost two years ago now -- we had huddles in place. I think when I talk to different caregivers and different people from different organizations, I always hear, "Yes. Well, we have a huddle." We had a huddle before we started our tiered huddles. We had different things in place across the system, but they weren't together. We didn't act as one where we are a culture, a systems approach to our huddles and understanding our enterprise as a whole as opposed to a unit maybe doing something on their own.

When it comes to what we're calling our frontline huddles, we take a look at what are those standard behaviors, what's the standard agenda, and what are the standard tools that we want to use to communicate with each other every single day.

Standardizing the Huddles

It's all the way from our tier one through our tier six. We have six tiers of huddles here at the Clinic, and we're talking about the same things, each and every single one of those levels of the huddles.

On the agenda, we have our metrics. Then we have other things that we talk about as well, but what are the quality and safety items that we want to make sure that we're talking about? What do we have in terms of patient and caregiver experience?

In terms of things like the falls or reducing serious infections or whatever that may be, we have our standard agenda that we have. We also have standard tools that we use. All caregivers are expected to use our same agenda.

We also have what we call our action log. For example, I would say before the tiered huddles, one common thing that I always heard in different workshops or working with different teams in different avenues, we always hear the term accountability.

I always, always ask and probe for what does that mean for you. Our tiered huddles have been another way to bring the accountability piece to life. One of the ways we do that is by using our daily action log.

As caregivers are bringing up issues and items to discuss, we are jotting down and writing down. That's part of the standard behaviors. What is it that is the issue, who brought it up, who's responsible for helping to resolve this, and when do we expect this to be resolved by, and truly what's your next step?

That's written down so that when we have a huddle the next day, we're able to follow up and see if these items have been resolved. I want to say that this has brought a whole another level of accountability and actions to our daily experience that we truly didn't have before.

Mark: Before we talk a little bit more about following up on items, how long are those huddles typically? Is that real consistent across different areas?

Cinnamon: Yes, it's consistent. One of the things that we really, really want to make sure is in place is these huddles are 15 minutes or less. Anything more than that truly ends up being a staff meeting.

That's not the goal of this. We want to make sure our huddles are 15 minutes or less. I will say that when we get to about our tier five -- and I'm sure we'll talk about what are the different tiers and who does the different tiers -- our tier five is an enterprise look. That is longer, but even that huddle is 30 minutes and less, talking about the entire enterprise, all of our hospitals.

Mark: Actually, could you elaborate on that piece? Before we come back and talk about what happens in the huddles, the follow-up, and the connections in those tiers, could you give an example of when tier one starts and whatever unit or team you might choose and how that traces up to different levels within the organization?

Cinnamon: Sure, yes. Like I said before, we have six tiers here at the Clinic.

1. Tier One is all caregivers meeting with their managers.
   
   I will say that you can liken this to nursing changes shift huddles that have gone on forever. Our caregivers then meet with their managers, but before, the information would just stay right there in that unit. Now, we actually have the manager going up to tier two, where we have the managers meeting with their director.
   
   This is happening both on the nursing side and on operations side. All across the Clinic, we have these huddles going on -- tier one all the way up.
   
   
2. Tier Two is managers with directors.
   
   
3. Tier Three is the directors with their hospital leader.
   
   For example, we'll have our Nursing Directors meeting with their Chief Nursing Officer and our Operations Directors meeting with their Chief Operating Officer.
   
   
4. Tier four is the hospital executive team.
   
   All of the information that's just come up through nursing at a hospital and all of the information that's just come up through the operations side is discussed at the hospital executive team level, where you have the president, the CNO, and the COO coming together to talk about what's happening in their hospital.
   
   
5. Tier Five is that enterprise view, where we have all of our hospitals sharing their information.
   
   
6. Tier Six is where we bring in our executive team, with our CEO and our enterprise counsel leader. 

Mark: There are a number of hospitals in the Cleveland area. You've got hospitals in Florida. There are international hospitals. Is that right?

Cinnamon: Correct. We have 17 hospitals that are involved in our tiered huddles, in Ohio and Florida. We also have over 40 outpatient areas that are involved in the daily huddles as well. We are always continuously improving and adding different sites and locations. We hope to add in our international team very soon as well.

Learning from the Metrics

Mark: Back to starting with a frontline department team huddle. Issues are raised. Things are recorded on the action log. There's follow-up. On the CCIM document, it talks about caregivers' tracking progress. Here's a quick detour. I think this is such a great point, where it says, "Learn from the metrics and improve your work."

