Implementing Lean: Preliminary Case Study Findings and Implications for Primary Care (Text Version)
On September 28, 2010, Kristin Carman made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (440 KB).
Implementing Lean: Preliminary Case Study Findings and Implications for Primary Care
September 28, 2010
American Institutes for Research
Funding: Agency for Healthcare Research and Quality, ACTION Network, Task Order #5 Contract #290200600019, Project Officer: Michael Harrison, Ph.D.
Acknowledgement of team members & funders
- Project team:
- AIR: Kristin Carman (Project Director), Callan Blough, Steve Garfinkel, Margarita Hurtado, Lauren Smeeding, Jennifer Stephens
- Urban Institute: Kelly Devers
- Mayo Clinic: Michelle Hoover, Andy Kollengoode, David Mapes, Tony Spaulding
- Participating sites: Virtua Health, Mayo Clinic Jacksonville, NYCHHC, Garfield Memorial Hospital, St. Vincent Indianapolis, Family Health Centers of San Diego
- Michael Harrison, Project Officer, AHRQ
- Dina Moss, AHRQ
- California HealthCare Foundation
- Funding: AHRQ ACTION Network and California HealthCare Foundation
- Lean is a process-redesign methodology adopted from Toyota Production Systems.
- Empowers front-line staff to apply continuous quality improvement methods to reduce waste and enhance value in workflows and operations.
- Has shown promise to improve quality, efficiency, and safety in various health care settings.
Images: Three small pictures on the bottom of the slide depict three popular Lean tools: Value Stream Mapping, Spaghetti Diagramming, and 5S, a tool to organize workspace.
Background: Lean (cont.)
- "Lean does not equal Lean."
- Lean training is usually done "just in time" as part of the implementation of project in that staff area.
- Projects are generally selected by an executive team.
- Training lasts from 3-4.5 days.
- Staff at all levels across multiple departments participate in the training, but there are two key roles:
- A senior leader to "sponsor" and support the project.
- A manager to become the "owner of the process" who keeps things going after the training.
Objectives for today's presentation
- Describe preliminary findings from case studies of current Lean implementation.
- Discuss the barriers, facilitators, and lessons learned from our preliminary case studies activities.
- Discuss the applicability and implications of using Lean in healthcare.
- Timeline: July 2008-June 2011.
- Identify challenges and solutions (i.e., lessons) to implementing Lean/TPS.
- Assess the impact of Lean/TPS.
- Present these lessons to prospective users.
- Develop a business case.
- Identify factors that are associated with variation in Lean results.
Slide 7 with figure on research sites was removed to ensure anonymity of the selected sites.
Lean Literature Scan
- Information about Lean implementation in healthcare is unreliable and anecdotal.
- Data are inconsistent or absent in many areas.
- Most studies are atheoretical.
- There is a positive publication bias.
- Highlights need for comparative case study design.
Project overview: cases selected for presentation
- Preliminary findings are based on four retrospective case studies:
- Family center patient flow.
- Hospital bed flow.
- Orthopedics process standardization.
- Emergency Department value stream... but also includes insights from our initial site visits for prospective case studies.
Methods: conceptual framework
Image: A flowchart showing the conceptual framework is shown. A double-headed arrow points between a box labeled "External Context of Local Environment" and four boxes captioned "Internal Context or Organization." The four boxes are labeled "Structure," "Process," "Intermediate Outcomes: Organizational," and "Ultimate Outcomes: Organizational and Patient." Arrows point from each box from left to right, and characteristics of each context are listed.
Methods: data collection
- Case study data collection:
- In-person, in-depth interviews.
- Documentation from sites on metrics and outcomes.
- Semi-structured telephone interviews (prospective cases).
- Digital diaries (prospective cases).
- Description of the Lean implementation.
- Impact of Lean.
- Sustainability to date.
- Dissemination of information about Lean.
- Lessons learned.
Lean can be successful, but not in all circumstances.
Here's what we've learned so far.
Preliminary findings: starting Lean
- Impetus for starting Lean varied.
- Lean used as part of a strategic set of tools for improvement.
- Lean communicated to staff using multiple methods:
- Organizational assessment recommendations.
- Leadership announcements in meetings.
- Bulletin boards with project status and outcomes.
