This report presents the results of the study of Central Hospital's experience implementing Lean. Two projects, Improvement of Door-to-Balloon Process and Management of Surgical Procedure Cards, were selected for study from this organization. The case study methods, including the criteria for selection of the projects for analysis, were described earlier in this document (see Introduction). For this case, we conducted 48 interviews with 51 individuals. Their roles and positions at the hospital varied as described in Exhibit 2.1.
The hospital serves the area surrounding the city it is located in and is a unit of a regional organized delivery system (ODS), known as HAU Care, which operates 20 health care organizations throughout the State. HAU Care is among those operated by a nationwide, not-for-profit health care system. The system's mission is to serve all persons, with special attention to those who are poor and vulnerable.
Central is a 588-bed urban hospital located in a mid-western state. It includes four Centers of Excellence: Orthopedic Center; Neuroscience Institute; Heart Center; and Cancer Center. The hospital has been ranked nationally multiple times and recently was recognized as one of the Nation's top hospitals from a respected private rating organization. Descriptive characteristics of Central reflecting the case selection criteria are shown in Exhibit 2.2.
The national health system operates under a distributed leadership model based on the premise that knowledge and leadership are distributed across the system. The national system provides an overarching legal and financial infrastructure; within that framework, the regional health systems, such as HAU Care, to which Central belongs, have input into the national strategy. Additionally HAU Care is able to establish strategies suited to the system. Certain departments that focus on nonclinical aspects of the hospital (e.g., human resources) are located at the regional health system.
Central's CEO is able to independently pursue strategies that are the most fitting for the local market area, in addition to funneling input up to the regional health system. The hospital is large and profitable, and thus has the opportunity to pursue initiatives appropriate for it.
Medical practices in the city were physician-owned until recently, when changes to reimbursement, competition, and other market dynamics led the hospital to purchase medical groups. When the study first began in early 2010, the cardiology practices were physician-owned, but these groups are now owned and employed by HAU Care. The emergency department physicians remain under contract with the hospital as equal partners in the Emergency Medical Physicians medical group. It is noteworthy that in recent years, staff turnover rates have been less than 3 percent.
Management of information technology (IT) and information security (IS) planning and support services at the hospital and the regional ODS levels are centralized at the national system level. HAU Care, the regional ODS uses Quest Diagnostics® (Madison, NJ) or ECLIPSE® (MPN Software Systems, Inc., Saddle River, NJ) as its electronic health records (EHR) system. Surgical services uses Horizon Service Manager, which includes a strong IS support system. The on-site IT/IS support for the hospital reports to regional and national IT/IS department managers. Because the IT/IS services are used across the national health system, any upgrades or updates to the software must be done system-wide. For example, the hospital must send a request for hardware or software upgrades to the national system's IT/IS staff.
The city's competitive market consists of a safety net hospital and four major hospital systems, including HAU Care. Historically, the four major hospital systems operated in different niches of the city and surrounding areas, but over the past 5 years they have increasingly competed with one another and with physician groups. Central is geographically located in an area with residents of relatively high socioeconomic status. Two of the other regional systems have hospitals close by, while the third is not considered a major competitor.
Historically, the city was a relatively high-utilization and high-cost market. Employers and purchasers either were less concerned about costs or were unable to work together to press providers to become more efficient and effective. The city is also home to major pharmaceutical and medical device companies. Additionally, it is the base for several major factories whose workers have union health benefits. HMOs are lightly represented in the State's health insurance market.
Funding and Payers
Many factors have led purchasers in the State market to put more pressure on providers to compete and become more efficient. Some of the major factors include the presence of larger, national insurance firms such as Anthem and speculation about the impact of national health reform on payer mix and payment levels. Central's largest payer—a private insurer—bases reimbursement on quality metrics performance.
As a result of volume and revenue decreases due to the U.S. economic recession, Central had to lay off 30 staff members in 2008. Since then, all of the regional ODS's have been on a capital freeze. Although the hospital maintained a strong bottom line through 2010, there continues to be a region-wide hiring freeze to support other hospitals in the system. Nevertheless, the hospital was one of the few hospitals in the city that gave incremental raises and bonuses in 2010.
In this section, we discuss the history of both Lean and quality improvement at Central. Exhibit 2.3 outlines the overall timeline for Lean and quality improvement initiatives. The specific activities noted in the timeline will be discussed throughout this report.
Historically, quality improvement at the hospital began at the department level, with limited organization-wide efforts. A hospital-wide quality safety committee exists; one committee member noted that the structure of the committee shifted in the last few years from focusing on quality reports to being more action oriented. Further, the committee is making an effort to use Rapid Cycle Improvement (RCI) report-outs and other quality reports across departments. These reports present the results and outcomes of the projects.
Prior to the initiation of Lean, the main quality improvement tool used by departments was Plan-Do-Study-Act (PDSA). Some staff members also mentioned participating in projects that used Find, Organize, Clarify, Understand, Select-Plan, Do, Study, Act (FOCUS-PDSA). There have been several smaller, less formal quality improvement projects throughout the hospital. For example, in the surgery department a few years ago, a physician spearheaded a quality project team for total knee and hip replacements.
The hospital participates in a coalition that provides a forum for area hospitals to share information about best practices and to collaborate to solve patient safety problems. The coalition focuses on improving high-risk processes, such as high-risk medications, surgical safety, and sepsis. Coalition hospitals agree to implement improvements generated through coalition activities.
The national health system mandates several patient safety initiatives in all hospitals as part of its overall strategic plan. Participation is required in the following priority areas: falls and fall injuries, pressure ulcers, perinatal safety, nosocomial infections, perioperative safety, Joint Commission national patient safety goals, and adverse drug events. Dissemination of procedures in these areas occurs throughout the health system. For example, in 2008 the national system launched a campaign to have zero preventable injuries or deaths within the health system. This effort and prior safety efforts have been a major focus for the system overall.
The introduction of Lean at the hospital corresponded with the hiring of a new president in December 2007. Previously, he served as the president of a smaller hospital within HAU Care, which worked with a consulting firm to implement Lean Process Improvement. The new president sought to implement a centralized quality improvement model that would bring culture change throughout the hospital, and he was excited by the results from implementing Lean at his previous hospital.
According to staff, the first consultant was a poor fit with many staff members because she had incompatible values and little experience applying Lean in health care. The consulting firm assigned a new consultant, and numerous interviewees at various levels agreed that he was a better match for the organization and a valuable asset.
Hospital staff members are evaluated annually, and staff may receive a financial incentive for contributing to improved performance on hospital metrics. This financial bonus, known as Share the Vision, is tied to performance on a metric system established by the national system and HAU Care, the regional ODS, for the fiscal year. This metric system includes a scorecard with the BEST (budget, experience, safety, team) metrics. Participation in RCIs, an expectation for all staff, is noted in the annual evaluation process.
Because the hospital often serves as a "test site" for the regional HAU Care, there are plans to implement Lean across the regional system based on the hospital's experience. The hospital's experience with Lean in terms of specific projects and processes will likely be tailored to other organizations within HAU Care. One example is the "Door-to-Balloon" case, which is discussed later in this report (see Intermediate Outcomes).
How an organization understands or defines an innovation or intervention is a crucial component of its implementation process and an understanding of its goals. Knowing how Lean was defined by upper management, conveyed to staff, and interpreted and understood by members of the organization is crucial to understanding this case. Although specific questions asking interviewees to describe Lean were not used, in this section we describe how interviewees described Lean by using the most frequent descriptions across interviewees (Exhibit 2.4).
Reducing waste and increasing efficiency. The hospital staff were unanimous in their descriptions of Lean as equating it with RCI events. Department leaders and senior staff at the hospital describe the Lean process as a way to examine hospital processes and improve them by reducing waste. These individuals noted that teams examine a process "in painstaking detail" and improve it. No frontline staff were this explicit in their description of waste reduction, and three noted that staff were confused about what Lean is overall.
Another way interviewees talked about Lean and waste was to talk about how efficiency, and thus cost savings, is a goal for implementing Lean. As Lean has evolved at the hospital, there has been more of a focus on projects that target cost and efficiency, according to interviewees. However, from the onset of Lean implementation, the hospital has promised that no staff members will lose their jobs because of efficiency gains from Lean. Rather, they will be transferred to another job or area within the hospital. Two frontline staff in the emergency department put forth the view that the goal of Lean was strictly financial, and that the purpose of Lean was to save money for the hospital rather than improve quality or efficiency.
