This report presents the results of the study of Lakeview Healthcare (LHC) and its experiences implementing Lean. Five projects—Bed Flow Value Stream, Lean Hospital (LHC Horizon), Outpatient Medical Records and Patient Flow, Outpatient Electronic Health Records, and Surgeons' Preference Cards—were selected for study. In addition, we studied two specific process changes implemented at the LHC Horizon to enrich our findings. The case study methods, including the criteria for selection of the projects for analysis, are described in the Introduction to the Case Studies.
To develop this case study, we conducted 67 interviews with a total of 65 individuals. Their roles at the hospital varied, as described in Exhibit 1.1.
An overview of LHC appears in Exhibit 1.2. LHC is a nonprofit, comprehensive health care system. 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. LHC was established in 1998 when four hospitals merged. In the same year, a new chief executive officer (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.
LHC offers numerous specialty services, with a strong focus on obstetrics. LHC provides neonatal intensive care as well as 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.
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 (called in this study "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 (Exhibit 1.3).
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 star. Executives and management can receive a 10 to 40 percent incentive based on the five points of a cultural transformation initiative, which are the basis for setting management goals and objectives.
Case 1 study included projects implemented at several hospitals, an ambulatory care center, and the physicians' offices as described in Exhibit 1.4.
Also included in our study was a comprehensive LHC Outpatient Medical Facility serving a different city and surrounding communities. The Outpatient Medical Facility offers primary care, dental care, and a variety of specialized care. All physicians there are community-based and not employed by LHC.
Finally, we also studied LHC Medical Group, which includes both primary and specialty care physicians' offices. Physicians who are part of the growing LHC Medical Group are employed physicians of LHC. As of May 2011, there were 32 medical groups, employing about 200 physicians.
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
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,i and noted 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. It does not receive incentives from its payers for their involvement with Lean. Nearly 50 percent of its 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.
In this section, we discuss the history of both Lean and quality improvement at LHC. Exhibit 1.5 outlines the overall timeline. The specific activities noted in the timeline will be discussed throughout this report.
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 one that promotes trust and openness to encourage conversations about performance and 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, the organization began working with the consulting firm on process improvement through Six Sigma projects. The consulting firm, having developed deep expertise in process improvement based on work to improve manufacturing processes, began offering consulting services 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,j Change Acceleration Process (CAP),k 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 a leadership award from a national hospital association. LHC is the recipient of multiple awards made by a firm that showcases hospitals chosen by health care consumers for having the highest quality and best image.
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 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."|
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 through 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's [the project's] scoped out in terms of how it's going to be measured and how it's going to be reported."|
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
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 1.6. 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 study.
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]."
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 organizationally, they hoped 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.
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 by 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 and related training and technical assistance.
The two process improvement departments, Six Sigma and Management Engineering/Lean, are corporate departments that 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 and 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.
Exhibit 1.7 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.
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). 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 prework 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?"
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. Prework 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.
- 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 prework 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.
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 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 is 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 prework. Training on the tools is provided as needed while the Kaizen is taking place; in other words, it is "just-in-time" 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.
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 1.8.
The length of a Kaizen at LHC ranges from 1 to 3.5 days, and it 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, 2-hour sessions each day for 5 days ensure 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.
LHC has identified several formal roles for projects, as described here (and depicted in Exhibit 1.9).
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 their 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 the organization's 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.
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.
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; but 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.
Spread of Knowledge and Findings Across the Organization
To implement new processes on a particular unit, the Lean project teams shared with their fellow staff members what they had experienced. The Bed Flow Value Stream projects started in one unit, initially on one floor. The project teams used PowerPoint presentations to communicate the process and outcomes of the project to the unit staff. The project team answered questions from the unit staff, and then the process was rolled out on that unit. Every 3 to 5 days over the course of a month, the project team rolled out the process to new units. At Hospital 2, staff worked to break down silos that existed within the hospital by sharing information about the patient census on each floor every morning and evening. One corporate executive noted that not all projects can be replicated and standardized for critical nodes (i.e., a point at which pathways in the process intersect) if the solutions across units, floors, or hospitals are not congruent. Identifying those critical nodes is vital to encouraging standardization and to seeing where compromises can be made.
Although it was not linked to Lean, the new electronic health record (EHR) was introduced to staff in the outpatient physicians' offices through group trainings. Some physicians were given one-on-one training. One physician executive explained that until staff actually begins using the new technology or process, they might not be able to identify all of the problems or concerns and instead might "learn as you go." However, this was not the case for the Lean projects that were implemented and studied as part of this research, since the processes were tested in advance of wider dissemination and rollout.
More than 40 Kaizens 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.
|"I think you just have to be very, very clear, otherwise what will happen to you is you've got managers that will say, ‘I'm different. Everybody else is the same. See, you gotta treat me differently.' So you've gotta really focus on what are the nodes of the critical pathway that is truly critical to the optimization of the process."
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:
- A 2006 week-long International Lean health Care 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 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 at the Institute for Healthcare Improvement (IHI) and the GetWellNetwork Users Conference.
At LHC, we selected five Lean projects for study as shown in Exhibit 1.10.
Two projects—Bed Flow Value Stream and Horizon (the Lean Hospital)—were large-scale projects that required resources from across an entire hospital and, in the case of the Bed Flow Value Stream project, across the health system. As the work on the project was being completed, three projects were studied to better understand how the team approached project implementation and what factors lead to implementation successes and challenges. Two of the prospective projects, however, were not completed during the study period—Outpatient Electronic Health Records and Surgeons' Preference Cards. The third prospective project, Lean Hospital, was a study of designing a hospital, here called Horizon, using Lean principles; this project is presented in a separate case study. We studied two specific process changes implemented at Horizon to enrich our findings.
This report of Lean projects is organized by the scope of the project (large-scale projects or department-specific projects) and the stage of the project.
One cross-cutting project was studied. Information on the retrospective study of the Bed Flow Value Stream projects is presented.
Bed Flow Value Stream Projects
Brief description of the project and project goal. The goal of the projects that made up the Bed Flow Value Stream was to reduce bed turnaround time so that a bed is ready for a new patient as soon as possible after an inpatient is discharged. As a frontline interviewee put it, the goal was to "simply shorten the amount of time that a bed is out of service" and reduce the time patients spend waiting for a bed. The projects from part of this value stream were implemented during December 2007–July 2009.
Description of department/unit where implemented. The Bed Flow projects took place at all four hospitals in the system. They were implemented independently at each hospital, with different staff at each location, rather than as a single system-wide project. Hospital 1 began implementing the project in December 2007, followed by Hospital 2 in mid-2008, Hospital 3 in March 2009, and Hospital 4 in June 2009. Hospital 1 repeated the project in July 2009.
- Hospital 1 has 188 beds with a concentration in surgical specialties and invasive cardiology.
- Hospital 2 has 433 beds and is a full-service community hospital. Its Emergency Department (ED) sees about 77,000 patients per year.
- Hospital 3 is a community hospital that, at the time, had 295 beds with a primary focus of serving mothers and babies and a great deal of medical–surgical work. Hospital 3's medical–surgery occupancy rates ranged from 99 to 102 percent.
- Hospital 4 has 95 beds and is the smallest hospital in the system. About 95 percent of its admissions come through the Emergency Department rather than direct referrals from physicians. It provides care for almost all types of patients, except maternity and pediatrics. The hospital is home to the one of the first acute care units for the elderly in the region and considers geriatrics a niche market for the hospital.
Project selection. The management engineer noted that discharge planning is a major issue in most hospitals that needs to be addressed; another engineer noted that as part of the daily work, it is a clear opportunity for improved efficiency. Hospital staff at Hospital 1 recognized inefficiencies in their processes for bed turnover and the capacity issues that resulted. At Hospital 3, all admissions are through the ED, yielding a high average daily census and creating the need for faster transfer of patients from the ED to an inpatient bed. At Hospital 4, when another area hospital closed, it experienced increased volume, particularly in the ED. A frontline staff person and a hospital executive suggested that the focus on this issue likely came about as the result of frontline staff recommendations and followup by the leadership to bring in process-improvement staff.
