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    James D. Hamilton
    James D. Hamilton, MBA, FACMPE

    Going from the demands of physician practice leadership/consulting work to now teaching the next generation of healthcare leaders has been a delightful change for me. The luxury of these mostly online instructional encounters help assemble students from across the United States, from every walk of healthcare organizations, as well international students representing healthcare in their countries of origin.

    This affords a great opportunity to see common threads of problems being encountered by healthcare organizations. Today’s top issues raised by students include meeting staffing needs, the use of agency staffing, management communication, and onboarding of staff and physicians which include proper orientation to organizational policies and procedures. These issues have been exacerbated by people working from home.

    If senior leaders provided a list of problems, it might include these issues as well additional considerations such as financial performance and pressures of today’s market, e.g., fixed reimbursement, pricing transparency, inflationary pressures/staff compensation and benefits and finding/retaining adequately trained staff plus maintaining an excellent level in customer service.

    Leadership education

    What is being done in graduate education to assist our future leaders to solve the operational demands of today’s healthcare organizations?  Subset to the list above are what appear to be longstanding problems from years ago, whether that be the management of telephonic communication, tackling system-work-related problems or just the lack of demonstrated management ability.

    With associates working from home, this requires new/updated management skills. I always encourage graduate students to think as leaders and not in their current position of work. Many students are frontline staff or lower to middle/director management and unaccustomed to problem solving, which should be a required expectation at all levels of the organization. It’s a process of continually working on your work. We assess students’ personal understanding of healthcare management and their emotional intelligence to be a leader, as these competencies help to prepare them for future workplace demands. However, it should not end there.
    Lost in a maze

    Gemba Walk – The new management by walking around

    The tool kit of work improvement practices is rather light weight relative to the many deep-seated problems found within healthcare organizations.

    One such tool is the Gemba Walk. Gemba — Japanese for “the real place” — or Genchi Gembutsu (“real location” or “real thing”) refer to the act of seeing where actual work happens. Gemba is a tool of Lean management.1 I find that many of today’s students get really fired up about using Gemba; however, Gemba can be very superficial in its application and is, in many ways, a rebirth of Management by Walking Around (MBWA).

    The concept of Gemba is to organize management interfacing with those performing the work so that management can experience and see the work being performed by company associates. Good planning of questions asked, and behavior performed by management is well orchestrated. Some of the principles of performing the Gemba Walk is to not make any real-time suggestions for change, criticize an employee or create any sense of intimidation.  The staff is assured that this is not a “gotcha” process by management; it should be an interactive interface between staff and management which at times is not easy to accomplish.

    For some, it is a time that a commonly identified problem can be discussed. After the walk has been completed, management will provide direction relative to any changes that need to be made. Associates have provided their insights, but the final decision falls within the purview of leadership. This is really a process of top-down management with the appearance of staff involvement. This seems to be a reversion back to the leadership style of the 1950s. Many problems found in healthcare operations today are much more complex than any casual walk by management through the organization could solve.

    Hardwiring for success

    Many hospitals today have been influenced by the work of Quint Studer.2 As I have dealt with students, the concepts of hardwiring, rounding and huddles have permeated the culture of many hospital-based organizations, a true legacy of Studer’s innovations. The structure of this process does afford a much stronger examination of organizational difficulties and operational problem solving; however, many organizations are not willing to embrace the concepts of Gemba due to Studer principles being used in their healthcare organization.

    Studer principles are fully integrated in the organization. This includes not only a highly organized interface and follow-up with associates work concerns but also aligned job descriptions, and performance evaluations to make certain any work being performed ties to the mission, vision, and values of the organization. Gemba does not have this structure or alignment.

    As I worked in and around organizations that imported Studer principles, the success was only as good as leadership embracing this change. However, students today are not being taught the deep influence of concepts such as the Studer principles. Knowing these concepts is a worthwhile arrow in the quiver of management tools.

    Quality circles — Rebirth is needed

    The concept that I used professionally and have taught is different than Studer-based principles or Gemba. The best methodology for creative organization change is based on the concepts of quality circles.3

    Quality circles are defined as a group of employees and management meeting to solve problems in the workplace. If the true process of quality circles is embraced, it does have many nuances of Lean management (e.g., data collection, etc.). Key to the success of quality circles is the direct involvement of management meeting with company associates to solve complex workflow problems that help build increased efficiencies/productivity in the workplace. Embracing this method has been the foundation of best practice implementation for an organization on multiple occasions.

    This method also helps manage what I would call system principles. Systems thinking is very complex and cuts across many parts of the organization, a much-desired trait in leadership excellence. Quality circles is a deep penetration into solving system-related work inefficiencies versus the superficiality of performing a Gemba Walk. Unlike the principles of Studer, quality circles can be performed timely, and efficiently without the complexity of changing the organization’s policies, procedures, and structure. For maximum performance, quality circle implementation does need management support and direct involvement.

    Over the years I learned to effectively modify quality circle principles to bring quick resolution to major organizational problems. In working with physicians, they want problems solved tomorrow. If the referring physicians are complaining about telephone access and referrals, they want this problem solved immediately since this impacts the business and revenue.

    In one scenario, major complaints were being filed by referring physicians to a neurology practice. As we examined the telephone/scheduling process, we saw that the schedulers needed to go through 72 steps to get a patient scheduled. Why so laborious? Over the years the physicians would indicate scheduling rules to the staff (“Do not let X happen again”).

    In another situation we identified that telephone calls coming into the clinic became totally bogged down about 2 p.m. We found that the hospital would only allow scheduling radiology procedures after 2 p.m. Thus, the office schedulers were calling at 2 p.m. for the morning appointments needing radiology follow-up; after the appointment was established, the schedulers were calling the patients to let them know when their procedure was scheduled. Therefore, they restricted access for incoming calls after the 2 p.m. time frame. These problems were not easily identified; they required time in management working with staff to get to the root cause of the problem and create effective solutions.

    In dealing with similar problems in managing organizations I found that this level of work intimidated leadership at all levels of the organization. Many managers did not want to do such processes due to the time involved, as well as hesitancy to not look like you as a leader are uninformed in workflow processes as well sustaining and creating change. It is much easier to slap a bandage on a problem, sometimes fully missing the root cause of the problem. Using the principles of quality circles is extremely effective when solving organizational problems.


    Healthcare management students don’t often receive effective instruction on exploring their organizations and creating meaningful change leading to excellent performance. This puts companies in a position to train management in how to do such work (which is rarely done), allowing organizational problems to recur without solutions.  Using the principles of concepts such as quality circles represents, in contrast to Gemba Walks, the real place for work.


    1. Womack J. Gemba Walks Expanded 2nd Edition. July 30, 2019.
    2. Studer Q. Hardwiring Excellence: Purpose, Worthwhile Work, Making a Difference. Jan. 1, 2003.
    3. Mulder P. “Quality Circle: Definition and Examples.” Toolshero. 2018. Available from:
    James D. Hamilton

    Written By

    James D. Hamilton, MBA, FACMPE

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