Implementing Lean: Preliminary Case Study Findings and Implications for Primary Care

On September 28, 2010, Kristin Carman made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (440 KB). Free PowerPoint® Viewer (Plugin Software Help).

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Implementing Lean: Preliminary Case Study Findings and Implications for Primary Care

AHRQ Conference
September 28, 2010

American Institutes for Research

Funding: Agency for Healthcare Research and Quality, ACTION Network, Task Order #5 Contract #290200600019, Project Officer: Michael Harrison, Ph.D.

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Acknowledgement of team members & funders

• Project team:
  • AIR: Kristin Carman (Project Director), Callan Blough, Steve Garfinkel, Margarita Hurtado, Lauren Smeeding, Jennifer Stephens
  • Urban Institute: Kelly Devers
  • Mayo Clinic: Michelle Hoover, Andy Kollengoode, David Mapes, Tony Spaulding
• Participating sites: Virtua Health, Mayo Clinic Jacksonville, NYCHHC, Garfield Memorial Hospital, St. Vincent Indianapolis, Family Health Centers of San Diego
• Michael Harrison, Project Officer, AHRQ
• Dina Moss, AHRQ
• California HealthCare Foundation
• Funding: AHRQ ACTION Network and California HealthCare Foundation

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Background: Lean

• Lean is a process-redesign methodology adopted from Toyota Production Systems.
• Empowers front-line staff to apply continuous quality improvement methods to reduce waste and enhance value in workflows and operations.
• Has shown promise to improve quality, efficiency, and safety in various health care settings.

Images: Three small pictures on the bottom of the slide depict three popular Lean tools: Value Stream Mapping, Spaghetti Diagramming, and 5S, a tool to organize workspace.

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Background: Lean (cont.)

• "Lean does not equal Lean."
• Lean training is usually done "just in time" as part of the implementation of project in that staff area.
• Projects are generally selected by an executive team.
• Training lasts from 3-4.5 days.
• Staff at all levels across multiple departments participate in the training, but there are two key roles:
  • A senior leader to "sponsor" and support the project.
  • A manager to become the "owner of the process" who keeps things going after the training.

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Objectives for today's presentation

• Describe preliminary findings from case studies of current Lean implementation.
• Discuss the barriers, facilitators, and lessons learned from our preliminary case studies activities.
• Discuss the applicability and implications of using Lean in healthcare.

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Project overview

• Timeline: July 2008-June 2011.
• Objectives:
  • Identify challenges and solutions (i.e., lessons) to implementing Lean/TPS.
  • Assess the impact of Lean/TPS.
  • Present these lessons to prospective users.
  • Develop a business case.
  • Identify factors that are associated with variation in Lean results.

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Project overview

• Conducted an extensive literature scan.
• Currently conducting 14 case studies at six different organizations (one study funded by the California HealthCare Foundation).

Image: Chart shows the Lean/TPS Case Studies.

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Lean Literature Scan

• Information about Lean implementation in healthcare is unreliable and anecdotal.
• Data are inconsistent or absent in many areas.
• Most studies are atheoretical.
• There is a positive publication bias.
• Highlights need for comparative case study design.

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Project overview: cases selected for presentation

• Preliminary findings are based on four retrospective case studies:
  • Family center patient flow.
  • Hospital bed flow.
  • Orthopedics process standardization.
  • Emergency Department value stream... but also includes insights from our initial site visits for prospective case studies.

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Methods: conceptual framework

Image: A chart showing the conceptual framework is shown. A double-headed arrow points between a box labeled "External Context of Local Environment" and four boxes captioned "Internal Context or Organization." The four boxes are labeled "Structure," "Process," "Intermediate Outcomes: Organizational," and "Ultimate Outcomes: Organizational and Patient." Arrows point from each box from left to right, and characteristics of each context are listed.

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Methods: data collection

• Case study data collection:
  • In-person, in-depth interviews.
  • Documentation from sites on metrics and outcomes.
  • Semi-structured telephone interviews (prospective cases).
  • Digital diaries (prospective cases).
• Topics:
  • Description of the Lean implementation.
  • Impact of Lean.
  • Sustainability to date.
  • Dissemination of information about Lean.
  • Lessons learned.

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Lean can be successful, but not in all circumstances.

Here's what we've learned so far.

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Preliminary findings: starting Lean

• Impetus for starting Lean varied.
• Lean used as part of a strategic set of tools for improvement.
• Lean communicated to staff using multiple methods:
  • Organizational assessment recommendations.
  • Leadership announcements in meetings.
  • Bulletin boards with project status and outcomes.
  • Write-ups on projects in electronic newsletters.
  • Participation in a Lean training.