Once the overarching issue was raised, leadership called on the process-improvement staff to conduct an assessment to determine where breakdowns in the process were occurring and what potential next steps might be taken; in this case, a Kaizen event was proposed.
Project staffing. The staffing of the Lean project teams for the Bed Flow projects at each hospital was similar but not exactly the same. As with all projects, each hospital's project included an executive sponsor, management engineer, and process owner. The process owner in each hospital was a medical–surgical unit administrative director. At least one hospital included three directors as process owners to engage nursing staff on multiple floors. Staff from different floors and departments were selected for multidisciplinary project teams by the executive leadership and department managers, as shown in Exhibit 1.11. In particular, staff from the ED, environmental services, and a few of the medical–surgical units were included on project teams. Only staff involved in the bed flow and discharge process were asked to participate. Thus, at Hospital 4, for example, transportation services staff did not participate because they did not have a role in transferring patients between units.
Planning and implementation. Management engineers' assessment identified delays in the bed flow process at key points and elucidated opportunities to change the current system from one where patients were being pushed out to the floors from the ED to one where the inpatient units were pulling patients from the ED. At Hospital 1 (first to implement), the Kaizen event lasted 1 week; however, subsequent hospital Kaizens lasted only 3 days. To identify the best process for communicating across so many staff, several tools were used, as shown in Exhibit 1.12.
To improve the communication and speed of inpatient transfer in and out of acute care bed units, the hospitals turned to the patient room closed circuit television system, the GetWellNetwork (GWN). The GWN includes a utility for use by the housekeeping department, called "Click to Clean (CTC)." When a patient is about to be discharged, a unit nurse clicks the option,l which informs environmental services that they will soon need to clean the room. The nurse strips the bed and ensures that the patient has all of his/her belongings and does not leave anything behind. At Hospital 3, transport staff were responsible for discharging patients or escorting them out of the hospital, but during peak times, they could not meet the needs in the ED and the inpatient floors. To improve the time it takes to discharge patients, Hospital 3 shifted the responsibility for discharging patients back to the unit staff. Once the patient is ready to leave, the nurse clicks another option to tell the environmental services staff that the room is ready to be cleaned. When the room is cleaned and ready for a new patient, an environmental services staff member clicks the option that shows that the room is available for a new patient. Then the nurses can assign the bed and call the ER or operating room (OR) to let staff know the bed is available. Previously, communication about the need for environmental services and bed availability was done by phone, which caused delays. Further, the ER staff or patient flow coordinator had to call around to find beds instead of having patients pulled from the ER onto the floors in a more automated fashion.
The "Click to Clean" system was working effectively immediately after the Kaizen event, but staff wanted more information about what to expect. So the project team developed a new tool: a morning and afternoon "state of the house" that showed the current census in the ED, OR, and on each of the floors. This tool was distributed across all departments. At one hospital, staff would meet to discuss the status of the house, but at another hospital, the information was simply emailed. This information allowed ED staff to know where beds were available so they could admit patients who had been waiting for a bed since the beginning of the day. Staff used this information to help prioritize their work, pointing physicians to where they should focus their time, which was to discharge patients from the inpatient units so that the beds could be opened up for those patients who were waiting for inpatient admission.
Implementing the new process developed in the Kaizen event in all units took 3 to 6 months. The Lean project teams met with the staff of each affected unit to describe the new procedure. The Bed Flow Value Stream projects started initially as a pilot in one unit on one floor. After the process was refined, it was rolled out to other inpatient units. In preparation for implementation on the subsequent unit, the project teams presented to the unit staff the process and outcomes of the project using PowerPoint presentations. The project team answered questions from the unit staff, and then the process was rolled out on that unit. Every 3 to 5 days over the course of a month, the project team rolled out the process to new units and departments using meetings and huddles as learning and training opportunities.
Monitoring, control, and sustainment. To create awareness, leaders at Hospitals 1 and 2 continue to use the "state of the house" report to show what is going on in each unit every morning and afternoon. Data on bed turnaround cycle time (i.e., duration from the time the patient leaves the room to the time it becomes available for the next patient) is automatically captured using the Click to Clean system. Leaders of the environmental and transportation service departments monitor the cycle time and, as necessary, provide reminders to their staff or followup on any issues or delays in the bed turnaround time. At Hospital 3, the team created a "what's working, what's not working" poster where staff could write feedback.
After the Kaizen event, the project teams continued to meet weekly to roll out the project across the hospital. During this meeting, weekly reports on project status were given. After 30 days had passed, the project team reported to the leadership on the outcomes as part of the regular report-outs to executives.
One management engineer noted that the management engineers were less involved in followup after the 30-day report-out. The process owners continued to monitor how the process was working and to address issues as they came up, but no mention was made that anyone looked at specific data on a regular basis as part of ongoing monitoring. The Environmental Service Department leaders continued to monitor the time between discharge and bed turnaround and report on progress to their staff.
Project outcomes. LHC staff reported that the Bed Flow Value Stream projects affected organizational culture, employee satisfaction, efficiency, clinical process assessment, patient experience, and dissemination of findings. The project outcomes are discussed in greater detail in Outcomes of Lean section of this report.
Organizational culture. The frontline staff from the Bed Flow Value Stream projects all agreed that having a multidisciplinary team with staff from several departments was vital to the success of the project. Further, they believed that this created improved communication and understanding across the units.
Employee satisfaction. A few frontline staff stated that they liked being able to control and contribute to their work place environment by introducing improved processes. For example, on the Bed Flow Value Stream project, nurses began identifying trends in patient flow through their unit and responding to them, reducing anxiety about not being in control of patient flow. The frontline staff members on the Bed Flow Value Stream project at Hospital 2 reported how exciting it was to receive recognition from other departments and from the corporate office for their cultural transformation initiative.
Efficiency. Nearly half of interviewees reported on efficiency gains on the Bed Flow Value Stream project. At Hospital 4, frontline staff and hospital executives reported that the average time a patient had to wait in the ED after the order for admission was written until he/she was transferred to an available bed decreased by 28 minutes, down from 194 minutes. Further, at Hospital 4, beds are now required to be cleaned within 30 minutes. At Hospital 1, with the exception of a few cases (e.g., isolation rooms), beds were cleaned within 45 minutes. Hospital 3 reported that they initially had a patient cycle time of 278 minutes. The team saved 46 minutes discharging inpatients; time from discharge instruction to patient departure is now 10 minutes instead of 56 minutes. Hospital 3 saved 32 minutes (from 87 minutes to 55 minutes) by reducing the time between bed assignments and getting a new patient into the room. An additional 25 minutes was saved (from 45 to 20 minutes) by reducing delays in assigning patients to available beds. At Hospitals 2 and 4, two frontline staff and two hospital executives reported fewer calls being made to nurses about the availability of rooms; staff at Hospital 4 quantified the reduction at 50 percent. Finally, one environmental staff person noted that the automated system allowed for faster response times and identification of delays and other issues.
Clinical process assessments. Little information on clinical process assessments was available; however, one frontline staff member stated that patients were less likely to be left unattended in the ED because of the improved patient flow. A negative outcome of the faster transfer of patients from the ED to the inpatient floors became apparent over time at Hospital 3. Because of the format and length of the written report from the ED, inpatient nurses weren't able to find and read the clinical information describing the patient's status before the patient was transferred to the inpatient unit. A new process was implemented to share vital information about the patient sooner, using oral reports. In addition, the nurses worked to streamline the written report.
Patient experience. The improved discharge process as a result of the Bed Flow Value Stream projects had a direct impact on patient experience scores. The Press Ganey patient satisfaction surveym asks specifically about how the inpatient discharge process went. At Hospital 3, patient satisfaction for this measure was around the 16th percentile before the Bed Flow project, and after the project, it was around the 97th percentile. At Hospital 1, a management engineer noted that although the patient volume is ever-increasing, they are able to maintain the patient satisfaction score at 95 percent.
Dissemination. A management engineer and two frontline staff attended and gave a presentation on the Bed Flow Value Stream at the Institute for Healthcare Improvement (IHI) and the GetWellNetwork Users Conference.
In addition to the two cross-cutting projects, we also studied an outpatient clinic project.
