This report presents the results of our study of Heights Hospital, a large full-service acute care hospital located in an East Coast city. Two projects at Heights were selected for study: a retrospective project on the ED Value Stream and a prospective project on Pediatric Continuity of Care. In all, 26 interviews were conducted with 25 interviewees. The interviewees' roles and positions at the hospital varied as described in Exhibit 5.1. About half of the interviewees were frontline, nonphysician, clinical staff, and the other half were mostly managers at various levels, many of whom were clinicians.
Heights Hospital is part of a safety net system, an integrated health care delivery system. Around a third of the system's patients are uninsured (Exhibit 5.2).
The system comprises a large group of acute care hospitals, skilled nursing facilities, diagnostic and treatment centers, and community-based clinics. These facilities offer medical, mental health, and substance abuse services.
Heights, located in an East Coast city, is a large safety net hospital that is affiliated with a medical school. As is the case with most public hospitals, it serves a high proportion of Medicaid and uninsured patients. The hospital (and the whole system) often runs at a deficit, partly because of the payer mix and its vulnerability to State and Federal budgetary actions.
Heights Hospital has a very large outpatient business. It operates 341 beds and, in 2009, provided 351,160 clinic visits and 61,393 emergency department (ED) visits (Exhibit 5.3). In March 2006, it was designated as an official Stroke Center. Heights Hospital offers many additional services, including asthma services, women's health services, youth health services, mental health services, a methadone treatment program, an AIDS center, a Level III perinatal center, and sexual health response teams.
The hospital has approximately 2,500 hospital staff, of which 95 percent are unionized, including most physicians. Although Heights does not directly employ attending physicians (they are contracted by the medical college), they function as staff physicians.
Since 2008, Heights Hospital has undergone significant leadership changes, including a new executive director, deputy executive director, chief nursing executive, and chief financial officer. All of these people were in place and did not change at the time the projects were completed and studied. The changes in leadership heightened concerns about effective communication across Heights Hospital, and senior leaders concluded that traditional management and staff communication methods (e.g., staff meetings, email blasts, and newsletters) were not effective. The leadership put into place Management By Walking Around (MBWA) as a new form of communication in order to interact more with the staff and become more visible.y
As a safety net provider, the system takes care of a large number of uninsured patients. The system competes with two other well known, private, not-for-profit systems for insured patients, but it is the primary provider for the uninsured, which includes a large immigrant population.
Funding and Payers
As noted above, Heights Hospital serves a high proportion of Medicaid and uninsured patients and often runs at a deficit, partly because of the payer mix and its vulnerability to State and Federal budgetary actions. Safety net and public hospitals have experienced additional strain during the economic recession. The city's public hospital system eliminated 400 positions and closed some children's mental health programs, pharmacies, and clinics in March 2009. The system's president said the cuts were necessary because of reductions in State Medicaid payments, a significant increase in uninsured patients seeking care, and rising costs of labor, pharmaceuticals, and medical supplies.z Given the organization's commitment to providing services to those who cannot pay, it was vital that the system and its hospitals find ways to efficiently and cost-effectively provide services to prevent layoffs and to avoid reaching capacity to see patients. At the time of the site visit in 2010, Heights Hospital was experiencing a hiring freeze.
In 2008, the safety net system's sources of payment were: 46 percent Medicaid, 16 percent Medicare, 7 percent private, 13 percent disproportionate share hospital, 9 percent upper payment limit, and 9 percent pools. The system saw an 8 percent rise in uninsured patients during 2008, probably because of increased unemployment from the economic downturn. This resulted in $850 million being spent to deliver care to the uninsured.
Additionally, many safety net hospitals feared that new health-reform legislation would reduce Medicaid subsidies for hospitals providing large amounts of uncompensated care.aa Safety net hospitals in particular feared that the mandate on health insurance would put further strain on an already depleted system.bb
In this section, we discuss the history of both Lean and quality improvement (QI) at the safety net hospital. Exhibit 5.4 outlines the overall timeline for Lean and QI initiatives. The specific activities noted in the timeline will be discussed throughout this report.
Historically, Heights Hospital has had an organization-wide focus on quality and performance improvement. About 10 years ago, corporate-wide quarterly reports were instituted. These reports are designed so that every hospital and department shares with the health system all QI activities during the quarter. In addition, the health system's board of directors hosts a quarterly meeting with hospital representatives to review the quarterly report.
Heights Hospital's QI plan is organized to improve the provision of clinical care, treatment, and services using a variety of QI tools and approaches. Efforts are based on the QI cycle of Plan, Do, Study, Act (PDSA) and typically focus on meeting expectations established by The Joint Commission, Medicare's Quality Initiative, and the Medicare Measures Management System. The executive in charge of Lean reported that the QI department annually plans and monitors QI projects across Heights Hospital and that process improvement meetings are held regularly.
Heights Hospital has conducted QI projects in such areas as environment of care, emergency management, information management, medical recordkeeping, medication management, and infection prevention and control. The executive in charge of Lean reported that the QI department annually plans and monitors QI projects across the hospital and that process improvement meetings are held regularly. Sometimes these projects are supported by external consultants, as is the case with Lean.
The not-for-profit corporation that operates the overall system considered both Six Sigma and Lean as they went through the process of selecting a corporation-wide improvement approach. The executive director of Heights Hospital (who was in another role in the system at the time) along with corporate executives visited Denver Health during the planning process to observe and learn about Lean processes.
|"Our intent is to be a corporation peopled by problem solvers, and we see that beginning to happen….The other big aspect of cultural change that Lean creates is…the esprit de corps that comes out of the teamwork, and we have a great deal of that, because we are already kind of tied together by our mission. But there is a great esprit de corps that grows out of the actual teams doing RIEs every week, and that those team members individually understand that they are valued, that their opinions are valued, that their expertise and the many years that they've put into this place are valued, and that they really do know the answer, and that people really are listening, and that there can be a safe environment in which to speak one's mind."
Planning for Lean adoption began in earnest in 2006, with implementation beginning in November 2007. According to executives, the main reason the corporation adopted Lean was to import an improvement process radically different from previous ones that would overcome barriers consistently identified as hampering change in the past. A major barrier was limited staff uptake. Corporate leadership perceived Lean as more accessible than other approaches, such as Six Sigma, and thought it was more likely to be adopted across the safety net system. Lean is viewed as an important way to transform the organizational culture, build teamwork, and increase staff engagement. The system branded Lean as "Project Advance" to avoid negative connotations, particularly those associated with a reduction in workforce that may accompany Lean in manufacturing settings. Senior executives, as well as department leaders interviewed at Heights, recognized that using Lean to change culture involves a long journey that can take 10 years or more.
Many staff members, according to interviewees, were unfamiliar with Lean and were unsure of its applicability to health care. Further, several staff indicated that when Lean was first introduced, they feared they could lose their jobs because of Lean implementation. Given this situation, senior leaders in the corporation signed a letter of agreement with the unions stating that no one would lose their system employment as a result of a Lean event. There was initial skepticism towards implementing Lean because a few staff recalled prior QI activities that had not been sustained at the organization.
Senior executives (four out of seven hospital executives) identified improved financial metrics as a key aim of Lean. Three senior executives identified transforming the organizational culture to improve teamwork as being an important goal of Lean. Two leaders believed that staff engagement and participation in developing solutions were key aims of Lean. Improved patient satisfaction was mentioned by two executives, followed by improved productivity/efficiency as goals mentioned by one executive. Four department leaders added to this list by identifying improved patient care as a central aim. Empowerment and employee satisfaction were mentioned by three department leaders. The remaining aims identified in Exhibit 5.5 were brought up by one department leader.
Providers and frontline staff were most likely to mention improved patient care and efficiency as the goals for Lean, with nurses and other frontline staff frequently couching these in terms of projects in which they had participated.
In the fall of 2007, a corporate subcommittee of the safety net system contracted with a consulting firm with extensive experience in Lean transformation. A Lean consultant was assigned to each of the 14 hospitals, and Heights Hospital was among the first, a decision enthusiastically supported by Heights Hospital's executive director. After the initial start-up period, the system's Board of Directors extended corporate funding for the consulting firm for an additional 3 years through 2014 to allow new sites to begin Lean work and provide resources to the sites with the greatest potential for transformation. The consultant made monthly week-long visits to facilities in the system during the first 12 months and then tapered off to every other month or as needed. Ultimately, the system hopes to build in-house expertise at all hospitals, so the consulting firm will no longer be needed to support Lean.
|"In the past, it seems like a lot of initiatives are true top-down-type initiatives even on the smaller level within departments, and this was the first true initiative that we really delved into here at Met that really brings the frontline staff in as decisionmakers and allows them to create what their changes are going to be."
Value streams, projects, and team members are defined by an Executive Steering Committee and Value Stream Steering Committees, indicating that Lean at Heights Hospital could be viewed mainly as a top-down, central office initiative (go to Lean Value Stream and Project Selection Process for more details). The executive director of Heights Hospital had a key role in the hospital becoming an early adopter. However, Lean, by its nature, increases participation of frontline staff in decisionmaking.
Many interviewees across roles and positions noted that the Lean process yielded better outcomes than other QI initiatives that did not involve frontline staff. They found that the Lean process was a productive way to reach end goals and that it went beyond traditional QI strategies (e.g., PDSA [Plan-Do-Study-Act] and the Product Development and Management Association).
The relationship between the QI department at Heights Hospital and its Advance Deployment Office, which the hospital established to carry out Lean, has evolved since Lean began at the hospital in 2008. Many senior leaders mentioned that the goals of these two entities are related: Lean was mentioned by one leader as the technology for QI and by another as a way to provide structure to QI. Most frontline staff interviewed noted that Lean focuses on process improvement, while QI focuses on clinical outcomes. While the departments in charge of Lean and QI remain distinct, and the two continue to move on somewhat parallel tracks (Exhibit 5.6), some senior leaders mentioned that the different processes could be used to complement each other.
|"The processes of QI [have] been completely incorporated into or [are] being incorporated with the Project Advance activities so that the improvement processes that are being used and the management processes that are being used for traditional quality projects are now becoming Advance processes."