- Write-ups on projects in electronic newsletters.
- Participation in a Lean training.
Preliminary findings: defining Lean
- Two ways of defining Lean:
- Series of projects.
- Overall strategy for organizational transformation.
- Improve financial status of the organization.
- Eliminate waste.
- Achieve better patient experience.
- Empower employees to define solutions to problems.
Preliminary findings: measuring Lean
- Collection and monitoring of overall metrics to evaluate the overall success of Lean are scarce:
- Staff engagement.
- Patient experience.
- Revenue impact.
- Project-level metrics are common, but depend on the project:
- Patient cycle or turnover time; unit of production per time (e.g., number of patients or cases/per physician/per hour); walking distance.
- Number of full-time equivalents required per unit of production; cost savings.
- Quality and patient safety measures:
- Rates of infection, number of adverse events.
Preliminary findings: major Lean activities
- Training: Generally an expert consultant conducts formal training or experiential training through projects with staff. Eventually training facilitation and leadership is transitioned to on-site staff.
- Lean projects in specific departments or through different value streams:
- Projects generally selected by executive level staff.
- Projects generally have a sponsor and an "owner."
- Projects include a "Lean event" as well as follow up activities.
Preliminary findings: Outcomes reported
- Increased patient safety and patient satisfaction.
- Cost savings.
- Increased employee engagement and satisfaction.
- Improved communication.
"I do believe the tools allow this health system to get the end user to participant in their own change.”
Preliminary findings: facilitators to Lean success
- Lean organizational culture that supports change, awareness of QI and continuous improve.
- Strategic plan supports Lean initiatives.
- Leadership support is tangible and holds individuals accountable.
- Buy-in from staff of all levels, including physicians.
- Lean expertise.
- Resources are available for Lean projects (staff time, data, etc.).
Preliminary findings: facilitators to Lean success (cont.)
- Most Lean tools are simple and easy to understand.
- Process fosters communication.and breaks down silos.
- Staff own the solutions to their problems.
- Results are seen quickly.
- Successes are shared.
"Lean, unlike Six-Sigma... is easier to start with if you do not have good improvement capabilities. And within Lean, a common start is 5S. And 5S is not rocket science."
Preliminary findings: barriers to Lean success
- Lack of understanding of applicability to healthcare.
- "Is this the flavor of the month?"
- "Will I lose my job?"
- Competing priorities.
- Training and projects.
- Data collection.
- Implement desired changes.
- Resistance to change.
- Physician affiliation to organization.
- Process ownership.
- Lack of compliance.
- Creation of "islands of excellence."
"We don't make cars."
Preliminary findings: lessons learned
- Lean is not simply a tool for organizing your work; staff buy-in for implementing QI is needed.
- Efficiency and quality can be complementary, not mutually exclusive.
- Set clear goals, define success, and set an appropriate scope.
- Start with the easier processes first.
- Train senior staff in Lean and provide learning opportunities for other staff.
- Use multi-disciplinary teams and engage all stakeholders in the process.
- Celebrate successes through rewards or recognition.
- Collect follow-up data on 9 prospective cases:
- Digital diaries.
- Telephone interviews.
- Follow-up site visit interviews.
- Analyze all findings.
- Share report findings.
Questions to consider as we continue our research
- How is Lean defined and assessed?
- Is Lean a promising approach for hospitals? For primary care?
- Where and when is Lean most applicable in health care?
- For what types of processes is Lean most useful?
- How do you better engage staff, including physicians, in Lean processes?
- How do you monitor and sustain results of Lean projects?
- How do you encourage integration of Lean into organization's standard QI process?
Questions to consider for policy and practice
- Is Lean likely to work in health care?
- When do you think it is most likely to work?
- For certain problems, but not others?
- When conditions are right?
- It depends on the team? The organization?
- Have you or someone you know applied Lean in a health care setting? What was their experience?
- How might efficiency gains affect quality in health care? Can Lean improve both efficiency and quality?
Reducing Waste and Inefficiency in Health Care Through Lean Process Redesign: Literature Review
Kristin L. Carman, PhD
Managing Director, Health Policy & Research
American Institutes for Research
1000 Thomas Jefferson St., NW
Washington, DC 20007