Outpatient Medical Records and Patient Flow
The outpatient medical records and patient flow project took place at an outpatient medical facility where providers see 80 to 100 patients each day. The practice directly employs three doctors and two nurse practitioners. The goal of this project was to create a new process for medical records flow to ensure that (1) patient charts could be easily located before a patient visit and promptly filed after the visit, (2) lab results would be inserted into the charts in advance of patient visits, and (3) the space in a small medical records room would be used more efficiently.
A nurse at the clinic nominated this project for consideration based on her assessment of inefficiency in the record-keeping system. After a physician saw a patient, the patient's record would be placed in a pile that was not organized, resulting in a backlog of over 1,000 unfiled records. Further, files were not signed in or out, so no one knew where a file was or who had last taken it out. Over time, it became ever more challenging to find files.
The project was staffed by members of the clinic staff as shown in Exhibit 1.13.
The process owner was the nurse who recommended the project, and an individual from the Management Engineering Department was the Lean leader. Additional clinic staff—including the physician leader—were also on the project. Other physicians were not formal members of the team but were kept up to date, and they were asked for their input on the process.
The management engineer began gathering initial data as part of project planning and preparation in December 2007. The 3.5-day Kaizen event was held in February 2008 and began with training on Lean tools and concepts. The steps or activities implemented by the project team and the Lean tools used are described in Exhibit 1.14.
As a result of the project, the team made several infrastructure changes to assure that medical records staff and frontline staff could better communicate and keep the files sorted properly. For example, front desk staff were responsible for pulling and/or requesting charts as patients arrived for their visits, but they were unable to find charts and keep the patient appointments running on time while managing their other duties, particularly responding to and triaging phone calls. to address this problem, the phone systems were changed to allow medical records and front desk staff to work together more effectively and prevent the front desk staff from being overwhelmed by phone calls. The automated phone message tree was adjusted to route calls more effectively throughout the practice without requiring staff to pick up the phone and transfer callers to the requested department or extension. A new cart was built to allow clinical staff to file patient charts near the exam rooms in alphabetical order once the patient had been seen. This further facilitated accurate filing in the records room.
Several positive outcomes resulted from the project. There was a significant reduction in transferred phone calls. The team expected to see a 40 percent increase in patient satisfaction; however, they did not have an adequate sample size to detect differences in patient satisfaction scores. The management engineer who facilitated the project reported that the in-house survey, unlike the Press-Ganey survey that is used at the hospitals, was not mailed to patients and likely resulted in lower survey completion rates. As a process measure, staff calculated the time it took to locate five charts and reduced search time from 50 minutes to 3 minutes over the course of the project. With the new cart and filing process, the time it took to file charts after patients were seen was reduced from 90 to 20 minutes. A physician noted that the improved handling of charts meant that information like lab reports was available in the chart when he entered the examination room, and he no longer had to step out to obtain the results. This reduced the patient's wait time. Frontline staff reported that these efficiency gains led to increased physician productivity and patient volume, but they did not provide data to support these observations. In addition, interviewees reported greater unity among the clinic staff.
Some additional changes to the process were made as issues arose. For example, a year after completing this Patient Flow project, an unfavorable shift in patient satisfaction scores led to a followup project to adjust the phone tree. Staff realized that they were receiving and having to triage more calls to the appropriate line. Ultimately, they came to understand that patients were pressing the option to be sent straight to the operator before listening to all of the options in the phone tree. The subsequent process improvement to address this issue offered patients fewer choices, in hopes that it would encourage more patients to listen to their options rather than asking to be transferred to an operator, once again reducing calls to the front desk staff. No formal monitoring process was mentioned by the project team. However, frontline staff noted that the process is still in place and working effectively.
Two prospective projects were scoped, and prework on the projects had begun; however, they were not fully implemented during the 1-year study period. As such, there is nothing to report on the monitoring, control, and sustainment processes, and there are relatively few outcomes for these two projects.
Outpatient Electronic Health Records
This project was intended to improve patient flow and processes in an ambulatory care practice by effectively implementing an electronic health record (EHR). Staff expected that the project would result in more efficiently organized physical space and more efficient use of the time clinicians spent with patients during office visits. Initially, the project was to take place at a family medicine practice and then be replicated in other LHC Medical Group practices. The family medicine practice is one of 32 primary and specialty care practices that make up the LHC Medical Group. Physicians are employed by LHC. As of May 2011, the 32 groups employed about 200 physicians. The family medicine practice had three physicians on staff and was selected as the initial site because of inherent structural issues in the clinic and room layout, as well as the small size of the practice.
The senior leadership, including executives of LHC Medical Group, wanted to implement this project to make sure that the practice's processes were as efficient as possible before introducing the new EHR technology. A management engineer stated that leadership wanted to focus on the physicians' offices because not much process improvement work had been done, and there were recently acquired offices that would benefit from the expertise available through LHC.
A management engineer and a Six Sigma Black Belt worked together to implement this project and collected observational data at the family medicine practice as part of the initial assessment to prepare for the Kaizen event. The process improvement staff worked with the practice manager and administrator to identify staff to participate in the Kaizen event. In addition, they included participants from other LHC Medical Group medical practices to increase the chances that the solution would generalize to other offices. Process improvement staff suggested using a Design Kaizen tool to plan for the changes and adjust the necessary processes. Design Kaizen differs from Kaizen because staff cannot implement the planned process, in this case the EMR, but can plan the process. In this way, staff would adjust to the new process before the EHR was implemented as part of a fuller Kaizen event and Lean project to come later.
Other offices began implementing the EHR before the family medicine practice project began, and these other offices ran into some challenges. Thus, the family medicine practice project was re-scoped to encourage participation of staff from practices that had already implemented the EHR and could provide feedback and insights on potential solutions. Several delays in implementation of the Lean project caused it to remain on hold, although the EHRs were still being rolled out to other LHC Medical Group physicians' offices.
Surgeons' Preference Cards
The Surgeons' Preference Card project was part of a larger process transformation of the operating rooms' information systems. Surgeons' Preference Cards are used to draw equipment and supplies before surgery, check for lost objects before closing out surgery, and charge after surgery. At each hospital, there were between 1,200 and 2,800 preference cards, each with an average of 40 items. The goal of this project was to update the surgeons' preference cards and define a standard process for managing surgeons' preference cards through their life cycle. The project focused on the surgical departments at all four hospitals and was also intended to facilitate better communication between the hospitals and the surgical practices that schedule surgeries and conduct followup appointments with patients.
LHC bought its first operating room (or surgical) information system (IS), in 1995; there were plans to replace it in 1999. However, the system was never replaced as it was considered a stable system. Notably, three of the four hospitals worked on this system, and a fourth worked on a different system. This was because the hospitals merged in 1998 to become LHC. In 2008, the corporate leadership decided to purchase information systems for all LHC hospitals from the same vendor in order to streamline vendors and make all information systems compatible systemwide.
The new IS, however, did not meet the needs of the surgical staff, even though it performed well in other areas. Hospital and corporate leadership agreed to let the surgical departments at the four hospitals pick a new system, with the understanding that a software interface would be necessary to ensure that it could communicate with other LHC ISs. From 10 to 20 of the clinical and management staff—including anesthesiologists, information technology (IT) staff, administrative support, and nursing leaders—came together as stakeholders. Although anesthesiologists participated, the surgeons did not. The process owner explained that only anesthesiologists would need to work in the new system, and other surgeons would not need to access the system and thus did not need to be included in the selection or process redesign.
The participating stakeholders brainstormed what they wanted from a system and how they would evaluate the options. They narrowed the options to three systems for pilot testing. A Hierarchy Task Analysis (HTA) was used to specify all of the tasks performed in the surgical suites. The candidate surgical ISs were evaluated with respect to their ability to support these tasks. Then, the management engineers created a Space Relation Diagram that plots the movement of each person during an activity. This tool helps to identify the frequency with which a person doing a specific task within the process goes to a specified location and when and where there are crowds or traffic during the process. Changes to the physical layout or location of tools and technology can then be identified to reduce crowding.