Steps are being taken at Heights to integrate traditional process improvement with the Advance initiative, according to three interviewees. In 2010, the hospital's director of QI received Lean training and began to integrate the PDSA and Lean A3 improvement methods. All Lean outcomes are reported to the Heights Hospital-wide QI committee, which is an interdisciplinary group of the hospital's clinical and administrative leaders who meet monthly to oversee the progress of all QI projects.
One corporate executive noted that in looking at the safety net system overall, some facilities and networks within the QI work have completely integrated Lean: traditional quality projects are now becoming Lean processes. One executive noted that corporate-level discussions are taking place about the parallel tracks that are being supported and the significant infrastructure that ultimately rests with the board. The system's board meets weekly to conduct QI meetings with each facility on a rotating basis. These reviews may include presentations of process improvement projects that have been conducted through Project Advance. This same corporate executive indicated that senior-level staff recognize that people are working on parallel QI tracks, which creates more work. She also acknowledged that it takes a variety of QI tools in a package to create a simple, clear pathway that affords monitoring and sustained improvement.
In addition to the two departments, there are several related committees that exist within the hospital. As noted in the next section—Process for Implementing Lean—some of the committees exist to support the Advance work. The Quality Assurance Committee is a corporate-wide committee that, on a weekly rotating basis, hears from the hospitals about their QI activities. The executive director noted that she includes a summary of quality activities, including clinical Lean projects, in a report to the Quality Assurance Committee.
In addition, each clinical department and each hospital department has a performance improvement committee. The performance improvement committees report up to a group called the hospital-wide performance improvement committee, which is chaired by the Chief of Medicine and the Chief Medical Officer. The hospital-wide performance improvement committee, which convenes monthly, tracks the metrics from all the performance improvement activities in heights, whether they are sponsored by Project Advance or a department-specific quality improvement activity.
In this section, we describe the approach used by Heights for implementing the Lean initiative, including planning and training, as well as general processes related to project selection, implementation, general monitoring and control, and monitoring of sustainment. This approach is illustrated in Exhibit 5.7.
Lean at the safety net system began with the hiring of a consulting firm to support the new initiative. Each of the delivery organizations within the system was asked to hire or reassign a staff member to be the Advance Deployment Officer (BDO) who would manage the effort for that organization. At Heights Hospital, the executive director reassigned the chief financial officer (CFO) to the role of BDO, a change that appears to have been welcomed by the BDO and other staff, who had positive relationships with the CFO and believed he was a good fit for the job. The BDO position was initially funded by the system, and Lean projects were facilitated by the consultants. By October 2010, the Advance Deployment Office had expanded to two full-time and three part-time facilitators and had a position open for a third full-time facilitator. However, a facilitator resigned, and because of a hiring freeze, her position could not be filled, so the number of full-time facilitator positions remained at three. As one of the first activities in planning Lean, an external consultant group conducted a day-long executive workshop for the safety net system's senior hospital managers, hospital union representatives, and other stakeholders to educate leaders about Lean and their roles in the effort corporate-wide. A consultant worked with each organization's executives to prepare individual plans—known as Transformational Plans of Care (TPOC)—for Lean deployment. Each plan identified initial value streams (processes or areas that deliver a core service to consumers through one or more departments) from which senior leadership at Heights identified projects. Senior leaders and department managers participated in defining the value streams and played different roles in the initial projects to gain knowledge and exposure to Lean.
An external consultant was assigned to support the hospital; this consultant provided onsite support 1 week per month for the first 12 months, every other month for the next 6 months, and on an as-needed basis after that. The consultant supported Heights and the Advance Deployment Office by providing management coaching on the Lean deployment strategy and conducting skills training in the use of Lean methods. The consultant assisted senior leaders with selecting and defining the scope of the value streams and corresponding metrics for tracking progress.
In the safety net system, the value stream was defined as the course of a patient's experience. The process for selection of value streams and projects at Heights was highly structured. Exhibit 5.8 provides an overview of the process.
|"It's more than an improvement method. It's like a whole management structure around building consensus on what it is we need to do, what's the most important thing we need to do."
As noted in Exhibit 5.8, there was an Executive Steering Committee and, for each value stream, a Value Stream Steering Committee. The Executive Steering Committee—comprising executives from nursing, medicine, operations, finance, and quality improvement, along with the hospital's executive director and BDO—selected the value streams and determined which value streams to continue. The Executive Steering Committee met monthly to review the progress of Lean activities and once each year with a senior consultant from the system's Lean consulting firm for TPOC meetings. Department managers and Value Steam Steering Committees were consulted. The purpose of the meetings was three-fold, to:
- Identify which value streams should be maintained and what new value streams should be created.
- Analyze gaps in Lean deployment and engagement.
- Direct changes in strategy where appropriate.
A Value Stream Steering Committee comprises an executive sponsor (generally an executive such as the chief financial officer, chief nursing officer, etc.), leadership from the department or areas where the value stream operates, and the process owner who is generally the chief of service or the department's lead administrator. The executive sponsor is responsible for ensuring that activities link to organizational goals. The process owner is tasked with overseeing the implementation of value stream projects and supporting ongoing monitoring.
- Productivity and financial impact.
- Quality and safety.
- Human development and growth.
The initial emphasis was on value streams related to revenue management and perioperative services because they could yield the highest financial returns. Soon, Heights began using Lean in behavioral health because of its large presence among the hospital services offered. For the ambulatory care value stream, several managers and executives stated that the administrative leader in the department saw opportunities to improve processes in the various outpatient clinics. The Emergency Department (ED) value stream became a priority after a patient in a neighboring county's ED died in the waiting room. Since 2008, when Lean was initiated at Heights Hospital, value streams have included the ED, perioperative surgical services, ambulatory care, behavioral health, revenue cycle (e.g., financial screening processes, accounts receivable, billing practices), pain management, and palliative or end-of-life care.
A new Lean project begins with a planning phase in which service-area leaders, most often working in value stream steering teams, draft a project charter and select a project team, either as part of a value stream analysis (VSA) event or as part of their monthly meetings to monitor Lean deployment. Whenever a project comes up that requires strong clinical support, the chief of service is asked to sit on the project team and participate in the rapid improvement event (RIE) week. When rapid cycle change is appropriate, the project moves to implementation with 4.5 days of an RIE that is coordinated by a facilitator from the Advance Deployment Office and includes Lean training.
At Heights, staff training is not formal but, rather, experiential: Lean team training occurs through the implementation of RIEs related to the specific projects.
Learning outside of project teams has been concentrated at higher levels of management through planning work with the consultant, activities such as value stream mapping with stakeholders, process preparation events (usually space design), and vertical value stream mapping events (project planning). RIE facilitators are trained in a 3-day session taught by the external consultant and sponsored by corporate.
|"Sometimes you do need to sit down at the table like this and say, "This is what we need to do to fix this. And we need to implement it now." I mean not every issue really needs a week and a team, because it is a lot of resources. But I think for larger systematic issues, it's been really helpful."
—Senior executive"Every site [hospital] typically starts with two value streams and grows to four to six in the first year. You select those value streams; we're not going to tell you what's the most important thing to improve. And because our focus at first was, "Let's just get this off the ground. Let's test it. Let's see what works. Let's make sure that there's ownership at the local level." And I'd say, based on results, that that was a good strategy."
Project Team Training
The corporation has opted to use a series of project-based trainings to bring about broader cultural change instead of broader training of Lean principles targeted to the entire staff. One executive compared the use of a series of project-based trainings to the use of a general training of the entire staff as a means for creating a Lean cultural transition. The executive stated that Heights was too large to implement broader training that wouldn't fall to the wayside with competing priorities. The project-based implementation is perceived as successful for the organization because staff get introduced to Lean concepts at the beginning of an RIE, learn more about Lean by participating in an event and conducting a project, and see immediate results. Ultimately, this process excites frontline staff and encourages future events.
Value stream training. At the start of Lean in 2008, service-area leaders from value streams that had been identified for Lean deployment received Lean training over 2.5 days through VSA events, which are how value stream stakeholders identify, prioritize, and schedule specific processes for Lean improvement, as verified by one executive. The BDO reported that service-area leaders conduct VSA events every 6–12 months in progressive "passes" to review sustainment and ensure that planned projects meet current needs.
Project team training. Training at Heights Hospital was initially conducted by a single consultant from an outside consulting firm; however, after the first year of Lean deployment, the trainer role—referred to as the "facilitator"—was gradually transferred to the Advance Deployment Office. Training on Lean principles and the process of completing Lean projects are now completely intertwined. Most of the hospital's Lean projects and, therefore, Lean project training, take the form of RIEs, which are structured to facilitate rapid-cycle change.
The main characteristics of Lean team training are in Exhibit 5.9. As in VSA events, project team training includes an overview of Lean tools and principles. This overview is provided during the first half, following which the project team begins the 4-day RIE using the A3 process as a guide (go to Alignment of Lean and Quality Improvement Efforts).
At the end of the 4.5-day event, the project might require additional activities or be ready to enter the monitoring phase. At the end of the event, a public report-out is held to share the results of the event, including how hospital processes have changed or will change and initial outcomes. The report-out is open to all, and senior leaders frequently attend.
In addition to the initial training provided by the consulting firm, the corporation also pays for the hospital project leadership to attend progressively more advanced training modules in formats accredited by the University of Iowa. These modules range from 1-day workshops to 2-week intensive courses led by the consulting firm or by staff from the health system's Advance Deployment Office. At the end of training, participants are tested. Candidates who pass certification tests and meet experiential requirements, such as participating or leading a required number of Lean projects, are awarded with a green, bronze, silver, gold, or platinum certification in Lean. The corporation also offers workshops in basic Lean tools and techniques.
After being defined as part of the value stream process, all Lean projects at Heights Hospital follow the same cycle. The weeklong RIE is the point where a Lean project suitable for rapid-cycle change goes from planning to testing to the execution of initial process changes. Frontline staff are first introduced to the project by their supervisor who communicates their assignment to a Lean project and corresponding RIE training. A facilitator walks the project team through the A3 tool, which serves as a project roadmap. Key project activities as defined by the A3 tool are presented in Exhibit 5.10. Steps 1 through 10 occur as part of the training, and steps 11 through 13 continue and close the project cycle.
|"I think the manager has to be the first to get the people involved."
