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January 13, 2022

Interview Excerpts: Trent Green, SVP and COO, Legacy Health (May 2021)

By Gene Kim


In the Idealcast podcast, I am on a quest to understand how and why organizations work in the way they do, both in the ideal and non-ideal. This is in support of work I’ve been doing with my mentor, Dr. Steven Spear from MIT Sloan, targeting a book in 2023.

At the end of May 2021, I had recorded my interview with Trent Green, SVP and Chief Operating Officer at Legacy Health, which is one of the four major healthcare systems in Oregon. This was during such an important period — then, as now, we are currently in a race to deliver vaccines into everyone’s arms in the shortest possible time.

Quite literally, the success of this endeavor affects the health and economies of the entire planet. We observed that in order to win this race, it was not sufficient just to have vaccines available, but we must vaccinate everyone on the planet.

During Spring and Summer 2021, the results were decidedly mixed. Some vaccine clinics are able to get 100% of the vaccines allocated to them successfully into people’s arms. Others struggled to achieve 30%.

The result is not just wasted precious doses, which could have gone to other vaccine clinics where they would have been successfully delivered, but also causes other serious consequences. Every day that people are not vaccinated, they risk getting sick and in turn getting other sick.

During Spring 2021, I had the privilege of getting a glimpse into the incredible unleashing of human creativity and problem-solving that enabled such high levels of vaccination rollouts possible. I heard amazing stories about how vaccination clinics were able to increase the number of vaccinations delivered by 4x, 6x, even 10x, by doing things like changing the onsite registration flows, or even reversing the path that people took through a building to put the elevator after the vaccine administration instead of before.

But those operations were happening on a much smaller scale than what is currently happening at Oregon’s largest vaccination site at the Oregon convention center. At the end of March, I had the privilege of spending three hours with Trent Green at the Portland Convention Center, where they are currently delivering 8,000 vaccines per day to people who need them — up from 2,000 per day in January.

Or measured a different way, they were able to increase the number of vaccines delivered from 100 per hour, to peaks of 1,300 per hour.

It was such an honor to see firsthand how human creativity has enabled them to ramp up vaccination capacity so dramatically. It was literally one of the most uplifting things I’ve gotten to see in years, and I am so grateful for the work that Mr. Green and team have been doing.

On April 28th, the Willamette Week published an article called “Oregon’s Largest Vaccination Site is a Logistical Masterpiece. We Take You Inside.” [insert link]

They described the site as “a medical Disneyland, like the best airport in the world…” They compared their daily operations to “the operations of a Swiss watch, where over 226,000 Oregonians have been vaccinated.”

Contrast that to other mass vaccination sites where people described it as having a war zone or apocalypse vibe, requiring people to wait hours in line, sometimes lines to get in another line.

Ever since my visit to the mass vaccination site with Mr. Green, I found myself talking about it over and over to so many people, and I had more questions I wanted to ask him. And for so many reasons, I am so glad that he agreed to be interviewed. So today, I have not only Mr. Trent Green, but also my mentor, Dr. Steven Spear from MIT Sloan as well.

I’ve actually known Mr. Green for years. I’ve always loved talking with him as he is always so full of insights — in fact, so many things he’s mentioned to me often in passing, become areas of intense study for me.

In fact, when we were discussing the phenomenon of “the square”qwe in the Unicorn Project, which describes need for vast escalations to get anything done that requires integrated problem-solving from different silos, he told me a couple of things that then became the topic of repeated conversations between Dr. Spear and me.

I’m so delighted that I have on today, both Mr. Trent Green and Dr. Steven Spear. Mr. Green has been at Legacy Health for 12 years, which is a $2 billion integrated delivery health system based here in Portland, Oregon, which is comprised of eight hospitals, a 600 provider multi-specialty medical group, a regional laboratory and a research Institute. And he has been in the healthcare industry for over two decades.

Enclosed in this post are some of my favorite written excerpts from the nearly two hour interview — and I’m so excited about interviews we’ve done, to explore how we can integrate this same problem-solving dynamic into all aspects of healthcare. Those interviews will be published throughout 2022.


Mr. Green has been at Legacy Health for 12 years, which is a $2 billion integrated delivery health system based here in Portland, Oregon, which is comprised of eight hospitals, a 600 provider multi-specialty medical group, a regional laboratory and a research Institute. And he has been in the healthcare industry for over two decades. So, Mr. Green, I’ve introduced you in my words.