Once the new system was selected, the process improvement team began implementing a process transformation approach to identify key areas for change. The approach employed stakeholder meetings, 15–16 focus groups with diverse staff for brainstorming, failure mode effect analyses, prioritization of opportunities (based on the analyses), a focused assessment of processes, and finally, implementation of process improvement. Surgeons' Preference Cards was one of eight key areas assessed. Many were not being used or were out of date because surgeons had left or new technology had replaced the specified equipment and supplies on the card. Of the other key activities assessed, several activities related to scheduling and preadmission testing were prioritized over and above supply and inventory management under which the Surgeons' Preference Card project fell. Ultimately, this meant that the Surgeons' Preference Cards project was not a focus of the staff because of the priorities for completing process improvements around scheduling and preadmission.
In May 2010, a small group including process improvement staff, an assistant nurse manager, a system administrator, and a clerical coordinator (Exhibit 1.15) gathered to develop a design. The purpose of the Design Kaizen was to define the standard process for managing surgeons' preference cards through their life cycle to keep up with surgeons' evolving preferences. Because staff were unable to test ideas and make in-time changes to the yet‑unimplemented technology, a followup Kaizen implementing the planned process with the technology in place was the next step in the process.
Barriers to the Lean project implementation (discussed in greater detail in the next section, Factors that Influence Success of Lean Implementation) were related to prioritization of other key issues, including scheduling, which were felt to yield greater, higher priority returns. As issues continued to come up with the surgeons' preference cards, the management engineer on the project reported that the process would eventually be revisited, and a Kaizen would be done to implement the proposed process; however, the timeline for implementation was uncertain. Thus, this project was not fully implemented during the 1-year study period, and there is nothing to report on the monitoring, control, and sustainment processes and only minimal information related to project outcomes. As part of the larger value stream of projects that included the Surgeons' Preference Cards, the management engineer reported improved patient safety as a result of building checklists into the computer system, which could be used as a communication and debriefing tool.
In this section, we discuss the outcomes of the Lean initiative at LHC based on interviews with staff and materials provided by the organization. Overall, respondents experienced gains in efficiency, cultural change, and patient experience and moderate improvements in routinization of Lean, employee satisfaction (including from an ongoing staff survey), and patient safety.
Executives, managers, and frontline staff reported that they experienced significant benefits in terms of culture change and were able to provide statistics indicating improved efficiency as the result of the Bed Flow Value Stream project. Executives reported that specific gains occurred in the patient and employee satisfaction surveys, which they attributed to Lean. LHC did not analyze return on investment from Lean projects or the overall initiative.
The discussion of Lean outcomes in this report is organized into two major categories based on our conceptual framework: intermediate outcomes and ultimate outcomes (Exhibit 1.16). Intermediate outcomes include culture change, employee satisfaction, change in Lean knowledge and skills and Lean routinization. Ultimate outcomes include impact on efficiency, patient satisfaction and experience, clinical process and outcomes assessments, and patient safety.
In our conceptual framework, intermediate outcomes refer to organizational culture, employee satisfaction, increased Lean knowledge and skills, routinization of Lean, and dissemination of Lean, both within the organization and externally. These intermediate outcomes are, in turn, linked to ultimate outcomes—efficiency, value, and quality—as defined in the conceptual framework and discussed in the next section.
Organizational Culture Change
About a third of interviewees noted significant changes in organizational culture. Interviewees at all levels of the organization indicated that Lean had improved teamwork and camaraderie and encouraged and mobilized staff to achieve better outcomes.
|"And, you know, that's one of the things that I like, you know, how people get educated and they, they gain a better appreciation for the interactions between departments or between functions, when they're involved in these Kaizen projects or Workouts or whatever, so that they can understand how, when you adjust this lever, it doesn't just impact here, it impacts over there. So they do gain that education and appreciation."
—Hospital Executive"I may work in the ED, you may work up in the telemetry floor, and it's different if I don't really know who you are, and you're just a voice on the phone; but when I [make] eye contact, and I just spent 3 days with you and we're informally talking about what you did last weekend and what you like to eat and…That relationship building, you can't buy that...It starts getting people to think more globally, so I think that's very positive."
Improved teamwork and camaraderie. Ten interviewees—from all levels of the organization—described the culture of LHC as one of transparency, honesty and trust, and teamwork. Several interviewees noted that LHC leadership creates opportunities to discuss issues in an open forum and asks for advice on improvements. One department manager explained that there is a strong commitment to creating a no-blame culture, which is carried out by adjusting processes to ensure positive outcomes. It is important to staff that the processes are ingrained to improve patient care. Transparency is carried through to outside the system by frequently allowing other health care organizations to visit LHC and observe the cutting-edge work there. Lean has produced a sense of global awareness across hospital departments and an intradepartmental camaraderie. Two hospital executives noted that Lean had improved the relationships of staff across different floors and roles, resulting in mutual appreciation of the work each department does and improved patient care. A few hospital executives applauded the growth in relationships across different floors and the positive effect on patient care and employee satisfaction.
Frontline staff reported improved teamwork as the greatest gain from Lean training and participation. Many staff reported how bringing together employees from "all walks" of the organization's operations in teams to work on a Kaizen event positively affected interactions among staff as well as operations. The frontline staff from the Bed Flow Value Stream projects all voiced their appreciation for information-sharing across departments and commented on the sense of respect and understanding of the overall hospital operations.
Two management engineers explained that, in order to anticipate changes that might affect other departments, one of the first steps in the process is identifying and pulling together all of the stakeholders to promote communication and partnership among the different departments. On the Bed Flow Value Stream projects, communication across units about the bed occupancy rates by department eliminated waste and frustration over why certain patients were routed to certain departments. Staff no longer felt the need to horde beds and did not feel targeted by an influx of new patients because they could see how their work impacted the hospital census at large.
Quick success begets engagement and further success. Three corporate executives and two hospital executives reported that a fundamental change in the culture at LHC has come about because of the quick turnaround of results on Lean projects. They went on to say how the quick results leading to immediate gratification makes staff more apt to volunteer for Lean projects. A few frontline staff agreed with the executives, affirming that staff felt able to control and contribute to their environment. For example, on the Bed Flow Value Stream project, nurses began identifying trends in patient flow through their unit and responding to them, reducing their anxiety about not being in control of patient flow. At Hospital 3, the frontline staff identified an opportunity to improve reports by the ED nurses to the inpatient staff on patients that were being admitted. Nurses independently began testing approaches to more efficiently convey critical information orally and by using a new form. Although this wasn't a formal Lean project, they continued trying new ideas and drew upon their experience with rapid tests of change as part of Kaizen events. A management engineer stated that the organizational culture was affected because the process improvements require frontline staff intimately familiar with day-to-day operations to think critically and develop a solution in a short period of time.
The three corporate executives noted above commented that the cultural transformation initiative and the shared mission to produce results has also led to organizational culture change because staff are excited and engaged in doing their part to achieve better outcomes. Lean has provided a path for staff to carry out the cultural transformation initiative that includes resource stewardship as one of the major points. Interviewees reported that hospital-wide awareness among employees about the success of Lean projects excited those that participated and encouraged them to volunteer to participate again in the future. The frontline staff members on the Bed Flow Value Stream project at Hospital 2 expressed how exciting it was to receive recognition from other departments and the corporation through the organization's cultural transformation initiative award for high-performing teams or projects.
Staff reported that Lean improved employee satisfaction as evidenced by an increase in reported satisfaction, a low nursing vacancy rate, and employees' willingness to participate in Lean.
LHC has experienced high employee satisfaction and low vacancy. A hospital executive reported an increase in employee satisfaction of nearly 20 percentage points over 5 years, as measured by LHC's annual employee surveys. Further, two hospital executives reported that there are no vacant nursing positions; even in a competitive market for nursing staff, all the organization's positions are filled. Corporate and hospital executives alike attribute this both to the rise in employee control and engagement brought about through Lean and Kaizen events and a new sense of teamwork. One hospital executive was careful to state that employee engagement and satisfaction improvements are "not solely a hundred percent because of Lean," but might stem from other efforts within the organization that ensure staff have input on their work environment.
|"We didn't appreciate and monitor how dramatically the workload would change with the new information system because of the connectivity issues and didn't appreciate that we should have redesigned the process before we rolled out, not after."