Culture change. The conceptualization of Lean as a way to change culture appeared to differ for executive leadership and frontline staff. According to two members of the executive leadership, the goal of Lean is to transform the organization into a Lean culture. One executive described a Lean culture as one that understands the need to improve processes globally and is dedicated to doing so. Implementing Lean is not simply about reducing costs or increasing safety but rather breaking down silos and improving processes globally.
The concept of culture change in the hospital was not mentioned by any frontline staff, including physicians, as a goal of Lean. For a small number of frontline staff, it was unclear what Lean was when it was first introduced, and it was still unclear even after they had participated in Lean events.
Most frontline staff equated Lean with the RCI events. That is, Lean is primarily about the specific RCI events and the outcomes to be achieved through doing them.
Staff engagement. One broadly stated goal of Lean is to fully engage staff in the process. Many interviewees, including both department leaders and frontline staff, noted that they thought Lean would get staff excited about the process and build it into their everyday work. Some interviewees even noted that a successful project is one that improves staff satisfaction and motivates people to participate in another project.
The hospital is continuing to use PDSA and various independent quality improvement projects while implementing Lean. Currently, PDSA is used by the quality department for unit-based and department-based quality improvement, and Lean is used for value streams,n identified as high priority by the executive steering team. Although PDSA is similar to Lean, it is not formally considered a Lean tool.
Since the arrival of the new president in 2007, the hospital has had a heavy focus on organizational development around change management. The hospital offers a leadership program titled Building the Best. All current titled leaders, informal leaders, and those associates identified as candidates for future leadership positions participate in the program. This course is based on a popular leadership training program. However, this training was not formally aligned with Lean. Many senior executives stressed the importance of a culture that focuses on excellence and leadership in implementing Lean.
Finally, the hospital is also part of a network that provides state-wide data on Door-to-Balloon (D2B) time and other measures that enable participating hospitals to assess their own performance and compare them against benchmarks.
At the hospital, the Lean process started with the leadership and the consultant reviewing the whole organization and outlining a strategic plan for Lean implementation. This initiative began with the leadership studying the whole organization, defining priorities, identifying departments for inclusion, and selecting Lean project teams.
In this section, we describe aspects related to Lean implementation, including training on Lean, the process for selecting Lean projects, the process of Lean implementation at the project level (including how the project and team are structured), and aspects related to monitoring and sustaining project results. Lean is implemented in several waves, as is further described here and illustrated in Exhibit 2.5.
The primary Lean tool used by the hospital is the Rapid Cycle Improvement event. These RCI events are weeklong meetings where a team gathers to develop and test solutions on a single issue. RCI team members are selected from the segment of the value stream that is the object of the RCI event and from the segments that affect and are affected by that segment, including segments from other value streams (see the Planning and Implementation section of this report). Numerous interviewees at various levels viewed RCI events as essentially synonymous with Lean, which is consistent with the finding that frontline staff often do not see the larger culture change purpose of Lean.
The RCI program is under the academic affairs department at the hospital. Two executives explained that Lean is part of academic affairs because it is seen as a means of culture change. Lean might have been seen as a regulatory program if housed in the quality department or solely as a cost-control program if housed in finance. Nevertheless, both executives and frontline staff saw the overlap between quality improvement and RCI events and had difficulty distinguishing the quality improvement and efficiency-oriented aspects of the Lean events.
As depicted in Exhibit 2.6, several steps led to the selection of Lean projects at the hospital:
First, the Administrative Council Level Transformational Plan of Care (TPOC) selected four key areas—surgical services, emergency department, cardiology services, and appropriate level of care—to target with Lean and planned escalation or ramp-up to eight active areas or value streams. These areas were selected on the basis of organizational-level metrics and opportunities for improvement on these metrics. The Administrative Council also looked at the readiness for Lean and the current leadership in each area. The four areas became individual value streams, or areas to target for Lean projects.
Second, after the value steams were selected, a steering committee for each was organized. The steering committee comprised departmental leadership, process improvement staff, and finance staff. Steering committee members, with assistance from the Lean consultant, met for 2.5 to 3 days and conducted a "value stream analysis (VSA)." The VSA was used to map out the current flow within an area, identify barriers or issues that affected the flow, and determine the target state flow (achievable within 12 months) based on Lean principles. As a result of this effort, opportunities for improvement were identified and then rated and ranked on their ability to affect the desired target state and level of effort (cost/resources and ease/difficulty) to implement. The result was a planned timeline of Lean projects, events, and "just do it" activities. Physician input played a large role in this selection process, and some interviewees felt that physicians were more likely to target areas in major cost centers. Each process or event on the value stream became a Lean event, with one Lean event scheduled per month.
Third, after selecting 18 projects within the four value streams, the steering committee defined the relative order for each event. The events were prioritized within the four value streams using two methods. One method involved voting and prioritizing by steering committee members and physicians. In this method, each individual was allowed to vote on the 18 different projects. Those projects receiving the most votes were targeted first. The second method involved examining the entire flow of the value stream and how each project might have an impact on the flow of another. Interviewees reported that this process worked better because it allowed a more logical organization of Lean events than did the ranking system, which did not necessarily take into account how one event might affect others. Physician engagement was taken into account when planning and organizing the events to ensure that physicians had enough lead time to participate.
Two interviewees raised concerns in regard to the organization and prioritization of Lean projects. One executive noted that projects often overlap and that the work of a previous Lean team was sometimes undone by a newer Lean project. Another pair of interviewees raised concerns that the current status and context of departments were not always taken into account during value stream selection. For example, the presence of poor leadership and staff conflict were not considered when selecting projects.
In general, the hospital has one Lean event per month for each value stream. Several interviewees at all staff levels noted that this aggressive pace of implementation often causes team members to feel burnt out by the Lean process.
Staff from all levels are involved in Lean projects at the hospital (Exhibit 2.7). Each RCI event is led by a facilitator, who is a member of the process improvement staff group. The facilitator receives formal training and is a full-time staff member who is either a formal or informal leader at the hospital and knows the organization. The executive who oversees the process improvement group and academic affairs selects the facilitators using his or her knowledge of the technical aspects of Lean and requirements of good facilitation. At the time of the first site visit, almost all the facilitators held full-time positions in line or staff departments and took on Lean facilitation as an additional function. Although they received partial dispensation from their regular jobs during RCI event weeks, they reported that they fell behind, causing some friction with their regular supervisors. To try to keep from falling too far behind during event weeks, some facilitators returned to their full-time job at the end of the day after the RCI team finished. In response to these problems, full-time Lean facilitator positions were eventually created.
Prior to the event week, the facilitator works extensively with the executive sponsor to develop the charter and select team members, including the team leader and the process owner. The executive sponsor is usually the director of the department implementing Lean and is also on the value stream steering committee.
The team leader is selected by the executive sponsor and is an individual from outside the value stream who has demonstrated leadership skills. The team leader assists the event week team in meeting its objective by organizing pre-event preparation, providing direction and guidance for the daily activities during the event, managing the team dynamics, and tracking followup items and metrics to demonstrate post-event performance. Some projects may use co-team leaders.
A process owner works with the team leader as the content expert for the team and the "go to" person for the facilitator and the team leader. The process owner works in the value stream in which the Lean project is occurring and assists with the event week preparation activities by planning and executing all event week communication and tracking followup items/metrics that demonstrate post-event performance.
The Lean team composition varies by project. All teams include individuals who are (1) managers or considered experts in the area, (2) directly involved in the process or customers of the process, and (3) not involved in the process at all (called "fresh eyes"). Generally, the hospital recommends that Lean teams do not exceed more than 10 individuals, but some teams have had as many as 16 members. Finally systems staff (e.g., IT/IS) are ad hoc members who participate as their expertise is required.
In the original implementation model, Lean teams did not include managers. However, after an initial period of implementing Lean, it became clear that without management involvement in the Lean team, staff often devised solutions that were not always feasible given resource constraints. Accordingly, departmental management staff were integrated into the Lean teams.
