Managing and Evaluating Rapid-Cycle Process Improvements as Vehicles for Hospital System Redesign
The project team confronted various challenges and learned many lessons as the implementation of redesign evolved, which was to be expected when putting a large system in motion for transformation. It is very important to constantly monitor the progress of change so that obstacles, challenges, and successes can be understood and addressed. This section summarizes some of these lessons learned at the global level, value stream level, RIE level (from the perspective of leadership and the RIE team members), and Black Belt level.
Many of the lessons learned at the global level occurred early on during the transformation process. There was much communication between the executive staff, Black Belts, facilitators, RIE team members, and engineers during the months of initial implementation. Adjustments were made in the approach to implementation as the challenges became clearer solutions were identified and put in place.
- Lean is a tool that is applicable to health care.
- There is no existing "cook book" template for implementing Lean in health care.
- Much of the existing published information on implementing and evaluating the impact of Lean tools relates to non-health care industries, while relevant is often not readily translatable to health care workers.
- Implementation of Lean is hard work.
- Implementation of Lean will not immediately provide results at the value stream level or system level. Therefore patience and commitment at the senior leadership level, along with executive guidance of the change process, are all important.
- Although the Lean tools are quite intuitive, their application takes learning and practice.
- Outside ongoing consultation is helpful for the implementation phase of Lean.
- Commitment and intense engagement of senior leadership (executive, operational directors, physicians and nursing) is necessary when transforming systems.
- The volume of data generated is considerable and requires disciplined and structured organization and coordination.
- There must be a structured and systematic process established for assessing the data.
- As there is no universal template for Lean implementation in health care, learning must be ongoing and process flexibility is essential.
- The identification of specific individuals within the organization to be key implementers is important. For Denver Health, these were the Black Belts and facilitators.
- Black belts drive the concept that Lean is part of everyday work not just an event.
- The core Lean operational structure must become part of organizational structure.
- For transformation, Lean must be one component of a more comprehensive strategy.
- Communication at all levels of the organization is essential.
- At some point, a tipping point occurs and system level results begin to emerge. For Denver Health, this was about 18 months.
Value Stream Lessons
- Value streams must reflect an organization's strategic imperatives.
- Executive staff must own value streams that represent their areas of operational responsibility.
- The most complex value streams may need several executive staff owners who work collaboratively.
- Value streams must be manageable in scope and reflect the entire flow of particular process.
- As processes are improved and changed within a value stream, remapping (depiction of the process flow) of the value stream is necessary.
- Facilitators might be best deployed by value stream, becoming experts in the processes that encompass a particular operational area.
RIE Lessons—Leadership Level
- Executive sponsors should identify RIEs at least three months prior to being scheduled, so team members can schedule these one-week commitments on their calendars. This is of particular importance for physician team members.
- Executives are convinced of the power of RIE process.
- Having Executive Staff lead RIEs for an entire week twice a year sends an important message to employees regarding the value of RIEs to the organization.
- Reporting RIE results to Executives on Friday mornings during RIE week is valued by team members and provides an opportunity for employees to showcase their work to executives.
- Physician engagement is highly valued by the team members.
- Most physician and nursing leaders have embraced the RIE approach to process improvement.
- Employees appreciate the opportunity to get together for a week to focus on a process that all see needs to be improved. It is much more efficient to focus the time for making an improvement in 1 week than having monthly meetings over a 6-month or year period, where all the employees involved in a process may not be available to make decisions.
- It is important to have a wide spread of employee involvement in change for the culture to embrace rapid improvement approach to change.
- In order for an RIE to be successful, it is key to clearly identify and limit scope of the RIE so that team members are clear on their purpose for the week and that it is doable.
- Creating the appropriate team size and composition are critical to a successful RIE. Team size is ideally eight where other employees that may be involved in a process can be pulled in as needed at specific times. Teams should be composed of a facilitator, team leader (not part of the process), process owner, and other team members involved in the relevant process. There should be never more than one-third of the team new to process. There should always be team members that are "new eyes" to the process—that is, people who have had no involvement with process.
- It is important to have all key personnel involved with a process on the RIE team.
- Starting with processes at the downstream end (i.e., patient discharge) of a process are preferred over processes at the upstream end (i.e., patient admissions), because a bottleneck in flow will be created until the farthest process downstream is reached.
- It is a greater challenge to improve processes that cross departments. In these cases it is important to have direction from executive sponsors.
- After RIE, momentum can be lost and process can return to the "old" approach. It is important for teams to develop communication plans for post-RIE and to identify responsible parties for followup.