Dr. Steve Spear (DBA MS MS) is principal for HVE LLC, the award-winning author of The High-Velocity Edge, and patent holder for the See to Solve Real Time Alert System. A Senior Lecturer at MIT’s Sloan School and a Senior Fellow at the Institute, Spear’s work focuses on accelerating learning dynamics within organizations so that they know better and faster what to do and how to do it. This has been informed and tested in practice in multiple “verticals” including heavy industry, high tech design, biopharm R&D, healthcare delivery and other social services, Army rapid equipping, and Navy readiness.

High velocity learning concepts became the basis of the Alcoa Business System—which led to 100s of millions in recurring savings, the Pittsburgh Regional Healthcare Initiatives “Perfecting Patient Care System”—credited with sharp reductions in complications like MRSA and CLABs, Pratt & Whitney’s “Engineering Standard Work”—which when piloted led to winning the engine contract for the Joint Strike Fighter, the operating system for Detroit Edison, and the Navy’s high velocity learning line of effort—an initiative led by the Chief of Naval Operations. A pilot with a pharma company cut the time for the ‘hit to lead’ phase in early stage drug discovery from twelve months to six.

Interview Excerpts

Gene Kim

Between you and Steve, who will introduce himself in just a couple of moments, I’m probably the most ignorant of how healthcare systems work. Can you describe the role of the chief operating officer versus the chief medical officer, and what are the key leadership positions in [00:06:30] a healthcare organization?

Trent Green

Sure. So, I report to our chief executive officer. And our executive team consists of myself, chief operating officer. We have a chief financial officer. We have a chief medical officer. We have chief integration officer, who handles a lot of our newer type ventures. And then we obviously have information technology and human resources, all part of the executive team. For my role, chief operating officer, I have responsibility for all hospital operations. I have responsibility for all pharmacy services, [00:07:00] all laboratory services. So, I handle what probably represents 70% of the total business on a day-to-day basis that runs through our facility.

And I partner a lot with our chief medical officer on the clinical aspects, quality aspects, our quality agenda. So, there’s a nice diad between myself and our chief medical officer. And then we have another individual who’s titled in our system, chief integration officer, who has responsibility for our medical group and a lot of our, what I would characterize as newer ventures. So, we’ve [00:07:30] gotten into urgent care as a for instance, outpatient surgery. We have, as I said earlier, an investment in a health plan. And so, he has responsibility for managing those newer aspects of where we’re trying to take our delivery system all in pursuit of value for customers.

Gene Kim

An important business for people who need to benefit from the healthcare system. That’s fantastic. So, Steve, I’m so delighted that you’re on today. Could you briefly introduce yourself and maybe take a moment to describe the work that you’ve done in the healthcare industry? [00:08:00] And if I remember correctly, that was actually done with someone that Trent and I have talked so much about, the honorable Paul O’Neill. Famously, the CEO of Alcoa.

Dr. Steven Spear

Yeah, Gene. Thank you. And Trent, really great to connect in this fashion. My work in general was around the question, why is it when some organizations try to pull together many specialists towards some collaborative effort towards common purpose, why are some few of them so much better at what they do than everybody else? And you start thinking about the benefit so much better, it means much more value [00:08:30] generated to meet society’s needs. It means much greater return on the investment. Some have made the effort, and it means that those doing the work have much richer and more certain realization that what they did was important to somebody else. So, that’s the general theme. How do you pull the pieces together so the whole is much, much greater than the sum of the parts?

In terms of work we did in healthcare, healthcare is just simply ripe for introducing this kind of thinking and doing, because it’s a sector which originally started with just individual doctors providing care, and everything was about that magic moment of touch where the term of art is to lay on hands, right? And what happened is, as science and technology advanced in healthcare, the number of specialists involved in bringing magic to that moment increased exponentially. What didn’t advance along at the same pace was an understanding of how to do that integration of the many into one.

And so, we got invited in to do some really inspiring work. Inspiring because of the people with whom we work, not because of what we actually did, but inspiring work in the Pittsburgh healthcare community. Back in the early two thousands, this was picking up off of a couple of pilots we did in the local healthcare community here in Boston with Beth Israel Deaconess hospital. And long and short, it proved out the idea that if you have a systematic way of creating systems, of integrating systems, the ability for people to express their fullest potential, it just goes up geometrically.

Trent Green

Oh, completely. We talk about this a lot. Our caregivers, clinicians in general, they diagnose problems and they implement solutions. They try a number of things, and not just our positions, but our frontline staff as well. We talk frequently about the amount of real-time problem-solving that happens in our facilities every day. The challenge is that oftentimes, we observed that our people, they solve problems, but they’re often work-arounds. They don’t get to really fundamentally solving to root.