Unfortunately, too many organizations, metrics are just used as this "green is good, red is bad," and a lot of times that breaks down. Then people are saying, "I want the metric to be green." Once it hits green, they might stop learning and they might stop improving.

That's one thing I like about the model. Before we come back to the question I was going to ask, is there anything else that you want to add about that dynamic of learning from the metrics?

Cinnamon: I would say when we first started out huddles, it truly was around getting the mechanics down-pat. As we've now matured and really gotten comfortable with having these huddles on a daily basis, we've now shifted our focus to really probing and really having that experience of understanding what the issues are and what we can do about them.

What has come out of the tiered huddle experience is better leaders, better coaches, better caregivers who are really asking really good questions of each other to find out, "Why is this happening? What can we do to resolve this? Do we take this to another level where we need a A3 project, or is it something that we can just resolve in real time?"

We've been able to have these great discussions and solve a lot of issues and problems, whereas before, things would just come up regularly, and we didn't have a great venue to talk about these things on a daily basis where we see improvement happening.

What Do You Escalate?

Mark: What I hear you saying is that problems or ideas in a way get triaged or sorted -- what can be done locally whereas what needs to be escalated?

Cinnamon: Yes. Yes, yes, yes. We definitely have that going on, and we take a look at what are those things that can be handled at the local level versus asking for help at a different level of tiers.

I will say that part of the tiered huddles has just been a huge learning along the way. Starting out, I think our teams in different areas, they asked the question, "What should I roll up," or "Is this appropriate to roll up," or "Do I keep this to myself?" I would say that that's part of what each area, each team has to learn as they go along and truly mature in the process.

We erred on the side of "Share as much as you can to start out with," and we do have our standard template, our standard agenda that we're following, but really share the information.

We also learned along the way that it's helpful to just add in simple cues like "Here's an issue we're experiencing, but we're handling this at the local level," or "Here's an experience that we're having, and we need help, so please help us."

I would say the one thing that's really been huge for us is that when a team asks for help, it's all hands on deck, and they get the help. We have to be very careful that we didn't have people helping where truly the help wasn't necessarily called for at that time. Having some parameters and rules of engagement along the way really start to form as your tiered huddle grows.

Mark: Since you're going back to the document, that managers should be ensuring the process drives improvement and fostering team participation. For senior leaders, one of the things here is, removing obstacles.

Maybe you can elaborate, because what I think I heard you saying was something that's really common in other organizations -- this tendency to jump in and help, or maybe there's pressure that more senior leaders put on themselves to say, "I'm going to be a good servant leader. I'm going to jump in and do it for the staff."

What I hear you saying is within this model, the intent is pulling for help instead of having help pushed on you. Is that fair to say?

Cinnamon: Yes, that's very fair to say. That was part of our learning, too, because truly everyone had the best of intentions in mind, especially starting out where our teams were swarmed with help when they brought something up on the tiered huddle phone call.

We really want to give that opportunity. Now, we err more on the side of it's going to be resolved at the team level. It's just a matter of sharing for others what's happening within this unit or within this hospital.

Definitely just taking the time to understand what's needed, what's going on, has been really important for us as we're communicating with each other every day.

What becomes an A3 vs. a Just Do It?

Mark: It seems like there's another level of triage, and maybe you can help try to paint a picture. I've had the benefit of seeing this -- that in different areas, there are boards on the wall, or there are little cards and templates for relatively small issues or ideas. Then there are A3s that are visible and they're posted.

Could you talk a little bit about some of that sorting of...You mentioned A3s earlier. How does a team know or get guidance around, "Hmm. Does this need to be an A3 or is this something that's relatively small?"

Cinnamon: At our huddles, one of the things that we have in place is our problem-solving standard. When is something truly just a "just do it"? For our huddle rooms -- I call them our huddle rooms, because it's usually not at tier one or two.

It can be, but for sure, at our hospital level, one of the things that we encourage is having a Kaizen process, where we're looking at, if this is something that can be resolved in less than 48 hours, then we just jot it down and we come back to see if it's resolved.

If it's something that we know is going to take more time and effort than 48 hours, then that truly becomes part of our Kaizen process and we put it on a Kaizen card and we put it on our Kaizen board. It may become a A3 project for us.