Lean Knowledge and Skills
Since 2006, more than 40 Kaizen events have occurred throughout LHC. Although a number of tools, concepts, and techniques are introduced to the staff through Lean training, only a few interviewees mentioned increased knowledge or skills as an outcome. Two management engineers and a hospital executive reported that employees have become more resourceful and now apply process improvement concepts and tools to problems as part of their everyday work.
This study of Lean at LHC included two IS implementation projects. A few corporate executives, two hospital executives, and two management engineers agreed that it was important to be proactive and implement process changes in advance of the technical change because additional issues might arise. Redesigning processes prior to IS implementation was not consistently done for all projects, as noted by a management engineer. Although LHC attempted to isolate the two major changes in the projects we studied to allow mastery of process changes before it brought in technology, scheduling issues made this difficult to carry out for at least one of the projects.
The Bed Flow Value Stream project provides an example of how new processes were embedded into the system at four hospitals using technology, reporting, and new-employee training to create the desired results. Staff reported that the use of new electronic communication systems facilitated the flow of information, freeing nursing time previously used to search for unoccupied beds and improving patient throughput in the ER. Because of the technology, a few frontline staff reported, the hospital's census has become more transparent and staff have become more aware of the need to turn over beds efficiently to meet incoming-patient demand. The environmental and transportation staff track how quickly beds are cleaned when patients depart and how long it takes to transport patients to the floor. This information has inspired healthy competition among the staff. A frontline employee described how the new Bed Flow Value Stream process has been added to the new employee orientation checklist to assure these redesigned processes are followed consistently by new employees across the hospitals.
Improving efficiency is at the core of Lean. One of LHC's key goals was to eliminate waste. Corporate executives discussed how several projects optimized hospital processes to facilitate cost and efficiency savings. The organization was able to report outcomes on a project-by-project basis but could not attribute overall, organization-wide findings directly to Lean, given that several other activities, (e.g., new leadership, a cultural shift with the cultural transformation initiative, and Six Sigma projects) occurred concurrently with the Lean initiative.
|"As an ER director, 3, 4 hour waits—it's not safe for people to be in waiting rooms for 3 or 4 hours. So, I looked at it as, we improved our throughput so the ER waiting people could get back [and be seen]. So that, for me, is a big safety [improvement]."
Efficiency and quality outcomes are closely tracked at the organization in several ways but not necessarily in dollars saved. Several interviewees at all levels of the organization stated that efficiency gains are reflected in such measurable outcomes as employee and patient satisfaction scores. Below are project-specific Lean outcomes showing improved efficiencies. No efficiency outcomes were reported related to the Surgeons' Preference Cards project.
|"When we built the new hospital, [LHC] had about $35 million of borrowing capacity and no cash, and that's a $463 million hospital. [sic] Knowing we didn't have the financials to get there, that was the goal and from 2002 to 2008, or '09 [sic]. How are we gonna get to that goal? We're gonna use these tools to reengineer our organization to generate the bottom line to borrow for that hospital. And that's what we did, and we got there."
Bed Flow Value Stream. Nearly half of interviewees reported that the Bed Flow Value Stream project resulted in efficiency gains in the time needed to discharge patients. At Hospital 4, frontline staff and hospital executives reported reducing by 28 minutes the time between when the ED doctor decides to admit a patient and when the patient leaves the ED for an inpatient bed. Hospital 3 reported substantial reductions in the time required to turnover an inpatient bed:
- 46 minutes saved in the time from discharge instruction until an inpatient leaves the room.
- 32 minutes saved in the time from inpatient departure from the room to reassignment to a new patient.
At Hospital 2, two frontline staff reported that floor nurses received fewer calls from the ED about the availability of rooms. This was also true at Hospital 4, and two hospital executives reported that bed assignment calls were reduced by 50 percent. One environmental staff member at Hospital 3 noted that if a problem in the process occurs, it can be addressed immediately because the system is automated and uses new technology to gather feedback on every step in the process.
|"For 2 weeks, we reduce schedules by 50 percent volume. And we carry that out through a 6-week schedule....We gave our offices [sic] time to sort of get up to speed. What we didn't realize is that the timeframe that we said was probably a little too aggressive. This week may not be enough time to have a reduced schedule so that people are comfortable. Maybe it needs to be longer, and that could be variable from site to site."
Outpatient Electronic Health Records. LHC's leaders expected and saw a reduction in productivity, especially for clinicians, as a result of implementing the EHR. This is primarily due to the learning curve associated with implementation of new technology, time to train staff, difficulties in exchanging records with other facilities that have not yet been upgraded to the EHR, and managing older patient records within the new system. To eliminate some of these challenges, a hospital executive reported that they quickened the pace of conversion from hard copy records to electronic records, forgoing the use of Lean to redesign processes.
Outpatient Medical Records and Patient Flow. On the Outpatient Medical Records and Patient Flow project at the Outpatient Medical Facility, a management engineer announced that the chart filing time was reduced by 70 minutes after the project was completed, partly because the charts were organized and alphabetized in a cart right after the patients were seen. Further, the time spent looking for charts decreased from 50 minutes for five charts to 3 minutes for five charts. A physician noted that the improved chart-management process meant that information, such as lab reports, was in the charts when doctors went into rooms, and that they no longer had to step out to obtain results. This ultimately reduces the patients' wait times.
Process changes sometimes, but not always, improved patient safety. A direct outcome of the Bed Flow Value Stream projects at the four hospitals was shorter patient wait times in the ED. One frontline staff member stated that patients were seen faster, and patient risk from being unattended had been greatly reduced. As part of the Bed Flow project at Hospital 3, patients were getting to the inpatient floors so quickly that the inpatient nursing staff couldn't obtain the patient information they needed (i.e., history, clinical condition) from the ED before the patient arrived. The project team instituted a new practice of getting verbal patient reports and streamlining the written report.
The use of technology meant integrated and improved patient safety processes. The management engineer reported that, as part of the larger value stream of projects that included the Surgeons' Preference Cards, patient safety improved as a result of checklists that were built into the computer system that could be used as a communication and debriefing tool.
|"When I pulled patient satisfaction scores by discharge date, right away, starting in [sic] April, I saw a significant jump [sic]. It had always been like the 15th percentile and lower, so I thought, 'Alright, I'll wait and it's only 1 month.' And then May came, and it was still like 80s, 90s, and then high 90s, and it has stayed that way the whole year."
Improved wait times have a positive impact on patient satisfaction and experience. The frontline staff expected this would be the case with the outpatient medical records and patient flow projects. However, because the outpatient offices don't implement a patient satisfaction survey, as is done in the hospitals, improvements to satisfaction could not be objectively reported. The improved discharge process as a result of the Bed Flow Value Stream projects had a direct impact on the patient experience scores. The Press-Ganey patient satisfaction survey asks specifically how the discharge process went. At Hospital 3, patient satisfaction for this measure was around the 16th percentile before the Bed Flow project and around the 97th percentile after. At Hospital 1, a management engineer noted that, although the patient volume is ever increasing, they are able to maintain the patient satisfaction score at 95 percent.
Senior and department-level staff were asked about the business case for Lean. Nearly all respondents stated that there was a positive business case for Lean because it yielded greater efficiency through reduced waste, avoidance of additional costs or staff, and greater patient volume, as well as improved patient satisfaction.
A few staff—a management engineer, a corporate executive, and a hospital executive—believed there was a business case for Lean because of positive financial gains or savings. Other interviewees discussed finances and costs of Lean but did not say that the business case for Lean should be based on cost. They felt that other factors, such as patient satisfaction, were more important.
The findings reported in this section are based on responses to questions about facilitators, barriers, and lessons learned related to Lean, and on a limited interpretation of findings overall by the research team. 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 personally faced in implementing Lean at LHC. Insights about lessons learned were gathered by asking interviewees whether and how they would change what they had done if they were to do it over again. As expected, lessons learned were closely aligned with the facilitators and barriers (Exhibit 1.17).
Executives provided information on a wide range of facilitators and barriers to the organization and implementation of Lean, whereas staff addressed the culture of the organization as a key facilitator to the success of Lean. Lessons learned referred most often to the scope, pace, and coordination of Lean activities; Lean team composition and size; alignment with existing structures and networks; and staff engagement.
