Improving Care Delivery Through Lean: Implementation Case Studies

Organizational Background 

This report presents the results of the study of Lakeview Healthcare (LHC) and its experiences applying Lean tools and philosophy to designing and moving into a new hospital. Four Lean projects—Bed Flow Value Stream, Outpatient Medical Records and Patient Flow, Outpatient Electronic Health Records, and Surgeons' Preference Cards—are reported in the first case study on LHC.^ee The case study methods, including the criteria for selection of the projects for analysis, are described in the introduction to this report. For this study, we conducted 67 interviews with a total of 65 individuals overall; 22 individuals were interviewed specific to the Horizon Hospital. Interviewee roles at the hospital varied as described in Exhibit 6.1.

Description of the Health System: Lakeview Healthcare 

LHC is a nonprofit, comprehensive health care system on the Eastern Seaboard. It comprises four hospitals, an ambulatory care center, physician offices, rehabilitation services, long-term care centers, home care services, physical therapy services, and Mobile Intensive Care Units. It also operates a health and wellness center in one town and plans to open another in second town. LHC was established in 1998 when four hospitals merged (go to Exhibit 6.2 for a detailed description). In the same year, a new CEO was appointed and maintained the position through 2011. In 2003, a new executive vice president for health services (now subsumed under the title of president and chief operating officer [COO]) was hired and is credited by several other executives and managers with encouraging the addition of Lean to LHC's quality improvement toolbox. Nearly 2,000 physicians serve on the medical staff, and 8,000 clinical and administrative staff are employed. 

LHC offers numerous specialty services, with a strong focus on obstetrics. There are more deliveries at its hospitals than at any other health care delivery system in the region. LHC provides neonatal intensive care and a wide range of pediatric specialty care through relationships with a children's hospital in a nearby city. In addition, a cancer program provides cancer patients with access to comprehensive treatment. LHC also has five emergency centers. Exhibit 6.3 illustrates the organized delivery system.

LHC has roughly 8,400 clinical and administrative employees and is one of the area's largest employers. Approximately 2,000 physicians serve as medical staff members, both as employed physicians and community-based physicians with privileges. LHC has been recognized 3 years in a row as the "#1 Best Employer" by a business journal. Staff turnover was only mentioned by one interviewee, a staff person from the Management Engineering Department, who indicated some degree of turnover in the nursing staff and Management Engineering Department. It is interesting to note that nearly all individuals interviewed had been with LHC for 5 years or longer.

In 2009, LHC acquired a series of physician practices and consolidated them into a medical group (in this study, called "LHC Medical Group"), which employs approximately 200 physicians from various specialties, including family medicine, surgery, and oncology. In addition, LHC's hospitals employ 130 hospitalists (physicians who specialize in treating inpatients) across the four locations. An additional 1,670 community-based physicians who are not employed by LHC receive privileges to practice at its hospitals and other care facilities.

Despite its large size, executives and other interviewees indicated that the structure of LHC was relatively "flat." Although leadership staff for the hospital, LHC Medical Group, and ambulatory care center report directly to the COO of the organization, individuals at all levels have access to senior staff.

LHC employs an extensive rewards system for staff performance. Hospital leadership bestows "Wow" Awards on individual staff members who go above and beyond the call of duty. When an individual receives five "Wow" Awards, he or she can turn them in for a $25 gift card. Individuals and teams are nominated and awarded "STAR Awards," which are likened to the Grammy Awards. LHC also offers monetary awards and end-of-year bonuses to staff, including management, directly tied to performance according to the five points of the cultural transformation initiative. Executives and management can receive a 10-40 percent incentive based on the five points of a cultural transformation initiative, which are the basis for setting management goals and objectives.

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Description of Horizon Hospital 

This case study reports on the replacement of Hospital 3 with a new hospital that opened in May 2011 with 73 additional beds. The new hospital, one of four LHC hospitals (Exhibit 6.4), was designed using Lean techniques.

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Other Environmental Context

Local Competition

LHC operates in a very competitive market. However, one corporate executive noted that about one-half of competing hospitals show a negative profit margin. For example, a previous competitor shut down in March, which added business to the Emergency Department at Hospital 4. Many interviewees noted that LHC needs to remain competitive, and that competition increases the need for high patient satisfaction scores and efficient processes, both of which are targets of the Lean projects.

Funding and Payers

Nearly 50 percent of LHC's revenue comes from commercial payers, followed closely by Medicare at roughly 46 percent. Medicaid makes up the remaining 4 percent of revenue. One executive noted that the payer mix has remained stable over time.

Executive-level interviewees noted that outside stakeholders (e.g., payers—including insurance companies—vendors, etc.) understand LHC's quality improvement initiative, which includes Lean and Six Sigma,^ff and note that it is a positive direction for the organization, but these stakeholders play no other role. Blue Cross Blue Shield attended a report-out of quality improvement (QI) activities (including Lean and Six Sigma) at LHC, and LHC has involved payers in projects related to denials and claims issues. LHC does not receive incentives from its payers for their involvement with Lean.

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Lean and Quality Improvement at the Organization 

In this section, we discuss the history of both Lean and quality improvement at LHC. Exhibit 6.5 outlines the overall timeline. The specific activities noted in the timeline will be discussed throughout this report.

History of Quality and Efficiency Improvement Efforts at the Organization

LHC prides itself on having an organization-wide focus on quality and performance improvement. It launched a new Initiative in 2000, a blueprint for achieving patient satisfaction that represents the cornerstones of its culture. The cultural transformation initiative came out of a decision made by executives and the Board of Directors to move LHC from being a mediocre-performing organization that was formed with the merger of two provider organizations to becoming a high-performing system. LHC had been in the 50th percentile in quality, safety, patient satisfaction, employee satisfaction, and financial performance. The cultural transformation initiative was launched to shift its culture to one where patient care became the sole center of everything that was done.

The initiative has five points: excellent service, best people, clinical quality and safety, resource stewardship, a caring culture, and—at the center—outstanding patient satisfaction. The initiatives' goals and accomplishments include transforming the culture to a culture that (1) promotes trust and openness to encourage conversations about performance and (2) removes bureaucratic barriers for employees and physicians in order to create an outstanding patient experience. To implement the cultural transformation initiative, LHC made several practice changes: standardized business practices, revamped hiring practices, improved departmental team building and ownership, implemented proactive communication around information systems, and leveraged technology to communicate more effectively. As LHC worked towards becoming a high-performing organization, they worked with the consulting firm to develop measurable goals and a roadmap for achieving them, which included the use of Six Sigma.

In 2000, LHC began working with a consulting firm on process improvement through Six Sigma projects. The consulting firm, having developed substantial expertise in process improvement in manufacturing began offering consulting services to firms interested in process improvement, particularly Six Sigma. As of 2002, LHC observed gains and attributed them—at least in part—to the use of Six Sigma. Based on those initial results, the organization continued to adopt additional process improvement methods from the consulting firm's toolbox for quality improvement, including Workout,^gg Change Acceleration Process (CAP),^hh and Lean. All of the process improvement approaches, referred to by staff as "tools," are centered on the DMAIC principles (define, measure, analyze, improve, and control).

The collective impact of the cultural transformation initiative on the patient experience at LHC has been externally recognized. The organization has been honored twice with the governor's award for clinical excellence and recognized with the Leadership Award for Outstanding Achievement by Voluntary Hospitals of America. LHC is the recipient of multiple Consumer Choice Awards (showcasing hospitals chosen by health care consumers for having the highest quality and best image) by the National Research Corporation.

