Implementing Lean: Preliminary Case Study Findings and Implications for Primary CareAHRQ ConferenceSeptember 28, 2010American Institutes for ResearchFunding: 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), CallanBlough, 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
Background: Lean • 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 These 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
Project overview • Timeline: July 2008-June 2011 • Objectives • 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
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: 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) • Topics • 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 • Goals • 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: • Efficiency • Patient cycle or turnover time; unit of production per time (e.g., number of patients or cases/per physician/per hour); walking distance • Cost • 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 communicationand 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 • Skepticism: • “Is this the flavor of the month?” • “Will I lose my job?” • Competing priorities • Resources • 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
Next steps 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?
Resources Reducing Waste and Inefficiency in Health Care Through Lean Process Redesign: Literature Review • http://www.ahrq.gov/qual/leanprocess.htm Key contact Kristin L. Carman, PhD Managing Director, Health Policy & Research American Institutes for Research 1000 Thomas Jefferson St., NW Washington, DC 20007 ph. 202.403-5090 fax 202.403.5990 email: firstname.lastname@example.org www.air.org