Operational Excellence in Healthcare:

Achieving Breakthrough Quality, Access and Affordability

Prepared For The American Academy Of Orthopaedic Surgeons
“Business, Policy, And Practice Management In Orthopaedics”
Lecture Series
By Kevin J. McGuire, MD MS, Steven J. Spear DBA MS MS, Prem Ramkumar, BA

Objectives
1. Understand how the principles of Total Quality Management as a tool that can
improve care.
2. Understand the History of Operational Excellence.
3. Understand what delineates the leaders of those organizations that lead the pack –
organizations that persistently outperform other organization in their sector – and
apply that to healthcare.

Table of Contents
1. Introduction
2. History: Understanding Source of Operational Excellence
3. History: Failure Modes in Copying the Masters
4. HealthCare: The Chief Complaint
5. Diagnosis: The Team, Standardization and Feedback
6. Treatment: Understanding and Developing Capabilities
7. Superlative Performance in Healthcare
8. Summary

Key Takeaways
1. Lessons learned in industry can and should be applied to the provision of Healthcare.
2. Successful organizations are able to harness individuals of differing roles and
expertise towards a common goal.
3. Successful organizations standardize work in order to quickly identify aberrations.
4. Successful organizations swarm these aberrations, clearly define the problems and
apply rapid iterative change with an ability to again detect aberrations.
5. Successful organizations disseminate both the knowledge of the process and the
solution to create organizational learning.
6. In successful organization, leadership is defined as one’s ability to create in those
around you the ability to see and solve problems.

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Chapter 1: Introduction
Healthcare professionals are encouraged to learn from industry to deliver better care to more
people at reduced per-unit and total cost. The challenge in looking to other industries is that
many lessons come cloaked in jargon—statistical process control, gemba walks, and the like—
that seem so context-specific and drawn from such seemingly distinct environments that the
application to healthcare is not obvious. Despite these distractions, there is sufficient similarity
that lessons can be drawn.
The common challenge in any work setting is driving towards a common purpose—the efforts
of many people of individual niche expertise towards one goal. Nevertheless, it is a common
phenomenon that in any sector where organizations are doing work similar to their
counterparts - using similar science and technology, similar workforce, targeting similar
markets—that there are the rare standouts whose outcomes are better and more efficient;
these organizations are superior at the harmonious coordination of many individual efforts into
one. What do the leaders of these organizations do that is so different?

Chapter 2: History – Understanding Source of Operational Excellence

How certain industrial organizations achieve superior outcomes has been an evolving field for
decades. Here is a summary of select concepts of organizational improvement.
Taylor: Scientific Management
Frederick Winslow Taylor popularized the concept of ‘scientific management’ in the late 1800s
and early 1900s, and with it, an attendant irony. On the positive side, the fundamentals are
appealing to those in the medical disciplines—that through observation and experimentation,
one can arrive at approaches superior to those not subjected to rigorous development and
improvement. The focus on experimental accumulation and application of knowledge is
fundamental to success in any field. The timing of developing, codifying, and institutionalizing
best known approaches for repeated use coincided with other developments (e.g.,
interchangeable parts, Henry Ford’s moving assembly line) that collectively allowed for the
industrial revolution—a period during which society saw exponential increases in the volume of
manufactured goods that could be produced affordably, well beyond anything imaginable in a
craft society.
The problem with Taylorism, as scientific management is often called derisively, is that for all its
emphasis on experimental discovery of ever improving methods, it is perceived (often correctly)
as reserving the responsibility and right of discovery to a select elite, with the resulting work
painfully subdivided and leaving workers diminished to repetitive drones. This reputation
adhered not only to Taylor’s legacy specifically, but continues to cling to many ideas originating
in the industrial setting, despite the far more inclusive, democratic approaches of subsequent
thought leaders.