Two types of Lean training are offered at the hospital, each tailored to different roles in the Lean process. Facilitators, or those who manage the RCI event, receive training that includes completion of a portfolio of Lean work, classroom time with the Lean consultant, and an evaluation component. Facilitators can work toward five increasing certification levels, and training is paid for by the organization. Additionally, facilitators receive just-in-time training from the consultant during the initial RCI event. This real-time feedback occurs after each day of the event, when the facilitator meets with the consultant to problem-solve and discuss the plan for the following day.
The Lean team members receive less training, and they are trained while participating in RCI events (Exhibit 2.8). Individuals attend a meet-and-greet training session 1 to 2 weeks before the RCI event, which lasts about 1.5 hours and introduces the basic premises of Lean: eliminating waste and strain while improving the staff's ability to care for patients. During this session, team members also learn how the RCI event will look and run. This training session was added to the Lean program after its original inception as a result of feedback from staff that more training was needed.
Lean team members also receive another 2‑hour training session on the first day of the RCI event. This session focuses on the principles of Lean and further examines the types of waste that team members might encounter. Team members referred to this session as more of an introduction to Lean than training.
One interviewee noted key differences between prior quality improvement initiatives and Lean in the selection of team members and the time to complete the project. In previous non-Lean projects, staff identified the problem, gathered a team closest to the work, worked through the problem, and then implemented change. With RCIs, however, the interviewee noted that participation in teams is no longer limited to those who are closest to the work. Further, as one noted, the RCI team is designed to work through the problem in just a few days, rather than taking 3 months. Other interviewees noted that RCIs are more focused on a single problem and have more resources to meet the desired outcome.
We received conflicting information from interviewees about what Lean training, if any, management and leadership staff received. Some frontline staff believed that managers and department leadership received training during the initial Lean value stream activities; another interviewee noted that management staff received specific management training similar to the facilitator training. One other staff person noted that no formal training was given to management and departmental leadership.
In general, many interviewees, including facilitators, Lean team members, and departmental leadership, noted that more formal training on Lean is needed. Team members desired more information on Lean tools and Lean terminology, noting that those who are new to RCIs are often confused by the concepts and language. Other interviewees generally felt that the organization needed to move from just-in-time training to formal training.
Lean projects at the hospital follow similar processes that revolve around an RCI event.
Before the Event
About 3 to 4 months before the start of an RCI, the facilitator and the executive sponsor create a charter for the RCI event that outlines the scope of the work, the current and target states, and the current and target metrics. The event team is also listed in the charter.
The facilitator works with the team leader, the process owner, and the executive sponsor prior to the RCI event. The facilitator helps clarify the roles of all team members, helps determine which data will be collected prior to the event, and engages with staff and managers in the event area to better understand the issues and challenges that the Lean team might face in the area in which they are trying to implement changes. The team leader and the process owner work with the facilitator to collect baseline data and observe the current processes. The team leader also works with the facilitator to become more familiar with Lean tools that might be used during the event.
RCIs lasting 4.5 days are scheduled for 1 week each month in each value stream. Using a process developed by the consulting firm, the RCI examines and tests solutions to the problems discussed by team members. A few interviewees described the RCI process as "too rigid" and not flexible enough to meet the individual needs of the department. The activities included in each RCI are described in Exhibit 2.9.
Some staff felt that it was difficult to realistically simulate certain conditions or events (e.g., a patient having a heart attack) and to test various redesign options during the RCI event. Also, some interviewees felt that these "tests" were very optimistic guesses of what would happen and what would be done on a routine basis.
|"There's just so much work and I would say there's actually more work in sustainment, because as each event overlaps, you're sustaining more and more, and sustainment is a function of problem solving."
—Lean Project Facilitator
Other interviewees, including those who have participated in multiple RCIs, believed that solutions generated during the RCIs are often generated beforehand by the executive sponsor, the process owner, and the facilitator and not by the team members. However, other team members believed that the facilitator was unbiased and that they were able to generate their own solutions during the RCI.
After the RCI Event
Changes are implemented the Monday following the event and sometimes sooner. Staff noted that there is a lot of pressure to implement changes quickly, and process improvement staff are "dead bent" on implementing changes on Monday. Lean teams also follow a completion plan that is generated during the RCI. Immediately after the RCI event, team leaders and process owners are responsible for implementing the solutions developed during the RCI, communicating with department staff about changes, and overseeing the changes.
Two other tools are used as part of Lean at the hospital: "just do it" activities and "project" work. In just-do-it activities, a known problem exists with a known solution, and the means to implement the known solution requires only one or two people and less than 8 hours of work. A project is defined as a problem having a known solution, but the means to implement the solution requires a multidisciplinary team and anywhere from 1 week to 2 months to complete. These tools involve using Lean principles, but the key difference is in whether a known solution exists. The primary premise for using an RCI event is to determine the root causes for problems in an area because even though efforts to solve the problem have been attempted in the past, the issues persist, indicating potentially that the solution resolved a symptom but not the underlying cause.
|"The reason that I think we're still doing it is because there is that commitment from the top down and they make it very clear that—in a nice way—that they expect us to work and that this is to be our model for how we improve our processes."
At the Lean project level, the team leader and the process owner, with support from the facilitator, monitor the project after the completion plan items are implemented. Team leaders are required to report out on the project metrics 30, 60, and 90 days after the RCI event. Sustainment involves continual monitoring of metrics related to project activities and frequent communication (e.g., weekly meeting, staff huddles).
One barrier to the sustainment of individual Lean projects is that new RCIs occur each month. It requires a tremendous amount of staff time and resources to get new projects off the ground while sustaining previous projects.
Spread of Knowledge and Findings Across Central Hospital
Executive team reporting. The main form of disseminating findings to the executive team is through the report-out on the Friday following the weeklong event. Each team presents the problem, the process for solution, and the outcomes. The executive team has begun tying the report-out meetings to financial meetings to increase the presence of executive leadership.
Internal hospital communications. According to numerous interviewees who participated in an RCI team, communication about Lean findings seems to be organized individually by projects. For example, in the surgery department, a newsletter was published to promote findings from RCI events. Additionally, a bulletin board was installed to post results. Cardiology department staff, including individuals who were not part of the D2B team, noted that they get updates on projects every Wednesday at staff meetings. Additionally, one interviewee involved with the procedure card project noted that the surgery department maintains a SharePoint site, which all surgical staff can access to view data and progress on their department's Lean projects.
There are few organization-wide tools for communicating about RCI projects. For example, the senior-level executive who oversees the RCI program occasionally presents outcomes from various RCIs at staff meetings. One interviewee, who served as a team member, noted that she did not think the results were shared beyond the project team. In her experience, after the conclusion of the event, even team members from outside the department did not get any further updates about the outcomes.
In addition to the spread of Lean within the hospital, there has been increased involvement of HAU Care, the regional ODS. Because some departments are led and coordinated across the regional health system, employees are often included as RCI team members for these departments. For example, the D2B team included a risk manager from HAU Care. Additionally, the many supply chain projects all have a representative from HAU Care because the supply chain department is run at the regional level.
Central is being used as a test location for Lean because it is one of the largest hospitals within HAU Care. Some interviewees noted that HAU Care plans to implement Lean across the system based on the hospital's experience. One example was described earlier in the discussion of the D2B project. This project is being implemented in another clinic within the system, accounting for lessons learned from the first clinic. Further, HAU Care is developing a Lean Steering Council for Lean process improvement to facilitate collaboration among regional health system members.
The hospital has used different collaborative groups around the State to discuss Lean implementation. Examples are the Association of periOperative Registered Nurses (AORN) meeting and the coalition for patient safety meetings where members share different Lean approaches. In addition, one value stream sponsor noted that she made a presentation for an RCI event to the national umbrella health care system. One executive sponsor mentioned that the hospital makes presentations at citywide or statewide meetings and participates in a Lean collaborative group. This collaborative group looks at Lean/Six Sigma initiatives within the city as they relate to patient safety as part of the coalition for patient safety. Additionally, the national system created a Lean/Six Sigma working group.