The conceptual framework lays out a number of factors to consider when preparing to implement Lean. Of these factors, alignment of Lean to the organization was most frequently identified by interviewees as a facilitator and barrier to organization of the Kaizen initiative. Notably, few comments were made about the applicability of Lean to health care processes.
Local Environment and External Context
Economy. The lagging economy during the period when the new hospital was being planned and built turned out to provide an advantage to LHC. Construction firms were competing for business.
|"They're [process improvement staff]—all the best and brightest. And then we promote them in the organization once they've finished their stay as either a Black Belt or an engineer."
Competition. A management engineer noted how important it was to be responsive to the surgeons who have privileges at LHC. If surgeons are not satisfied practicing at LHC, they can choose to move their surgeries to other hospitals in the community, including relocating to other hospitals within LHC. Three of LHC's hospitals are located within just a 7-mile radius of one another. As the new Hospital 3 opened, a hospital executive expressed concern about drawing patients away from the system's other hospitals.
Health care reform and trends. Looking to the future, two executives, a management engineer, and a frontline staff person noted how health care reform and trends will require changes to be made to the current system. They offered that more technology will be needed to meet the increased demand for health care services that is projected. They recognize there could be exponential growth in the number of LHC physicians' offices and saw this as offering physicians the security of a larger entity and improved access to both colleagues and technology.
Alignment of the Lean Initiative with the Organization
Process improvement is at the core of LHC's culture. The process improvement toolkit initiated by the consulting firm was established in 2001. Three corporate executives stated that they were committed to these tools and the process improvement framework for the long term. Thus, the introduction of new quality improvement tools, such as Lean in 2003, was not foreign to the staff. Two process improvement department leads reported that frontline staff view Lean in a limited way—as only Kaizen events—rather than a cultural transformation to a waste-reduction mindset. They commented that frontline staff don't understand how Lean is integrated into the larger quality improvement toolkit at LHC and how to achieve the organization's overall strategic goals. Three interviewees—an executive, management engineer, and frontline staff—noted that LHC is committed to and values the work and expertise of its process improvement professionals and the work done in this area by frontline staff.
|"It's a very different organization to come in to. Because [if] you come in from the outside when you haven't been exposed to the tools, it can be overwhelming. There's many additional things that now they are required to know about and encouraged to use, and you have to be careful not to get sucked into the quagmire, saying, ‘I'm now gonna focus 90 percent of my time on these things,' and lose sight of what my fundamental role is right for the customers and the patients we take care of. So, I think in our organization, it's about finding that balance. Coming in from the outside, that can be overwhelming."
One corporate executive noted that process improvement is integrated with leadership development. Management engineers and Black Belts are often promoted to executive and management positions within the organization. Three executives—one at the corporate and two at the hospital level—noted that aligning the goals of Lean with the organizational culture caused growing pains, particularly for leaders coming from outside the organization. Two hospital executives noted that trying to find the balance between process improvement (i.e., learning new tools, implementing initiatives) and managing patient care services can be overwhelming for clinical leadership. One corporate executive noted that there were chiefs of service who were replaced because they did not apply Lean tools in their work. Two management engineers noted that it was virtually impossible to step down from a Lean project and that this had only happened when staff left the organization.
Scope, Coordination, and Pace of Lean Activities
Coordinating the timing of projects. As observed two projects—Outpatient Electronic Health Records and Surgeons' Preference Cards—competing priorities delayed Lean projects. Upcoming building renovations that would change the layout of the clinic and thus the flow of activities were cited by two management engineers for the delays on the Outpatient Electronic Health Records project. The Surgeons' Preference Cards project was part of a larger value stream to change the IS for operating rooms. According to a management engineer, the project was delayed because of two competing priorities: a desire to focus on projects within the value stream yielding better financial returns and a need to address related issues first. One hospital executive stated that with limited resources, leaders must focus on the highest priority areas—usually those that reap the greatest cost savings—and other things must fall to the wayside. In practice, this means that the acute care setting receives the most attention and resources for process improvement before ambulatory care: but, the executive did not give any specifics related to the projects in this study.
Although several leaders agreed on the importance of addressing process before implementing an IT solution, on the Outpatient EHR project, the EHR rollout plan and timeline were developed separately from the plans for Lean. Two management engineers stated that the EHR rollout was stalled, in part, because of a need for Lean. However, a hospital executive adamantly expressed that the rollout plan forged ahead at an accelerated rate without support from Lean.
Getting buy-in from leadership and managers was also critical to the success of scheduling and implementing projects. One management engineer stated that there was not a manager or leader within the clinic to champion the Outpatient EHR project and, as a result, staff did not understand the need for a Lean project. However, another management engineer noted that senior leaders were more engaged after implementing the EHR at a few clinic locations and facing challenges that they believed required additional support from management engineers.
|You've gotta really commit that this toolkit will help you provide a better, outstanding patient experience. We're gonna tell you to use it. We're gonna educate you as to how to use it. And it's not going away. It's the way we're gonna do business to fix things in the hospital."
—Corporate Executive"And I think, also, it's that you have the support and buy-in from the management, administrative level. ‘Cause I've been involved in some workouts where we've come up with these beautiful policies and nobody wants to enforce it because we're not getting the support from the administration and management."
Pacing activities and allowing time necessary. A process improvement department head stated how important it is to control the rate of change by carefully planning Lean activities during the design, construction, and transition to the Horizon – the Lean Hospital. Otherwise, according to the department lead, staff might feel overwhelmed and ultimately reject Lean. Two senior leaders and a process improvement department lead agreed that cultural change using Lean and process improvement requires patience and time. Similarly, two frontline staff discussed the importance of taking the time needed to be successful. Specifically, staff mentioned the benefit of taking more time as a team during the Kaizen event; taking additional time, as necessary, to roll out the process within a department; and delaying the start of a pilot or rapid test of change to a time that is appropriate and will yield better success. A process improvement department lead noted that Horizon has been subtly embedded within the culture because it was applied through projects and other activities (e.g., design, observation, simulation) over an extended period of time.
|"We didn't want to implement the technology without evaluating our processes. Because if we didn't, we would just basically—some of our processes aren't ideal either. We're using our engineers and our Black Belts to help us really optimize our current processes before we overlay any technology on to it."
—Executive"Technology is gonna be a part of our life. We've learned, when we've brought on technology solutions, and put it on top of processes that are broken, it causes really a collapse of the system."
A Kaizen event's very compressed schedule of day-long events over consecutive days might not be possible in a clinic setting, as was observed on the Outpatient Medical Record and Patient Flow project. Two management engineers noted that outpatient clinic staff were eventually willing to commit to participating in a Kaizen event on the EHRs, but managers insisted that the event vary from the typical schedule. Selecting team members for the Kaizen event is particularly difficult when there are only a few clinic staff to draw from because the office still has to provide patient care. As such, clinic managers could not commit to a Kaizen event where all stakeholders were together in a room at the same time for a series of days.
Project scope. Four interviewees—one senior leader, two frontline staff, and one management engineer—stated that narrowly scoped projects were most successful. Key characteristics of a narrowly scoped project as mentioned by interviewees included:
- Data collection by management engineers in advance of the Kaizen event that informed selection of the right Lean tools to use.
- Team agreement on the definition of project success early on.
- Careful evaluation of the current state to determine what is feasible to accomplish as part of the project.
Applicability of Lean to Processes and Loci of Activities
Lean and information technology. Two executives and three management engineers agreed that IT solutions are valuable, but it's important to use Lean to plan out the related processes before implementing new technology. One executive went on to say that a new tool or technology is not helpful unless it is used correctly. In another area of the health care delivery system, a process improvement lead reported that the EHR did not yield any benefits or efficiencies as promised by the technology's vendor because the overall process remained the same.
Leadership Activities and Qualities
Several corporate and hospital executives reported that Lean starts at the top of the organization. It must be supported by executives in order to engage staff, enforce long-term commitment, and change culture. A few executives reported that leadership for the project, within the department and at the organization, will often define the success of the project, and that it is also this group that is held accountable for the success and sustainment of the project outcomes. A management engineer noted that because process owners and unit or department leaders are responsible for carrying the project forward to the frontline, they must be very engaged.