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Deming: SPDC, PDCA, and Profound Knowledge
The economic turbulence of the 1920s and 1930s followed by an emphasis on high volume
production in the aggregate during the war years, meant that an emphasis on comparative
productivity and quality did not rise again until after the war.
A luminary of the post war period was W. Edwards Deming, who had profound impact on
Japanese organizations (enough so that by 1950, the prestigious award for industrial quality in
Japan was named the Deming Prize). Like Taylor, Deming emphasized that effective
management meant that you should not tweak because doing so would exacerbate rather than
ameliorate problems. Rather, you should see a real problem before acting, and when solving
problems, you should do so experimentally, not haphazardly.
Seeing Problems: Because he was immersed in the world of high volume, repetitive
manufacturing, Deming argued that processes should be studied statistically, with their means
and variances characterized and control charts constructed. Once processes were running,
operators were coached to respond only to real problems not perceived ones, intervening only
when sampling and analysis revealed bona fide drift in mean or variance (the essence of
statistical process control—S.P.C.). Responding to random variation would only make matters
worse.
Solving Problems: Consistent with a the idea that undisciplined tweaking is a source of
disruption, Deming was a champion of what he called the “Shewhart Cycle”—in deference to
his mentor. More commonly known as the “Deming Cycle” of Plan-Do-Check-Act, it is an
articulation of the scientific method applied to industry (Plan = construct hypotheses of action
and outcome, Do = carry out the design as planned, Check = compare actual experience against
planned experience, and Act = when a hypothesis is proven, incorporate it as the new
standard).
While Deming shared with Taylor (and Ford for that matter) a commitment to disciplined
learning (problem seeing, problem solving), Deming took a more holistic, engaging, and
democratic view of management and the relationships between management and labor. His
“14 points” hold that learning and improvement occur by engaging everyone (not just a
Tayloristic elite) in doing work and making work better. For instance, fear had to be driven out.
Otherwise, people wouldn’t expose problems, raise concerns, or express ideas. Barriers
towards collaborative problem solving had to be broken—both horizontally and vertically
across disciplines to allow cross-functional problem solving. Only in this way could problems
that impeded hourly workers be removed, and middle managers feel safe to escalate to senior
management problems beyond their immediate control.
Deming also maintained that piece rate work should be discouraged because it encourages
volume over quality, penalizes individuals for factors beyond their control, and impedes
continuous improvement. Ultimately, there is no rest, as there is always something to be
improved by studying the work that is being done. The dynamic of restless, relentless
improvement must be modeled, championed and energized by the senior leadership.
Toyota: Affordable Reliability

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Toyota rose to the forefront as a model of industrial excellence during the 1980s. Whereas
“made in Japan” was largely a disparaging term through the 1950s and 1960s, by the 1980s, its
meaning had reversed as Japanese manufacturers across a broad economic swath—heavy
industry like steel manufacturing, high tech like semiconductors, and consumer electronics--
came to displace long-heralded American corporations as world leaders. This was no more true
than in the world’s largest manufacturing sector, automobiles, in which General Motors, Ford,
and Chrysler were devastated by competition from Toyota, Nissan, and Honda. While early
commentary blamed “cheating” in the form of adversarial trade policies, advantageous
financing, and the like, subsequent studies showed that Japanese firms were winning because
they had determined how to create far better products in far greater volume at far lower
expense, both in ‘routine’ production and in complicated product and process engineering.
Toyota became the exemplar of this “lean” approach—doing more with so much less effort.
Toyota’s leadership role was earned by having achieved exceptional levels of performance by
generating and sustaining exceptional rates of broad-based learning. Though an inadequate
manufacturer in the late 1950s, it demonstrated improvement rates in labor productivity,
capital productivity, and quality that dwarfed the industry, continuing to strengthen its
leadership position with accelerated pace of new model and new brand introduction (e.g.,
Lexus and Scion), technology innovation (e.g., hybrid drive), and regional diversification of
design, production, and sales. The rewards were (and continue to be) exceptional sales,
revenue, profitability, market share, and market capitalization growth.
Toyota developed an approach in which “seeing” and solving problems was a natural part of
everyday work. This was embodied in four capabilities, the disciplines that led to high short-
term reliability and generated accelerated improvement, responsiveness, and adaptation.
Capability 1: Standardization of self-diagnostic work-processes– a declaration of what is
expected to happen and building in tests to see what is actually happening contrary to
expectations.
This high degree of design specification is the means by which best-known approaches are
captured, thereby increasing the chance of initial success. It echoes Taylor’s emphasis on
‘scientific’ design and Deming’s emphasis on understanding what a process is capable of
accomplishing. Unlike Taylor, the emphasis remains on developing everyone’s capacity for
work design and improvement.
Unique to Toyota was the additional concept of building tests into all work, called jidoka by the
company (translated loosely into English as autonomation—e.g., referencing the concept of
autonomic, as in the autonomic nervous system), so at the earliest moment problems (defined
as gaps between what was predicted in the work design and what was actually occurring) could
be detected.
In this regard, Toyota set its approach apart from that of Deming and certainly that of Taylor.
Deming’s statistical sampling was appropriate for high volume, low variety, and repetitive
processes. In contrast, Toyota determined to wrap all work, be it repetitive or one-off, in
hypothesis-testing diagnostics so that problems could be seen sooner, with greater acuity, and
across a far broader range of activities than sampling alone would allow.