—Lean team member
The Value Stream Steering Committee selects the project participants and their roles. When selecting participants, the committee seeks active, vocal employees who know the process being improved. Further, the committee must have staff on the team for a week while still fully staffing their areas. There is always someone from another department and/or process to provide an outsider's perspective. Heights Hospital has identified formal roles, described below, for RIEs and projects. Typical job titles for staff assigned to these roles are presented in Exhibit 5.11.
Facilitator. Staff members from the Advance Deployment Office serve as the project team facilitators and trainers. They might also participate in other projects in different roles. Facilitators might also assist with educating team members on Lean tools and measures and with monitoring team progress.
Project process owner. The process owner is responsible for managing the day-to-day aspects of the Lean project, including overseeing implementation of the completion plan, data collection, reporting on outcomes to the team, and ongoing monitoring.
|"Lean is basically the line staff doing the work and coming up with the solution to the situation. And believe it or not, I think that's how you get buy-in. That's how you move the needle."
Team leader. The team leader participates on the project during the event week. The team leader is selected outside the department where the process under scrutiny takes place so that he or she can serve as a neutral entity to organize and focus the team. A person with management experience who is a positive thinker and able to lead groups is ideal for this team role.
Team members. Staff at every level, including both clinical and administrative staff, might participate in a Lean project or RIE. It is a priority that physicians be involved in all clinical projects. Physicians are also encouraged to participate in administrative projects that might affect them, such as appointment scheduling. An executive indicated that including residents on week-long RIE teams has been difficult because of their schedules. He stated that they have addressed this by having RIE teams set aside an afternoon for residents to participate or by using residents as consultants to the team. Another executive noted the importance of having an information systems representative on RIE teams, since there is such a reliance on computers to get the work done.
Value stream process owner. The Value Stream Steering Committee defines a value stream process owner. Although this person is not a member of the project, the value stream process owner oversees implementation of projects belonging to that value stream and supports ongoing monitoring. The process owner is the clinical or administrative director with managerial authority for the value stream's primary services or functions. In terms of projects, this person executes several functions to improve value stream outcomes:
- Reviewing project progress.
- Removing barriers to implementation (e.g., getting approvals and resources).
- Assuring activities are linked to the value stream and organizational goals.
- Helping to select project team members.
- Keeping the team focused.
An executive sponsor provides the linkage between the value stream process owner and the steering committee.
|"You don't want any politics or just sitting to be a part of the room, kind of without portfolio or agenda, just leading the exercises... but you want them to be respected…The best team leader is somebody who has some management experience, is a positive thinker, is open to new ideas and knows how to get a group organized, focused on an activity."
After the RIE is completed, the Advance Deployment Office facilitator continues to follow up with the team. In the first 30 days of the project, the facilitator might follow up with the process owner and team leader in daily 15–20-minute meetings. The purpose of these meetings is to check on how the project is progressing and to ensure activities in the completion plan are being implemented. The entire project team might get together during the week after the RIE to go through completion items, address concerns from staff members who aren't familiar with the event or are upset about the new process, and see if any changes need to be made to the approach. One full month following implementation, the process owner provides a written report—the 30-day report—of the project's progress and resulting metrics to the Advance Deployment Office and to the Value Stream Steering Committee.
During the following month, the facilitator meets with the process owner and team leader less frequently—once per week. The process owner continues to submit monthly reports of outcome data to the Advance Deployment Office and the Value Stream Steering Committee (60-day report, 90-day report, and so on). After the 90-day report, the Value Stream Steering Committee evaluates results to determine if outcomes are satisfactory and should be reported to the Hospital-wide Performance Improvement Committee or if additional process improvements are necessary. Results submitted to the hospital-wide group are included in the quarterly QI reports that are shared with the corporation.
Process owners will sometimes share the 30-, 60-, and 90-day reports with the team or the entire department by email or by posting them on a bulletin board in the department where they might be visible to patients. There are no rules or guidance about the frequency with which the project team and other staff should meet to discuss the project; frequency is based on the project needs and perceived value of the meetings.
Sustainment monitoring process. After the Value Stream Steering Committee has reported a minimum of 3 months of outcomes to the Hospital-wide Performance Improvement Committee, the project enters the sustainment phase. A project might continue to be actively monitored, and changes could be instituted, if the goals for the project have not been achieved.
|"The first year, people had to learn what the terminology was…the second year, we started to "rock and roll" and get a little bit of enthusiasm. In the third year, [we're] getting a little more serious, getting at how to really achieve the vision. [We] work really [hard] on [developing] metrics and targets."
The process owner and executive sponsor ensure that the project continues to be monitored; however, the Advance Deployment Office no longer keeps track of progress on the project because the office prepares and facilitates all new Lean projects at Heights, and the hospital completed over 70 projects through December 2010. The project's process owner and executive sponsor are responsible for sustaining outcomes by making sure that staff have taken ownership of and implemented the process changes. If progress slips, one of these individuals, usually the process owner, must alert the others, and a solution must be found. It is possible that the team will go back and do another RIE in the same area to find another solution.
Monitoring intensity in the sustainment phase at the project team level is highly dependent on the project. For example, daily monitoring might be necessary for projects that examine scheduling and patient-flow issues. Other projects might require less frequent monitoring, for example on a weekly, monthly, or quarterly basis. Monitoring might require review of a reporting form, generating statistics from patient records, staff reports, or other documentation to show process compliance or noncompliance. Other metrics monitored might, depending on the project, include patient cycle time, productivity, cost reports, or continuity of care.
The new executive leadership believes word of mouth and small group meetings are the key to spreading Lean throughout the organization. Hospital executives and department managers used Management by Walking Arounddd techniques to help educate employees about Lean. The executive leadership at Heights completes regularly scheduled safety walkarounds in different areas of the hospital. During these walkarounds, the leadership (e.g., chiefs of service, department managers, chief medical officer, chief executive officer, chief operations officer) tries to discuss Lean in connection to the focus on patient safety. Additionally, the Lean project team visits the area of focus for their project to observe and ask frontline staff about their duties and means of increasing efficiency in Gemba walks. These walks help promote the visibility of Lean while also serving as a useful tool for recognizing inefficiencies.
Internal hospital communications. At the completion of a Lean event week (typically on Friday), there is a public outreach presentation in the auditorium, which many hospital leaders and chiefs of service attend. Also, findings are shared at quarterly staff meetings and QI meetings, which are highly attended by executives and department managers.
At the completion of a Lean project, results are posted within the department on a blackboard or storyboard. These boards are updated as the project progresses and are visible to all staff. Heights Hospital also uses newsletters and email blasts to inform staff about outcomes.
External communications. The majority of the hospital's external dissemination of information about a Lean outcome is to its corporate offices. There are also corporate-wide projects, and results from these are shared with all of the organizations annually. For example, the hospital shared the outcomes of its Lean projects at a corporate-wide, day-long conference. At this conference, members of all hospitals were invited to learn about other projects and value stream progress. The corporation hopes to develop a "Lean University" that includes a Lean Lab, which would allow staff from other hospitals and at corporate headquarters to learn and participate in Lean activities and events.
Implementation of Lean at Heights Hospital includes clearly defined value streams and corresponding projects as already described. For this case study, we retrospectively studied the ED value stream as a whole and prospectively examined a project to improve pediatric continuity of care. Retrospective projects were studied after the project had been completed and in the sustainment phase. Prospective projects were studied as the project occurred (i.e., from the initial training and project implementation to sustainment).
The ED value stream included a number of RIEs for study. A hospital executive said one of the motivators for improving the ED value stream was an incident in a neighboring county hospital in which a patient died in the ED waiting room. Lean projects in the ED value stream began in January 2009 and continued through our second site visit in October 2010.
|"Eighty-seven percent of our admissions come from the emergency room. So, getting the flow through the emergency room smoothly is a major issue. We've made major strides but there are also major issues."
The goal of the ED Value Stream projects was primarily to create efficiencies in the department and improve clinical practices. The specific goals were to:
- Improve efficiency of triage and identification of resources needed through to ED disposition.
- Reduce patient wait times.
- Reduce the number of patients leaving without being seen.
- Decrease number of charts open at a given time.
- Create a standard work process for patients presenting with abdominal pain.
- Remove duplication of effort.
- Improve workspace organization.
- Improve billing and medical records processing.
- Encourage hand washing.
- Improve pain management.
|"The most difficult time we've had so far is the emergency department because their volume is unpredictable. It's easier to do things with patient flow. The emergency department, one of our TPOC metrics is getting patients through the system quickly. It starts in the emergency room."
The following projects that were part of the ED value stream were mentioned in documents supplied by Heights or by interviewees, but detailed information was not provided:
- Triage system change.
- Triage system change: Convert from Canadian Triage and Acuity Scale system to the Emergency Severity Index (ESI) triage system.
- Cycle time for patients, primarily women of childbearing age with abdominal pain.
- Time reduction for urgent care patients to be seen by a doctor.
- Nurse workstation and code area organization.
- Chart billing and scanning enhancement.
- Discharge process improvement.
- Pain management improvement.
Implementation Site: Emergency Department
The value stream focused entirely on the ED, which is headed by a physician, as the chief of service, and a nurse manager. There are approximately 40 beds, but only 11 rooms in the department for evaluating and triaging patients. The ED is located in a cramped space, and patients are sometimes placed in common areas when no examination areas are available. In addition to emergency care, the department includes an urgent care service, known as Express Care, which treats walk-in patients with minor emergencies.
The value stream process owner, who is also the chief of the ED, reported that 13 potential RIEs were identified by the ED Value Stream Steering Committee. Projects were selected if they addressed the value stream goals mentioned previously. Patient wait times and service quality were most often the focus of the projects, either directly or as an indirect outcome of more efficient operations. Examples of some of the projects undertaken include:
- ESI Triage: Expediting patient access to an initial clinical encounter by improving time to triage using the ESI triage system.
- Reducing Wait Time/Increasing Urgent Care Capacity: Increasing the ED treatment capacity and decreasing the number of patients with immediate care needs that are not serious enough to warrant treatment in the emergency area.
- Diagnosis and Discharge Cycle Time: Reducing the cycle time patients spend during diagnosis and disposition.