One of the ways that senior leaders show their engagement is by participating in process improvement report-outs. Research staff observed and five executives reported that a large group of executives from across the four hospitals gather to hear report‑outs and are engaged and attentive during the meetings. The corporate executives will often engage the project team in discussions about the project after their presentation.
Several frontline staff from two of the Bed Flow projects cited leadership support and buy-in of management as being critical to the success of the project. One frontline staff and a management engineer described ways in which senior leaders' involvement was critical to moving things along at a faster pace. For example, getting IT to move equipment or facilities or to install or move outlets as part of the Lean event week could require support from senior leaders.
Notably, at LHC, all of the senior leaders and many of the frontline managers have training in process improvement. Namely, they are Six-Sigma belted to at least yellow level. Two executives noted that the Six Sigma Black Belt program is used as a training ground and as a source of professional development for future leaders.
Two executives explained that staff at LHC are highly engaged in providing high-quality patient care. Thus, as reported by five frontline staff and a physician, when staff are made aware of an opportunity to improve patient care and staff processes, they work towards it. One example of this is the Bed Flow project where staff requested that more information be shared twice per day on the hospital's census (via a meeting or an email with the "state of the house"). Nurses used this information to help prioritize their work, pointing physicians to where they should first focus their time to discharge patients and indicating to ED staff which inpatient units to transfer patients to so that patient load would be equalized.
One hospital executive stated that the initiative and the project teams must be as inclusive as possible and engage staff at all levels of the organization. Many staff—several hospital executives, a physician, five frontline staff, and two management engineers—stated that staff are more engaged when they are able to define the solution to a problem. A management engineer explained, however, that it is important for staff to understand why they are completing the project and what benefits will come out of their participation. On a Bed Flow project, four frontline staff explained how staff engagement lagged when the project team did not invest enough time in gathering stakeholders' input. When the team returned to the unit, staff not on the project team were hesitant and reserved about the new process.
|"I [as a manager] don't wanna be sitting in a meeting every day making decisions. I want them [staff] to be involved in the decisionmaking. And that, I think, is a huge thing moving forward….it also empowers them. They feel good about the changes."
—Frontline Manager"You get buy-in from all the team players. It's not like someone from the top just says, or I'm just saying, ‘This is how we're gonna do it.' They developed this, all the workers, everyone, every, every single level bought into it."
—Physician"It gave them more responsibility; thus, they had more control over their workday, and the accountability went up.
Quick, visible outcomes from Lean also help to engage staff further in using Lean. Several staff—including a few executives, two management engineers, and a few frontline staff—all agreed that positive outcomes further engage staff in Lean. These outcomes can be from projects the staff members worked on directly or from other sites or units. During a report-out, frontline staff spoke about how changes to their work area after using 5S (sorting, straightening, systematic cleaning, standardizing, and sustaining) particularly engaged staff on the unit. A couple of management engineers reported how they too felt more confident in their work after completing the first Bed Flow project and using those lessons learned to improve on the next Bed Flow project.
There can be challenges in trying to bring a multidisciplinary group together for a Lean project. On the outpatient EHR project, the Lean team eventually tried to put together a team from multiple offices across the system but found that many of the new offices joining LHC had different organizational cultures, were unfamiliar with Lean, and were anxious about the new technology. Bringing together individuals unfamiliar with the organization's culture for a Lean project proved very challenging and did not occur during the timeframe of this case study.
Physicians are also a difficult group to engage according to many staff, including several executives, a management engineer, and a couple of frontline staff. This is particularly true of community physicians who may not have the time to participate on a Lean project without reducing their billable patient hours. One corporate executive reported that hospitalists and ER doctors seem to be more engaged with Lean because of its team-based approach. In fact, a Six Sigma project showed how a hospitalist model can achieve good outcomes using QI methods.
Several staff, including two hospital executives and a few frontline staff, discussed how rewards can be used to encourage and engage staff in Lean. Staff rewards include "Wow," which are certificates for good work that can be converted into gift cards; funds for parties or celebrations on the unit; and plaques.
LHC also offers monetary awards and end-of-year bonuses to staff. The Hospital 2 Bed Flow project team won a Super Star Award for being a high-performing team.
|"We just finished a project...looking at how we could utilize our hospitalists—which are employed physicians, they're not independent doctors—in terms of coordinating care of patients and improving patient satisfaction. [sic] We had the hospitalists take over ownership of the patient, and we cohorted their patients on a separate unit, and we allowed them to work out a schedule so they tried to be able to have the same hospitalists seeing the same patients day in and day out during their course of treatment. We were able to see substantial improvement, really dramatic improvement in patient satisfaction. [sic] Now, we're looking at how do we replicate that across the system and how do we start to roll that out as a model of care."
Two executives recommended that training on the Lean tools be done with leaders in the organization before trying to implement the process. Currently, a management engineer said, new managers attend a training called Great Beginnings that includes information on Lean and process improvement. Another executive noted that providing this training early on to leaders helps erode skepticism about the tool: "Better buy-in from leaders might have been had if we'd done training on the tools before trying to implement the process."
In contrast, one frontline staff noted the "just-in-time" training provided at the Kaizen event was preferred because the entire multidisciplinary team was learning at the same time. A few staff—two management engineers and two frontline staff— stated that Lean terminology (i.e., names of tools and concepts) is challenging for staff not on the project team; however, staff might be familiar with the name of a specific project. As part of the monitoring and sustainment processes, two management engineers mentioned that staff needed to be trained and coached on how to collect data because the data were unfamiliar to them. Staff training was an part important of ensuring comparability of the pre- and post-event data.
Communicating about Lean requires staff to be flexible in both their method and content of communication. On the Bed Flow project, two hospitals found it important to provide daily information on the current census for the entire hospital. One hospital decided to send this out via email, while another hospital found that meetings were more appropriate. A hospital executive explained that this communication allowed staff to understand more about the efficiencies that Lean might bring about. The Bed Flow project also required staff to rely on the "Click to Clean" system as part of the GetWellNetwork, but they also had to learn what to do when technology went down. The daily census information helped to alleviate any issues.
Communicating with physicians, especially community physicians, to get them engaged in Lean can prove challenging. Two senior leaders noted some helpful techniques to communicate with physicians. One leader suggested finding a common goal and communicating about the benefits of Lean through that goal. To change the surgical information system during the Value Stream project, the project team reported that getting a surgeon's buy-in on the process wouldn't be necessary if the outcome facilitated the surgeon's work. Another leader suggested getting a physician involved in Lean, even tangentially, would help reduce resistance because the benefit could be seen firsthand.
A large proportion of interviewees—four executives, a manager, a physician, and eight frontline staff—declared that a diverse, multidisciplinary team of the "right people" was needed for successful projects. When describing who should serve on a diverse team, interviewees named executives, management engineers, managers, and frontline staff. In addition, several frontline staff emphasized the importance of including stakeholders from other departments. For example, on the Bed Flow project, nurses from different units, nurse managers, environmental staff, and sometimes even dietary staff were included. A diverse team ensured better teamwork and generated distinctive ideas and solutions to problems. For example, two executives and two management engineers noted the importance of having skeptics on the team to help determine the solution and increase buy-in with staff not on the project who might be skeptical. One management engineer noted that in the outpatient clinic, which had a small staff, picking who would participate on the team could be particularly difficult because the office still had to serve patients.
|"So, being flexible, finding a way to involve them [physicians], especially if they're a key stakeholder, and taking what you can get, and keeping them informed, communicating, so that you have that.…it may not be ideal, but it's better than not having them participate at all."
On the Outpatient EHR project, some offices had already implemented the EHR before the project began. A management engineer recommended including staff who had not implemented the HER, along with staff who had, because the experienced offices could provide insights on the challenges they faced and pose feasible solutions.
|"I think when you have those right people in the room, it takes you away from anecdote to reality. So now you have the silos broken down because you have people who are experts, they're local experts in their own area."