We selected two Lean projects that focus on processes relevant to frontline staff: improvement of "door-to-balloon" process (prospective) and surgical preference cards. Prospective projects were studied as the project occurred (i.e., from the initial training and project implementation to sustainment).
Door-to-balloon (D2B) time refers to the interval between the time an acute myocardial infarction (AMI) patient enters the emergency room and the time a percutaneous coronary intervention is completed; often, this intervention involves the insertion of a balloon into the blocked artery. The Centers for Medicare & Medicaid Services (CMS) standard for D2B is a maximum of 90 minutes. At the time D2B was selected as a Lean project, the average time reported to CMS by the hospital was 89 minutes, very close to the maximum. Thus, the goal of this project was to bring the average D2B time well under 90 minutes.
Site of Implementation
The emergency department (ED) was chosen as the first value stream at the hospital because of its high volume of patients and because it was struggling with space issues and throughput. The D2B project was the 11th Lean event completed in the ED value stream and the 5th event for the cardiology value stream.
Various levels of ED staff, ranging from nurses to departmental managers, commented on the culture of the ED at the onset of the Lean project. During 2009, the department lacked leadership, and morale was poor. In early 2009, the ED was understaffed with nurses and had high turnover within the contracted physician group, with 18 positions open. According to one nurse and one executive, the department had disciplinary, staff, and quality issues. Concurrent with the Lean process, the department was working toward certification as an American College of Surgeons (ACS) Level II Trauma Center. The ED successfully launched a trauma center and identified a new director in early 2010.
The emergency department steering group selected this project because of the significant opportunity to improve care of patients who may be having a heart attack and because D2B times are reported to CMS.
The executive sponsor and the facilitator selected the team members (Exhibit 2.10). The team leaders included an individual from patient care services and another individual from training and development. Because the D2B value stream involves the ED and the cardiology department (specifically, the cardiac catheterization lab), individuals from both departments were included in this RCI. Moreover, because D2B times are reported and monitored on a system level, members of a heart institute, another unit within the ODS, were invited to participate because physicians from this group work at both locations. The "fresh eyes" included the risk manager and the chief nursing officer (CNO). Neither of the team leaders was associated with the ED or the cardiology department. Eventually, as one team leader became busy with her other roles, team responsibilities fell to the other team leader. Moreover, the process owner also became busy with other responsibilities, leaving much of the monitoring and sustainment responsibility with the team leader from outside the value stream. This team leader was described by several staff members as "diligent."
Planning and Implementation
A charter was developed in July 2009, but the RCI was scheduled for February 2010 to allow physician participation. The weeklong RCI began on February 8, 2010. The steps or activities implemented by the project team and any Lean tools used are described below.
- Mapped initial state of D2B process (Lean team members described as "confusing," "disjointed" and "practitioner variable" but "focused on patient goals" and "committed)."
- Mapped target state. Lean team members noted the target state should be "fast," "goal oriented," "have clear roles," "be patient centered," "be a good use of resources," and "be easy to instruct."
- Conducted gap analysis between current and target state.
- Brainstormed possible solutions to reach target state and reduce gaps.
- Conducted rapid "experiments" (trial runs).
- Developed completion plan.
Monitoring, Control, and Sustainment
After the RCI, the team leader collected data on the D2B times using manual tracking sheets. She met monthly with directors of the ED and the cardiology department and also worked with HAU Care's heart institute to review the D2B data and reconcile the tracking sheets.
In the monitoring phase, the team leader and staff believed that one of the major issues with decreasing D2B times was not the process developed by the Lean team. Rather, it was the ability to quickly determine whether someone was truly having a specific type of heart attack (an ST segment elevation myocardial infarction, or STEMI) appropriate for angioplasty (balloon insertion). Staff wanted to get more experience with identifying, but there were too few STEMIs each year (about 56 out of 55,000) to allow everyone to develop expertise in identification.
Continued collection of D2B data occurred during sustainment monitoring for the ED and the catheterization lab. In general, interviewees from the ED believed that the process implemented as part of the D2B RCI sustained itself and continued to function well. ED staff believed that they were implementing the new process and their times were showing improvement. Data and adherence to the new process from the catheterization laboratory were less clear because tracking sheets were often not completed or submitted to the team leader.
The perception of success for the D2B project was relatively consistent among Lean team members and department leadership. Most interviewees believed that D2B was "successful" or "somewhat successful." One interviewee who participated in multiple RCIs described the D2B project as "her favorite" because of its success. Specifically, staff noted the following outcomes of the Lean project that contributed to its success:
- A decrease in average D2B time from 89 to 77 minutes as a result of a new standardized process. A checklist was developed to improve the process and to ensure that the catheterization lab staff knew exactly what the ED staff had completed prior to handing off the patient.
- A feeling that patients were truly being helped.
- Better rapport and communication between the catheterization lab and the ED. As a result of the project, as soon as ED staff identify a STEMI patient, they notify the catheterization lab so they can begin preparing. Additionally, the catheterization lab helped the ED prioritize the steps to take before a patient moves to the catheterization lab.
- Improved staff morale in the ED.
- For some, a change in the perception of RCIs. Because this event was more successful than other RCI events in the ED value stream, staff's perception of the value of RCIs improved.
|"With door-to-balloon… I don't think there is that much room for going back."
—Nurse, Lean Team Member
A facilitator, three department leaders, and a physician said the D2B project had seen 60-70 percent improvement, due to tracking and the improved communication with the catheterization lab through a streamlined notification process.
Surgical procedure cards list the supplies and equipment for each surgical procedure for each physician. The goals for the management of surgical procedure cards (procedure cards) project were to reduce the overall number of procedure cards, improve the accuracy of procedure cards, and improve physician satisfaction. Prior to the surgical procedure, a nurse or other staff member ensures that all supplies on the card are in the operating room. Typically, each surgeon has his or her own set of cards limited to the procedures that the surgeon performs. Each surgeon's set is unique to that surgeon. If there are a lot of idiosyncratic procedures that vary considerably, the process becomes inefficient—it takes longer to stock the carts and the room, and it is easier to mistakenly leave something out. If something the surgeon needs is missing, the surgeon will have to use an available substitute that might be less than optimal, or the surgery will have to stop while someone goes to get the item that is missing. If surgeons include items on their cards that they rarely use, the items have to be returned to stock. Items that cannot be restocked are considered contaminated and are disposed. Over time, procedure cards tend to proliferate because the number of surgeons increases and it might not be clear when a card becomes obsolete.
Site of Implementation
The procedure card project was implemented in the surgical services department. There are approximately 300 associates in the surgical department. Staff from this department describe it as one of "open communication" with weekly staff meetings. Staff in this department were described as assertive and accustomed to using evidence for decisionmaking. Prior to the procedure card project, this department implemented several projects from the value stream, including case card accuracy, patient-to-room process, pre-admission screening, surgical scheduling, and chart preparation. Additionally, this department did a specific RCI to ensure appropriate linkages between each project.
The idea for this project was generated during the value stream analysis conducted by the steering committee (see Lean Project Selection Process section). However, the main impetus for selecting this project was physician dissatisfaction with the accuracy of the procedure cards. The nature of the surgical supply packaging and linkages of procedure cards to other surgery processes also made this an ideal candidate. Prior to the project, the national organization began using unbundled surgical supplies, which allowed the system to purchase individual supplies at the best price and enabled the delivery of supplies and equipment that are more closely tailored to the preferences of each surgeon. For instance, when tools are bundled and the surgeon uses only one tool in the bundle, the others are considered spoiled. Unbundling minimizes this problem. However, unbundling increases the chances that a required tool will be overlooked. Thus, the need for accuracy and efficiency in the surgical procedure cards increases.
The surgical department leadership and the executive sponsor selected the team members for the procedure cards project (Exhibit 2.11). The process owner monitored much of the project, as a coordinator in the department. A physician and the chief medical officer (CMO) participated in the RCI because a goal for the project was to improve physician satisfaction. Individuals from HAU Care, the regional ODS, also participated in this event because the procedure cards are managed using the surgical information system at the regional ODS level. Finally, two individuals were ad hoc members of the team, meaning they participated only when needed. One ad hoc member said that she was called into the RCI twice to provide input.