- Cycle Time for Patients with Abdominal Pain: Reducing the time spent in the ED by a female patient presenting with abdominal pain.
- Storage and Work Area Organization: Reorganizing supply storage areas and specific work areas (e.g., code area and the nursing workstation) with the goal of eliminating expired equipment; better organizing the area, particularly for supplies, charts, and staff; and reducing clutter. The BDO reported that such work space organization efforts were a core Lean activity known as 6-S for Sort, Straighten, Scrub, Safety, Standardize, and Sustain.
- Chart Coding and Billing: Improving performance in finance-related processes, specifically the confirmation of patient demographics and financial information and the service coding and billing process for ED visits.
The projects in the ED value stream were staffed, as shown in Exhibit 5.12, with physicians, nurses, administrative staff, and team leaders from outside the department. Several interviewees reported that the project focusing on cycle time for patients with abdominal pain did not include any administrative staff. One interviewee, a clinical department manager, noted that RIE staffing needs were sometimes revealed during events and that staff were then brought in as consultants for part of the training or asked to participate in the remainder of the week-long event.
Planning and Implementation
As with all RIEs and projects at Heights Hospital, project teams that were part of RIEs in the ED value stream followed the A3 process. There was a heavy focus on walking the process, repeating the process as necessary to understand the current state and to continuously adjust the future state map.
The project to reduce triage times resulted in adopting the ESI triage process during the RIE week. The urgent care project changed patient flow so arriving patients were directed into available exam rooms. The project focused on cycle time for patients with abdominal pain created a standard work process to ensure the contrast fluid required for the CT scan was stocked at all times and that the patient drank the contrast fluid in a sequence synchronized with the availability of radiology staff to conduct the scan. This ensured that the scan did not have to be repeated, which would lengthen the patient's stay in the ED.
The nurse workstation organization project created a neater area by moving desks and office equipment and by relocating the medication station, which had been in the workstation, to the former triage room that was nearby. This saved space and provided a more controlled environment for medication administration. The reorganization allowed for the establishment of a new process to organize patient charts so physicians could clearly see which patient was next. The project team reorganized cycle time, equipment, and supplies in the code area.
To improve business processes, project teams created a brief preregistration process to improve the collection and documentation of demographic information recorded in patient records and to relocate medical records coding staff into available space in the ED. The intent was to improve communication between physicians and coding staff and to decrease billing delays.
Monitoring, Control, and Sustainment
Only one monitoring activity was mentioned by participants in the ED Value Stream projects. The team monitored the patient's cycle time in the ED using daily improvement management techniques. For example, whenever a patient was in the ED for more than 5 hours, a provider registered that fact and the cause of the delay on a tracking sheet posted on a bulletin board in the hall. Within the week, the project team and ED staff not on the team discussed what had happened and how to improve the process in the future.
Heights Hospital shared sustainment information on some of the ED value stream projects:
- ESI Triage: The ESI triage process was sustained from implementation.
- Diagnosis and Discharge: Teams created to accelerate diagnoses and discharges were also sustained, as were the whiteboards used by these teams to track the status of their patients.
- Abdominal Pain: Staff continued to monitor patient cycle time and posted it on the department's bulletin board on a daily basis.
- Nursing Workstation Organization: Structural changes to reorganize the seating and set up of the nurse workstation remain in place, although executives and senior managers stated that the conversion of the triage room into a medication room might be revisited. One frontline staff member noted that after the nurse workstation event, pictures from the RIE event were posted in the areas that were cleaned, providing visual cues and guidance for how to keep the area clean and organized.
A few ED frontline staff stated that, for several projects, no one on the project team was tasked with monitoring the project's progress, so processes had reverted back to their original state. Staff did not specify what those processes were.
Interviewees from the ED Value Stream project teams mentioned very few metrics stemming from their value stream projects. Most of the projects sought to reduce inefficiencies in process time, but this was not tracked with any rigor or in a public manner except for one project—the Cycle Time for Patients with Abdominal Pain project.
The BDO reported that the new patient flow process implemented in Urgent Care increased the percentage of ED patients treated in that service area from 15 percent to 30 percent during the months immediately following the project, but results have not been tracked since then.
|"They developed a process to be able to do the whole process faster. And the goal is to increase the volume of patients they put through...The more patients we can take care of, the better off all patients are, and coincidentally it covers cost [to operate the hospital]."
The BDO also reported that the adoption of ESI at triage had decreased the lead time from patient entry to initial clinical evaluation from at least 1 hour to only a few minutes. In some cases, nursing staff were more comfortable conducting full nursing assessments at the point of initial evaluation, which tended to increase patient flow time beyond expectations.
Making the nurse workstation area cleaner made it easier to organize charts and to triage patients. Now, physician-led patient care teams could be held accountable for seeing patients and could no longer pick and choose which cases to see. Ultimately, clinical project participants felt this would reduce patient wait time, but project team members provided no metrics to show this outcome was achieved.
Not only did the project result in a cleaner area, a few of the clinical project participants reported that changing the physical layout reduced wasted space and created fewer steps. Participants felt this contributed toward increasing their productivity. Heights provided data to this project team that indirectly supported this finding. Comparing the 7-month periods ending January 31, 2010 and January 31, 2011, Heights Hospital showed that while the number of adult visits to the hospital's ED increased from 20,888 to 25,255—a 21 percent increase—staffing didn't need to be increased to accommodate this growth, and patients didn't experience increased cycle times.
The Chart Billing and Scanning project altered the process so that visits to the ED were coded and closed on the same day as the patient's visit or soon afterwards. The BDO reported anecdotal evidence that the timeliness of communication between medical records staff and ED physicians regarding the accuracy of documentation had improved.
|"Everything is an emergency, and everything has to be taken care of yesterday. [Which makes] concentrating on one problem [during an RIE] and not bringing in all the tangents [a challenge]."
One physician executive noted that there have been challenges to implementing Lean in the ED because of a number of factors. For example, because of the nature of the department, the ED was constantly under stress and had difficulty retaining nursing staff. Further, Lean had to be halted at times in the ED because of staffing issues with nurses and an H1N1 outbreak. In like manner, it was also reported by staff that projects that focused on clinical operational process were more successful and were monitored more consistently through daily management of improvement when they included clinical staff only vs. when administrative staff were included on the teams.
The Pediatric Continuity of Care project was the fifth project in the ambulatory care value stream. The project built upon a similar project conducted in the adult outpatient unit a few months earlier.
The Pediatrics Department sought to increase continuity of care for patients by increasing the number of patients who saw their assigned primary care physician in a subsequent visit, which would help to reduce insurance payment denials and lay a foundation for improved quality. In this way, the number of walk-in appointments necessary could also be reduced by redirecting patients to available appointments.
Department Where Implemented: Pediatric Ambulatory Care
This project was implemented in Ambulatory Care in the Pediatrics Outpatient Department. The department also holds specialty clinics (e.g., an HIV clinic) for pediatric specialists on certain days of the month. One executive stated that the outpatient units had an increasingly high volume of care.
This project is part of the ambulatory care value stream, which was identified by the Executive Steering Committee during its Transformation Plan of Care review meetings. A couple of executives reported that ambulatory care was added as a value stream because it would provide a high rate of return, was in need of process improvement, and could break down existing silos among staff in different departments and across staff in different roles within the organization. Finally, one executive noted that changes to reimbursements based on the Ambulatory Patient Group, a patient classification system that was designed to be used as the basis for an outpatient prospective payment system, in 2010 made focusing on pediatric continuity of care a way to optimize the synergies between flow and financial aspects of care.
One reason for action, according to interviewees on the team, was to improve compliance with an insurance company requirement that patients be seen by their primary care providers, rather than any available provider; otherwise Heights would risk insurance denials. A second reason, as noted by interviewees, was to move towards becoming a patient-centered clinic by improving continuity of care.
The project leadership included an executive sponsor, a facilitator from the Advance Deployment Office, a process owner from within the department, and a team leader. Initially, because the assistant director was new, the process owner was the pediatric floor manager. The assistant director attended the RIE during his first week and, once he became more familiar with the department's operations, he and the floor manager shared duties as process owners. Eventually the assistant director felt comfortable enough with the staff, department operations, and RIE duties to fully take on the role of process owner. The process owner(s) was the most active team member outside of meetings. He communicated decisions made by the project team to clerical staff and put new processes into practice.
In addition to the project team leadership, team members included floor managers, nurse managers, staff nurses, physicians, schedulers, and other staff from key areas. A nurse manager stated that it was important to have staff on the team who knew the process and felt comfortable being vocal about the process so project outcomes could be achieved. Exhibit 5.13 lists the members of the project team.
The facilitator from the Advance Deployment Office met with the project team to help scope the project and provide some minimal background on Lean principles in advance of the RIE. No data were collected in advance of the RIE week. The team began the RIE on Monday and continued through Friday afternoon. The tools used by the project team and team activities are described in Exhibit 5.14.
The team created a series of standard workflow processes so that staff called patients in advance to verify their appointments and insurance coverage. The process owner held 20-minute meetings with clerical associates every Wednesday after the RIE to explain what needed to be done and how to go about it. Issues were addressed such as who is going to take over if staff call in sick. During this RIE, three new clerical associates were hired, so the process owner assumed responsibility for training them on how to do insurance verification and scheduling, following the processes designed by the RIE team.
|"I tell you, the Lean process, they gave us the tools. Great tellers, good system, that's where they get to do it. They don't force things on us. They tell us, "These are the tools that we have. You can implement these tools and go this avenue." And we use the tools that they gave us and we run with them."
The new insurance verification process required staff to identify patients with expired Medicaid managed care coverage who needed to be recertified in advance of their visits. In addition, staff regularly verified that physicians were on the primary care physician list with the managed care insurer. A booking system was revised to ensure patients would see their primary care physician. The appointment center was standardized and the residents' schedules updated so that appointments could be booked 6 to 8 months in advance.
The Pediatric Department director described how the frontline manger had been working in a clerical capacity rather than as a manager. His role was revised to working alongside the residents in the processor room, a space where physicians had previously not allowed clerks to work. This change enabled the frontline manager to more fully use his skills to manage walk-in patients.
The team ran into challenges and needed to make adjustments to the project plan. Initially, the team had not planned to make changes to the pediatric appointment scheduling template to improve clinic flow but then realized the template made it difficult to provide continuity of care. Phantom slots were put on the schedule to hold appointments for same day and next day availability.
At first, the goal was for 90 percent of patients to be seen by their assigned primary care doctors, but the goal was later raised to 100 percent when the definition of the metric changed. The project team realized that it would be impossible to reach 100 percent if walk-ins were included, because including them would have required that all doctors be available at all times. Thus, walk-ins were excluded from the measure and the target was raised to 100 percent. The project team formed provider teams to facilitate continuity of care so that patients would see the same resident(s) and/or attending physician at each visit.
Monitoring, Control, and Sustainment
The RIE process owner monitored data on a weekly basis to determine whether pediatric patients were seen by their assigned primary care physician and to assess clinic productivity. Clinic productivity was measured as the ratio of the number of patients actually seen to the total slots available per provider. This process was initially completed by hand, but the floor manager and former process owner helped develop a spreadsheet for entering the data to calculate the measures more efficiently. The following measures were reviewed on a weekly basis:
- Verification completed to determine whether physicians were on the primary care physician list with the patient's managed care insurer.
- Verification of patient insurance coverage 72 hours before the visit.
- Cleaning of the clerical area.
- Patients seen by the assigned primary care physician.
In addition, ambulatory care administration tracks:
- Clinic productivity, which was calculated as the number of patients actually seen by each provider as a rate of total scheduling slots available per provider.
- Staff absenteeism.
- Time to third, next-available appointment.
Once the project ended and the team reported on the data after 90 days, no formal tracking or reporting was completed. However, all of the interviewees reported that the changes from the project had been sustained and had become ingrained in the department. During our visit in October 2010, the standard work process was still posted and being followed by the staff, and the process owner continued to follow up with staff to make sure they were following the new process.
|"We've had a number of events that haven't been as successful and I think that it's been a learning process. We might not have seen the success in their 30-, 60-, or 90-day reports, but they've definitely taught us lessons for how to move forward and what events we're going to do in the future and how we're going to approach different problems."
The project team members and process owner/assistant director felt the project was very successful because, as they reported, they achieved their goal of 100 percent accuracy in scheduling patients with the patients' primary care providers and verifying insurance in advance of patient appointments. At the start of the RIE, none of these activities was being monitored, so there is no baseline with which to compare the outcomes. However, the rates did progress throughout the project.
- At 30 days, 75 percent of patients were being seen by their primary care doctors.
- At 60 days, 95 percent of patients were being seen by their primary care doctors after the metric was altered to exclude walk-ins.
- At 90 days, 100 percent of patients were being seen by their assigned physicians.
Other reported outcomes mentioned by at least one interviewee, including the process owner/assistant director, consultant/physician manager, executive sponsor/administrative director, or another executive, include:
- Fostered a stronger sense of teamwork and connection to others across nursing, physician, and administrative roles.
- Changed patient workflow and scheduling, which ensures that the daily clinics start and end on time.
- Eliminated staffing with a separate doctor just to see walk-ins.
- Decreased denials of payment by an estimated 70 percent.
- Further, one manager observed that staff absenteeism rates and promptness had improved as the result of an increased sense of camaraderie among the team, but no factual evidence was provided.
The amount of efficiency that could be gained from this RIE was limited, according to two department directors. As the result of process changes, staff took on increased duties and responsibilities that require more documentation and checkpoints per patient. These changes mean that staff are spending more time checking insurance cards and patient insurance-related data on the computer rather than engaging with the patient. This additional work was offset by fewer denied claims requiring followup by the billing department.
A few senior leaders and executives reported that the Pediatric Continuity of Care project was less successful than others in the ambulatory care value stream because Lean principles have not spread as far as in, for example, the emergency room where multiple projects were undertaken. The Continuity of Care project was the only Lean project conducted in pediatric ambulatory care.
In this section, we discuss the outcomes of Lean for the organization as a whole, based on the projects included in the case study, as well as other information about Lean implementation provided by interviewees. Outcomes are classified as intermediate or ultimate outcomes, according to the conceptual framework. As described previously, intermediate outcomes are culture change, employee satisfaction, change in Lean knowledge and skills, and Lean routinization. Ultimate outcomes are impacts on efficiency, patient satisfaction and experience, clinical process and outcomes assessments, and patient safety. For organizations to sustain Lean, there has to be a business and/or strategic case resulting from the initiative. Exhibit 5.15 offers a convenient overview of the outcomes, and Exhibit 5.16 identifies some of the facilitators and barriers to implementing Lean at Heights Hospital.
Before describing outcomes according to these categories, we address two overarching themes that surfaced at Heights Hospital.
"True north" metrics were established to guide the Lean initiative at all levels. As described by two executives, the hospital set forth hospital-wide goals and "true north" metrics in five domains to measure the success of Lean beyond the project
level: quality and safety, human development, financial impact, throughput/delivery, and growth/capacity building. Selection of value streams and definition of value stream goals and metrics are defined at the Value Stream Steering Committee level. A departmental leader and a frontline staff person, however, reported that the "true north" metrics and project metrics were not always aligned. This is attributed to the wide degree of project scope; projects could be organization-wide or focused exclusively at the patient care unit or department level.
Perspective that all outcomes have a financial impact. The executive director mandates that financial metrics be included in every project. Nearly all senior leaders and managers emphasized the importance of positive financial returns and perceived Lean as contributing to increased revenue or reduced costs. For example, staff identified fewer insurance payment rejections, reductions in process times, and increased patient volume (stemming from referrals from satisfied patients and improved patient flow) as financial outcomes beyond efficiency outcomes. However, at both the organizational and project levels, executives and managers struggled to identify concrete financial outcomes stemming directly from Lean, except as they relate to revenue cycle value stream activities.
Executives also had difficulty attributing clinical outcomes to Lean. A few executives stated that financial targets were easier to capture than were measures representing changes in clinical outcomes, patient safety, or patient and staff satisfaction. There were challenges, particularly in the first year, as leaders were becoming familiar with Lean principles, but by the time this evaluation took place there was an overall sense that Lean was yielding clinical successes.
We present here the findings from intermediate outcomes of the Lean initiative according to the categories mentioned in Exhibit 5.16. Intermediate outcomes are linked to ultimate outcomes described in the next section. Progress was noted by interviewees in the areas of culture change most of all, as well as employee satisfaction and routinization of Lean. Interestingly, when we analyzed the findings by interviewee, we found some differences in perceived intermediate outcomes between leaders (executives and department managers) and frontline staff. Culture change, employee satisfaction, and increased Lean knowledge and skills were solely reported by those in leadership positions, while outcomes related to Lean routinization were reported by all.
Organizational Culture Change
Four executives and two managers indicated that Lean has produced positive cultural changes, with five of these six interviewees emphasizing that many areas still had not experienced an RIE. Participation in an RIE was key to this cultural shift, since Lean training took place within the RIEs, and RIEparticipants develop a strong sense of teamwork as the result of diverse staff—nursing, medical, clerical and administrative—coming together to work towards a common goal. One executive emphasized that this shift was only the beginning of a long journey of cultural transformation for the organization.
|"More and more people are participating and feel good about it. Not only because they were exhausted and they're glad [the project is] over, but because they feel like they accomplished something."
Interviewees (four executives and one manger) saw a change in culture with respect to increased participation, teamwork, and more accountability at all levels. There was a sense that prior to Lean, some frontline staff were coming late to work and calling in sick, making other employees frustrated with the lack of commitment to the team. After participating in an RIE, absenteeism rates went down. Staff felt responsible to each other to arrive on time each morning so they could meet as a team. One executive noted the increased teamwork across departments where historically there had been little, and another commented on the enthusiasm of the clerical staff that was transmitted to the medical staff.
The cultural shift also manifested itself in the approach to how work was done. One executive noted how staff not only came to him with problems but now offered solutions to those problems as well. A manger observed two frontline staff working together on the unit to get everyone on "one side," creating a more inclusive, team-oriented environment.
|"People work together as a team and they understand how to solve problems. And they don't just present with problems but they present with solutions. Our intent is to be a corporation of problem solvers, and we see that beginning to happen."
One physician executive noted that it is hard to say that cultural changes were due solely to Lean activities because the new executive director, a nurse who knows staff by their first name and readily shares her cell phone number, came to the organization in 2008 and began implementing MBWA. A couple of other executives concurred that the organizational culture had shifted since the arrival of the new executive director.
Reports of improvements in employee satisfaction come from observation and discussions with others rather than standardized instruments. One executive reported that too few employees have participated on RIEs to see a shift in an employee satisfaction survey.
Several staff at all levels of the organization reported that Lean activities engendered greater connection to others. Overall, executives and higher order managers reported that employees were satisfied with Lean because it gave them the opportunity to provide input on process changes and speak up when proposed changes weren't feasible. One executive stated that project participants were enthusiastic: "This is the first time they owned anything in their job—felt empowered." One frontline staff person described the emotional rollercoaster of participating in the Lean event in which the participants start the first day excited: "The second day [you ask] 'Can I do this?' On the third day you're okay, and on the last day you say, 'Wow. Look at everything we did.'" However, some interviewees felt that the 4.5-day RIE was too long, taking away from patient care.
Examples of increased job satisfaction came as the result of process changes instituted through Lean projects. A frontline manger had previously been operating only in a clerical capacity. Following the RIE, he was able to reinstitute his managerial role within the adult care clinic to direct walk-in patients to the appropriate point of service within the clinic.
In the adult primary care clinic where a project similar to the Pediatric Continuity of Care project had occurred, several interviewees reported that before Lean, physicians felt overworked, stressed, and burned out because, by seeing walk-ins in addition to attending to a full schedule, they were seeing many more patients than expected in a day. After the system was modified by applying Lean, two managers agreed that physicians were less stressed; they commented to one another that there were fewer complaints and less frustration from physicians.
Lean Knowledge and Skills
Although a number of tools, concepts, and techniques were introduced to the staff during Lean training, only the BDO and one manager mentioned increased knowledge or skills as an outcome of training and project participation. The BDO does track the number of newly trained staff and the number of RIEs conducted. A process owner stated that he had trouble communicating with senior staff about the status of the Lean project during the report-out. This process owner felt that it would have been beneficial to have some training or preparation for effectively carrying out this function. A couple of staff stated that there is a positive cumulative effect if the Lean team is able to focus on an area and do four to five projects in a year, causing staff to start understanding and using Lean language consistently.