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Initiation of Lean at the Organization

Corporate executives reported that Lean was initiated in 2003 and, according to a few hospital executives and managers, did not ramp up significantly until 2006–2007 when a large educational program was launched to inform staff about Lean. In 2006, LHC and the consulting firm cosponsored a week-long International Lean Healthcare Seminar. During that week, five projects were implemented with health care professionals from 18 hospitals and health systems and four countries in conjunction with LHC and other process improvement leaders.

Interviewees noted four factors that influenced the decision to implement Lean at LHC in 2003: Lean was viewed as the right tool for the problem, an organizational culture shift had taken place, there were new staff, and operating margins were negative.

Lean was viewed as the right tool for the problem. Many staff at the management and executive levels stated the importance of finding the right tool for the problem at hand. Six Sigma was the only process improvement technique (as opposed to general management tools) in use until the consultant group introduced Lean to management at LHC. Many executives and management engineers noted that Lean is a tool for eliminating waste, whereas Six Sigma is a tool for reducing defects and variations in processes. The introduction of Lean allowed LHC to focus attention on reducing waste at an opportune moment, consistent with changes in the organizational culture and financial imperatives (described below).

An organizational culture shift had taken place. In 2003, the CEO set organizational goals of becoming a leader in quality, safety, patient satisfaction, and employee satisfaction. These goals motivated staff to strive for excellence in these areas and reinforced the cultural change stemming from the cultural transformation initiative introduced in 2000. Respondents felt the cultural transformation initiative provided a coherent approach for organizing LHC's approach to Lean—each Lean project must fit into one of the five points of the cultural transformation initiative (best people, caring culture, excellent service, highest clinical quality and safety, and resource stewardship).
 

"It's not always the hammer that's gonna fix the problem. Sometimes it's a screwdriver, sometimes the wrench, and sometimes you gotta use all three, because that's what the problem dictates." —Manager

There were new staff. In 2003, a new executive vice president for health services (now subsumed under the title of president and COO) was hired and is credited by several other executives and managers with encouraging the addition of Lean to LHC's quality improvement toolbox. The new vice president had been exposed to process management techniques in previous positions and as part of his education, and promoted the use of additional tools including Lean. Shortly thereafter, in 2003, the COO hired management engineers to support the Lean work.

At [LHC]...we have five points to the cultural transformation initiative. Every point of the cultural transformation initiative has a strategic imperative. The engineers know they better get in touch with the executive that will be responsible for the strategic imperatives to make sure that that [the project's] scoped out in terms of how it's going to be measured and how it's going to be reported." —Corporate Executive

Operating margins were negative. In 2003, LHC had a negative operating margin for the first time in its history. This development focused the organization's attention on taking steps to reduce costs, including reducing waste and employing Lean as a tool toward that end.

Motivated by these factors, LHC engaged the consulting firm in a consulting capacity to guide the organization in reviewing what was missing from its toolbox in terms of people, process, and strategy. The result was the adoption of new tools, including Lean as an organization-wide initiative.

Conceptualization of and Goals for Lean

To meet its organizational needs and goals, LHC uses Lean as a mechanism to improve efficiencies and patient experience, according to statements by nearly all interviewees. 

Interviewees mentioned at least one of the following goals for Lean: improve efficiency and reduce process time (n=19), improve patient experience (n=7), integrate process improvement into the culture (n=4), and increase clinician time at the bedside (n=2). The organizational goals of Lean varied by type of interviewee, as shown in Exhibit 6.6. A handful of frontline staff described the goals of Lean only in terms of the specific Lean projects in which they participated; these goals are discussed later in this Case (refer to Lean Hospital Project).

Improve efficiency, reduce process time, and eliminate waste. Nearly all staff across all levels of the organization indicated some form of waste reduction as an organizational goal for Lean. However, this was a more prominent goal for the process improvement and frontline staff than it was for executives and physicians. Efficiencies included a better organized space, reduced travel time for staff and patients, efficient patient and staff flow, and reduced process cycle times (e.g., bed turnaround). Notably, none of the participants directly stated that a goal of Lean was to reduce costs or save money but assumed that improved efficiency would lead to that outcome.

"We don't typically set an ROI [Return on Investment] target and work the other way [to identify changes to meet the ROI]. We say, 'How can we build the best mousetrap?' [sic] and we know that the best mousetrap will produce a good or better ROI return. So we work from the operations [target] back[wards]." —Corporate Executive

Improve patient experience. Many interviewees across all levels of staff described improvement in quality of patient satisfaction and experience as a core goal of Lean. Several executives and process improvement staff linked the importance of patient satisfaction and experience to the cultural transformation initiative at the organization.

Integrate process improvement into the culture. Two executives and two process improvement staff members noted that they hope the process improvement activities across the organization—including Lean and Six Sigma—would become a natural part of how the organization does business. As a result, employees facing day-to-day challenges in their work could raise awareness for the need to bring in functional experts in process improvement to help. One hospital executive explained that in this way, staff would participate in and own the changes at the organization. In addition, one process improvement staff member mentioned that awareness of the tools would generate a culture of transparency and reduce blame and judgment.

Increase clinician time at the bedside. Finally, two interviewees stated that there is hope that the improved efficiencies could increase clinician time at the bedside, ultimately improving the quality of care provided.

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Alignment of Lean and Quality Improvement Efforts

At LHC, process improvement and quality improvement are housed in three different corporate departments (Management Engineering/Lean, Six Sigma, and Quality Improvement). The Quality Improvement Department is responsible for the clinical quality outcomes and abstracts and submits the data required by the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission. Data include clinical process and outcomes data, patient safety data, patient satisfaction data, and other data. The Management Engineering/Lean and Six Sigma departments are largely in charge of process improvement, related training, and technical assistance.

The two process improvement departments, Six Sigma and Management Engineering/Lean, are corporate departments and report directly to the president and COO. Management Engineering/Lean began in 2003. The leaders of both departments, together with staff, work in tandem to collect data and identify solutions. Depending on the circumstances, they might also work together to apply a set of tools toward a joint solution. Staff in the Six Sigma Department have varied backgrounds. They spend 3 years in the department and earn a “black belt” before moving on to more senior management and executive roles in the organization. Staff in the Management Engineering Department must have specialized engineering education and/or experience. The CEO stated that staff in this department are also considered for leadership roles in the organization.

LHC has overall objectives for Lean, referred to as “Global Golden Objectives,” that are reviewed by the corporate executives on a quarterly basis. The objectives serve as global metrics for monitoring and tracking the success of Lean activities, both on a micro level (for project-specific indicators) and on a macro level. The Global Golden Objectives comprise positive financial returns, reduced space utilization, optimization of clinicians' time to see patients, and reduction of travel distance. The objectives are derived from the cultural transformation initiative's points. For example, one of the objectives is to reduce travel distance for both staff and patients. By better organizing the location of materials and services and planning the flow of patients and staff, a number of unnecessary steps can be eliminated, and the amount of walking can be reduced.

Several interviewees reported that the Lean approach was well suited for use in clinical processes (as compared to administrative processes) because it could reduce waste, offer quick results, and involve frontline staff in finding solutions. Other tools, such as Six Sigma, were described as being more rigorous solutions to reducing variation across the organization but taking 4–9 months to achieve returns.

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Process for Implementing Lean 

Exhibit 6.7 displays the key steps involved in LHC's Lean implementation process, including project selection, planning, training, project implementation (including how the project and team are structured), monitoring and control, and sustainment of project results. Each of these steps is described in more detail in this section.

Lean Project Selection Process

LHC decided to implement Lean using a Kaizen approach. Projects are identified in multiple ways. Hospital executives, managers, physicians, and other frontline staff can raise an issue to be reviewed by the process improvement departments (Six Sigma and Management Engineering). At LHC, a weekly financial, patient satisfaction, and quality briefing brings together the leadership of all of the hospitals and the management engineers. During those meetings, issues are raised and corporate leadership refers staff to the management engineers and Six Sigma Black Belts to help them with any areas in which they are struggling.