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Capability 2: Immediate swarming and solving of problems with the discipline of high speed
experiments (i.e., A3 format) rather than working around problems and applying true
countermeasures sound in logic and tested in practice rather than non-tested solutions.
When problems are seen, they are ideally immediately swarmed. This is to contain their effect.
Once swarmed, problems should be solved using the discipline of the scientific method—work-
up and examination of the problematic situation, root cause diagnosis as to why the problem
occurred, planning of counter-measure treatments to prevent the problems from recurring,
test of the countermeasures (both in offline mock up and online) to validate their efficacy,
follow up, and—if proven—implementation. The problem solving discipline of Toyota echoes
that encouraged by Deming’s PDCA cycle, and it mirrors the clinical problem solving discipline
of workup and examination, diagnosis, treatment planning, implementation, and follow up.
Capability 3: New knowledge is spread by explaining the discovery process, not by simply
describing the solutions that were developed.
Historically, Toyota created a variety of mechanisms in which those who have learned
something have opportunity to recreate their learning experience for others. For healthcare
professionals this should feel familiar. After all, labs, seminars, conference presentations,
poster sessions, journals, and even bed-side clinical reports share the common structure of
exploring and exposing the entire problem-solving thought process.
Capability 4: Leadership is exercised by developing capabilities 1, 2, and 3 in their direct
reports.
Characteristic of Toyota is the commitment of leadership to cascade to their subordinates the
capabilities described above and to support their subordinates in escalating problems that
cannot be resolved at lower levels. In many regards this echoes Deming’s emphasis on
management engaging with processes and the people charged with performing them. It is
echoed by other high performance organizations in which senior leaders define their role
heavily by their teaching and coaching responsibilities. It must be familiar to healthcare
professionals who remember well their best mentors and teachers who were superlative, not
just for subject matter expertise, but especially for their capacity for developing the problem-
solving skills of others.

Chapter 3: History: Failure Modes in Copying the Masters

Both Deming and Toyota have inspired quality movements in industry (Deming of six-sigma,
Toyota of “lean manufacturing”). Failure is most often attributed to implementation of the
tools without developing problem-solving behaviors and the culture that supports this
approach. Thus Deming’s work, TPS, and Lean Management have experienced a dumbing down
of a sophisticated management system to a quiver of tools to be applied in rote fashion. In its
application, organizations have mistaken the means for the end. As Rother points out about
lean manufacturing application in his book Toyota Kata, the “critical aspects of Lean were not
visible.” In other words, the critical aspects were not the tools. An example is the application of

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the A3 described by John Shook in Managing to Learn not as merely a tool but as a way to
facilitate and sustain a learning organization greater than the tool itself.
The Tool: A3 is named after a particular size of paper. In simple terms the A3 paper is folded in
half. On the left of the paper is the “current condition” and on the right side is the “target
condition.” The “A3 team” is inclusive of all those involved in the work as well as facilitators.
The first step is the hardest – defining the problem. Although this may seem easy, one’s first
experience is a challenge. A common mistake is to immediately jump to proposed solutions to
the problem. Instead, in the A3 process, solutions should not yet be discussed. Through
dialogue and iteration based preferably on data, the root cause or possible root causes would
be vetted, and the problem would be restated and refined.
Importantly, by being forced to work on the left side of the A3, the group is driven to clearly
define the problem and current condition before moving on to develop “countermeasures”
(i.e., solutions). Once the problem and current condition are well defined, countermeasures
are proposed. Importantly, the next step is that the expected results of the countermeasures
are worked out before they are implemented. Predictions are made. Perhaps small
“experiments” are done. This may seem like an unimportant step, but it is crucial. Only by
defining the predicted results can the team compare the actual results to what was expected
and learn.
The Process: John Shook stressed that the learning aspects of this process are more critical than
the tool itself. He sees the A3 as accomplishing key organizational goals. The first comprises
dialogue and collaboration. He writes that the A3 is “more than the simple powerful tool. It
embodies the spirit of lively debate, the establishment of mutual understanding and
confirmation of agreement that underpinned everything that I saw occurring in a way in which
work took place day to day.”
The second was accountability as well as leading with responsibility instead of authority. He
writes that the A3 is a “mechanism for companies to authorize activities, while keeping the
initiation of action in the hands of the person doing the work, the responsible individual.”
Perhaps he sums it up best when he writes, “It takes two to A3.” Rother put it another way,
that a learning organization is an “outcome that springs from its members’ routines of thinking
and behavior…It is human behavior.” The most valuable part of an organization is not visible.
As Spear wrote, “Try benchmarking that.”