The team leader for this event led the RCI event team but did not participate in pre-event or post-event activities because of her responsibilities as a nursing leader. Redefining the role of the team leader was part of an attempt by the Lean leadership at the hospital to see whether the process owner could take more responsibility for the pre- and post-RCI event work and the sustainment efforts in the belief that the process owner would be a more effective change agent, especially when the team leader did not work in the department being changed.
Planning and Implementation
The RCI event on surgical procedure cards was the ninth event of the surgical services value stream. A charter for this project was finalized at the start of February 2010, and the week-long RCI event began on February 8, 2010. The steps or activities implemented by the project team and any Lean tools used are described below.
- Mapped initial state for creating, modifying, and maintaining all procedure cards. The initial state was described as "complex," "time consuming," and "not meeting the customer's needs."
- Mapped target state. Interviewees who were team members stated that the target state should be "simplified," "smoother," "safer," and "more reliable."
- Conducted a gap analysis between current and target state using root cause analysis techniques.
- Brainstormed possible solutions to reach target state and reduce gaps.
- Conducted rapid "experiments" involving operating room motion; IT/IS system opportunities; and standard work for building procedure cards.
- Developed completion plan.
After the RCI, the team communicated the changes made at the staff meeting held the Wednesday of the following week, despite the pressure from the process improvement team to implement the changes on Monday.
The procedure card team needed three upgrades to the IT/IS system to fully execute the changes from the RCI event. The first upgrade, a free upgrade to existing software, was made. However, the other two upgrades required additional funds and were not been completed during the period of our research.
Monitoring, Control, and Sustainment
The process owner monitored the metrics (specifically, the number of procedure cards) from this project weekly through the first few months of the project. After that, data were monitored monthly. Although the number of procedure cards initially decreased, it eventually increased as new physicians and new procedures were added to the system. This pattern reflects an increase in the size of the practice, not necessarily a decrease in efficiency. Additionally, it was the general consensus that further improvements could not be made to reduce the number of procedure cards until the additional upgrades to the IT/IS system were made.
Metrics for the accuracy of procedure cards and the number of times a staff member needed to leave the operating room to get missing supplies or equipment were measured during the RCI event. The number of times staff left the operating room to get missing supplies or equipment was manually tracked at random times throughout the first 30 days after the RCI. The surgery department also maintains a SharePoint site, where all surgical staff can view data and progress on their department's Lean projects.
The RCI event enabled the surgery department to create a business case scenario to approve funding for the IS upgrades. However, despite approvals and funding, the IS upgrades had not been made at the time this report was prepared. The IT/IS staff were unaware of the delay imposed on this project as a result. As of November 2010, this project had not been completed and had not entered the sustainment phase because the hospital was still awaiting the IT/IS upgrade.
The procedure card project was considered a "success" by most Lean team members and the executive sponsor because it was successful in ultimately reducing the number of cards. The delay for an IT/IS upgrade caused frustration because the project was halted until upgrades could be made. The nurses reported that they are satisfied with the outcome because they do not need to leave the surgical room as frequently to retrieve supplies and equipment.Physicians report satisfaction in having the appropriate supplies and equipment in the room. Additional outcomes attributed to this project include the following:
- The number of procedure cards decreased by 57 percent (from 15,000 to about 8,000 cards) over the duration of this case study.
- The IT/IS infrastructure was recognized as a major constraint on improving efficiency in this and other processes. The team realized that the IT/IS infrastructure was largely inflexible and did not always suit the needs of surgical services staff.
- Heightened and continued engagement of the process owner and a surgeon champion was viewed as a major success factor.
- Physician satisfaction improved.
- A "business case scenario" was developed for funding the IT/IS upgrades. This scenario included a description of the project and anticipated outcomes to justify the financial investment.
- A process was defined and implemented to ensure that procedure cards are updated, current, and accurate. Although the percentage of accurate procedure cards cannot be confirmed (until the new IT/IS system is in place), staff felt that progress had been made in this area as a result of the new standard process.
- The amount of paper printed for procedure cards decreased from 600 sheets per week to 60 sheets per week. This reduction in printing is a result of fewer and more accurate procedure cards.
- The procedure cards event was also seen as a partial success in that nurses were pleased that they did not have to leave the room for supplies and surgeons appreciated the increase in accuracy with their equipment. However, the delay in the IT/IS upgrade caused great frustration for all staff involved.
In this section, we discuss the outcomes of the Lean initiative at Central based on information provided by interviewees (Exhibit 2.12). The focus of this case study report is on the qualitative data collected, and thus it addresses mostly the process and perceived impacts of Lean. Where available, we provide outcomes data, including quantitative measures, provided by the hospital during the study.
The discussion of Lean outcomes is organized into two major categories based on our conceptual framework: intermediate outcomes and ultimate outcomes. As described previously (see the Conceptual Framework section of this report), intermediate outcomes include culture change, employee satisfaction, change in Lean knowledge and skills, and Lean routinization. These outcomes can be viewed as intermediary to the ultimate goals of increased efficiency, increased patient satisfaction and experience, improved clinical processes and outcomes assessments, and increased patient safety.
While the findings for outcomes are structured around our conceptual model, most data for outcomes for the hospital are related to employee satisfaction or frustration owing to Lean and increases and challenges to efficiency.
The hospital measures impact at the project level, at the value stream level and ultimately at the organizational level.
Organizational Culture Change
|"I do hear conversations around standardization and doing standard work that has become normal conversation. Those two terms are part of our culture now."
—Department leader, procedure cards
Change in organizational culture was discussed mostly by process improvement and senior-level staff. These individuals believe that the culture is slowly changing, and concomitantly, enthusiasm to participate in Lean is slowing increasing.
One of the original goals for Lean was a change in the culture at the hospital from a silo organization to one of increased standardization and communication. The outcomes for this appear to be bimodal, with executive staff mentioning and believing that the implementation of Lean can have an impact on the culture of the organization or at least on units, whereas frontline staff mostly described Lean in terms of discrete RCI events. The vision for a "Lean" culture exists primarily for executive staff. However, one department leader felt that although there is "room for improvement" in understanding Lean principles, there is a high level of interest in the concepts. One department leader noted that language around standardization is becoming a normal and frequent part of the staff discussion about procedure cards. This same respondent said that terms like "standard work" and "standardized processes" are becoming commonplace among department leaders in the hospital.
However, administration's and frontline staff's perceptions of culture change appear to differ in that at least three frontline staff felt that the Lean process has not changed the way staff think about their job. An ED staff member felt that the culture that already existed in the unit (i.e., physician dominance of decisionmaking) prohibited the full integration of the Lean process—namely, that the physicians do not have to adopt the Lean process, which creates a situation where only some staff change their behavior.
Outcomes related to employee satisfaction were mixed; quantifiable successes improved morale in some cases, but an increase in tension caused by implementing Lean processes negatively affected moral in others.
Visible and quantifiable success improves employee morale. For D2B, two facilitators noted how the tracking process they implemented for the RCI helped employees see how quickly they were working and where they could improve. They felt it increased their job satisfaction because employees knew when they had done things well and could follow up for improvement. One ED nurse attributed improved employee morale to the fact that the D2B RCI went smoothly and helped them identify problems in communication and mutual understanding with the catheterization lab.
For the procedure cards RCI, two department leaders said that nurse, physician, and team satisfaction increased because of having the appropriate supplies and the right procedure card. This improvement in procedures led to staff having the tools they need to do their job well, in turn leading to improved employee satisfaction. Improved satisfaction also appeared to be due to increased understanding of the process.
There was also a difference in perception by facilitators and frontline staff about the root of the increase in employee satisfaction. One facilitator attributed the improvement in morale to seeing the change in the whole value stream, while the frontline staff did not comment on the bigger picture but instead focused more on their immediate environment.
Tension among staff caused by Lean has a negative impact on morale. Six staff, including frontline staff and leadership, indicated that Lean actually had generated a negative impact on employee satisfaction because tensions among staff increased. One department leader cited an example where staff morale decreased when changes from one RCI could not be implemented because the organization would not purchase equipment necessary for the change. Another department leader noted that an RCI resulted in the redeployment of one staff member to another department; according to this interviewee, this staff member was unhappy with the move.
ED physicians were initially contractors, rather than employees, and were not mandated to participate. This caused great tension mentioned by at least two nurses in the D2B project because some physicians resisted or refused to implement changes. The physicians involved in the procedure card process were under a different employment structure and were hospital staff; thus, they were more engaged in the process.
|"I think that the staff morale did improve… It also improved the morale of our staff towards RCI as a whole because… they got something that made sense to them."
Lean Knowledge and Skills
Findings related to Lean knowledge and skills can be grouped into three themes: staff have a new appreciation for other teams, standardization increased across locations, and clinical knowledge improved. Evidence and discussion are limited in this area.
Some staff have a new appreciation for other teams. One nurse in the ED mentioned that due to the D2B RCI, she learned what the order entry clerks did and what the catheterization lab was looking for, thus making it easier to understand the needs of others with whom she worked.
Standardization increased across locations. One department leader noted that for the first time, the two cardiovascular sites have collaborated on making the D2B project work. He noted that the experience has been positive for all involved.
Clinical knowledge improved. Because the D2B process focuses on getting STEMI patients to the catheterization lab quickly, some ER staff were unclear why the team did not use this process for all myocardial infarction (MI) patients. The cardiologist helped staff in the ER understand that not everyone with MI needs an immediate catheterization, so the process helped focus efficiency on those patients who could have an improved clinical outcome.
Findings related to Lean routinization can be grouped into three main categories: gaps or errors were identified, IT/IS upgrade delays were a challenge, and staff learned to be open to changes.
Lean processes can help identify gaps or errors to streamline the process. The Lean process as applied to the D2B project involved the application of a STEMI tracking sheet that follows the patient from the ER to the catheterization lab. One ED nurse reported that they now know the priorities for what to do and in what order for STEMI patients and have created a STEMI kit with the drugs needed in that situation. By using this tracking sheet, the ER, the catheterization lab, and the physicians can see how their timing improves. The process also helped standardize efforts across the two locations. While many found this change to be positive, one nurse felt that the routinization process focused on the bottom line instead of on standardization. A facilitator also felt the outcomes never reached the desired level.
In the procedure cards project, the team has a routine in place to check the cards every day to make immediate changes when necessary. The project has also resulted in an increase in accuracy, with the result that the team does not have to leave the operating room as often.
IT/IS upgrade delays caused challenges to routinization. While the procedure card RCI led to improvements and routinization of the cards, the team was still waiting for two IT/IS upgrades to complete the process. The CMO also noted a problem with some entries populating the wrong procedure cards, which needs to be corrected with the software. A department leader for the process felt that having the RCI event supported their efforts to get an upgrade. Another department leader expressed disappointment that they did not get the result they anticipated because they did not have the correct systems upgrade.
Staff learned to be open to changes. One procedure cards department leader felt that the Lean process taught them to try different processes. They also learned to not be afraid to return to old patterns if the new processes did not bring improvements.
This section is organized according to the types of ultimate outcomes represented in the conceptual framework. Findings regarding ultimate outcomes were reported by interviewees. Information is available for three of these outcomes: efficiency, value (business case), and patient experiences of care.
Nearly all staff at all levels, from senior management to frontline staff, reported on efficiency-related outcomes as a result of Lean.
Organizational level. Staff reported many substantial gains in efficiency in the hospital during and after implementing Lean. Senior-level and process improvement staff indicated that Lean saved the hospital $1.5 million in 2009. This figure was corroborated by the CFO; however, it is unclear which costs and savings were included in this figure.
Project level. The following impacts on efficiency were linked directly with specific Lean projects. Several of these impacts were discussed in Section 6. However, we have repeated these outcomes in this section to highlight the totality of impacts on this area.
- D2B times improved from an average of 89 minutes to 77 minutes, with only one patient falling outside 90 minutes, in May and April 2010.
- ED door (i.e., time patient enters the ED) to doctor time (i.e., time patient sees doctor) decreased from approximately 55 to 37 minutes.
- One ED project focused on capturing charges and billing. As a result of this project, billing accuracy was improved to 98 percent and revenue increased approximately 5 percent.
Management of surgical procedure cards. For the procedure card process, one department leader cautioned that although it looked like the number of cards increased, this higher number was due to an increase in the number of physicians and procedures. According to three department heads, there has been a 57 percent reduction in the number of cards because they had physicians review their cards for accuracy and maintained them.
|"When you start to look at the whole process, it has turned like that the work is being pushed back from one set of people to another rather than overall getting more efficient."
—Department leader, procedure cards
There were some negative perceptions surrounding efficiency gains. Staff perceived a shift of work to other staff because of the pressures of Lean process. According to two department leaders, some efficiency improvements in one part of the value stream resulting from the RCI event were achieved by pushing work to another set of staff downstream, instead of truly improving the efficiency of the entire value stream.
Additionally, although staff members were told at the beginning of the Lean process that they were guaranteed not to lose their jobs due to increased efficiency from Lean projects, as mentioned one person was redeployed from the procedure cards team. This led some interviewees to question the motivations of leadership.
Other projects. One RCI resulted in the addition of one full-time-equivalent (FTE) position to improve the overall process. Interviewees were unsure how this affected efficiency because the additional resource may have resulted in greater efficiency gains. Additionally, one interviewee who had some experience in other RCIs at the hospital noted that improved patient throughput leads to more patients being admitted, which may increase the patient load of the nursing staff, if other factors remain equal.
One department leader for D2B commented that patient satisfaction seemed to increase during the events; however, there was no evidence for this except personal perception. Other than that, patient experiences and patient satisfaction were not specifically mentioned by interviewees. In general, a few staff mentioned that some RCI projects, especially those involving housekeeping and support services, included process changes that allowed nurses to spend more time caring for patients, resulting in a better patient experience.
Clinical Processes or Outcomes Assessment and Patient Safety
One finding regarding patient safety was that the focus on the patient increased when the goal of the RCI aligned with the goals of the department, such as improved patient outcomes. Further, in the D2B RCI, one nurse felt that this event was aligned with the department's goal for increased patient safety and that this common goal facilitated staff communication and engagement. Because of improved communication between the catheterization lab and the ER due to this RCI, the catheterization lab team is more likely to follow up with the ER team on the patient outcome, reinforcing the focus on the success of the patient.
Some staff felt patient safety could be compromised by the Lean process. Two department leaders commented on a project at the hospital not specifically studied in this research. Staff members voiced their concerns regarding patient safety during an RCI on triage, for which a nurse was taken from the triage desk and replaced with an emergency medical technician (EMT). This caused two near misses because the EMT had less medical knowledge and did not recognize certain symptoms. The department leaders stopped the process because of concerns for patient safety.
Business or Strategic Case
Senior and department-level staff at the hospital were asked about the business case for Lean. While many interviewees noted the resources required for implementing Lean, senior executives also noted the value in bringing teams together to solve problems and increase efficiency. At the hospital, outcomes were often measured in terms of ROI. Using their consultant's tools, the hospital estimates the benefit from implementing Lean was 4.5:1 ROI at the end of 2010. This breaks down into cost savings of approximately $8 million with $130,000 per Lean team in 2010.
Overall, the business case at the hospital was somewhat hard to measure beyond ROI because according to one department leader, they often picked projects with "aches and pains" not necessarily projects that would lead to high ROI. The same interviewee noted that the hospital does not have a history of holding people to metrics, and fostering this culture may quantify gains beyond an increase in ROI. From the perspective of some respondents, however, the benefits of implementing Lean at the hospital reach beyond financial gains to increased employee morale, an increase in clinical knowledge, increases in efficiency, and in some cases a perceived increase in patient satisfaction and safety.
In sum, the overall perception of success on the two projects was mixed, and staff were still uncertain about Lean. The CEO noted that some staff have embraced the concepts fully, some see Lean as a passing trend, and some are resistant to change and undermine the process. The D2B project was viewed as a partial success because the D2B time decreased, and staff communication between departments improved.
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 witnessed or faced in implementing Lean (Exhibit 2.13). Findings regarding facilitators and barriers are based on responses to these questions. Barriers to implementation were identified approximately three times more often by staff than facilitators. Staff mentioned a great number of factors that helped or impeded Lean organization or implementation.