Staff in the Management Engineering Department work directly with the executive vice president of health services (now subsumed under the title of president and COO) to consider how to prioritize projects. To help with this process, the executive vice president and engineers consider the impact that the project would have on the five points of the cultural transformation initiative. It is interesting that none of the interviewees mentioned a project that had been rejected. This might be because of the extensive amount of pre-work and scoping done to understand the root cause of the problem before beginning a project.

"When I'm looking at the project, I'm looking at, What is the financial return? What is the impact on patient quality and safety? What is the impact on employee satisfaction? What is the impact in terms of our focus on a caring culture, to support the employees in terms of the individuality of that particular practitioner, who may not be the same as the person on the other side?" —Corporate Executive

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Planning Implementation of Lean

Once a possible project is raised for consideration, management engineering or Six Sigma Black Belt staff might spend 3 to 5 weeks studying the problem to understand the underlying issues. Pre-work often involves reviewing data and/or observing processes within an area. A few members of the departmental staff are identified by the departmental leadership to support data collection and the planning process. From this information, an assessment template—a tool created by the organization to track the findings from observation—is completed. Included within the assessment template are:

• Vision/goal statement.
• Potential process owner.
• Stakeholder departments.
• Alignment with strategic imperatives or points of the cultural transformation initiative.
• Problem statement.
• Data available.
• Scope/boundaries.
• Key performance indicators.
• Consequences of doing nothing.

Notably, there is no analysis of cost-benefit estimates included within the assessment template: management assumed that improved efficiency would naturally lead to financial benefits. Based on the results of pre-work and information in the assessment, targeted interventions are proposed to solve the problem. Tools may include CAP, Workout, Lean Kaizen, or Six Sigma. Or the process change might simply be implemented without using a formal project to do so. A meeting is held with the hospital leadership to discuss the recommended approach.

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Lean Training

General Lean Training

LHC demonstrates commitment to introducing staff to Lean principles and other process improvement tools. For example, orientation training for new staff includes information about process improvement. In addition, new staff members are made aware of the combined Lean-Six Sigma curriculum and the training available to all staff.

New managers—both those new to the organization and those promoted from within—are provided with training called Great Beginnings. As part of the training, management engineers and Six Sigma Black Belts teach a segment on the process improvement toolkit. Managers are expected to earn a Six Sigma yellow belt at a minimum.

Project Team Training

Training at LHC is conducted by internal staff in the Management Engineering Department, sometimes with support from Black Belts in the Six Sigma Department. Training on Lean principles and initiation of Lean projects are fully intertwined.

A new project begins after project planning is completed. Senior leaders at each hospital, including the hospital CEO and vice president of operations, work with department managers to select the team for the Kaizen event. Management engineers and Six Sigma Black Belts can make recommendations about the type of staff to include on the team based on their observations and assessments during the project scoping process. The project team of 5–10 people convenes for a Kaizen event that begins with training. The first few hours of the event are spent on Lean education and introducing staff to Lean and how the Kaizen is going to be run. The rest of the Kaizen event is customized based on the scope of the project, the type of staff participating, and the level of exposure to Lean that the project team has had. The tools to be used are identified in the assessment that is completed as part of planning and pre-work. Training on the tools is provided as needed while the Kaizen is taking place; in other words, it is “just-in-time” training.

Other Training

In addition to Lean, there is also training available for staff to become certified in Six Sigma at different levels identified with green, yellow, and black belts. Senior managers must become certified in Six Sigma. The Process Improvement Department managers provide the management engineers and black belts with advanced training on optimizing Lean techniques and combining techniques on a single project.

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Lean Project Implementation

Event Week

At LHC, the Kaizen approach is used to implement Lean when focusing on the work systems or processes that need to be improved. The Kaizen event is, in essence, the Lean project kickoff. 

At the Kaizen event, the management engineer introduces applicable tools and concepts to help achieve a successful project. Sample tools and activities are shown in Exhibit 6.8.

The length of a Kaizen at LHC ranges from 1 to 3.5 days, and can be broken into smaller portions, such as 2 hours per day over 5 days. The duration of the event varies depending on the scope of the project and availability of team members. For example, in a small outpatient clinic, the number of staff involved on the project team would require that the clinic shut down. Thus, having 2-hour sessions each day for 5 days ensures that patient care services are not interrupted. One or two management engineers and/or Six Sigma Black Belts lead the Kaizen week. At the end of each day, the team reports to the local hospital leadership (e.g., hospital CEO, operations manager, department chiefs) to share the results of the event, including information on initial outcomes and how the project has affected process.

Immediately following the Kaizen, the project team process owner is responsible for implementing the action plan, communicating changes to other staff members in the department who are on the project, and overseeing the changes.

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Lean Teams 

LHC has identified several formal roles for projects as depicted in Exhibit 6.9 and described below.

Executive sponsor. An executive sponsor is assigned to each project team. Generally, the executive sponsor is the CEO of the hospital or the vice president of operations. The sponsor's major responsibilities include reviewing progress, removing barriers (e.g., getting approvals and resources), introducing the project at report-outs, helping select project team members, and keeping the team focused.

Management engineer/Lean leader. Staff from the Management Engineering Department serve as project team facilitators and trainers. In addition, they conduct the pre-work for the project, collecting data and developing an assessment which includes: project goal statement, potential process owner, stakeholder departments, alignment with strategic imperatives or points of the cultural transformation initiative, problem statement, any data available from observation or records, scope/boundaries of the project, key performance indicators, and consequences of doing nothing. They educate team members on Lean tools and measures and on monitoring. Further, they follow up with team progress in the initial months of implementation and may also assist with monitoring activities.

Process owner. The process owner is responsible for managing the day-to-day aspects of his or her Lean project, including overseeing implementation of the action plan, managing data collection, reporting on outcomes to the team, and ongoing monitoring.

Team members. In addition to the sponsor, Lean leader, and process owner, each team has approximately two to seven members. Staff at every level, including both clinical and administrative, may participate in a Lean project. In particular, representatives from all departments affected by a project are included on the project team. Further, a few interviewees noted the importance of including proponents and skeptics on the project team for balance. Notably, LHC does not prioritize participation by physicians. The majority of physicians who provide patient care at LHC hospitals are affiliated through a contractual rather than an employment relationship, and LHC does not compensate them for the time that would be required to participate. As a result, relatively few physicians are on Lean project teams; instead, physicians are consulted at critical points in the project.

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Monitoring, Control, and Sustainment

After the Kaizen event, including training and project implementation, the management engineers work with the project team for 30 days. Over this period, the team rolls out the change to the department and implements the action plan. The action plan serves to keep the team accountable; the process owner is responsible for ensuring that the items in the action plan are completed. Many project teams continue the Kaizen-week routine of reporting progress to local hospital leadership at the end of each day. Adjustments may be made during this time as part of continuous improvement. At the end of the 30-day period, a corporate report is sent to all senior leaders across the system.

"If the process owner is not there during the Kaizen, we will walk out…Because at the end of the Kaizen, that person is responsible and accountable for managing the change." —Management engineer

Monitoring activities vary widely by project, but the most successful include ongoing daily meetings or communication about the project. For example, for a project tracking bed flow, an email to all of the nursing floor, housekeeping, and emergency department managers goes out every morning and afternoon announcing the "state of the house" or number of open beds.

After the 30-day report, the project enters what LHC terms the "control" phase, the goal of which is to sustain the changes brought about through the Kaizen. Then, 90 days after the Kaizen week, the team presents the project and outcomes to the senior leaders across the corporation. At this point, the project is officially completed; some projects will continue to be reported on for as long as 6 months to provide information on how outcomes have been sustained. To allow Six Sigma and Management Engineering staff to support ongoing implementation of new Lean projects, there is a clear handoff to the process owner who must continue to monitor progress. Several interviewees at all levels noted that projects incorporating physical changes, technological changes, and changes to the communication process that require daily meetings and/or emails are more likely to be sustained than are projects that do not employ any of these changes as part of their process. To help keep staff motivated after the formal project process has ended, some project team members planned to hold a 1-year anniversary party.

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Dissemination and Spread of Findings

Spread of knowledge and findings across LHC. More than 40 Kaizen events have occurred since 2006. Given the level of Lean spread within the organization, executive staff and process improvement staff noted that they have seen Lean and other process improvement activities occurring in a more organic fashion across the hospital. LHC disseminates and promotes findings from Lean projects across the organization by sending monthly reports of process improvement activities and projects to corporate and hospital executives. Process improvement staff also share what they learned from similar projects or activities when a process is being replicated, furthered, or customized at a new location.

External dissemination. The executive leadership of the organization, particularly the CEO, stated that they felt an obligation to share their findings and experiences widely, not only so others can learn from their experiences, but also so they can get different viewpoints. A number of avenues have been used to share findings externally:

• In 2006 a week-long International Lean Healthcare Seminar implementing five projects with health care professionals from 18 hospitals and health systems and four countries.
• Meetings for outside organizations to hear reports from LHC executives on different process improvement projects.
• Travel by executives to Scotland to share Lean activities with the National Health System.
• Promotion by the architecture firm that worked on Lean to disseminate how the firm uses the Lean tool.
• Presentation by a management engineer and two frontline staff (at the suggestion and with the support of executive hospital sponsors) on the Bed Flow Value Stream project at the Institute for Healthcare Improvement (IHI) and the GetWellNetwork Users Conference.

"We approached the design process from the very beginning in a different way. The mandate was that we were going to build around process. We are not going to have process fit into the building. At the beginning, we did not really know what that meant .. that was given to us as a challenge to figure out." —Corporate Executive "Our vision is to transform the patient experience, providing world-class health care right here in our local community. With the best physicians, most advanced facilities and the next generation of technology and processes, [LHC] will be able to ensure that our patients have the best outcomes possible." —Corporate Executive

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Lean Hospital Project

Horizon Hospital

Brief Description of Project and Project Goal

The goal of this project was to build a new hospital designed around process with a focus on improving care for patients and their families. To design the building around work processes, LHC used Lean concepts, tools, and techniques.

Description of Department/Unit Where Implemented

In October 1998, a health system that included Hospital 2 and a second health system consisting of Hospitals 1, 3, and 4 merged to create LHC. Senior leadership felt it was important to build a consistent culture and strategic plan for the newly formed organization. In 2002, an external consulting group developed an overall strategic plan that called for developing an LHC North and a combined LHC South. However, a financial assessment of the plan indicated that sufficient financial capital was not available to consolidate the three hospitals and create an LHC South. Instead, the organization planned to replace or renovate individual hospitals, beginning with Hospital 4. It was chosen to be first because it was at full capacity; the site was landlocked, limiting opportunities for expansion; it had only semi-private rooms; it lacked the technological infrastructure to support digital medicine; and the existing infrastructure was considered costly and inefficient.

Project Staffing

The Horizon Hospital project was staffed very differently from typical Lean projects given its size and scope. Support from employees at other LHC hospitals and at the corporate level helped the processes and leadership of Horizon to remain internal, since they had to continue to meet the demands of their usual jobs in addition to Horizon Hospital activities. LHC's corporate executives provided overall support of the project. A hospital steering committee led by Hospital 4's COO was created. Hospital 4 executives, a Six Sigma Black Belt, and a management engineer were identified as the point persons to lead the overall Horizon construction and transition. 

The overall Horizon construction and transition was divided into nine management areas. The leadership structure for the Horizon project and each of the nine management areas is shown in Exhibit 6.10. Our focus is on the process transformation aspect of the transition. The major process transformation projects (i.e., NICU, emergency room, labor and delivery triage, short stay or "hotel space," and equipment depot) were housed under the process transformation management area. Process transformation was led by a management engineer and a Six Sigma Black Belt. Larger process transformation projects were staffed by a management engineer and members of the department where transformation was taking place.

Planning, Implementation, and Project Selection 

Planning for Horizon Hospital and implementation spanned several phases, including design and building, process improvement preparation, and move-in. Several tools were used throughout the process as shown below in Exhibit 6.11.

Design and building. Senior leadership visited nine hospitals across the country to learn how they approached building new or replacement facilities. A steering committee of board members, senior leaders, and physicians was established to select an architectural firm. Working with the consulting firm, the steering committee prepared a request for proposal in 2005, which included a "test" or sample project that asked the architecture firm to apply Lean tools to a workflow assessment. LHC provided data to the firms to help them determine sizing and capacity. Responses from the firms ranged from 6 million to 12 million square feet and 291 to 396 beds. Firms that effectively used Lean tools found that fewer beds and less physical space were necessary to meet demand. This scenario analysis was used as part of the overall selection process. In March 2005, an architecture firm was selected.

Between June and September 2005, LHC studied patient and staff experience and current-state mapping and technology roadmaps. Approximately 400 physicians, staff members, and patients participated in focus groups to identify concerns with the current hospital that could be addressed in the new hospital, as well as to identify the hopes and desires for the new facility. During the summer of 2005, frontline staff and patients were given disposable cameras and asked to use photojournaling to document issues they saw in their areas.

Next, to identify areas for process improvement teams from each clinical area including a physician representative; if appropriate, a department leader (usually the nursing director); and an assistant nurse manager worked with a management engineer or Six Sigma Black Belt on process mapping. The process maps developed by teams from each clinical area helped inform the architecture firm as they drafted the design for each department. The teams viewed options for the designs and, together with the management engineers, evaluated the floor plans between October 2005 and January 2006 using current-state, future-state, and spaghetti maps. Key considerations for the design options were:

• Optimizing space utilization.
• Reducing staff movements or distance traveled to increase time at the bedside.
• Improving clinical quality and safety by building workspaces that facilitate the delivery of effective care.

Traditional hospital structures and layouts were altered to better serve patients and to employ a process-focused Lean design. One example of the process-focused Lean design that encouraged a move away from traditional hospital design was observed in the location of the pharmacy and equipment depot. Typically, these frequently used services are on the first floor or basement of a hospital, but to reduce time and distance traveled, the new facility located these services in the middle of the hospital on the fourth floor. In some cases, the focus on serving the patient superseded staff desires.

Serving the patient went beyond patient satisfaction. Another key consideration in approaching the design was the integration of evidence-based design into the planning of the building. Shifting from a traditional, large, one-room nursery layout to private patient rooms in the NICU is an example where the evidence showed potential benefits to the patient (e.g., reduced infections, individualized and customizable environments) and superseded the staff's desires. The traditional nursery layout was more efficient for staff, since it allowed the nursing team to work together in one large room. Nonetheless, senior leaders made the decision to build private rooms using the evidence on hand and information from site visits to similar hospitals that used the proposed layout. The staff was asked for their input on the layout, but the decision to build private rooms was not changed. Other applications of evidence-based design were also evident: to reduce noise in the halls, LHC installed carpet in the main hallways. LHC also explored with their architecture firm the most effective products to prevent spread of infections.

Sample rooms were built in the existing hospital for staff to experiment with and provide feedback. Based on feedback from the staff, a pocket door connecting adjacent NICU rooms was added to the design of the unit so that parents of twins could visit with both babies at once. Based on current safety design practices, LHC determined that each room should have a window onto the internal corridor, which would be visible from a nursing station so that nurses could observe patients better. However, the use of sample rooms and feedback from patients enabled designers to determine that this feature was not appropriate for postpartum rooms, because it reduced the mother's privacy. Thus, the postpartum rooms were altered from the standard medical-surgical design to move the bathroom to the front of the room, even though it would impede clinical staff visibility from the hallway and nursing station.

Process improvement/project selection. Teams from each clinical area identified areas for process improvement. Management engineers, Black Belts, and executives each reported a different number of processes across the hospital, with reports ranging from 60–200 processes. Most processes did not require extensive Lean or Six Sigma projects; rather, simple process changes required only a quick decision by management or a 1- to 2-day Workout with a small team of staff. The management engineers and Black Belts worked with the then executive vice president of health services to prioritize the identified projects. Priority was given to major projects, which required more resources from the process improvement department. As part of process transformation, major projects mentioned by interviewees were:

• Neonatal intensive care unit (NICU). Additional beds were being added to the hospital, and there was a shift to individual rooms from a large, centralized nursery format.
• Emergency room. The adult and pediatric emergency rooms were separated in the new hospital and required patients to use separate entrances.
• Labor and delivery triage. Women thought to be in labor would be evaluated in a new triage space adjacent to the ER, rather than being brought up to the labor and delivery floor.
• Short stay or "hotel space." To save space and beds, LHC created an intermediate, distinct space for patients who were either placed under observation in the ER or were recovering from outpatient services and needed to stay in the hospital for just a few hours before being discharged.
• Equipment depot. Centralized equipment management space was created in the new hospital. Previously, the equipment was decentralized.

As part of this study, we also looked closely at the NICU and at the changes in how nurses on the medical–surgical units had to work given the structural changes in the hospital.

Move-in. The Management Engineering Department was charged with planning the move-in process instead of using outside consultants. The move-in was planned using an electronic program built by the management engineers. In the weeks prior to the move, internal staff from every department ran three table-top simulations and then conducted three live dry runs with staff and volunteers acting as patients.

The final two live dry runs included outside vendors, such as the ambulance services that transported patients to the new hospital. Several issues were identified and solved as part of the simulation process: improving communications among staff and emergency service technicians; identifying the best tools for communication given a lack of cell phone coverage; and making sure that emergency medical services and ambulance staff felt comfortable navigating the new hospital.

In the first live dry run, radios were put on the same channel, and communications broke down, leading people to "chase" each other around to communicate. They were able to correct this in the second dry run. This final live dry run, conducted a week before the move-in, went smoothly and was described by process improvement leadership as "a morale booster," giving staff the confidence that the move-in process would go smoothly.

LHC planned to reduce the patient census to 225 patients to ensure the move could be completed in 8-9 hours, but because of careful planning, only 149 patients had to be transported to the new hospital. The move was completed on May 22, 2011, in less than 4 hours. All interviewees, representing all levels of the hospital, reported that the move-in process went smoothly, and nearly all stated that there were no problems. One management engineer reported that a woman began labor during the move, and an ambulance had a flat tire; but, because the team had planned and practiced for these contingencies, the move was not affected in any way.

Monitoring, Control, and Sustainment

Although quality improvement data have been collected in the new facility, the management engineers have only just begun to identify the measures for evaluating performance specific to the new hospital. Management engineers and two hospital executives stated how important it was to allow staff to settle in to the new facility and become comfortable with the new processes before assessing performance.

As of the final site visit in September 2011, the new facility had been open for just over 4 months; since the monitoring phase had only just begun, no information on sustainment monitoring is available. Currently, there are no plans for additional process improvements or Lean projects at the hospital. However, some design changes had to be made to processes that were found not to work immediately after the move-in. For example, the supply rooms were not all the same size—there were two sizes—thus, they could not be standardized as planned. Four supply rooms were built into a 24-bed unit with supplies for six patient rooms per supply room. All the necessary supplies could not be accommodated in the smaller rooms. Rooms were standardized by supply type so that there were two distinct linen rooms and two distinct rooms with all other patient care supplies. The distance nurses walked was minimally impacted.

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Outcomes of Lean 

Given that the evaluation is just beginning, information on outcomes in the Horizon Hospital initiative is limited to primarily qualitative data. Information on culture, employee satisfaction, efficiencies, clinical process or outcomes assessment, patient safety, and patient satisfaction is presented. As shown in Exhibit 6.12, intermediate outcomes include culture change, employee satisfaction, change in Lean knowledge and skills, Lean routinization, and dissemination. Ultimate outcomes include impacts on efficiency, patient satisfaction and experience, clinical process and outcomes assessments, and patient safety.

Intermediate Outcomes

Organizational Culture Change

Application of Lean techniques. In referring to the Horizon Hospital, a senior executive noted that Lean and Six Sigma have been engrained in the staff over 9 to 10 years, making them an integral part of the culture. Staff may not know the Lean vocabulary, but they are able to exercise Lean techniques when "attacking problems," according to two other senior executives. A frontline staff person further explained that prior to the move, staff were entitled to speak out and make suggestions for modifications of processes. Each offered an example of how staff improved processes of their own accord; one described a process related to equipment maintenance, and the other referred to patient discharge. In an example that occurred following the move, an executive described how staff recognized, despite their best planning efforts, that the supply rooms were not laid out exactly the same way in the new hospital. Groups quickly worked on standardizing the supply rooms, essentially applying 5Sⁱⁱ to make their jobs easier and more reliable. A management engineer noted trust in Lean has created a process driven facility and attributes the trust in the Lean process to experiences with good outcomes.

Improved teamwork and camaraderie. The Horizon Hospital project has brought about a sense of shared pride among staff, as reported by a management engineer. Researchers observed excited staff touring the new hospital proudly wearing "Extreme Hospital Makeover" T-shirts. Because the hospital move involved every staff person at the hospital, there was increased exposure to the process improvement and Lean tools and concepts that were incorporated into the design of the building. All of the interviewees at all levels of the organization were able to discuss elements of the design that improved efficiencies or reduced waste, as intended by the Lean design.

Employee Satisfaction

Only anecdotal evidence is presented on employee satisfaction, since the latest annual employee satisfaction survey was administered just prior to the move. (According to one executive, this most recent survey found overall employee satisfaction to be at 93 percent.) Anecdotal reports on employee satisfaction were most often in reference to the physical layout of the new hospital.

Reviews of the decentralized unit layouts have been mixed, with physical isolation of frontline staff being the source of most comments. An executive noted that the patient care unit design isolates both staff and patients using the example of a U-shaped hallway that prevents staff from seeing end-to-end. Two frontline staff felt that the nurses are still getting used to the decrease in communal workspace, with phones replacing face-to-face contact as the means of communication. Although interviewees from the NICU did not express dislike of the redesign placing each neonate in a separate room, they were less enthusiastic about their work environment compared to other staff.

The NICU's higher census (more than 40 neonates) and workload have contributed toward the slow adjustment, according to two frontline staff. These two frontline staff had the toughest critique of the new hospital, stating that a number of their peers left the new, more physically-isolating work environment. They estimated a 10 percent turnover in staff following the move, with some nurses leaving who were close to retirement, while others sought employment elsewhere. One of the frontline staff knew of five per diem nurses who left in anticipation of the move. The layout was said to be one factor in their decision to leave, but other changes such as a new electronic medical record, new bar code scanner system, and added educational requirements were also mentioned.

