Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Governance Board - Kaizen - Board Creates Culture of Safety and Quality
View in PDF Format Print this page

Governance Board
Appendix A
LD.03.01.01 -- Leaders create and Maintain a
Culture of Safety and Quality throughout SETMA

Leadership in SETMA is more than members of the Governance Board and of the Executive Management staff. Based on teamwork, SETMA’s leadership is diverse and organized and it has created a culture which continually purses quality and safety.


In response to a discussion about Concierge Medicine, SETMA’s continuous quality improvement was addressed.  “July 27, 2013, A colleague and friend turned me on to the previous article and then to this one and I wanted to share both because I believe you (Dr. Holly) have ‘Kaizen’ and you are not a for-profit, multinational corporation, but a doctor working in a border town in Texas who's sharing of Kaizen has far reaching systemic impact! Best” ( Richard Cohen YAI NYC, emphasis added,   (

“Kaizen” is a Japanese word meaning, “a system of continuous improvement in quality, technology, processes, company culture, productivity, safety and leadership. Kaizen was created in Japan following World War II. The word Kaizen means "continuous improvement". It comes from the Japanese words"kai") which means "change" or "to correct" and"zen") which means "good". Kaizen is a system that involves every employee - from upper management to the cleaning crew. Everyone is encouraged to come up with small improvement suggestions on a regular basis. This is not a once a month or once a year activity. It is continuous. Japanese companies, such as Toyota and Canon, a total of 60 to 70 suggestions per employee per year are written down, shared and implemented.

“In most cases these are not ideas for major changes. Kaizen is based on making little changes on a regular basis: always improving productivity, safety and effectiveness while reducing waste. Suggestions are not limited to a specific area such as production or marketing. Kaizen is based on making changes anywhere that improvements can be made. Western philosophy may be summarized as, ‘if it ain't broke, don't fix it.’ The Kaizen philosophy is to ‘do it better, make it better, improve it even if it isn't broken, because if we don't, we can't compete with those who do.’

“Kaizen in Japan is a system of improvement that includes both home and business life. Kaizen even includes social activities. It is a concept that is applied in every aspect of a person's life. In business Kaizen encompasses many of the components of Japanese businesses that have been seen as a part of their success. Quality circles, automation, suggestion systems, just-in-time delivery, Kanban and 5S are all included within the Kaizen system of running a business.

Kaizen involves setting standards and then continually improving those standards. To support the higher standards Kaizen also involves providing the training, materials and supervision that is needed for employees to achieve the higher standards and maintain their ability to meet those standards on an on-going basis.”

A Learning Organization and Peter Senge’s The Fifth Discipline

SETMA cannot be understood without knowing the impact that Dr. Peter Senge’s The Fifth Discipline had upon SETMA’s development, upon the design of our Model of Care and upon the deployment of our EMR. Electronic medical records (EMR) provides the means for the required “shift of mind,” but does not necessarily dictate that such a shift will take place. Often, EMR is only used as a glorified transcription tool whereby a patient encounter is documented electronically, without providing significant advantages in processing of information, and without the patient’s care profiting from sound science.

Change is not easy. It often creates anxiety and insecurity, even, and maybe especially, among healthcare providers. However, to create excellence in healthcare, providers must continually be "learning" which will require a change in the understanding of the nature of learning and will also require the elimination of barriers to learning. The externship will help the student, at whatever level of training, understand the sustainability of excellence through morphing from the pursuit of EMR to the pursuit of electronic patient management.

Team Building - Individuals Functioning as a Unit

We emphasized that we should never minimize how important it is for each of us to be a positive, constructive part of SETMA’s team. We acknowledged that such a team does not happen without a great deal of effort on everyone’s part. The attitudes identified above would turn into action through which building such a team would occur. The actions are:

  1. Doing more than is expected of you, and expecting nothing for it.
  2. Doing someone else’s work when they are overwhelmed and expecting no thanks for it. And, also, not expecting others to do your work. Interesting dynamic isn’t it? When everyone is operating on these two principles, you will be amazed how much work can get done, and how “good you will feel” about having done it. Working by these principles results in the attitude: “I’m going to do this now, because if I don’t someone else will do it or will have to do it!” rather than the attitude, “If I just procrastinate or neglect this, someone else will do it.” You’ll be amazed at how your job satisfaction will increase when you work in an environment where everyone is trying to do the job so that someone else doesn’t have to do it.
  3. Seeing pressures and problems as opportunities for non-verbally expressing your appreciation for others.
  4. Not complaining when you feel pressured, or when you are asked to do something, which you would rather not do. Anyone can complain and cause dissension, that’s easy. But, it takes a creative and constructive person to turn their irritations into opportunities to promote teamwork and team spirit.
  5. Remember, the best insurance which you have against layoffs is to make yourself such an integral part of the SETMA team that you would be the last person anyone would ever think about “letting go.”

A team is built by the response team members have to stress, problems and crisis. They may be little, like being asked to do something you don’t like to do, or they may be larger, like feeling overwhelmed by the amount of work in a day, or they may be huge like having a child critically ill, but however large, when responded to positively, they can build character and team spirit.

The process of team building never ceases. On Nov 22, 2012, at 4:51 AM, SETMA’s CEO sent the following note to all of SETMA’s team: “Yesterday, Dr. Caesar Deiparine and I decided that as our Thanksgiving Gift to our associates we would see all of the patients at Baptist on Thanksgiving Day. We have done that - all of Baptist has been seen.”

“I hope that you learn from this that ‘random acts of kindness,’ are the most valuable gifts to others. The only debt you incur in receiving this gift is that you are now obligated to do the same, not necessarily for us but for others. On this Thanksgiving day, we hope that this gives you an additional reason to thank God for your life and for your living.”

When one of SETMA’s physicians responded with a “thank you,” the following response was sent, “Thank you; the only appropriate repayment for a random act of kindness is gratitude and that some day, you extended to others your own random act of kindness.” The principle was explained that a “random act of kindness” cannot be repaid to the one who acted kindly but it must be repaid to another, creating in the team a culture of “random acts of kindness” which are repaid to others.

SETMA leadership is based on the following teams:

  1. The Patient-Centered Medical Home Work Group made up of operations staff, information technology staff, medical staff and executive management staff.
  2. The Quality Review Work Group which is made up of an RN and an LVN who have special skills in reviewing medical records for completeness and for compliance with quality initiatives. They also serve as trainers for new staff and as chart reviews for Risk Amusement Factors in regard to Medical Advantage, Medical Home and Accountable Care Organization.
  3. The Business Intelligence and Analytics Work Group which is made up of IT staff and the CEO. This group creates reports and analytics for staff meetings and for public reporting by provider name of over 300 quality metrics on SETMA website. At the beginning of 2014, SETMA has five-years of this reporting posted on
  4. Inpatient Hospital Care Team which is made up of fifteen staff members who work in the hospital twenty-four hours a day, seven days a week to fulfill all Care Transitions measure and an collaborative relationship between the hospital and the physicians who admit patients to the hospital.
  5. The I-CARE Team which organizes and supports SETMA care of nursing home patients with an emphasis on quality and safety.

The Quality Improvement Education Team which is made up of an RN, the Director of SETMA’s Care Coordination Department and SETMA’s CEO. This team conducts monthly, half-day teaching sessions for all SETMA providers. An example of one of these sessions can be found on SETMA’s website at The plan of action for improvement following this meeting can be reviewed at: