Acknowledgement of team members & funders

1. 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.

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. Methods: conceptual framework

10. 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

11. Lean can be successful, but not in all circumstances. Here’s what we’ve learned so far.

12. 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

13. 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

14. 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

15. 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

16. 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.”

17. 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.)

18. 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.”

19. 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.”

20. 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

21. 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

22. 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?

23. 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?

24. Questions? Comments?

25. 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: kcarman@air.org www.air.org