And so, what we’re trying to now unpack as a system is how do we liberate people to actually solve problems, not just work-around so you can get through to the next thing or the next patient because that happens all the time. We stack up all these work-arounds, they’re not all the same. Same problems encountered in one facility is solved this way, it’s solved this way in another facility, and neither of which ultimately get to what the root cause of the problem is. And so, what we’re trying to step back and do is, how do we create a mechanism by which we can consistently solve problems ultimately to root and eliminate whatever harm or process breakdown it creates?

Gene Kim

Trent, I’d love to rewind the clock to January or whenever that was when you realized that you might be responsible for standing up a big part of the mass vaccination [00:11:30] clinic. Can you talk about what those first days of operations were like. If I remember correctly, you said you were struggling to get 2,000 doses out a day and eventually heading to 8,000. So, can you describe what that felt like in the early days?

Trent Green

It was a long story that we don’t need to rehash on how we got to ultimately standing up a mass vaccination site. But when we concluded that we needed to do that, you’re right, we ran an operation scheduled to operate 10 hours a day, very frequently operated 12 to 13 hours a day. And we were lucky if we could crank out 200 doses an hour and ultimately get 2,000 doses in people’s arms during a day. And it was extraordinarily high stress. We were trying to be as efficient as possible, but we had never done something like this. What we actually put together was a collaboration of four competing health systems. So, you had that dynamic to manage, but also just the complexity of doing it. We immunize patients every day. We don’t immunize [00:12:30] patients with a two-dose regimen that has a lot of care and handling on the actual pharmaceutical side.

So, that added the complexity. So, just a lot of early stress. What we found is, back to these systems and improving systems, we had all these microsystems. We had a registration microsystem. We had a vaccination microsystem. We had a pharmacy microsystem. We had a observation area microsystem. And what we didn’t understand in the beginning at all was how, as you made a change in one of those areas, we forgot that we needed to evaluate the implications in the other microsystems. And so, we created a lot of our own problems and it took us a while to get to where we are now. We’re administering close to 8,000 doses a day. We do that in seven hours. So, over 1100 an hour is what we’re up to. Now, we can do it in less than 30 minutes and that includes a 15 minutes of observation that’s required.

We could never do that in the early stages. So, we’ve made a ton of improvement. I think one principle that I learned early was, you can’t improve a process until you stabilize a process. And so, one of the things that we struggled with early on is, people would have bright ideas, oh, we should do this. We should do that. We should do this. We attempted to stack way too many improvements on, and it would just make things, frankly, it made things worse either in that microsystem or in another microsystem. So, we learned, and then we started to slow walk our improvements a little bit and do a better job of testing [00:14:00] things before we actually ultimately implement.

Gene Kim

Before we talk about the mechanics of that, could you talk about maybe some of the major milestones as you went from 2,000 a day to 8,000 a day? What strikes as the breakthroughs that you would point to in that journey?

Trent Green

Yeah. So our first date of operation at the Oregon Convention Center, which is where we run this mass vac site, was January 25th. We started, first administrations would go in people’s arms at nine o’clock in the morning. We would have people there at six in the morning doing training, doing walkthroughs, making sure everybody was in the right chairs. Theoretically, the last appointment was at seven o’clock at night. But as I mentioned, we routinely went over in those early days. There’ve been so many improvements. I’m not even sure where to start. I think some key milestones for us have been, we’ve never wasted a dose, never wasted a single dose. Now, oftentimes, what that meant is, at the end of the day, if we overproduced in pharmacy… Again, one of the microsystems, if we overproduced in pharmacy, there’d be a lot of people on the phone trying to find people that were eligible to receive the vaccine that could come to the convention center quickly.

We now have a process down where we are extremely efficient at the end of day operation, so that oftentimes, we’ll have to open up another vile to finish the day, but we still don’t waste and we don’t have to find 50 people at the end of the day to administer the vaccine too. So, I think key milestones were a stabilization of processes. We’ve actually reduced hours now. So, as I said, we were doing 2,000 in 10 hours, which often ended up being 12 hours. We’ve now moved it to a seven-hour operation. What we found is, the burnout was real. It’s intense when you’re in there, and recruitment of volunteers or paid staff and so on and trying to run multiple shifts just became too complex for us. So, we actually got faster when we condensed that time. So, we went from 10 hours… For a period of time, we ran 7:00 AM to 7:00 PM.