Chapter 4: HealthCare: The Chief Complaint

Healthcare is fraught with A Tale of Two Cities contradictions. On the one hand, well-meaning
well-trained people, using the most advanced science and technology, have unprecedented
capability for providing care, comfort, and cure to those who, through illness or injury, would
otherwise be compromised. On the other hand, healthcare services consume such a large and
ever growing portion of national and personal income and wealth that they crowd out other
vital social needs. More than ever, they are beyond the reach of many individuals. Moreover,
cost (and, consequently, availability) is not the only dimension on which these contradictions

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exist. For all its promises for comfort, healthcare is characterized by rates of injury to patients
and staff that are uncharacteristic and would be unacceptable in other settings.

Chapter 5: Diagnosis: The Team, Standardization and Feedback

The Team Matters: Delivering care effectively, efficiently, reliably, and responsively requires
harmonious coordination among many, many individuals with disparate levels of expertise.
Providers and in particular surgeons are only effective with a tremendous amount of resources.
To be blunt, how effectively can a surgeon perform an intramedullary rodding of a femur
without an operating room, fluoroscopy, and an intramedullary rod, to name only a few of the
resources required. Despite this basic truth, healthcare professionals are largely trained to act
as individuals – as quarterbacks that are well trained to throw the ball and execute specific
plays, but have not been trained to work with and effectively lead a team. It takes a team to
be an effective quarterback, and it takes a team to be an effective surgeon.
Standardization and Routines in Order to Build the Right Culture: What gives certain
organizations the ability to be far more productive, effective, efficient, reliable, robust, and
responsive despite using the same science, same technology, and employees from the same
labor pool? The compelling analysis is one of the longer-term dynamic—that greatness is
achieved by the organization as a whole over time. Organizations that lead their sectors now
do so because they have generated a breadth of iterative improvement over a sustained period
of time that their counterparts have not matched. This is true for work that is a one-off as well
as work that is repeated. It is also true for work performed by small teams to teams of
thousands. Although improving, healthcare has a culture of the “work-around.” It is a culture
of taking care of the patient despite the system rather than being supported by it or a part of it.
Instead, healthcare providers should lead and engage the system as part of the care of the
patient and build these larger disciplines and routines.
Feedback and Rapid Adjustments: All systems—at least those that demonstrate health and
resiliency—give the appearance of balance as the result of never ending adjustments and
recalibrations. No amount of cleverness will provide the right allocation of people to positions,
skills to tasks, tasks to objectives all of the time. Rather, success depends on constant
adjustment in terms of objectives being pursued, responsibility being assigned, relationships
being managed, and skills being applied. Even the most ‘routine’ tasks – running a hand surgery
clinic, for example – involves coordinating the work of several people, and no matter how well
devised the plan, there are inevitably disturbances that have to be identified and addressed for
the system to maintain its resiliency. This concept is especially true for the complexities around
orthopaedic surgery.

Chapter 6: Treatment: Understanding and Developing Capabilities

There are great opportunities in healthcare to apply some of the basic principles of total quality
management, but first we must recognize as a community that physicians are part of a larger
team that includes people from different disciplines and different backgrounds. While we may