In addition, these same interviewees mentioned that Lean offered an opportunity for staff to engage in new roles and to develop leadership skills. One executive stated, "Employee morale and leadership skills develop every time we do one of these rapid improvement events."
As of December 2010, about 337 staff at Heights Hospital had participated in Lean events, which represents approximately 13 percent of all staff. The Advance Deployment Office set a goal of reaching 20 percent of staff through projects and training by the end of 2010. Interviewees noted that staff members often participated on more than one team. It is expected that these supporters will help spread Lean through the organization.
There have been a few attempts to transfer modified workflows and other Lean project outcomes to other departments within the hospital; some have been successful, and others have not. Interviewees shared an example of each. Although the lessons of the Pediatric Continuity of Care project have been shared with other departments (e.g., adult primary care, women's health, dental, and the geriatrics clinic), several interviewees were skeptical of the feasibility of transferring the actual processes. Because of the vastness of adult primary care at Heights Hospital and the individuality of the clinics, the process defined in pediatrics could not be directly applied to these other departments. On the other hand, a previous project that focused on creating a schedule for the eye clinics has been transferred to other departments. This case developed a template for scheduling that is now used in the neurology, rheumatology, and gastroenterology departments.
|"I kind of wished in the beginning that if we did one continuity [project] in adult primary care [it] would be applicable to all primary care clinics; and we quickly learned that is not the case because they all operate differently. They have very different leadership, very different leadership styles, and then the care provided from the clinic is so distinctly different."
Internal hospital communications. At the completion of a Lean event week, there is a presentation in the auditorium, findings are shared at quarterly staff and QI meetings, and results are posted in the department, newsletters, and email blasts. However, two senior executives and a department head said that there is no formal method for communicating successes to staff. The CFO stated that the return on investment from an enterprise level is unknown and therefore cannot be communicated to employees.
External communications. As noted previously, most of the external communication about a Lean outcome at Heights Hospital is primarily to the corporate offices, including at a day-long conference.
This section is organized according to the types of ultimate outcomes noted in the conceptual framework and as reported by interviewees and in documentation provided by the organization. According to interviewees' anecdotal accounts, the hospital and safety net system have realized substantial cost savings and efficiencies as a result of Lean. To a lesser extent, Heights has seen improvements in patient experience, clinical process or outcomes assessment, and patient safety.
|"The charter of the RIE has to set realistic goals…You got to break it down. And early on we were too ambitious and we chartered RIEs with doing more than they were capable of doing."
In addition to cost reductions, Heights Hospital was able to increase efficiency on a number of projects and overall by reducing the amount of time a process takes, reassigning staff and space, and using existing resources more efficiently.
Project level. The following impacts on efficiency were linked directly with specific Lean projects. These impacts were discussed in in the Case, but we have repeated these outcomes here to highlight the totality of impacts on this area.
Emergency department value stream:
- An administrative project changed the coding and billing processes so that activities were completed on the same day as the visit.
- The new patient flow process implemented in Urgent Care increased the percentage of ED patients treated in that service area from 15 percent to 30 percent during the months immediately following the project.
- The BDO reported that the adoption of ESI at triage had decreased the lead time from patient entry to initial clinical evaluation from at least 1 hour to only a few minutes in most cases.
- Organizing the workspace made it easier to properly position charts for the medical team's review and triage patients, ultimately reducing patient wait time.
- Workspace reorganization also reduced wasted space and created fewer steps. Participants felt this contributed toward increasing their productivity.
- A standard work process for stocking CT contrast fluid and synchronizing patient ingestion of contrast fluid with availability of radiology staff ensured that the scan did not have to be repeated.
- Comparing the 7-month periods ending January 31, 2010 and January 31, 2011, the number of adult visits to the hospital's ED increased from 20,888 to 25,255, a 21 percent increase; however, Heights reported that staff didn't need to be increased to accommodate this growth, and patients didn't experience increased cycle times.
Pediatric continuity of care:
- After the project's 90-Day Report, 100 percent of patients, excluding walk-ins, were seen by their primary care provider.
- There was a reduction in missed appointments and a decrease in payment denials by an estimated 70 percent as the result of: 1) calling pediatric patients in advance to verify appointments and coverage; 2) recertification of Medicaid patients with expired coverage prior to the visit; and 3) verification that physicians were on the insurer's primary care panel.
- Residents' schedules were obtained 6–8 months in advance, further allowing patients to get an appointment with the same physician.
- Space was made for last-minute appointments with the patient's primary care provider. Thus, the need to staff a separate doctor just to see walk-ins was eliminated.
- Staff absenteeism rates were lowered and timeliness improved.
- Changes to the patient workflow and scheduling helped ensure that the pediatric clinics started and ended on time.
Two managers in Pediatrics noted that there may be a limit to the amount of efficiency the RIE brings to workflow because the RIE also leads to redesign of processes that increase work (e.g. checkpoints, increased documentation).
Other Lean projects:
- A project in the Oncology Department reduced wait times for patients and increased the volume of patients being seen.
- In a perioperative surgery value stream project, a daily meeting, or huddle, was called to improve communication and planning for operating room cases and to incorporated staff from Central Supply into the meeting. Ultimately, this created a central cell for all staff to communicate daily about what went well the previous day and what could be improved, especially with regard to availability of specialty surgical instruments. The BDO reported that, following implementation of the daily operating room huddle with Central Supply, immediate-use steam sterilization in the main operating suite at Heights Hospital decreased from a rate of between 5–8 percent of cases to a rate of 1 percent or fewer of cases.
The Advance Deployment Office encourages project teams that can reduce full-time staff by using process improvements to shift those staff to a value-added activity. However, a hiring freeze at the hospital makes this shift difficult for some, even though it can benefit departments in need. Managers fear that shifting full-time staff to another department will make their own departments short staffed if any of their staff were to leave their department or become unavailable during the hiring freeze.
|"The hard freeze on the budget has made it hard for people to be willing to let go. If I come in and do an event and I say, 'Well you've got one more FTE than you really need.' It's hard enough to get the manager."
Minimal data on patient experience and satisfaction were obtained as part of Lean projects. Information on patient experience data comes from CAHPS® measures used in the inpatient, outpatient, and ED settings. For the Pediatric Continuity of Care project, an executive stated that the project improved patient experience because the department assured patients that they would see the same doctor at every visit, and a pediatric manager reported that patient satisfaction was 90 percent (pre-intervention score not known); however, the primary concern of patients and parents was waiting time.
Clinical Process or Outcomes Assessment and Patient Safety
There were no changes in clinical quality indicators reported as a result of Lean projects, other than the scheduling of pediatric patients with their primary care physician resulting in better continuity of care. An executive reported that process indicators for pain assessment and pain management in the ED had also improved, although data on the patients' perceptions were inconclusive. He also cited more efficient records management as an indicator of improved care.
Patient safety was only discussed by one person, a member of the ED nursing team who said that as a result of Lean, there was a more accountable process of ensuring cleanliness of equipment, which is important to infection control, and of removing expired equipment.
Business or Strategic Case
Heights Hospital attempts to integrate some type of financial component into all Lean projects. In addition, there are corporation-wide projects and value streams that seek to expand cost savings through Lean activities.
Cost savings. From 2007 through 2010, a corporate executive reported that the safety net system had achieved $104 million in cost savings and new revenues as a result of Lean implementation. At Heights Hospital, all executives and high-order managers reported savings as a result of Lean of between $2 million and $6 million, with most reporting $3.5–$4 million. The hospital's BDO and CFO reported that, through December 2010, heights had realized cumulative cash flow and recurring new revenue of $9.6 million from all hospital-based and corporation-wide Lean projects, including one-time cash flow increases or savings totaling $3.5 million and recurring new revenue estimated at $5 million annually, which was 1.7 percent of Heights Hospital's $296.3 million revenue budget in fiscal year 2011. At heights, the returns were attributed primarily to major improvements in coding and documentation, reductions in accounts receivable by following up with collections, and reduced errors and turnaround times in the process for assisting eligible acute care patients with Medicaid applications. Gains were also credited to utilization growth and increased rates of collection resulting from patient- and documentation-flow improvements in adult primary care and outpatient mental health services.
For the Pediatric Continuity of Care project, one executive believed that financial returns were immaterial; in other words, they were not the key outcome of the project. Neither the team nor any other entity conducted a financial analysis. However, the process owner reported that he believed payment denials from managed care have been reduced by an estimated 70 percent since the project began, which could represent additional revenue for the department.
During site visits and interviews, staff at all levels were asked to name the two or three greatest contributors to success, as well as the problems or challenges they had witnessed or faced in implementing Lean. Findings regarding facilitators and barriers are based on responses to these questions and on a limited interpretation of findings overall by the research team. As expected, barriers to implementation were identified more often than facilitators. Senior managers and clinic directors provided the greatest amount of information regarding these issues. Given the structure for implementing Lean on a project-by-project basis and differences in the goals for Lean depending on the level of staff within the organization, the results of Lean are viewed differently. Frontline staff, clinical staff, and managers tended to look at project results as signs of success. However, executives tended to view the results of Lean on a broader basis. A reflection of this is that only executives knew about and discussed the "true north" metrics.
All interviewees were also asked to share their insights, that is, their lessons learned based on their experience with Lean at Heights 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. Lessons learned referred solely to the implementation of Lean, and most often, to leadership and staff engagement.
Senior executives and department leaders provided the most information regarding barriers and facilitators, particularly in terms of staff engagement, resources, leadership, and Lean team composition and size. They also shared the most insight regarding lessons learned about scope, pace, and coordination. Frontline staff provided the most comments on staff engagement.
In this section, we discuss barriers, facilitators, and lessons learned concerning organization of the Lean initiative. The most frequently mentioned facilitators and barriers discussed by interviewees were engagement and leadership. Notably, there were very few statements related to alignment and routinization.
Alignment of the Initiative to the Organization
Senior executives emphasized that Lean is part of the corporation's strategic plan to transform the organizational culture, build teamwork, and increase staff engagement. The system recognizes that embedding Lean in the organization will take a long time.