- It was necessary to hire external expertsm to motivate staff and provide momentum and structure for implementing RIEs.
- Some process changes are readily transferable, such as replicating an improvement from one clinic to another, where other process changes require "tailoring" to the specific environment and culture.
- Tuesday is the most difficult day during RIE week.
- It is difficult for RIE teams to identify people whose work is not value-added, and therefore elimination of positions is rare.
- As the Lean philosophy took hold throughout the organization, it was necessary to create an organizational structure to support Lean and RIEs.
- This structure was created by establishing a Lean department and by hiring additional facilitators. With the creation of this department, employees understood that Lean was no longer "an experiment" but a way of life.
- At the RIE level, data collection can be a challenge even when responsible parties are identified. The easier the data are to collect, the more readily they will be collected.
- The most successful RIEs have included the clear identification of the problem, the relevant metrics, and the collection of data at least 1 to 2 months in advance of RIE week.
- Metrics are not something that most health care workers understand and therefore guidance by experts is necessary.
- Visual production boards posted in each operational area affected by an RIE are important. Through the display and monitoring of RIE metrics, improvement challenges are readily visible and improve the ability to sustain these process improvements.
- Continuous communication to employees about the progress of Lean is critical. Denver Health developed a new internal publication to communicate to employees called the "Getting It Right" newsletter.n
RIE Lessons—Team Member Level
At the end of each RIE week, individual participants describe their lessons learned and accomplishments. The following list is a summary of the feedback from over 200 participants in 59 RIEs over an 18-month period. Through the application of formative methods, this summary categorizes responses by common themes.
- The 3-week preparation time for the RIEs is very important.
- Pre-event work is critical to RIE success (data collection, team identification, and meeting 1 week ahead).
- There is a need to collect data in advance.
- Information technology input and assistance are invaluable.
- Baseline metrics are very important to gauge success.
- Teams have a lot of data but they are not readily available or usable.
- Data should be used during the RIE week rather than preconceived beliefs about the proposed change.
- A seemingly simple problem can be very complex.
- Processes that initially seemed complex can be simplified.
- There was a continued need to work harder to remove preexisting agendas from the RIE process.
- Communication must be reinforced.
- Communication between areas that could resolve errors is lacking.
- Not everyone in the organization is informed about the RIE process.
- Expanded knowledge of each other's processes was invaluable.
- It takes courage and buy-in to successfully transform the current state.
- Team buy-in is essential for success.
- A "no show policy" should be enforced.
- It is important to have the right mix of people on the RIE team.
- It is important to involve the entire team in the RIE process, both during the RIE and during the sustainment period.
- Strong team membership with appropriate expertise was crucial to success.
- Executive sponsorship is vital for RIEs to be a success.
- There is great value in having the executive sponsor meet with the team at the start of each day and each afternoon before the daily recap so that the team could benefit from their knowledge of Lean practices.
- The introductory meeting covering the Lean process and RIE basics was invaluable.
- There is a need to educate general staff more on what Lean/RIEs are before the event and to promote Lean.
- Change is a continuous process and feedback must be implemented.
- It helps to constantly revisit the future state so that daily adjustments can be made.
- There are benefits to the standardized work process.
Black Belt Lessons
- The Black Belt concept (training mid-managers in Lean throughout the organization and expecting them to apply Lean tools in everyday work) does not appear common in Lean implementation in health care.
- The development of the Black Belt layer for implementing Lean tools was effective both in creating a culture of Lean as a way of doing everyday work and for improving financial outcomes.
- The Black Belts value their role.
- In the beginning stages of implementing Lean, there has been more work for managers that were Black Belts (i.e., dual job responsibilities).
- Monthly Black Belt reports to CEO encourage them to apply Lean tools daily.
- There is variability in the ability of Black Belts to apply Lean tools.
One of the important lessons for developing an approach to system transformation was that the right pieces to the puzzle are in place. All five pieces are important and are truly integrated when information technology helps with integrating each piece. For instance the right physical environment was promoted not only through the construction of new buildings but through the application of Lean tools. Lean was used to map the work process within the new physical environment prior to moving into the newly constructed space.
A Lean tool variant of 3Po was applied to assist with planning a move to a new wing of the hospital. Through the application of this tool, it was demonstrated that the obstetrics staff walk fewer steps each day to complete their job tasks. The project team has also been able to demonstrate that, through the use of this tool, patients who use these services travel faster through the hospital, creating improved throughput (flow) in the new buildings compared with throughput in the older buildings.