We work through that by really just looking at the time frame and giving a quick judgment, because our tiered huddles, of course, are less than 15 minutes, so just from what someone's sharing and from what they know about what's happening, we can quickly just ask, "Do you think this is going to be resolved in 48 hours or less?"

Yes -- then we just jot it down. If no, then we're going to take you through the whole Kaizen process on that one.

Mark: Do you have a sense of even rough proportions, or maybe you have data on this -- what proportion of ideas get handled within the level one team versus how many get escalated upward?

Cinnamon: The majority of things that come up are truly handled at the local level. We have really three parameters around what's escalated in going up through the tiers

1. If you want to share something up the tier, please feel free to share up the tier.
   
   
2. If we know that there's going to be a risk to the patient or a risk to the organization, then that's something that we want to make sure we're escalating so that others are aware and we're problem-solving around that. If someone needs help, then that's something that we know we're escalating and looking to get help on for that team.
   
   
3. If we feel as though others will benefit from hearing what's happened in an area, then that's something that we want to share and escalate to the next tier level.

Those are really the three things around what we escalate. I would say, going back to the original question, that the majority of issues truly are handled at that local level.

A lot of the sharing that we do do, especially enterprise-wide, is more so of "Here's our 24-hour snapshot of what's happening at our different hospitals. Here's what we're doing about them, and here's where we need help." That's truly what the conversation looks like.

Increased Speed of Communication

Mark: I've heard other organizations that are also doing tiered huddles say is that it just really speeds up the flow of information (whether that's good or bad). 

You mentioned earlier that with that speed, leaders get a better sense of what's going on in the organization. Do you have any examples that you can share about where that speed of communication was beneficial?

Cinnamon: I want to comment on something you actually just said. With Lean, it's understanding that work. I would say that early on, literally within the first week, the two weeks that we rode out tiered huddles at the hospitals, I heard our presidents, our COOs saying, "You know what? I feel like I have such a great grasp of what's happening within my hospital. I now feel way more confident about knowing what are the issues, what's the good, what's the bad.

"If something is happening on a certain unit or if I need to go check in on a caregiver, I know in real time what's happening, versus hearing about something a month or two later." I would say that has been big for us here at the clinic, is our leaders are very confident in knowing what's happening within the walls of their hospital. That's been a big one for us.

Mark: Then the other question was about the advantages of that speed of communication. Are there any examples that you can share about where that's helpful?

Cinnamon: Yes. Every day, there's something coming up or something going on across the system. You'll be amazed when you hear the tiered huddle phone calls, when you hear from the enterprise view.

Some of the things that we hear are when there's something that's affecting one hospital, you feel like you're alone in this and that it's only affecting your hospital. I'll give one example where we had a laundry issue.

We thought it was just the one hospital having this issue, when it turned out it actually was the facility that serviced the number of our different sites. They had the same laundry issue going on.

We wouldn't have known that in that real-time besides the fact that we took it up through the tiers and we learned that it truly was a problem that they were having at their warehouse and that we have to go out to another vendor to get our laundry issue fixed.

That was just one of the examples of what happened a while ago that instantly we knew what was happening that we would've been scrambling the entire day to figure out why this was happening.

We have things like that go on every single day where we will have a shortage of supplies or a shortage in a pharmaceutical need, where there's a bigger shortage in what's happening at a hospital. It could be enterprise-wide, or it could even be a national emergency that we hear about through our tiered huddles.

I would say that one of the great things is that we now look to our huddles every day to get that real-time information of what's affecting us, what should we know about, so we can point our tiered huddles and our leaders to give us that on-time view of what can we expect.

Rolling Out Tiered Huddles

Mark: One other question. You mention these have been happening for 18 months. Can you talk a little bit about some of the design of the role out here where there are some initial pilots? What's the timeframe? From my customer standing and visits, I know that it wasn't all at once. There was an intentional approach, if you can talk about that for us.

Cinnamon: We didn't know until we tried, but one of the good things we had along the way was our continuous improvement theme. Our team partnered with every single hospital in our family health centers to help roll out their facility.

We did it on a pretty much one-by-one basis. We probably have a new hospital or a new FHC joining on a daily basis for a period of about three to four weeks, and that's how we did our rapid rollout.

It was a good team effort. Truly, we had huddles around the huddles, so what's working, what's not. What do we want to change? 

