Document Type


Executive Sponsor(s)

Mark Parker, Omar Hasan

Publication Date



Maine Medical Center

MeSH Headings

academic tertiary medical center, leadership, workflows, pilot, root cause analysis, maintain, feedback survey, coaching



At an academic tertiary care medical center, there are 110 Operational Excellence teams across 4 campuses. Every weekday, 10 GEMBA walks occur with the 11th on Wednesdays. The expanding program has made daily leadership visits to all KPIs challenging. As a result, consideration of reduced gemba walks to departments who have met specific maturity/performance criteria.

The scope of the eight-week pilot consisted of 13 pre-identified teams that have weekly workflows. The teams must have met a baseline level of performance. Performance was scored for 9 variables measuring engagement, PDSA, use of daily management and infrastructure. Teams also must have been live on Operational Excellence for minimum of 6 months

The main objective was that teams would maintain or advance their current performance level with the KPI process.

A root cause analysis identified barriers to gemba walk participation for frontline and senior leaders. Several countermeasures were developed to include a feedback survey for department leaders one month post pilot start and weekly evaluation of pilot teams.

The outcomes supported the conclusion that pilot team performance was similar to teams receiving daily gemba walks. Next steps include continued coaching the pilot teams to ensure performance advancement and conduct quarterly audits. In addition, look to add other units to the adjusted frequency walk that meet the performance criteria.



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