Right people are the key to process improvement and in identifying the right process. By recruiting and hiring people with talents that are the best fit for a position, the workforce is more likely to participate in innovative approaches to improvement. For example, phlebotomy used the talent profiling hiring tool to hire phlebotomists; the same number of phlebotomists is able to fulfill the needs of the hospital, including the new wing. Through the use of talent profiling and hiring appropriate staff, the new staff was more efficient in providing phlebotomy services.
Right communication represents the correct flow of information and therefore reflects the concept of barrier free flow. For example, Denver Health has implemented the use of a structured communication tool between physicians and nurses within the acute care setting. Through the application of this tool, there has been a reduction in the number of communication steps between physicians and nurses that relate to patient care. The removal of non-value-added steps to communication is linked with creating improved processes, and this improved communication also promotes patient safety and enhances employee engagement.
Right incentives reflect the observation that people will do what is they have an incentive to do. Team-based incentives which emphasize the team concept applied by Lean have been developed. To date 22 teams have been paid for Lean projects through the team incentive award program, and the number of Lean teams that are applying for these awards is rapidly growing.
Communication and Knowledge Transfer
Numerous approaches that were developed to communicate the coordination, implementation, and evaluation of the RIEs include the following:
- "Getting It Right" newsletter.
- Friday out-briefings to leadership (during RIE week).
- Facilitator sharepoint (intranet) site.
- Black Belt quarterly meetings.
- Employee engagement in rapid improvement events.
- Incentive system.
The "Getting It Right" newsletter is published monthly by the Denver Health Public Relations Department. This newsletter highlights process improvement projects, particularly RIEs and Black Belt projects, through staff interviews and by identifying the staff engaged in these events. It also offers a communication link to all 4,300 Denver Health employees about the system transformation efforts, as this newsletter is readily available on the internal Denver Health Web site.
Denver Health has developed a common employee screensaver that activates when employees are inactive at their computer for a specified length of time. This screensaver is changed at least twice monthly and provides a forum for communicating information throughout the health care system. Numerous screen savers have been developed to communicate the Lean philosophy and how it applies to Denver Health and employees in their everyday work environment.
During the 1-hour Friday morning out-briefings during RIE week, each of the five teams has the opportunity to report on the purpose, scope, Lean method, and results of their projects to executive staff, other teams, and Black Belts. This has provided an opportunity for all employees to communicate with executives and other operational leaders.
The facilitator sharepoint site, a Microsoft® intranet site for sharing documents and information, provides a forum for facilitators to communicate with each other. As the RIE approach to continuous improvement is a standardized process, the sharepoint site reinforces the standardization of implementation through this communication tool.
Black Belt quarterly meetings provided a forum for Black Belts to discuss their projects with each other and to learn from each other. During these meetings leadership also received feedback regarding the progress of RIEs and the challenges Black Belts face applying Lean tools as part of their daily work.
The number of employees directly and indirectly engaged and affected by RIEs continues to grow. The spread of engagement to more and more employees located throughout the health care system assists in creating a culture of continuous process improvement through the application of Lean principles.
With an incentive system that rewards a team approach to process improvement, the culture reinforces communication and collaboration among employees.
The results of this study have been presented to many groups, including:
- National Association of Public Hospitals and Health Systems.
- Business and community leaders.
- Other hospitals.
- Institute for Healthcare Improvement annual meeting.
Denver Health also received support from AHRQ to sponsor a national Lean training conference that focused on communicating Lean tools as applied in health care to safety-net hospitals.p Other hospitals have also requested an opportunity to observe and participate in RIEs. External Advisory Committee members have also shared process development with other industries.
Finally, the following journal articles have been published or in process:
- Gabow PA, Karkhanis A, Knight A, Dixon P, Eisert S, Albert RK. Observation of residents' work activities for 24 consecutive hours: implications for workflow redesign. Academic Medicine 2006 August;81(8):766-75.
- Gabow PA, Eisert SL. A construct for transformation of a health system. Under review.
- Gabow PA, Kaufman L, Wilson M, Goodman P, Albert R, Karkhanis A, Husby B. Applying the Lean tool 5S in a health care system. Under review.
m. Denver Health refers to these experts as "sensei."
n. Additional activities and methods relating to internal communication are described in "Communications and Knowledge Transfer" (below).
o. "3P" (that is, Production Preparation Process) focuses on eliminating waste through product and process design.
p. "Getting Lean: Health Care's Challenge" was held in Denver, CO, on October 19-21, 2005, The conference agenda can be accessed at http://www.denverhealth.org/gettingLean/.
AHRQ Publication No. 07-0074-EF