One of the big things we learned was to do batch changes, instead making changes one at a time as they came up. There's so many people involved in the huddles every day that if we change thing too regularly, we get frustrated. We adjusted the cadence of changes to only happen once a month versus once a week. That was very helpful.

Mark: The reason for batching up those changes is that just so there wasn't a constant stream of changes that it made more sense to say, "Here's a couple of changes," and experiment with that, going forward.

Cinnamon: Absolutely. I'll tell you, we had a little bit of change fatigue at first, going through this. It was a big change to start the tier whole. That was a huge change to clear out our mornings to make time for our huddles to happen every day. That was big for our leaders.

Then on top of that, to now say, "OK, instead of sharing your information this way, I want you to share this way," Or, "Instead of focusing on this metric, we're going to focus on that metric."

We had to stop all of the changes from happening all at once and then go to, "All right. You can expect this change in the next two weeks on this date to come about. Or if you have questions, then in the meanwhile, you can ask your continuous improvement person to get further clarification."

We learned along the way that we have to slow down in order to speed it up.

Mark: It's a classic Toyota advice. Sometimes, you need to slow down to go fast. Go slow to go fast.

Cinnamon: Yes.

Advice for Getting Started

Mark: Thank you, Cinnamon, for sharing not just about the huddles. I also appreciate hearing about the process of testing and improving the huddles, applying that continuous improvement mindset to these tools or who's supposed to help, that do help encourage and facilitate continuous improvement.

Are there any other final thought, any other advice that you would give for others? Let's say they want to get started with daily huddles. You've already shared a lot of great advice, but is there any other last tip that comes to mind?

Cinnamon: Yes. Thank you for having me as well. I appreciate it. I love talking about the tiered huddles, because it's been an amazing journey for us here at the Clinic. Some other thing that I would share in terms of advice or tips to get started is, first, starting out with understanding what matters most for your organization.

That's really important. What would tell you if you're winning or losing the day? Start out with just a few, not with a whole list of items that you're looking to gauge - but rather, what are those few things that will help you out in knowing that.

Then another thing is finding out how do you make it meaningful for every single level when we're talking about tiered huddles. This isn't about... it can very easily turn into an exercise for executive leaders.

We're getting this information through the huddles so that our executive leaders know what's going on. That's not the purpose of the tiered huddles. We want to understand at each level what's happening within your view. What's happening for you at your level and how can you affect the patient experience in a positive way?

How do you bring it to life and make it meaningful for every single level and not just to exercise about how to get information with senior leaders. Quite frankly, we have dashboards. We have information. We have data, but this is truly how do we bring the life to things that are on these dashboards and the information that the data is self-contained. How do we learn more about the story behind it?

Then the last tip I will leave with is taking the time to ensure that caregivers or employees feel safe and secure with sharing and bringing up issues and creating that environment where they feel like they can share and talk about things.

This could lead to a point of, "Well, I really don't want to share, because that will show that I may not know something about the work that I'm doing and something I should know."

We did have to, for ourselves, work on how do we create an environment where it is OK to share problems. It is OK to learn. It's OK to problem-solve, and we're all in this together." That's really important for teams to work through. That would be my tip.

Upcoming Workshops

Mark: I agree. If people want to learn more on, for one, again the CCIM, Cleveland Clinic Improvement Model is available to look at online. You can go to ccf.org/improve. Then, Cinnamon, you were going to mention that you've got some workshops coming up. If you want to tell people about that.

Cinnamon: Yes. We are excited. We've actually had a lot of people contact us about our tiered huddles and about some of the other ways in which we do our improvement work.

For the first time, we're offering now our workshop series to external visitors. If you go on our site, which is www.ccf -- and that's Cleveland Clinic Foundation -- so ccfcme.org/ccim, then you can find that.

Or you can find me on Twitter, which is @CinnamonDixon1. The link is posted there, but those workshop to be offered for the first time in December. Then hopefully, we'll have some more coming up next year as well, where we're sharing especially our tiered huddles.

You can actually go visit our tiered huddles and experience what we experience every day, which is a phenomenal learning experience.

Mark: It sure looks like it. I will certainly guess that there will be a fantastic experience based on my own couple opportunities to come visit Cleveland Clinic and looking at the website here. At first glance, this is going to be helpful for people.

I'll encourage people to check that out. We'll put a link to that in the show notes for this episode. Cinnamon, thank you again for taking time and sharing so much good stuff here with us today. I really appreciate it.