"They said they had a 10 percent turnover rate after they moved. There are some people that are just not meant to work in this environment. We had so much going on… and now the move on top of it. They just couldn't keep up." —Frontline staff person

On the other hand, another frontline staff person saw the new floor design as favorable because the natural segregation of space provided room for everyone, from nurses to physicians; physicians now had their own documentation room. One frontline staff person believed that her peers had a better understanding of Lean processes and, in understanding the purpose of the unit setup, they were able to propagate Lean moving forward.

Some hospital leaders believed staff were accepting of the new layout. A senior executive commented that the nursing manager and staff are happier because the new layout reduced chaos, creating a more conducive "staff experience." A Six Sigma Champion/Mastered Black Belt echoed this, noting that a quieter work space facilitates more focused thinking.

A management engineer commented on physicians' mixed feelings about the layout; they were used to one big gallery where staff are centralized at the nurses' station. A senior executive stated that physicians now have greater access to computers and are incorporating technology into their workflow to optimize their work. Although they may be covering more distance due to the new layout, they are able to complete their rounds in the same time as before because of the efficiencies gained from technology.

Despite the concerns about the patient care unit layout, one senior executive described the increased sense of staff pride from those involved with the design of the new hospital; he noted how everyone seems to love the technology being located in the patient's room, so they no longer have to push mobile computing devices around. He believed the NICU staff have embraced the new model of care.

Soon after move-in to Horizon, staff representing all levels reported that a major complaint of frontline staff was the distance from the staff parking lot to the hospital. In subsequent interviews, a management engineer reported that the complaints about parking have "settled down," and parking is no longer a problem.

Lean Knowledge and Skills

The hospital move involved all hospital staff, and there was widespread exposure of staff to process improvement and to the Lean tools and Lean concepts that were used to design the building. This immersion into Lean was designed to give staff the opportunity to apply Lean over a period of time, deepening their understanding of how to put Lean into practice. Although staff were not necessarily articulate in using Lean terminology, they were able to independently apply Lean techniques to solve problems that arose in their daily work.

"For the staff in general, I'm hoping it manifests itself in engagement but I would describe it as pride. There's definitely a higher level of pride for the folks who lived through the last 3 years as we've been designing and developing and seeing it come to fruition." —Management Engineer

Lean Routinization

Although there were few specific comments in regards to the Horizon Hospital and routinization, a management engineer did cite the Horizon Hospital in the context of standardizing practices across all of LHC's hospital campuses. Practices will be standardized to match the most efficient campuses, with Lean events prioritized and implemented to support this strategy.

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Ultimate Outcomes

Efficiency

In building Horizon Hospital, executives (both corporate and hospital level) and process improvement professionals reported that they were able to efficiently use internal resources, thereby saving considerable expenditures. As a result of having management engineers and Six Sigma Black Belts in-house, no consultants were hired to support the overall planning process related to work area layout. In addition, according to respondents, careful planning of the building and frequent and early check-ins helped keep change order costs during construction to a minimum. Clinical flow change orders typically occur when changes are made that impact the design significantly. Often, the change orders occur when the clinical flow processes are determined retroactively, after the design work has been completed. LHC used this savings to fund Horizon Hospital projects that were scheduled for a future date.

Executives and engineers reported that the hospital move-in went smoothly and took nearly 2 hours less than expected. Frontline staff agreed that there were no major issues with move-in.

Patient Safety

At Horizon Hospital, managers expected that the use of private rooms, including the NICU rooms, would lead to a reduction in infection rates. However, in the first few months after opening, the NICU reported higher infection rates than expected. Frontline nurses and department leaders believe this could be attributed to increased patient volume and changes to the care processes. For example, the staff frequently communicated with each other using face-to-face and non-verbal signals at the old hospital, but they switched to cordless/portable phones at the new hospital. This practice may have led to the transmission of infections between patients. Two frontline staff mentioned that in the new NICU, visitors were asked to scrub before entering the baby's room rather than when entering the unit, as was done before. Scrubbing by visitors could not be monitored by staff with the use of private rooms because nurses may be in another patient room. To remedy the problem, visitors are now expected to scrub before entering the NICU, and then, they are asked to apply sanitizing gel to their hands before entering the neonate's room. A script was developed for unit secretaries to enforce this process as they let visitors into the NICU.

Another issue brought on by the new decentralized layout relates to team work. A nurse manger pointed out that in the old unit, nurses could look over and see that a colleague needed help. Since babies are now kept in separate rooms, nurses have to adjust to using the phones and asking for help. The separation of staff reduced the opportunity for nursing staff to talk with colleagues and ask questions or discuss difficult patient problems.

Patient Experience

A few executives reported that the patient experience survey showed improved patient experience in the initial months after Horizon Hospital opened, particularly in the reduction of hospital noise. Several staff at all levels of the organization reported how quiet the hospital is and that patients had expressed concern over the lack of noise indicating that people might not be nearby. A management engineer discussed how the hospital structured the individual rooms to have a distinct area for visitors as part of a greater focus on family-centered care, which may have contributed to the reduction in noise.

Business or Strategic Case

Executives (both corporate and hospital level) and process improvement professionals reported that in building Horizon Hospital, they saved substantial amounts by using internal resources, careful planning, and Lean tools. A typical health care construction project of Horizon's size incurs clinical flow change order costs in the range of 3-5 percent of project costs, usually built into the total project costs. The change order cost for LHC was only 0.35 percent of total project costs and 0.50 percent of total construction costs. Given these figures, the savings at Horizon Hospital accounted for 2.65-4.65 percent of the total project costs of over $434 million.

Other savings came from the use of in-house staff. Corporate executives and management engineers reported that they received multiple quotes of upwards of $2 million to plan and facilitate the hospital move-in process; instead, they used internal process improvement staff resources to plan the move-in, with internal staff and a limited number of contractors executing the plan.

There were no expectations of a reduction in the hospital's ongoing operational budget from increased operational efficiencies because of the larger size of the facility (three times the space of the old hospital), and the anticipated increase in patient volume. Cost per discharge remained unchanged; the increased patient volume compensated for the additional costs associated with running a larger facility and hiring more staff. The increased patient volume was the result of patients from areas outside of the original hospital's usual market now being seen at the new facility.

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Factors that Influenced Success of Lean Implementation 

During site visits and interviews, staff at all levels were asked to name the two or three greatest contributors to success, as well as the problems or challenges they had witnessed or faced in using Lean processes and tools to design, build, and ultimately work in a new hospital (Exhibit 6.13). Findings regarding facilitators and barriers are based on responses to these questions and on interpretation of findings overall by the research team. Unlike other cases, barriers and facilitators were mentioned equally, and no real barriers or facilitators stood out as prominent themes across interviewees. In our other case studies of Lean, barriers were usually mentioned much more often than facilitators. Senior executives, management engineers, department leaders, and other hospital leaders provided the greatest amount of information regarding these issues.

Here, we discuss the factors mentioned by interviewees, noting how they operated as facilitators and/or barriers in designing and executing the Horizon Hospital project. We also link lessons learned to these facilitators and barriers.  

Overall, only a few key barriers and facilitators emerged in the Horizon case. Using the categories identified in the conceptual framework, alignment of Lean to the organization, leadership, resources, and staff engagement were the most frequently mentioned facilitators. Employees mentioned barriers that were related to resources, communication, and staff engagement. We have organized this section by first providing a summary table of Major Factors that Facilitated Lean Success (Exhibit 6.14), followed by Major Factors that Inhibited Lean Success (Exhibit 6.15).

Organizing the Lean Initiative

In this section, we discuss barriers, facilitators, and lessons learned related to organizing the Lean initiative. The most frequently discussed facilitator was related to alignment of Lean to the organization. A key barrier involved difficulty in staff understanding how to use Lean to design processes in a facility that had not yet been built.

