A Letter to Physician Leaders

Posted on by CATALYSIS

Jim Marks, the Chief of Staff and Chief of Anesthesia at San Francisco General Hospital (SFGH), in this open letter to his colleagues, details the importance of teaching the principles and thinking behind lean management, the work ahead of his organization, and what they’ve accomplished so far. The shift in thinking required to switch to a lean management system is difficult work, but as he explains below, it’s well worth the effort.

Dear Colleagues,

I apologize for the long e-mail below. As you know from other e-communications, my e-mails are typically BRIEF. But as it turns out, it takes length to answer the question I was asked after the Deans meeting yesterday.

A number of you have asked me what I meant when I said at the meeting that I thought there was a gap in medical school and resident education around the teaching of Lean-based thinking for problem solving, Lean management principles and Lean-based improvement processes culminating in the failure to develop Lean leaders. I was specifically asked “what is a Lean leader?”

I am not the ideal person to answer the question, as I am early on my journey to become a Lean leader, though I have aspirations. But since I was asked, I will try.

  • As opposed to the classic Sloan leader, a Lean leader is humble, curious, perseverant, self-disciplined and willing.
  • A Lean leader employs what is called A3 thinking (the scientific method and PDSA cycles (plan, do, study, act)) to define and “solve” our wicked clinical problems.
  • A Lean leader teaches and develops their people through humble inquiry using the A3 thinking process and other tools.
  • A Lean leader uses Lean improvement tools to develop processes that transform care service lines throughout the organization.
  • A Lean leader is a key part of the Lean (SFGH) management system that we are developing.

SFGH has been on its Lean journey for three years, but as many of us involved in the process know, we have hit a barrier. This is because: 1) we have not clearly defined our goals and their associated metrics, the “where are we going?”; 2) we have not defined what the role of individual units and their personnel and providers are, “what is my role?”; 3) we have failed to fully engage frontline staff and providers in the process, “is my voice being heard?”; and 4) we have not developed and deployed Lean leaders and A3 thinkers.

Those of you who were at the recent Performance Improvement and Patient Safety meeting will have seen that we have made significant progress on all these fronts. With respect to “where are we going?” SFGH has defined its “True North,” which consists of “buckets” for Quality, Safety, Patient Experience, Developing our People and Financial Stewardship.  Under each of these five buckets, we have two organizational metrics, for example for quality—eliminate preventable mortality and reduce 30 day readmission rates. We are developing strategies and tactics around how to move these metrics towards their target goals. For example, Terry Dentoni, Todd May, and I have volunteered to lead the plan to address patient flow throughout the hospital.

We will be asking each clinical care area and service line to develop their own “driver metrics” that when “hit” move our organizations True North metrics towards their targets. This is not possible to accomplish simultaneously throughout SFGH; instead we have two ‘model cells’, the OR and 5D Med-Surg ward. These model cells are developing their own front line staff leadership teams who will develop their unit’s driver metrics. This creates ownership and responsibility at the frontline (not the traditional top-down management, but bottom-up). This is the Lean management system which creates alignment throughout the organization, but spreads the improvement work horizontally at the unit level where the work is done and where it is owned; this is the “what is my role?” and “is my voice being heard?” part.

Finally, we are developing problem solvers via A3 Thinking workshops and the practice of developing real A3s, a tool used to define a problem and propose and test countermeasures. The A3 is also a tool that provides the framework for supervisors (for example Chiefs) to develop their department leaders (faculty) by having them write their own A3s around the problems they are tasked with solving and then assessing and developing their thinking through the process of humble enquiry by their Chief. I had the pleasure recently of taking one of these workshops, and it has been transformational for me, both in terms of how I think about problems and how I mentor my faculty. I can’t believe I had to reach the age of 61 before finding such a tool! In fact, I am in the process of calendaring the same workshop for my Division and Department.

A number of us involved in the roll out of the two model cells recently visited ThedaCare in Wisconsin where the management system was developed and where we saw firsthand what an organization populated by Lean leaders using A3 thinking and Lean management and improvement techniques can accomplish. The level of staff engagement and their ability to identify and solve problems in real time was stunning. As you can see from the JAMA article “How the Pioneer ACO Model Needs to Change: Lessons From Its Best-Performing ACO,” ThedaCare is now the top performing ACO in the nation.

The past eight months serving as your Chief of Staff has been one of the most energizing and fulfilling of my 35 years at SFGH. During the last three months, my excitement has increased further upon exposure to a system and a process that when we embrace it will be transformational and take us to the next level; the best public hospital in the nation! I look forward to traveling on this journey with you; stay tuned for more.


James D. Marks, M.D., Ph.D.
Professor and Vice Chairman, Dept. of Anesthesia
University of California, San Francisco
Chief of Staff and Chief of Anesthesia
San Francisco General Hospital

As Dr. Marks shares in this letter, A3 Thinking was one of the major influencers in his own journey of lean thinking. It is one important step in shifting the thinking of the members of an organization. If you’d like to learn more about this workshop or bring it to your own organization, click here.


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