That was really taxing for people. So, now, we’ve moved the operation to five days a week, seven hours a day when we’re, operating. And for instance, my daughter’s 16 years old, she became eligible two weeks ago. Last night, I took her to the Oregon Convention Center. I was such a proud father walking her through. She didn’t really care about all the things that Dad had done, but we were in and out in 34 minutes. Now, that included 10 minutes of waiting because we were one of the last appointments of the day. And at the end of the day, we do do what we refer to as a pharmacy draw down where we slow down the process a little bit so we don’t overproduce. And that included a 10-minute delay, [00:16:30] and that was car door to car door, 34 minutes.

Gene Kim

Awesome. It was such a heady day. And one of the things that really caught my attention was how you moved the area of operations from one of the banquet halls to the huge 116,000 foot area. Can you talk about like what led to that?

Trent Green

Yeah, so we started out actually in, as Gene mentions, in a ballroom and we thought that would be sufficient space for us. Frankly, there’s nothing going on at the Oregon Convention Center, so we can have as much space as we wanted. We thought we would have sufficient space in the ballroom, but this is even another learning. We didn’t design that space very well. So, we had, I would call it a waterfall concept. So, you would enter the ballroom, that would be where registration was. Just behind registration is where the vaccination center was. And then the waterfall concept was, you either went left or right and that’s where the observation would occur. Well, the problem with having two observation centers is, we had to double the number of staff. We had to have double the number of people that are sitting in there. We had to have two medical tents for people.

And so, we built in some inefficiencies in the beginning. And then, we also realized we just didn’t have enough space to process. We could only end up doing about 500 per hour was our max in that space. It just wasn’t enough. So, we moved to the exhibit halls where we had ample space. And then we modified our approach where we created six pods, and the pod strategy was really key because it just enabled people to move that much more rapidly and us to process that many more people efficiently.

When we first moved to the space, we actually had a consult from Starbucks. So, Starbucks had been very involved in the state of Washington and their mass vacs operations. And so, I met this gentlemen, Josh, at the convention center in February, the first day we had moved into the new space and he said, “Well, do you mind if I take some time studies and I’d be happy to give you some suggestions for improvement?” I said, “No, that’d be great.” He spent, I don’t know, half a day there, observed all of our systems. Came back, sat down with me and said, “I got to be honest, I don’t really have any suggestions for you. You guys are doing such a good job of processing. I want to go [00:18:30] back and study this a little bit more.” He said, “You might be able to open one more pod, but beyond that, keep doing what you’re doing.”

Gene Kim

That’s great. In fact, I’ll put a link to the FEMA video that was put together that featured the Starbucks person and the back of your head too, Trent.

Before we get to Steve, when you look back at this, what are you most proud of getting to the vaccination clinic this far?

Trent Green

Well, to be a healthcare, any role and healthcare the last 14 months, it’s been hard. February 28th is when our first case was identified in the state of Oregon, and I still remember that day. It was a Friday night. I was supposed to be at a high school girl’s basketball game, and I spent the entire time out in the parking lot on the telephone trying to figure out what to do. It wasn’t even a case in our hospital. We’d been monitoring COVID, and the last year has been hard. Emotionally, it’s been hard for people management of protective equipment. I have to say, though, this vaccination effort has been a bright spot for me personally. I get so much joy. One of the things we lose, I think we’ve lost is recognition of how important [00:19:30] smiles are with masks. It’s really hard to tell when somebody’s smiling. But I can tell you, when you go to the Oregon Convention Center and you walk around, you see everybody in masks, you can tell they’re smiling. You can see it in their eyes.

And that’s just been really gratifying for me. We worked with the governor to actually move teachers ahead of seniors. That was a controversial move, but Oregon had been very slow in restarting schools, and we worked with superintendents of schools who were phenomenal partners to help us test our systems. Again, we didn’t know how to do this and they were organized. We were organized. We figured out a way to get them scheduled efficiently. And so, Gene, I’m going to remember this for the rest of my life, the role that I played in this vaccination effort. And it’s just been really personally gratifying for me and for our people. I can tell, people’s spirits at work have even been lifted. I’m now vaccinated and they’re vaccinated. And there’s still protection, but it’s been really hard in healthcare and this has been a bright spot in the last 14 months.

Gene Kim

I just read that amazing [00:20:30] article in the Willamette Week describing the vaccination site as a magical Disneyland, like the best airport in the world, like an f-ing Swiss watch. That’s got to feel pretty good.