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see the same problems differently and even speak different “languages”, we are all on the
same team, and we all want the same thing: to deliver quality healthcare to our community.
We must also understand that quality improvement is not a “one-and-done” project. Rather, it
is a continuous process that requires a culture that values and is empowered at all levels to
make things better. Once understood and embraced, these Capabilities can be developed:
Capability 1: Standardization in order to “See” the problem.
Capability 2: “Swarm” the problem. Addressing the problem immediately through an
iterative process.
Capability 3: “Spread” the knowledge about the process of solving the problem and the
solution.
Capability 4: To lead is to develop Capabilities 1,2,3 in those around you so that they can
See, Solve, and Spread Knowledge.
Healthcare professionals will notice the obvious parallels between the industrial requirements
for creating a self-correcting organization and those in healthcare. Discipline about managing
complex processes to see problems is entirely consistent with the discipline of procedures and
treatment plans, coupled with the real time monitoring to ensure that what is occurring
matches what is expected both in execution and outcome.
Discipline about solving problems (adhering to the scientific methods) is precisely the discipline
applied to the cycle of the patient history, examination, workup, diagnosis, treatment planning,
implementation and follow up. Although not perfect, healthcare has mechanisms to spread
locally-made discoveries systemically, much how bench top and clinical discoveries move to
broad dissemination and practice by healthcare professions.

Chapter 7: Superlative Performance in Healthcare

A number of institutions have and are trying to implement TQM systems with the goal of
becoming a high velocity learning organizations. Our goal in this chapter is to provide some
examples from the simple and mundane to the system-wide.
The Simple: Instrument Reduction in Surgical Case Sets.
This is an ongoing project at our institution to decrease the number of instruments opened for
spine surgical cases. The hypothesis is that the majority of operative instruments were not
being utilized. In Lean terms of muda, this simple problem has significant opportunities.
1. Overproduction. The “batch” size of instruments is not appropriate to what is utilized.
2. Unnecessary transportation. The majority of instruments are opened, not used,
transported, processed, transported again, and opened (repeat) without being utilized.
3. Inventory. Instruments were stored and never used.
4. Motion. For all instruments not utilized motion is waste.
5. Defects. Repetitive processing degrades instruments, staff, and machines.
6. Over-processing. Excessive turnover, set-up, processing.
7. Waiting. Turnover of instruments increases operative time and process time.

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 8. Latent Skills. Staff’s expertise is wasted on efforts associated with non-value added
steps. With minimization of these efforts, more time and expertise can be utilized on
care, safety, and quality leading to higher staff and patient satisfaction.
Most of the surgical team queried about this issue and offered solutions – “Just remove these,
they are never used.” Instead of jumping to solutions, data was collected to clearly define the
problem. Cases were prospectively audited across all spine surgeons and cases. The results
showed that only 58% of instruments were utilized at least once. A working group was formed
of all the individuals involved, including surgeons, nurses, scrub technicians, and central
processing staff. The A3 model was utilized. The problem and the current condition with the
data were defined. Countermeasures included a “Spine Instrument Fair” where all the
individuals came together and based on consensus and data, decided as a group what
instruments should be included in the sets, what instruments should be removed from the sets,
and what instruments should be available and opened only upon request.
As with most projects the problem feeds into a larger process and identifies other problems
around the current process. For example, there were problems in obtaining more of the agreed
upon instruments. There were problems with getting central processing to provide the exact
instruments agreed upon. The solution was removal of all the unwanted instruments from
circulation.
In the end, 152 instruments were taken down to 89 instruments. 17.5 lbs. were removed from
the sets. The estimated savings per year was approximately $41,000, and these changes have
been maintained. The current team is also now modeling case-specific sets in spine rather than
surgeon-specific sets. Because of this work, the organization not only finds it much easier to
obtain buy-in and go through a process to make them case-specific, but also has fostered other
projects through the culture that the process has created.
More complex: ICU beds
Mike Howell, MD an intensivist and director of the Health Care Delivery Science Center at Beth
Israel Deaconess and Medical Center (BIDMC) outlined a seven-year journey of intensive care at
BIDMC. ICUs are inherently complex places with the most medically complex patients in the
health system at their sickest. Becoming a learning organization where mistakes can have
catastrophic consequences is in Dr. Howell’s words “Kaizan without a Net,” improvement with
high stakes when failure occurs.
Nevertheless, this is what they did. The initial goal was to build “stability” in the ICUs. To do so,
they created “Closed or semi-closed ICUs” with a dedicated intensivist on duty 24/7. Once
stability was reached, they moved on to improvement. Then they instituted a Multiple Urgent
Sepsis Therapies Protocol. The team focused on central line infections and reduced the
infection rate by 86%. Then they instituted a “Triggers” program - a protocol with criteria for
floor nurses to trigger patients at risk and reduced the number of deaths outside the ICU by
more than 70%. Then they moved on to Ventilator-associated pneumonia prevention, again
drastically reducing the rate. Then the team instituted “Person Centered Critical Care,” where
patients and families were an integral part of the care team. They have sustained these efforts
through continuous refinements.

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What happened when they did all these things? The mean length of stay in the ICU dropped by
one day – a 25% decrease. This does not seem like much but this allowed a 45% increase in the
throughput of ICU patients. In-hospital mortality dropped 24%. For every 35 ICU patients,
there was one fewer death. What about throughput? There was a >50% increase in ICU
patients per month from 2004 to 2010. What is perhaps the most astounding part of the story
is that the throughput continued to increase and still does; yet since about 2006, there has
been no increase in the ICU bed capacity. In fact, BIDMC’s plan for making a multi-million
investment to increase bed capacity was halted due to the efficiency. The expansion was no
longer required. Paul Levy, former CEO of BIDMC wrote in his blog, “They were able to avoid
the multi-million dollar capital cost of expanding our ICU capacity. Indeed, we were able to
create capacity out of the existing facilities and improve throughput.”
System Wide: ThedaCare
ThedaCare medical system is in the Wisconsin’s Fox River Valley. It is a cradle-to-grave care
system consisting of hospitals, clinics, nursing homes and other services. John Toussaint, MD,
the previous CEO of ThedaCare wrote in his book On the Mend: Revolutionizing Health Care,
that over 7 years they removed from the cardiac surgery service 40% of wasted time and effort.
Cardiac mortality was decreased to nearly zero. Average time in the hospital fell from 6.3 days
to 4.9 days. The cost of coronary bypass declined 22%.
ThedaCare also established collaborative care units to organize care delivery around the
patient’s experience. When a patient is admitted, an inter-disciplinary care team coordinates
with him or her to arrive at a mutually agreed-on care plan. The program has reduced hospital
lengths-of-stay, errors in patient care, and inpatient care costs (by 25 percent), while improving
care protocol compliance by providers and achieving a patient satisfaction rate of 5 out of 5,
95% of the time.
In the end Toussaint wrote, “Teamwork like this has saved us more than $27 million, and
ThedaCare has passed those savings along, becoming the overall lowest-price healthcare
provider in Wisconsin.” ThedaCare utilized the Toyota Production System as an improvement
model. The goal was and is “Lean HealthCare.” The system is organized around the principles
of a “focus on patients, value, and time – that are built upon a foundation of continuous
improvement and respect for people.”
All of these examples from the simple to the system wide focus on switching from managing
functions in isolation to managing the provision of care as a coherent integrated process, with
the goal of creating a learning organization that can identify problems, solve problems, diffuse
the knowledge gained, and create leaders at all levels to iterate and innovate the learning
process. At their heart, they seek to add value to the care of patients.

Chapter 8: Summary
Leading organizations place great effort in seeing each function as part of the whole process.
They see each problem and process improvement as a chance to experiment and learn. They
utilize a “scientific” method to institute change in an inclusive and iterative fashion. They

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swarm problems. They diffuse new knowledge about the current solution and the process of
getting to that next best way of doing something. They lead to create managers and workers
who can innovate and develop new skills and capabilities. The leaders of the organization have
to develop a structure and culture that is designed for high-speed learning, persuasion,
incubation and spread.
In health care, providers are the leaders. It is true that health care is not a factory, but the
concepts of TQM are not foreign to providers’ basic clinical work – to evaluate, test, diagnose,
treat, analyze, evaluate. The task is to do so from the perspective of the whole process of care
as viewed by the consumer of care along the continuum of care. Providers can see and take
responsibility for the function of the whole system of care as an opportunity to focus on a
product – the value of care. In doing so, leaders create, cultivate, and spread a dynamic
organization that learns and innovates at a rapid pace.
It is not enough to diagnose and treat patients. As Dr. Weinstein and Mr. Kim noted in their
editorial in the Washington Post, we as providers have a moral and fiscal obligation to diagnose
and treat the patient in the most efficient, safest, and value-based manner possible. Although
becoming a learning organization is a multidisciplinary, inclusive and significant investment in
time and expertise, the providers of care best champion such transformational changes. There
is no finish line.

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12. For elaboration on these capabilities please see Spear, Steven J. (2010) The High Velocity
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