A senior executive indicated that Lean fits with the shared governance structure that nursing at Heights Hospital has had in place for 20 years. Nurses are involved in making their own schedules, creating new policies, and making other types of decisions that impact their work. She indicated that Lean offers additional opportunities for nurses to provide input.
Project Scope and Pace
The scope and pace of Lean activities at Heights Hospital were viewed in a positive light by executives. The focused effort of prioritizing two value streams for launching RIEs, conducting multiple projects within those value streams, and branching out to other value streams over time was seen by senior executives as a productive approach to Lean implementation. One executive commented that maintaining a disciplined focus on the value stream implementation plan can be difficult when something "comes up" outside of the selected value streams. Failure to adhere to the plan by becoming reactive can scatter resources.
Several interviewees noted that the project scope must be clear and include realistic goals or the project can become unmanageable. For example, the wide scope of the ambulatory care value stream was identified as a barrier to successful implementation. At first, the value stream attempted to conduct a series of projects in each area of ambulatory care—women's health, internal medicine, pediatrics, and an eye clinic. However, the administrative director found that without focus in one specific area at a time, the chiefs of service were not engaged and committed to Lean. Ultimately, the value stream was revised and the scope limited to just internal medicine at first.
The pace of Lean activities was an issue at the department level, with clinical staff and leadership not always in agreement. An executive and a department manager stated that the key to getting more people to understand Lean is to do a series of small projects in one area. However, the clinical staff interviewed found the concentrated focus in one area to be the most trying aspect of Lean. Multiple projects in one department resulted in a great deal of staff being away from patient care for an extended period of time, sometimes repeatedly.
The corporation and Heights Hospital have not kept up with the aggressive implementation plan they originally developed as they were embarking on Lean implementation. The system had hoped to launch Lean at all 23 of the largest health care delivery sites in 3 years. This time period has been extended to 6 years because of the need to give every process redesign project more attention than anticipated. At Heights Hospital, the BDO noted that a lack of staff resources and the extensive time required for RIE-related work slowed progress. He felt a good pace was one RIE every month in a value stream; an event every 2 to 3 weeks would be preferred if the resources were in place. This same executive reported that 300 different people had participated in RIEs (11 percent of staff). He hoped for a participation rate of 20 percent by the end of the year but was unsure if that would be possible given diversions such as a Joint Commission review and financial constraints.
A clinical director and corporate executive said that Lean can be used for clinical, administrative, and operational processes. Some projects (e.g. clinical projects) are more difficult than others, according to the corporate executive. The decision of which process to focus on is based on organizational need and not the overall applicability of Lean. Lean tools, however, may be appropriate for certain types of projects/focus areas more so than others. The clinical director commented that not everything is an RIE. RIEs are reserved for processes that require a group process to redesign. When a solution is known, a "just-do-it" approach is used.
Although there were a number of factors that aided Heights in implementing Lean or made it more difficult to do so, leadership support stood out as a facilitator to Lean implementation. Engagement and resources were the most frequently mentioned barriers.
|"The executive director was a Lean proponent before she came here. She started here, I guess, about 3-1/2 years ago, and the first thing that she did was to make that clear to her senior staff..."
—Senior executive"I think probably the best move she made was to appoint (the former CFO) as the BDO. And he has just taken it, embraced it and has a lot of credibility. (CFO) came into it with a lot of credibility and just flew with it...."
Leadership, both corporate and at Heights Hospital, was very supportive of Lean projects.
Corporate support. According to several executives, leadership support from corporate's board of directors and corporate offices has been an important facilitator to employees' acceptance of Lean—particularly among the skeptics—and the overall success of Lean at the hospital. The system supported the Lean initiative by providing a structure for implementing Lean and technical assistance to each hospital in the system. This included funding for a consultant. Lean was a corporate, systemwide initiative, yet corporate leaders were not overly directive. Leaders allowed those facilities that were most interested to launch Lean first. Each hospital was given the leeway to select value stream priorities and forge its path.
Hospital executives. Nearly all interviewees mentioned the importance of leadership support and commitment to the Lean initiative from the top management at Heights Hospital, in particular the chief executive officer. Many department managers, executives, and frontline staff stated that hospital executives showed their support by promoting Lean, ensuring that the effort was going to stay, participating in the RIEs, and staying informed by participating in monthly steering meetings. Executives communicated that Lean is part of the strategic plan to move the hospital to the next level. One executive mentioned that the relatively small size of the hospital allowed leadership to exert their influence on staff "since in a week I can visit every [employee] in the hospital."
|"You really need to start with people [leadership] who understand the process and who are onboard… And until you sell it to that group, you can't sell it to the frontline staff because they have to see that someone believes in it before they even give it a chance."
The executive director and the BDO were highly supportive of Lean implementation. The executive director was a Lean proponent before she came to Heights Hospital. According to one executive, one of the first steps she took was to make clear the importance of Lean to her senior staff. The BDO was viewed by hospital employees from the executive level to the frontline as the right person for the job. The BDO was established and well respected as the former CFO of Heights Hospital. According to two executives, his strong rapport with staff helped to develop staff buy-in to Lean, and his flexibility in solving problems, creativity, and vision gave him the ability to take Lean to another level.
The hospital and the hospital-system interviewees consistently stated that senior leadership supported the development of solutions through bottom-up Lean process improvement activities. An executive noted that selecting the value streams at the senior level—while allowing departments to determine what needed improvement within the value stream—was a good strategy that supported ownership at the department level.
Departmental leaders. A corporate executive noted that the executive director and BDO at Heights Hospital selected the "right sort of people" to lead frontline staff — people who facilitated staff engagement through their commitment, enthusiasm, creativity, and visible, active leadership. This was echoed by a middle manager and a frontline staff member who identified individuals in leadership positions participating on RIE teams whose commitment and leadership skills contributed to project success.
Several managers noted the importance of having a solid point of contact on RIE teams to engage the rest of the RIE team. This person is a department chief, manager, or physician who provides direction, good communication, and enforcement. The chief of service participating on one of the RIEs was well established. He had a small and well integrated team, which helped in achieving successful outcomes. A department director commented on how the process owner for an RIE within her department assumed his role quickly. He closely watched the completion planand got support from the chief of service and head nurse.
|"It brings the group together, like it brought us together. I only think of my problems and what I want fixed, but I don't recognize that these are all hardworking individuals and they have issues too. So, together…we share individual problems and then look at it... [and find] what's the best strategy to smooth the operation and work as a team."
This is not to say that there were no leadership challenges. According to an executive and two department leaders, there were chiefs of service and department directors who were reluctant to support Lean at first. While some department leaders encouraged additional Lean projects and promoted Lean with their staff, others disagreed with the outcomes or were concerned about the time projects took away from patient care. In addition, several interviewees suggested that department leadership did not hold individuals accountable for maintaining Lean changes after a project ended; they commented that processes reverted back to their original state.
Project leader. At Heights, the Lean project leader usually comes from outside the department of focus to reduce the potential for department politics and hidden agendas to derail the RIE. A few interviewees—an executive, a department manager, and a floor manager—noted that the Lean leader should have management experience, be a positive thinker, be open to new ideas, and be organized and focused. Interviewees did not mention project leadership as a barrier or a facilitator to Lean implementation or sustainability of the RIEs in which they had participated.
Availability of Resources
In general, available resources were cited as key facilitators to Lean implementation, while a dearth of resources was considered to be a barrier to Lean implementation and sustainability.
Expert consultant. During the initial 3 years of Lean implementation, the hospital's BDO had access to a Lean expert consultant. This consultant, funded by the corporation, provided support for developing an infrastructure for Lean and provided training for facilitators and project teams. One executive noted that consultants bridge relationships with internal staff. A corporate executive noted that the system will "wean" itself off of the consultant over a 3-year period. This will be done by accelerating staff training so that they have the capacity needed to carry on independently.
According to an executive and several frontline staff, staff at other locations who had participated on Lean projects similar to their own project served as an additional resource to Lean teams.
Budgeted positions. Heights Hospital was able to establish a full-time position for oversight of Lean—the BDO who oversees Lean implementation. With time, two full-time and three part-time facilitator positions were added to the Advance office. The department was able to grow because of monies recovered from Advance projects.
Frontline staff. Heights Hospital included staff at many levels in the week-long RIE events; this broad-based involvement facilitated implementation but was challenging to achieve. Hiring freezes with staff reduction through attrition and lack of back-up staff to fill in for frontline RIE participants were barriers highlighted, particularly by clinical managers. Scheduling multiple staff from the same department to participate in an event was difficult, particularly on short notice, since staff schedules are established far in advance. Sick leave, among other issues, added further pressure on staff resources.
Clinical staff noted that the concentrated focus with multiple RIEs in one area was the most trying aspect of Lean because it required a great deal of staff to be away from the floor for an extended period of time, sometimes on a repeated basis. The same staff (including physicians) felt they were repeatedly selected to participate in an event. Although they were generally released from their regular duties, a few frontline staff reported that they attended to their work in the mornings and evenings before and after the RIE event.
|"The most valuable thing [about Lean is] to force people to be together for 4-1/2 days. [This] is something that never, ever…happened regularly to resolve patients' needs. That's the key benefit of it. And it's also the bad part of it, because it's wasting your whole week."
—Physician, department manager
Availability of data. Limited funds to compile and analyze data meant that data often were not collected in advance of starting a project to inform the RIE team. Outcome data were collected at least in the early period following the implementation of process changes. Some RIE process owners took the lead in tracking outcome data. One executive noted that the data might not be highly reliable, but collection of any data is a step in the right direction. He noted that in many cases there was willingness by staff to collect, publicly track, and use the data for daily improvement. This was true, for example, for one ED Value Stream project in which daily data that tracked the length of time patients stayed in the ED were posted on a public bulletin board.
Because there are so many completed projects (more than 70), the BDO could no longer keep track of monitoring data for all of them. Rather, monitoring in the sustainment phase was highly dependent on the project team. However, when no formal method for monitoring and revisiting the project is in place, the process tended to revert back to its original state, according to several frontline staff.