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Preliminary findings: defining Lean

• Two ways of defining Lean:
  • Series of projects.
  • Overall strategy for organizational transformation.
• Goals:
  • Improve financial status of the organization.
  • Eliminate waste.
  • Achieve better patient experience.
  • Empower employees to define solutions to problems.

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Preliminary findings: measuring Lean

• Collection and monitoring of overall metrics to evaluate the overall success of Lean are scarce:
  • Staff engagement.
  • Patient experience.
  • Revenue impact.
• Project-level metrics are common, but depend on the project:
  • Efficiency:
    • Patient cycle or turnover time; unit of production per time (e.g., number of patients or cases/per physician/per hour); walking distance.
  • Cost:
    • Number of full-time equivalents required per unit of production; cost savings.
  • Quality and patient safety measures:
    • Rates of infection, number of adverse events.

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Preliminary findings: major Lean activities

• Training: Generally an expert consultant conducts formal training or experiential training through projects with staff. Eventually training facilitation and leadership is transitioned to on-site staff.
• Lean projects in specific departments or through different value streams:
  • Projects generally selected by executive level staff.
  • Projects generally have a sponsor and an "owner."
  • Projects include a "Lean event" as well as follow up activities.

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Preliminary findings: Outcomes reported

• Increased patient safety and patient satisfaction.
• Cost savings.
• Increased employee engagement and satisfaction.
• Improved communication.

"I do believe the tools allow this health system to get the end user to participant in their own change.”

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Preliminary findings: facilitators to Lean success

• Lean organizational culture that supports change, awareness of QI and continuous improve.
• Strategic plan supports Lean initiatives.
• Leadership support is tangible and holds individuals accountable.
• Buy-in from staff of all levels, including physicians.
• Lean expertise.
• Resources are available for Lean projects (staff time, data, etc.).

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Preliminary findings: facilitators to Lean success (cont.)

• Most Lean tools are simple and easy to understand.
• Process fosters communication.and breaks down silos.
• Staff own the solutions to their problems.
• Results are seen quickly.
• Successes are shared.

"Lean, unlike Six-Sigma... is easier to start with if you do not have good improvement capabilities. And within Lean, a common start is 5S. And 5S is not rocket science."

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Preliminary findings: barriers to Lean success

• Lack of understanding of applicability to healthcare.
• Skepticism:
  • "Is this the flavor of the month?"
  • "Will I lose my job?"
• Competing priorities.
• Resources:
  • Training and projects.
  • Data collection.
  • Implement desired changes.
• Resistance to change.
• Physician affiliation to organization.
• Process ownership.
• Lack of compliance.
• Creation of "islands of excellence."

"We don't make cars."

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Preliminary findings: lessons learned

• Lean is not simply a tool for organizing your work; staff buy-in for implementing QI is needed.
• Efficiency and quality can be complementary, not mutually exclusive.
• Set clear goals, define success, and set an appropriate scope.
• Start with the easier processes first.
• Train senior staff in Lean and provide learning opportunities for other staff.
• Use multi-disciplinary teams and engage all stakeholders in the process.
• Celebrate successes through rewards or recognition.

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Next steps

• Collect follow-up data on 9 prospective cases:
  • Digital diaries.
  • Telephone interviews.
  • Follow-up site visit interviews.
• Analyze all findings.
• Share report findings.

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Questions to consider as we continue our research

• How is Lean defined and assessed?
• Is Lean a promising approach for hospitals? For primary care?
• Where and when is Lean most applicable in health care?
• For what types of processes is Lean most useful?
• How do you better engage staff, including physicians, in Lean processes?
• How do you monitor and sustain results of Lean projects?
• How do you encourage integration of Lean into organization's standard QI process?

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Questions to consider for policy and practice

• Is Lean likely to work in health care?
• When do you think it is most likely to work?
  • For certain problems, but not others?
  • When conditions are right?
  • It depends on the team? The organization?
• Have you or someone you know applied Lean in a health care setting? What was their experience?
• How might efficiency gains affect quality in health care? Can Lean improve both efficiency and quality?

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Questions?
Comments?

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Resources

Reducing Waste and Inefficiency in Health Care Through Lean Process Redesign: Literature Review

• http://www.ahrq.gov/qual/leanprocess.htm

Key contact
Kristin L. Carman, PhD
Managing Director, Health Policy & Research
American Institutes for Research
1000 Thomas Jefferson St., NW
Washington, DC 20007
ph. 202.403-5090
fax 202.403.5990
E-mail: kcarman@air.org
www.air.org