Local Environment and External Context

One senior executive indicated that increase in demand for patient services played a role in the need for hospital enabling efficient processes. This interviewee stated that efficiency is required for the new hospital to meet the anticipated increase in patient demand. However, this interviewee also warned that the new hospital could pull patients away from other LHC hospitals.

Upon opening the new Lean Hospital, patient volumes did increase much more than anticipated. Consequently, LHC had to reallocate and hire additional staff to meet this demand. One physician manager noted how adding the additional staff and moving away from planned processes was a juxtaposition to being "Lean and mean."

Alignment of the Lean Initiative with the Organization

According to many interviewees across all levels of the organization, process improvement is ingrained in LHC culture. Embracing this type of culture was critical to the successful design and execution of the Horizon project. Senior executives noted that many frontline staff are using the Lean tools, such as checklists and standardization, on a daily basis. Senior executives noted that staff may not even realize these tools are part of the Lean methodology. Senior executive interviewees also emphasized that Lean thinking is ingrained into the organization. Alignment of Lean to the organization's culture was only mentioned as a facilitator by interviewees; none of the interviewees indicated that alignment of the Lean initiative was a barrier to success.

Scope, Coordination, and Pace of Lean Activities

Management engineers suggested that the rapid pace of Lean projects in designing Horizon Hospital may have facilitated the move in to the hospital. The project plan required that the design projects be completed by 2011, allowing nearly 6 months to test new processes in the current (old) hospital before the move. This additional time was provided to eliminate the stress of simultaneously trying new processes, moving into the hospital, and adjusting to the hospital post-move-in.

"When we talk about the culture at LHC, the culture is really one that states that we embrace change as an organization. We look for opportunities to change in a positive way." —Senior executive "I have had CFOs come to me and say, 'Okay what's the bullet point for your financial success in your ability to build a $463 million hospital?' It's almost like they just want a bullet point outline that they think they can take back and implement. It doesn't work that way. First of all, it starts with culture. Everybody has to be on the same sheet of music…you've got to have a cultural alignment. … For us, it is the cultural transformation initiative—that people mean everything." —Senior executive

Applicability of Lean to Processes and Loci of Activities

One department leader who played a role managing the Horizon Hospital project noted that staff were particularly challenged in designing Horizon. This interviewee noted that it was difficult for staff to envision building a space around processes instead of traditionally building the processes to fit the existing spaces. These challenges also required the use of additional tools outside of the Lean toolbox. These challenges also required the use of additional tools outside of the Lean toolbox. In particular, a frontline staff member and a physician manager indicated that design of the new NICU required use of a Six Sigma tool, known as "design for Six Sigma." This tool helped guide staff in the creation of a NICU with private patient rooms, in lieu of a central nursery.

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Implementing the Lean Initiative

Major facilitators and barriers to implementing Lean were related to leadership qualities and activities, level of staff engagement, resource availability, and Lean team composition and size.

Leadership Activities and Qualities

Leadership activities and qualities were mentioned by numerous interviewees across all levels of the organization as facilitators to designing and executing the Horizon project. Despite being asked explicitly, none of the interviewees suggested that leadership at the senior or project level was a barrier to using Lean to design Horizon Hospital.

"From the leadership perspective, it has to start at the top. This is not like the Quality Department where you delegate it to an area and say, 'take off.' This has to have the support of senior executive leadership to be effective because it is part of the dynamic change." —Senior executive

Nearly one-half of interviewees, mostly senior executives, management engineers, and department leadership noted that "Lean starts at the top." These individuals indicated that senior executives at LHC enforce and engage the use of Lean, visibly showing commitment to the process improvement toolkit. This support, in turn, gives staff confidence to try something new and trust that the data presented to them means that what is being proposed will work or is working. A department director commented that if employees "have their information and ducks in a row, they are given support including the needed resources to figure out a solution to a problem."

A few interviewees also noted that project-level leadership facilitated successful implementation of new processes at Horizon. These project leaders—specifically process owners and department leadership—held other staff accountable for adherence to the changes and ensured sustainability of the Lean successes. This accountability and commitment to the Lean changes was critical to ensure the new processes were maintained. An executive commented that having high performing staff on the team to role model implementation of a new process was critical for achieving uptake among other staff.

"It is hard to change people so you have to stay on top of them. Someone that can actually enforce the [new] process. If you have a weak leader, they won't do that, they'll go amok." —Executive

Communication About Lean

A process improvement department lead noted that building the facility required considerable communication between architects and medical staff. Management engineers served as translators because they understood the organization and had an engineering background that was useful in communicating with the architects. Both department leadership and management engineers noted that this ability to communicate between the architects and staff was critical to the successful design of Horizon.

"One of the things that saved a huge amount of steps for everyone was having a thermometer in every room. That did not initially translate over here. If one of us had not been involved in a Kaizen at another division [we would not have known]." —Administrative director

Another department leader noted that communication of best practices is sometimes a struggle across the organization. Because the organization is so large, changes or best practices from one unit are often not translated to another unit. According to this interviewee, the size of the organization also results in a struggle to keep all staff informed of Lean changes.

Staff Engagement

Nearly all senior executives and management engineers provided insights on staff engagement in the Horizon process. A few senior executives and management engineers indicated that getting more people involved in designing the new processes garnered more ownership in processes designed into the new hospital. Personal involvement did not always result in support of changes. One frontline staff person indicated that some NICU staff did not see the benefits of private nursery rooms. However, by the time the new hospital opened, a manager reported that some NICU staff who were resistant accepted that there were theoretical positive improvements in the design for patients and their families. Shifting of sentiment continued after move-in with other staff who were positive in the planning phase becoming less so as they experienced the new layout first hand.

"Staff were probably 50/50 with mixed feelings about the new NICU. As we started with our work out and [were] getting closer… we were probably about a 60/40 ratio of staff eager to go and staff not very ready to go. And it has flipped… some NICU staff have been a little more negative, not about the private rooms, per se, but just the layout itself, not that many… maybe 10 percent now." —Nurse Manager

Senior executives also indicated that flexible structures were necessary to ensure all types of staff, particularly community physicians, could be involved in the design of Horizon. Because community physicians were not involved in the longer Kaizen activities, LHC created ways for physicians to provide input in processes outside of the traditional Kaizen. As described by LHC executives, physicians were involved at key junctures in decisionmaking, giving the sense of physician ownership. This flexible process allowed for input but also was respectful of the physicians' time away from patient care. One executive noted that involving physicians required judgment, since a balance had to be achieved between using their time judiciously while being sure to include them. An important piece was to make sure physicians were aware up front of what LHC was trying to accomplish.

"In the planning process, the physicians were very engaged. They had input right from the very beginning even to the point of taking field trips when we were looking at other new hospitals… They felt like they had had a significant amount of input." —Executive

Finally, a few executives indicated that the excitement of the new facility "recharged" individuals and made them excited to participate and be a part of the Lean hospital design process.

"I think the excitement of the facility definitely helps. Staff wanted to be a part of it and most of these guys, even if they've been working for 50 years, have not been involved with a new building being built and moving." —Management Engineer

Education and Training

None of the interviewees mentioned education and training as a barrier, facilitator, or lesson learned.

Lean Team Composition and Size

Nearly one half of interviewees across all levels of the organization noted that each Lean team must have the "right" people. Interviewees described the "right" people as individuals who are most involved in the process, including team members from different disciplines. The notion of having the right people on the team was particularly important in the design and execution of the Horizon project; several interviewees indicated that partnership between the architects and Lean team members was a critical facilitator for success. Two interviewees described a project where all critical parties weren't represented at the table. Communication between the LHC Lean team and the architects failed, resulting in equipment distribution problems to the NICU when Horizon Hospital first opened.