A frontline staff person and an executive both stated the importance of picking the right leader or process owner for the team, but they did not clarify who that person might be. New managers receive training on Lean and Six Sigma concepts as part of the "New Beginnings" training; however, managers might not fully understand how Lean is implemented or how the tools could facilitate a more efficient outcome in a specific situation. A management engineer described the challenge of engaging the right leader or process owner on the Outpatient EHR project. At the Family Medicine Practice, two new managers leading the practice did not have much knowledge of Lean, making it difficult for a management engineer to gain their buy-in and deploy the Lean project.
As discussed in the staff engagement section, two executives noted that community physicians are difficult to engage but should be consulted on projects to get their buy-in, and a hospitalist model shows promise. No other staff recommended or believed that there was a need to include physicians in Lean projects.
|"Most of the management engineers that we have have an engineering background. They look at things, they bring a different perspective than many of us who've been involved in health care a long time and may have, you know, grown up in health care and look at it through a certain lens. And, one of the things that I value most about our management engineers is I can pull them into something and say, ‘I need you to look at this. Tell me what you see,' because what they see may be entirely different than how I'm viewing it. And, I value that. Now, that's not to say that it's right or wrong, but they'll give me a different perspective, often, and I'll be able to say, ‘Okay, I didn't see that. That makes sense,' or, you know, ‘If we look at it that way, we might be able to do this.'"
Availability of Resources
Far and away, the most critical resource was the management engineers. Many staff—six executives, and four frontline staff—cited the management engineers as a key resource in the implementation of Lean and recommended that other hospitals employ staff with similar skills. One leader noted that it was particularly helpful that a management engineer's background offered a different perspective. Others agreed that management engineers help the project team carefully think through a new process and help ensure the team stays within the scope of the project. Several executives stated that they only get a small percentage of the management engineers' time, but they are fortunate that the engineers are so committed and often go above and beyond. Frontline staff noted how management engineers made data available to help understand where to focus on solutions. In addition, several executives recognized that the management engineers are disseminating the knowledge and tools from LHC's quality improvement toolkit, another valuable resource.
Staff time was another in-demand resource for Lean implementation. Several staff, including executives and management engineers, noted that because everyone has responsibilities beyond the Lean projects, staff time to participate on projects is limited. Further, restrictions on hiring and backfilling positions in 2009–2010 further constrained staff time. A process improvement department lead noted that on the Horizon Lean Hospital project, two management engineers who served as project managers left the organization, and their positions were not backfilled. Instead, existing staff worked to fill the void.
A few interviewees—an executive, a management engineer, and two frontline staff— noted that in some cases, additional staffing resources are made available to take on the day-to-day duties of those assigned to projects. In the ER, additional staff were brought in to make sure staff could fulfill their roles on the Bed Flow project. One hospital had staff willing to work overtime and used them to fill any gaps in coverage caused by staff attending Kaizen events.
Technology played an important role in several projects, but it also posed challenges to implementation. For example, a delay in equipment delivery meant that the Bed Flow project's "Click to Clean" process had to be postponed. Two frontline staff reported that following implementation, staff weren't sure at first what to do when the "Click to Clean" system and GetWellNetwork had problems or were unavailable. On the Surgeons' Preference Card project, an executive and a management engineer noted how important the IT package was, but that sometimes, the IT software didn't work correctly or didn't fit with other information systems in the hospital. Two management engineers mentioned the importance of engaging IT in the process redesign to be successful and avoid unnecessary challenges and errors in decisionmaking.
|"We are very transparent, showing how things worked or didn't work, if we've been able to sustain our work. Sometimes we've spent many months or a year doing a project and when we check back and it isn't still sustained at a certain level, you know, there's explanations and refocus and we put more resources towards it, so that's something that the whole room agrees to, and we put a lot of support there."
Routinizing processes can prove challenging in disparate organizations. One management engineer noted that it was proving difficult to routinize the Lean process, given that LHC, when it came to be, was made up of four hospitals from two different health systems, and they sometimes still act like individual entities instead of one system. A hospital executive noted that this problem might continue as more physicians' offices and ambulatory care sites join the organization.
Sharing information across sites builds on the work being done and begins to standardize processes across hospitals. Two management engineers noted that it was very helpful to share what's gone on at other sites with similar projects to help gain buy-in with staff. Frontline staff and management engineers then used the learning from the other sites to build on their work, instead of starting at the beginning. One example of this is the Bed Flow project. Management engineers were able to build on what they had learned at each hospital, since the process was implemented sequentially.
Maintaining the changes resulting from a Lean project can be difficult. To prevent staff from reverting to old processes, frontline staff and a management engineer noted that they hardwire the process, removing any possible workarounds. As issues arise, staff are encouraged to engage a diverse group of personnel to solve the problem just as was done on the Lean projects. Two other frontline staff reported that daily 3-minute unit meetings offer an opportunity to reinforce new practices, discuss revised rules and practices, and allow the entire unit to "touch base." To further prevent slippage, one executive reported that management engineers assist with monitoring data. Two other executives stated that having senior leaders participate in followup monitoring and project report-outs helps to sustain outcomes.
An executive and a process improvement department head reported that another way LHC ensures that the culture of Lean is integrated throughout the organization is by negotiation with outside vendors, building clauses into their contracts that requires them to work with the organization's process improvement methodologies, in this case, Lean.
LHC executives and management view Lean as a tool to reduce waste and as one technique in a toolbox of quality improvement tools that includes Six Sigma. Lean is used as a mechanism to improve efficiency and patient experience, while Six Sigma is applied to reduce variation. Lean was adopted during a period when the operating margin was negative. LHC's approach to implementing Lean involves developing a management workforce with the ability to apply Lean concepts to solving problems that they encounter in the course of their work and formally training frontline staff through participation in Kaizen events.
- Incorporate Lean process redesign in the schedule for new IT system deployment. It is important to revise inefficient processes before introducing IT system upgrades, so that the new IT systems are designed to support that optimal process, not the previous, inefficient process. Lean process redesign should begin soon after the decision is made to purchase a major IT system, since process redesign and testing require substantial time.
- Continue to use management engineers to support Lean events. The building of Horizon Hospital served as a catalyst for far-reaching cultural change throughout this facility. Staff had an opportunity to work closely with management engineers to learn how to apply Lean as they were developing new processes. Expanding the use of the management engineers to guide teams in using Lean tools and project implementation in other parts of the system might be beneficial to accelerating system-wide cultural transformation, including integration by staff of Lean tools into their day-to-day work.
- As more clinical projects come about, seek out opportunities to involve physicians more integrally in the Lean events. As noted by a few staff, physicians are not involved in the events. As LHC continues to work towards more clinical interventions, consider how physicians might move beyond a consultative role. It may be necessary to look for greater involvement of hospitalists to achieve the same success as the projects that primarily involved nurses and administrative staff.
- Align process improvement with strategic initiatives. By adopting Lean and other process improvement methods, LHC gave staff a path for carrying out the cultural transformation initiative—a blueprint for achieving patient satisfaction that includes resource stewardship as one of five major thrusts of the initiative.
- Lean does not replace other quality improvement methods. LHC developed a toolbox of quality improvement methods to achieve the organization's goals. Lean is a companion to other quality improvement methods; methods should be selected based on suitability to the issue being addressed.
- Integrate Lean and process improvement into leadership development and promotion. LHC integrated Lean and Six Sigma into leadership development. In-house quality improvement experts were promoted to management. This strategy contributed to the development of a strong quality improvement culture. If management is to promote the use of quality improvement among their staff, they must understand it themselves.
- Lean and process improvement implementation requires expertise. LHC has invested in building the quality improvement capacity of the organization by developing executives' and managers' expertise and by staffing departments devoted to quality improvement, which includes management engineers. A more hierarchically controlled, and expert-led approach to Lean may improve success.
- The cost of Lean implementation can be offset. Increased patient satisfaction, improved employee satisfaction and reduced turnover, an increased sense of teamwork, the breaking down of department silos, and increased efficiencies can make up for the outlay that is required to train staff, hire experts, and conduct Lean events.
- Expect that not all Lean projects will be a success. Even an organization as experienced in quality improvement as LHC can have projects that don't yield the desired results. Less-than-optimal results build internal expertise and provide useful lessons to inform the execution of future projects.