All interviewees were also asked to share their insights, that is, their lessons learned based on their experience with Lean at the hospital. More specifically, they were asked whether and how they would change what they had done if they were to do it over again. As expected, these lessons learned were closely aligned with the facilitators and barriers.
Here, we discuss the aspects or factors mentioned by interviewees, noting how they operated as facilitators and/or barriers in the context of organizing the Lean initiative and then implementing it. We also link lessons learned to these facilitators and barriers.
In sum, facilitators related to staff engagement were the most frequently mentioned, with leadership and resources a distant second. Conversely, resource issues were by far the most frequently noted barriers. Issues surrounding communication about Lean and staff engagement were the second highest and were noted with less than half the references. There were far fewer data on lessons learned than barriers and facilitators; nevertheless, issues around scope, pace, and coordination of Lean activities were noted most often.
Because the experiences at the hospital were so mixed, we have organized this section by first providing a summary table showing major factors that facilitated Lean success at Central Hospital (Exhibit 2.14), followed by a table that presents major factors that inhibited its success (Exhibit 2.15).
Alignment of Initiative to Organization
Lack of alignment was listed as a barrier by over half of the department leaders, with three main themes emerging. The first lack of alignment was in the consultant.
The original consultant was not culturally aligned with the hospital. The staff found her to be too focused on manufacturing, and they had a hard time transferring the principles to health care.
When the hospital switched to a consultant who was more aligned with its values and health care, Lean knowledge increased within the organization.
|"And in part, some of it is leadership. You saw today, I think a very good example of our executive sponsors that there's a bit of bimodal distribution between those are strong bought in and driving this and others that are followers and sort of timid about it, and that's been a challenge for us. So, how you light a fire under someone who wants to do the right thing, but struggles with their—with their own confidence or against the system that they feel like they can't really change the way they want to, and a lot of that is change management. And so, we've been doing a lot of change management coaching."
The second area of misalignment was in how staff viewed their primary responsibility to meeting patient needs as being misaligned with the goals of Lean. It was also difficult for some staff to transfer Lean principles to health care, especially around spending time with patients. For instance, many staff felt pressure to standardize the time spent with patients even though they believed this should vary depending on patients' needs. Thus, the new consultant, who had a history of working in health care, was able to help staff better understand how standardization and efficiency in time spent with patients could actually be patient- and customer-focused.
Finally, an executive discussed plans for expanding the leadership development program, "Building the Best," so that all staff could be taught change management skills. The training will be integrated into Lean events, and management will attend a 3-day change management training with the experience solidified by participating in a Lean event. The expanded change management program is at least partly in response to a "bimodal distribution," where some executive sponsors have shown strength in driving Lean forward while others have been more timid.
Scope, Pace, and Coordination of Lean Projects
Many lessons were learned at the hospital surrounding scope, pace, and coordination of Lean projects as mentioned by all department leaders and executive staff interviewed.
Interviewees at the executive level recommended starting the Lean process with a project that is relatively simple to implement and has visible gains for frontline workers. When staff see a quick reduction in waste and can link this to improved patient outcomes, their engagement is higher for future projects. Staff leadership noted that the hospital did not follow this advice from consultants, and complex processes and events were targeted first (e.g., the ED value stream) because they represented significant room for improvement. This resulted in frustration from staff, as projects such as D2B felt overwhelming.
Correspondingly, one facilitator also noted that highly interdependent projects require a lot of buy-in, which is sometimes difficult to obtain early on. Thus, an "early win" can improve staff engagement early on in the value stream and pave the way for more difficult projects.
Nearly all interviewees from the ED said that the scope of Lean projects is an important factor in their chances of success. For example, in the D2B project, many interviewees felt that the narrow, well-defined scope of this project facilitated its success. In contrast, they noted that other Lean projects in the ED were too large in scope and eventually needed to be redefined or ultimately failed.
Many staff, including nearly all ED interviewees, believed that the pace of the Lean projects was too fast. They felt that it was far too difficult to implement Lean changes on the Monday following the weeklong RCI events as instructed. They wanted more time to plan for changes and communicate with other staff about them. Additionally, on a value stream level, the steering committee planned projects each month. As such, staff became very worn out from the events. One Lean project facilitator indicated that it was sometimes difficult to monitor and follow up on all the projects because of limited resources and overlapping events.
Leadership Activities and Qualities
Organizational leadership. Leadership was mentioned as both a facilitator and a barrier to Lean implementation. Interviewees noted the significant buy-in from senior staff at the organizational level. The CEO's belief in Lean motivates other staff to keep committed to the process. Likewise, the organizational champion of Lean at the hospital is strategically positioned because he oversees 300 physicians, resident physicians, and staff and is well respected by his peers. Interviewees noted that organizational leadership participated in report-out meetings and also discussed issues with staff when problems at Lean events arose.
Departmental leadership. According to a department leader, the consultant originally did not include departmental leadership on the teams, believing that their participation would inhibit sharing and transparency. The staff learned that not including leadership led to solutions that might not be feasible, and leaders have since been included on teams. By including department leads on the team, leaders are aware of changes that have been made and can hold staff more accountable for following through.
Department leaders, process improvement staff, and team members identified the lack of engaged leaders at the department level as a barrier to Lean implementation and sustainability. Specifically, they mentioned that department leaders do not monitor progress to make sure that staff follow new processes designed by Lean teams. One interviewee noted that department leaders are very compassionate people but do not have a history of setting goals and holding staff accountable.
Project leadership. The nature of project leadership was mentioned as a barrier by many interviewees from the ED. Because team leaders often were not from the department or the value stream implementing Lean, ED staff interviewees believed that the team leaders were unable to understand the work of the ED and defined changes that were not sustainable. Some interviewees felt very strongly that the team leader should come from the department implementing the Lean projects. Interviewees from the procedure card project did not mention this aspect of project leadership as a barrier or a facilitator to Lean implementation or sustainability; however, the team leader for this project did not play a large role, and most leadership fell to the process owner, who is a member of the department.
Availability of Resources
Overall, commitment of sufficient resources was cited as a key facilitator, and limited resources was the most frequently cited barrier to the implementation and/or sustainability of Lean. Resources mentioned included capital resources for implementing solutions identified through the RCI events, additional IT/IS resources, data collection resources, and staff time resources.
Capital resources. Solutions generated in RCI events sometimes required the use of capital resources. Several interviewees, including Lean team members and departmental leadership, mentioned frustration when the resources were not available to implement solutions. For example, several interviewees were frustrated after Lean events showed the need for another FTE position, but the organization would not provide it. Another solution from an RCI was to put a label maker in each room to label medications, but the organization did not provide it.
IT/IS resources. Every interviewee from the procedure card project in the surgical services department indicated that a lack of IT/IS resources was a barrier to implementing solutions identified through this project. Because IT/IS has different priorities and slim resources and is located at the health care system level, the upgrade necessary to complete changes identified through the RCI was delayed for over a year.
Data collection resources. Several interviewees at all levels noted that data collection was a huge barrier to Lean sustainability. Because nearly all data collection is time consuming, it is difficult to monitor changes from the Lean projects. For the D2B project specifically, data were collected using paper tracking sheets that staff did not always complete.
Staff time resources. The hospital involved staff at many levels in the weeklong RCI events. However, there was frequently a lack of physician participation due to limited time. Further, time constraints on staff to follow up on and monitor the progress of Lean projects were cited as a barrier by many interviewees. The hospital process improvement staff indicated that time for staff to participate as process owners or team leaders was 10 percent of their time after the RCI event. However, while staff are leading and participating in Lean projects, their regular duties are typically unchanged, essentially adding responsibilities. Staff time was especially an issue during the first months of Lean implementation when Lean facilitators were not full-time facilitators and still maintained other clinical or administrative responsibilities. However, Lean project facilitators are now full-time and can dedicate more time to Lean projects. Further, three frontline staff specifically described Lean as mostly just more work for team members. For them, Lean resulted in additional responsibilities, which they felt put them behind in their core work obligations after an RCI event.
|"Education [on the Lean process] ahead of time for all of the hospital staff I think is key."