Communication About Lean
The hospital does not have a formal plan to communicate information about Advance in a targeted way. Instead, information about Lean is shared informally person-to-person and at routine meetings, such as monthly department staff meetings. At the end of every event week, a report-out takes place, where the RIE team outlines improvements made and results. However, this meeting is not attended by many frontline staff outside of the department related to the event's focus. Newsletters and emails about Lean are circulated, in addition to reports at meetings and face-to-face communication. A few senior leaders (including executives and department managers) stated that if staff were asked about Lean using Lean terminology, staff might not recognize the terms. However, when a term is described, a different term is used (i.e., RIE instead of Advance), or when a specific project is described, staff recognize the activity and can provide an explanation of what it is. Even an executive noted that he doesn't know all of the right terms for types of tools or projects but can describe them. Further, the term "Lean" is not used because of the negative connotation that it has in relation to job retention.
Management. In the first year of Lean implementation, engaging the executive team's and managers' support for Lean was a challenge for the CEO. The CEO and COO identified senior staff's inexperience in Lean methodology and their difficulty in understanding how Lean would benefit the organization as a formidable barrier. The CEO indicated that in year two, senior staff became more supportive of Lean because their involvement in the RIE process allowed them to directly see results.
Some directors and chiefs of service continued to be unwilling to adapt to the Lean culture, according to senior executives and department leaders. One executive described a director whose inflexibility hampered staff involvement in an RIE. The director and chief of service struggled with taking clinical staff away from their regular duties and saw Lean as a waste of valuable resources within their department. In reference to this situation, an executive said that after 2 years, he has come to the conclusion that certain people can be won over, but others can literally be placed on the sidelines.
|"None of us really understood what this was. I don't think we all fully understand it now. But you know what? All of the senior staff have participated in RIEs since it started. You learn the process. You say you participated and you're an equal participant, then you see the benefits and difficulties."
—Frontline staff member
A director described the benefit of Lean as forcing people to be together for 4-1/2 days to come to a problem resolution. Cloistering employees was also the worst part of Lean since it "wasted your whole week." One executive mentioned how having nursing and physician department leadership on an RIE team together enabled them to get to know each other better. The experience reinforced their mutual commitment to process improvement and sense of teamwork
Frontline staff. Comments were not always positive about staff morale and willingness to participate in Lean. The director of pediatrics stated that staff are often very negative because they have only a narrow perception of past failed improvement initiatives and, therefore, are often unwilling to become involved. The COO said motivating some employees has been a struggle. He commented that there has not been an effective way to communicate to all employees about the success/failure rate.
According to one senior executive, some staff resisted Lean because it came from the automobile industry and specifically from Toyota, which is nonunion. He commented that Lean was rebranded as "Project Advance" because "Lean sounded like cutting." Corporate had to commit to a no-lay-off policy as a result of Project Advance activity. This commitment did not preclude changes to job responsibilities subject to union restrictions. Another executive felt that the initial problems in applying Lean stemmed at first from staff not understanding what Lean was. He added that even 3 years later, there is not a full understanding.
A senior executive indicated that nursing as a group has not engaged enough in the Lean process; she hopes in time they will become more involved. Another executive attributed nursing's reluctance to the challenges of reaching a compromise with such a large group, both on and off the RIE team. One problem associated with nursing was seen in the Pediatric RIE. Patient care associates (PCAs) saw certain clerical duties to be outside of their job scope as clinical staff. According to a frontline staff person, the PCAs would not assume the new task of calling patients after the RIE was over because it was not a part of their job description. This conflict may be rooted in the hiring freeze, which created a shortage of administrative staff in the ED. One executive reported that the hiring freeze had reduced staff confidence and caused people to feel strapped for time.
Despite the challenges of engaging frontline staff, leadership at Heights was able to find approaches to make progress on RIEs. A physician leader set the expectation among new residents that Lean would be part of their work while they are at Heights Hospital. Educating project team members and department staff on the need for a particular Lean project can decrease resistance to change. A few interviewees stated that it is easier to facilitate a project when people understand the background of a problem and the need for change. This knowledge helps those involved to buy-in to the solution.
Two senior executives believed that starting the improvement cycle with employees who were enthusiastic about Lean was crucial to building momentum and staff confidence in Lean. They commented that this strategy helped to set an ambitious pace for future Lean events.
One director believed that staff's strong commitment to helping an underserved community was a facilitator to Lean implementation because staff were engaged in providing good service to patients prior to Lean implementation. Lean provided a means for staff to better meet patients' needs by achieving such improvements as reducing wait time and improving care coordination.
Two senior executives noted that having clinical staff on the team was essential to gaining frontline clinical staff support for process changes. A physician leader described how physicians are reluctant to adhere to Lean changes unless there is a peer motivator. A nurse leader noted that involvement of nurses in RIE-related decisions created ownership in support of process changes. A few executives commented that the employment model at Heights Hospital makes it easier to engage physicians because physicians are present at the hospital full-time.
The BDO explained that because Lean is a weeklong activity, it feels like a major investment of time; people feel frustrated when it does not work. He believed it is important that staff persist with a Lean project until they are successful. Some failures are expected, but eventually teams will "hit a home run." Every time staff members participate in Lean, they learn more, and their expertise increases.
|"When we have a successful RIE, there's no better way to get buy-in. Nurses see the process that's implemented and then want to be part of making a decision that would go into a new process."
—Frontline staff member
Lean Team Composition and Size
Many interviewees of all types mentioned that a diverse RIE team membership with all types of job categories (e.g. hospital police to nurses, housekeepers, schedulers and physicians) relevant to the process at hand yielded powerful results. Staff frequently referred to the fact that being on a project team helped to reduce silos because during the RIE, all perspectives were viewed equally, and staff left their titles at the door. One leader specifically mentioned how pleased he was with the number of doctors and nurses who had participated on teams. Two other executives noted how important it was for clinicians to have their peers on the team in order to motivate them to change behavior and comply with the team's process redesign.
|"I'm pleased with the number of doctors who have been on teams. Of all the hospitals, we are really good. I haven't done numbers in a long time but the last time I looked, I was like, 'Wow, there are a lot of doctors and chiefs of service."
Staff who are not familiar with the process that is the focus of the RIE are considered by some RIE team members to be important contributors to the work of team. A few interviewees believed these "fresh eyes" were critical to helping view the process in a new light and to generate additional suggestions for solutions. On the other hand, one physician felt that "fresh eyes" required too much time consuming explanation about the department processes.
The implementation of Lean at Heights Hospital has been successful, despite the challenges of a hiring freeze, reluctant senior leadership engagement early on, and the resistance of some staff and physicians. Corporate and hospital executives showed continued dedication to strategically using Lean to improve the system and hospital. The corporation has committed to providing system hospitals with a longer period of consultant support than initially planned. The hospital senior leadership has clearly communicated that Lean is a pivotal part of the strategic plan for moving Heights Hospital forward. Positions have been created for additional Project Advance facilitators with the savings incurred through Lean.
Thus far, Heights Hospital's experience provides evidence that Lean can be successful when applied to administrative and management processes. Lean has been focused primarily on administrative tasks (e.g., scheduling, patient flow, medical records, billing) within clinical settings, with success particularly in revenue management. For example, one project helped reduce the open accounts receivable, yielding more than $2.3 million. Lean's applicability to clinical processes is not yet demonstrated, since Heights has not yet implemented many projects in this area and has not reported clinical results from the few projects it has conducted. Further incorporation of clinical quality of care measures, other than patient cycle time, into future projects is required to understand if Lean can be successful in standardizing clinical work.
Celebrate success. The staff at Heights Hospital worked hard to improve patient care and financial indicators with many successes. Leadership should take the time to acknowledge and reward those staff who have carried out Lean while continuing their day-to-day work.
Set direction from the top down while generating solutions from the bottom. Heights Hospital engages all levels of the organization in Lean. Steering committees direct organization-wide strategy, identify value streams, and monitor results at the executive level. They set goals and charter projects at the mid-management level and, finally, execute projects at the frontline. This structure led to a well-coordinated effort that yielded results.
Maintain focus. An executive director's unyielding and public focus on Lean can overcome seemingly overwhelming obstacles, such as widespread resistance to Lean and financial challenges (e.g., hiring freeze). Particularly at first, Lean can be tumultuous, creating considerable conflict. Conflict for some can stem from difficulty ceding the power to make decisions to Lean teams, and for others it can arise from uncertainty and discomfort with change.
Expect setbacks. Lean is not easy to implement because it is rooted in a major cultural change for health care organizations, including a new way of thinking about work. It requires considerable skill development and staff time commitments. Organizations should expect that not all Lean projects will be successful and plan that it will take time to develop internal expertise in Lean thinking and techniques.
Recognize that visible support from management is required to make Lean work. Hospital executives showed their support for Lean by attending monthly steering committee meetings, actively participating in RIEs, removing barriers to and backing decisions made by RIEs, and seeking opportunities to communicate about Lean to staff face-to-face and in meetings.
Limit the scope of projects to a manageable size and define realistic goals. Several interviewees noted that scope is a critical part of the success of Lean projects. The project scope must be clear and include realistic goals or the project can become unmanageable.
Understand that multiple small projects in one area can result in major gains. The ED experience showed how concentrating small Lean projects in one clinical area can positively impact a number of indicators and build momentum for success. Leadership must weigh this approach against the risk of overwhelming staff and managers who still have day-to-day operational demands on their time.
Develop a formal communication plan to engage employees. Employees lacked understanding of the long-term vision for Lean and its potential contribution to Heights Hospital's mission. Employees' lack of understanding of Lean was likely a factor in their reluctance to support Lean. A formal plan of what all employees should know about Lean, and how and when this information should be communicated, is important to aligning staff toward achieving organizational goals through Lean and, ultimately, transitioning to a Lean culture.
Simplify quality improvement structure. As Lean becomes more mature, leaders should consider simplifying the complicated structure that may include committees for quality assurance, quality improvement, process improvement, and the Lean initiative. A simplified structure improves efficiency, integration, and communication about the improvement work being done throughout the organization.
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cc. An activity (similar to Management by Walking Around) that takes management to the front lines to look for waste and for opportunities to practice practical improvement in the direct service area.
dd. Unstructured approach to hands-on, direct participation by the managers in the work-related affairs of their subordinates.