Gene Kim

Steve, you had told me something some months ago that, literally my jaw dropped and that also became the focus of lots of effort and other studies. You made the observation that some hospitals, as they’re delivering vaccines, they can get a hundred percent of vaccines in people arms, where some are struggling [00:21:00] to get 30%. And then you also made the observation that some school systems, once the decision is made to return to in-person learning, some can reopen on a dime, maybe weeks, others take months or quarters. And you made the claim that both of those are probably a very good proxy for an organization’s ability to adapt, learn, act upon learnings, re-engineer all the relevant processes and really unleashing the creativity of the entire workforce, especially on the front. So, to what extent [00:21:30] does the story that Trent told, does that affirm your hypothesis on a scale of one to 10? One is not at all, 10 is exactly in line with what you expected.

Dr. Steven Spear

This is incredible. On a sacle of 1-10, this is like Spinal Tap — it’s an 11. I want to say thank you to Trent and his colleagues for all the hard work they’ve done both in the gloomy times and now to get us to the end of the tunnel. Just to put things in perspective, people were talking about having to be a masked society well into 2022 and even 2023. And the fact [00:22:00] that by mid 2021, we’ll have some return to normal is fantastic.

And again, to Trent and his colleagues that during the dark periods, they took on real personal risk to help usher the rest of us through this terrible event. What I’d like to encourage anyone listening to this is to listen to Trent’s account with great appreciation. It’s well-deserved, but also to recognize that in his account, there’s some general lessons which are applicable to them too.

And I’ll just pick up on a couple. One was this idea of, the problem was we didn’t run a system, we were running a series of microsystems. That is common, and Gene and I have spent a lot of time talking about why we end up with these very complex organizations which looked like these kind of loose confederations, loose collections of microsystems that don’t really come together.

The reality is, that’s true and where you get systems of systems to parlay one of our favorite books, team of teams, is by actually having someone draw the line through the systems to figure out the sequence, the dependencies by which value gets created. [00:23:00] And when you start seeing the system of systems, then you can start doing all the system level [inaudible 00:23:06] and the system level improvement to make things better. So, that was one point. And again, why I encourage people to listen beyond the well-deserved appreciation is that anyone listening to this podcast, they are probably working within a microsystem, which is part, not part of a microsystem and a larger system, it is a microsystem next to a lot of other microsystems.

So that’s one. The second thing that Trent said, of the many things he said, but the second thing that comes to mind is this idea that first we need a standard before we start to improve. And that’s so key, because until we actually make a sound declaration of what we think is going to work, we can’t find out we’re wrong. Until we create a standard, create a declaration, set up the hypothesis for an experiment, it’s just air confetti, it’s just nothing.

And even if the first standard you create, and inevitably, something as complex and novel as a mass vaccination, the first standard you create is going to be deficient in some way, at [00:24:00] least you could see the deficiencies in the standard and then quickly close the loop and find out what’s wrong with the standard and modify, modify, modify so that you get to a better standard, whether it’s the realization that waiting to the left and to the right complicates things out. Fine, one waiting place. From one location to another location, fine. Again, that wasn’t in the first standard, but it was in version three and four and 12 and 24 and et cetera, et cetera.

Similarly, like the slowdown in the pharmacy, which is, if we don’t stop the pharmacy filling syringes with some lead time… And then you probably, once you had that realization, I’m willing to bet you had six iterations on just how much time you needed, right?

Trent Green

Well, probably 15.

Dr. Steven Spear

One thing, and then I’ll stop gushing praise on this is, like I said, there were three. One was, we live inside microsystems rather than a system of systems and this… you need a standard to make an improvement. But the other is, where Trent ended, which was, you can see the smiles behind the masks. February 28th, 2020, no one was smiling. [00:26:00] But when this kicked off with your mass vaccination, probably, January 2021, still, no one was smiling, even though you were giving a vaccinations, because it was just so overburdensome. It was so frustrating, it was so difficult to actually do the right thing.

And now here we are in mid April and people are doing quote unquote, the same work, but they’re doing it with gracefulness. They’re doing it with appreciation. And the thing I just want to offer, why is anyone ever asked to do work, where they can’t smile with the sense that they’ve done something that someone else will appreciate? I almost have to get to the point that, it’s a choice that we make and that people responsible or other people make, that we make a choice as to whether we’re going to be energetic and open-minded, and inquisitive like Trent and his colleagues. And try to get systems to evolve and adapt and adjust so that the people in this system want to smile because they know that they’re doing something appreciated. And it’s an alternative that’s chosen, if we don’t do that. Anyway, this has been a fantastic… I’m going to stop talking because I want to listen.

Listen To The Whole Interview!

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