"Key drivers to success are, one, having scientific thinking behind it. Two, making sure that you're involving the majority of the people who are going to be impacted. Without these two, we could not have made any change. We could have told the architects to do what they do best and just sit." —Management Engineer "I would tell anybody in this kind of project with this size and scope that if you have access to an internal talent pool to do it yourself, do it yourself. Pull the expertise that you need where you need to apply it, where you know that you've got gaps and bench strength. Where you need to pull in people from the outside, learn and be constant learners. Learn from others in terms of what their experiences are." —Executive

Finally, in designing Horizon, executives also indicated that staff, physicians, and even patients must play a role in designing the new hospital. As noted above, these interviewees believed that Horizon was successful because of the partnership between the architects and other critical stakeholders who were part of the Lean teams.

Availability of Resources

Barriers related to the constraints on staff time were mentioned by nearly all interviewees. Nearly one-half of interviewees across all levels of the organization mentioned that getting release time for staff and management engineers to work on the new Lean Hospital process was difficult due to competing responsibilities. One executive noted that the demands on the leadership team were more than expected; this may have led to a decrease in patient satisfaction but not quality in the last year of the project. As the intensity of planning for Horizon and move-in increased, mangers were not able to round on patients as frequently and work with staff.

"Now as the work kept piling on and on and on and there was intensity, were there periods of meltdown behind closed doors? Sure, but that's okay and I encouraged each one of them that way. I said, 'It's okay. At any given time it's hard not to feel overwhelmed because of the size and the scope of this, but it's okay because we have the support of the network and of each other, number one, and we have the tools and the resources to pull it off.' And we did." —Executive

An executive even noted that designing Horizon was sometimes marked by "periods of meltdown behind closed doors" because employees were overwhelmed. Additionally, while resources were already strained, leadership turnover exacerbated the issue. During the design of Horizon, two management engineers and one administrative leader left the organization. Work teams were able to recover because of the ability of other management-level employees to fill in. In addition, much of the process design work had already been done. Replacements were always found with someone internal who understood Lean.

Several senior executives indicated that the management engineers were a resource that greatly facilitated the design and move-in to Horizon. Management engineers brought unique skills and a different lens for viewing process issues. This lens came from having an engineering background as opposed to "growing up in health care," as most other employees of LHC have done. Retention of management engineers was becoming a problem, according to the engineering department leader. Competitors were developing management engineering programs and offering attractive salaries and management positions. Unlike the LHC case study ( ), frontline staff did not mention the management engineers as being an important asset to the design and move-in process at Horizon Hospital.

"I think we are blessed to have our management engineers. That program is phenomenal. They are of extreme value and it has been demonstrated overall. They provide sufficient savings on not only current operations but designing your future operations." —Executive "We really take the best and the brightest at [LHC] and they are management engineers." —Executive

Finally, resources emerged as a barrier after Horizon was opened, as staffing resources were not adequately planned for in the new hospital. Several interviewees noted that the census in the NICU was much higher than anticipated after the opening of the new Horizon Hospital. Instead of the planned census of 32 patients, there were 44 patients. Accordingly, the NICU was understaffed, creating challenges in the management of the department as a whole. New staff had to be hired to orient and handle the unanticipated volume. Plans to have staff run a new room for stabilizing neonates, which would facilitate moving babies into NICU beds as they improved post-delivery, were scrapped. Instead, stabilization room nurses were assigned to staff NICU beds.

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Conclusions

LHC uses Lean methodology as a process improvement tool; as Lean became core to LHC culture, the methodology became a way of thinking, empowering staff to continuously improve. Since Horizon was still quite new during the last set of interviews and adjustments were still occurring, fully assessing outcomes from the Horizon planning process was premature. Overall, in the process of designing the new hospital using Lean principles, interviewees seemed to be concerned with the strain on staff time and with ensuring all necessary staff and patient voices were being involved in the design process. Further complicating matters, LHC experienced turnover of key management engineers and administrative personnel during the latter half of the process redesign process. LHC was able to adjust staff to keep the planning process moving forward. Since opening Horizon, meeting the demands of a growing number of patients and services is a top priority. Applying Lean tools and Lean thinking to unexpected problems has helped staff manage change.

Recommendations suggested below emphasize LHC's experience in designing Horizon Hospital and also address strengths and barriers faced.

Recommendations for Similar Organizations Using Lean Principles to Design a Hospital

• Ensure the culture of the organization supports readiness to undertake building a hospital on Lean principles. Interviewees indicated that designing a hospital around processes was a challenge for staff. However, LHC was able to meet these challenges because of the strong cultural underpinnings in process improvement and Lean thinking. According to LHC management, the culture supported the readiness to undergo this massive endeavor.
• Engage a team of architects who will open lines of communication to staff. LHC put extensive effort into the selection of their architecture firm. In turn, the architecture firm ensured that LHC staff were involved in designing processes, which led to the final hospital design. A key tenet of success involved the open communication between architects and staff.
• Engage management engineers to facilitate the process. The availability of in-house management engineers was central to the successes experienced at Horizon, including the cost savings that occurred. They served as a bridge between the architects and Lean teams, planned the move-in, and facilitated the process redesign work.
• Do not allow the Lean process to depend on any one person. During the planning and designing of Horizon, LHC lost several critical leaders supporting project teams. However, according to LHC leadership and management engineers, the planning was transparent and clearly laid out, allowing existing staff to continue with the planning process.
• Create flexible structures that allow physicians to engage in the Lean process. LHC ensured that community physicians were able to provide input throughout the process. Even though these individuals could not participate in lengthy Kaizens or other Lean projects, LHC obtained physicians' input ad hoc and at critical junctures. Physicians were kept informed about the project by LHC's leadership throughout all stages of the process.
• Allocate sufficient time for practice. Management engineers and managers put in a significant amount of time simulating the move into the new Lean Hospital and educating staff on the move-in protocol. This planning and training ensured a relatively smooth move-in to the new hospital and increased staff confidence in the move-in plan.
• Understand that more efficient processes may lead to unintended consequences. After the move into Horizon, nurses in the NICU were still struggling to adjust to the redesign of their unit and the increased patient load. The new layout improved efficiency and patient care, but it created unintended consequences on staff communication and infection control.
• Listen to frontline employees' concerns and offer strong support in the months following a move into a new hospital. Moving into Horizon was a major change for nursing staff that was not always positive. Some processes did not work and needed to be redesigned. Loss of staff coupled with increased patient volume resulted in staff shortages and the need to continue putting forth extraordinary effort. Leaders should recognize frontline staff for their commitment and be particularly attentive to their concerns in the months following the opening of a new hospital.
• Provide resources to support ongoing continuous improvement. Although staff report that Horizon Hospital has shown success in the initial months since opening, continuous improvement must occur as soon as possible. This is especially true in areas where the greatest changes occurred and where staff are facing unexpected challenges.

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^ee. Note that some of the background text presented here is duplicative, at least in part, of similar information presented in Case 1. Because it is central to a discussion of this case, we have elected to present it again. Readers who are familiar with LHC may wish to proceed directly to the discussion focused explicitly on Horizon Hospital.

^ff. Six Sigma is a process-improvement technique that seeks to improve the quality of process outputs by identifying and removing errors and minimizing variability.

^gg. Workout is a gathering of organization stakeholders designed to discuss and take action on major issues.

^hh. CAP is a technique comprising best practices in organizational change management.

^ii. 5S is waste elimination through organizing workspace by sorting, straightening, scrubbing, systematizing, and standardizing.

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