Communication About Lean
Many individuals at all levels indicated that lack of training prior to Lean events was a barrier to participation. As a result, process improvement staff at the hospital added a short 1- to 2-hour introductory session to Lean a few weeks before the RCI. Nevertheless, some interviewees still desired more preparation on the Lean/RCI process and on the issues or problems being tackled in the Lean events prior to engaging in the actual RCI process.
|"Do I think that there are things in Lean that have value such as eliminating the things that are wasteful? Yes, I do. But to be able to apply an assembly production to patient care and the things that we do for them. You know, they talk about tact time and all of those things. Well, there is no set pre-established, this is amount of time that it should take to do this, because every patient's an individual and their needs are individual. And, you know, I tried to explain that a sore throat is not a sore throat is not a sore throat and we don't have a patient that presents every 15 minutes, you know?."
Several interviewees suggested doing more training on Lean and data collection on the problem being targeted prior to the start of the project. Further, a senior-level clinical executive noted that it is important to make sure participants know that the goal is attainable and to make the pre-event training actionable. Some project team members also commented that there was too much training in the week of the event, which became overwhelming. These individuals believed that more training, especially on Lean terminology and concepts, would be useful prior to the RCI. Therefore, doing the pre-work and more extensive education on both Lean and the problem prior to the event would help reduce the intensity during the week of the RCI.
Lack of communication with department staff about process changes resulting from the RCI was mentioned as a barrier to sustainability by Lean team members and departmental leadership. Specifically, communication about the RCI and solutions to be implemented was largely left to the staff participating in the RCI to do in meetings or small-group settings. This was a difficult role because staff not involved in the event sometimes felt that their voice was not heard.
The employment status of physicians within the hospital was mentioned as a barrier to their engagement, participation, and buy-in to Lean. These interviewees noted that it was difficult to engage physicians in the ED and in surgical services in the Lean process because they were contracted or independent medical staff and were not employed by the organization. Further, the CMO noted that even with employed physicians, the organization needed to consider the short-term productivity loss if they participated in Lean events.
Events considered by participants to be successful had managers who were engaged and held staff accountable. It was also important to have buy-in from executive management; without buy-in, it is difficult to get the necessary resources to implement the Lean changes. It is frustrating for employees to spend time on events and then not be able to implement changes because of a lack of resources.
Lean Team Composition and Size
Use of a consultant. Perceptions of the quality of the external Lean consulting group used by the hospital varied among interviewees. A few interviewees, including senior-level leadership, process improvement staff, and several individuals from surgical services, believed that the consulting organization had been very responsive, and one described the consultant as a "masterful teacher." In contrast, a greater number of interviewees expressed frustration toward the external consulting group used by the hospital and considered the particular consultant who was first assigned to work with the hospital to be a barrier to Lean implementation. The hospital asked the consulting group to change its initial consultant a few months into the Lean process. Some interviewees felt that the initial consultant did not fit in culturally with the organization's mission and values. Other interviewees believed that this individual was not familiar with health care and used too much "Lean jargon." Further, several interviewees believed that the consultant had predefined solutions to issues instead of taking into account staff's opinions when coming up with solutions during the RCIs. Staff were more satisfied with the second consultant, who was more versed in health care principles.
Additionally, a few interviewees believed that the consulting group could have done a better job of providing information and sharing lessons learned from the experiences of other health care organizations implementing Lean. They believed that their hospital was "recreating the wheel" and that the consulting firm was not sharing tools that had already been developed.
Staff. Interviewees indicated that team member selection and composition were barriers for the following reasons:
- For some departments, such as the ED, that are short staffed, department leaders reported that it was difficult to get staff to participate.
- "Fresh eyes," or staff who were not familiar with the process and were considered an important member of the Lean team, were seen as both helpful and disruptive to Lean events. One individual believed they were essential to helping view the process in a new light and to generating additional suggestions for solutions, while many others believed that "fresh eyes" suggested unrealistic or untenable solutions. Staff in the program also often felt criticized by the "fresh eyes"; they took pride in the work they were doing and were resistant to critique from outsiders.
- Staff who were close to the work were not always those making the changes. Related to the issue with "fresh eyes" participants, many interviewees, especially from the ED, noted that when staff outside the work area defined solutions, there was usually a huge barrier in implementing and sustaining them. However, the Lean team also included staff closest to the work, which facilitated making the changes.
- Departmental leadership was not initially involved on the Lean teams in their departments. As such, department staff participating in the teams sometimes came up with solutions that were not feasible given resource constraints. Accordingly, departmental leadership was included in the Lean teams after the first few months of implementation.
- A few staff noted that when physicians were not involved in the Lean projects, they often resisted changes defined from RCI events.
- Roles of team members, particularly after the RCI event, were not well defined, and team members were unsure who to talk to when Lean project solutions begin to slip or fail.
Further, several staff from the D2B project mentioned that having a common goal across team members facilitated buy-in for Lean implementation and sustainability. Because all Lean team members shared a common goal and understanding of the importance of decreasing D2B times, implementing solutions became easier.
Interviewees agreed that when staff saw the changes and improvements resulting from Lean, buy-in increased. However, there was some disagreement on whether this aspect was a facilitator at the hospital. Some staff did believe that the effects of Lean were seen quickly, and that changes were realized in a relatively short time. However, other staff noted that changes from Lean projects often failed to bring about the desired results, and in turn, staff became unenthusiastic about Lean.
Two staff involved in the early Lean projects recommended not including too many people because this could introduce competing priorities among team members. One interviewee cited 8 to 10 people as the ideal project team size to ensure that everyone would have a chance to express his or her opinion.
Central Hospital has aggressively moved forward with Lean while in a relatively early phase of implementation. The hospital's approach to implementing Lean involves training senior management on the concepts and tools a priori and training frontline staff on a project-by-project basis. This training happens by doing while putting Lean principles into practice. Executive leadership sees Lean as a tool for changing the culture, breaking down silos, and improving care, in addition to improving efficiency. Conversely, many frontline staff equate Lean solely with improved efficiency and an improved bottom line for the hospital. This appears to impede staff buy-in to Lean projects. While executive managers are concerned with all ultimate outcomes (efficiency, quality, safety, and patient satisfaction), frontline staff appear to be less concerned with an improved hospital cost savings and more concerned with improved patient quality, safety, and satisfaction.
- Align Lean with what matters to clinicians and their patients. Executives must carefully map out and effectively communicate how Lean will support fulfillment of the organization's mission in a meaningful way. This message should be repeatedly and publically reinforced in in a variety of ways from the selection of Lean projects to rewarding of staff.
- Senior leaders must respond quickly when Lean implementation challenges arise. Senior executives must closely monitor the execution of Lean in the early phases by being involved on rapid improvement event (RIE) teams and talking with staff members, managers, and staff supporting Lean implementation. Executives should use a variety of sources to become familiar with Lean so that they have the knowledge to make decisions and effectively respond when implementation goes awry.
- Consultants must engage managers and frontline staff. Don't assume that all Lean consultants will have the ability to translate Lean into health care and communicate effectively with managers and frontline staff. Build internal expertise by allocating staff in positions where they will assume RIE support and, eventually, Lean training responsibilities.
- Start simple and show visible gains to staff. There will be the desire to go after more complex projects that may save more money, but tackling complex projects requires training, buy-in, and experience, which take time to achieve. Moving too fast or too aggressively can have very negative and unintended consequences for staff engagement, motivation, and hoped-for outcomes. Start with simple projects that have a narrow and well-defined scope. Gain experience in executing RIEs before taking on clinically focused projects.
- Moving too fast to implement changes can hinder success. Lean is time consuming for staff, and organizations require time to collectively develop the expertise to show consistent success with RIEs. Starting with a smaller number of RIEs allows organizations to perfect their implementation strategy without expending undue resources on projects that may not yield the desired return.
- Middle management support is critical for frontline staff buy-in. Some managers may actively resist Lean and impede staff from constructively engaging in RIEs. As with all new initiatives, there will be early and late adopters. Particularly in the early phases of Lean implementation, middle management support should be considered as a deciding factor in selecting projects.
- There is a learning curve to Lean implementation. Expect that challenges and setbacks will arise as Lean is introduced to a health care organization. Thoughtful planning can avert some problems, but inevitably, the unexpected will arise. Quick corrective action will minimize the lost momentum that can occur from setbacks.