Improving Care Delivery Through Lean: Implementation Case Studies

Organizational Background

This report presents the results of the study of an academic medical center, Grand Hospital Center, and its experience implementing Lean. Two projects, Hip and Knee Replacement Costs and Cardiology Follow-up Appointment Scheduling, were selected for study from this organization. The case study methods, including the criteria for selection of the projects for analysis, are described in the introduction section of this document. For this case, we conducted 31 interviews with 20 individuals. Their roles and positions at the hospital varied as described in Exhibit 3.1.

Description of the Health Care System

Grand Hospital Center is part of a larger, not-for-profit enterprise, which includes hospitals, clinics, and other health care facilities (Exhibit 3.2). The system has two major components: the parent organization and an affiliated multi-State network of community hospitals and clinics. The parent organization trains many students and researchers.

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Description of the Health Care Organization

The focus of this report is a 214-bed academic medical center situated in a Southern city. Grand's hospital and clinic facilities are located on a joint campus. Prior to 2008, inpatient care was provided at an affiliated hospital. In 2008, the academic medical center opened its own hospital facility. Exhibit 3.3 highlights key characteristics of the center.

All of the physicians are salaried staff physicians. The organization as a whole and each department are managed jointly by a clinical and an administrative leader (Exhibit 3.4). Interviewees indicated that Grand is a physician-led organization, but that these complementary roles of clinical lead and administrative lead are equal in hierarchy. All medical staff report to the Chief Executive Officer (CEO); all administrative and non-physician staff report to the Chief Administrative Officer (CAO). Many clinical and administrative managers, as well as many executive leaders, had previously worked at other sites in the parent organization before coming to Grand.

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Other Environmental Context

Local Competition

Grand operates in a competitive market. The CEO described local competition as greater than national competition; however, he noted that his medical center competes with large hospital systems in the region (South) and beyond it. The CEO indicated that Lean may make the medical center more competitive in this market by reducing the cost of care.

Funding and Payers

Grand's largest payer is Medicare, accounting for 52 percent of payments. Further, given the large population of older residents in the State and the importance of Medicare as a payer, it is critical for Grand to deliver care at or below Medicare reimbursement rates. One interviewee noted that with limited resources, shrinking reimbursements, and an aging population, if Grand cannot provide quality care at Medicare reimbursement rates, it will not survive.

"We've got huge waste in health care, prices aren't that good, prices may go up, but there's not going to be any more money for us going forward. The only way we're going to survive in an era of declining reimbursement is to lower our costs. The way you lower your cost is to take out waste." —Executive leadership

Local Resources

An important aspect of the context for Lean adoption is the availability of local expertise. In 2009, Grand joined a Lean consortium, which is a cross-industry group of more than 50 area organizations that are implementing Lean. The group collaborates to improve the performance of businesses and organizations applying Lean methods and tools, so they may become more efficient, profitable, and competitive. Grand is the first health care delivery system to join this consortium. Through the consortium, it has access to resources for Lean projects (e.g., seminars, materials), participates in tours of other Lean organizations, and learns from the experiences of other members. For example, as part of the consortium, several medical center employees had the opportunity to observe Lean implementation at a printing company and at a manufacturing facility that produces surgical devices. Of note, only one other hospital is part of this consortium.

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Lean and Quality Improvement at the Organization

In this section, we discuss the history of both Lean and QI at Grand. Exhibit 3.5 outlines the overall timeline for Lean and QI initiatives at the center. The specific activities noted in the timeline will be discussed throughout this report.

History of Quality and Efficiency Improvement Efforts at the Organization

As noted by executive level staff and other senior staff, the parent organization as a whole has historically placed a strong emphasis on performance and QI. A philosophy of continuous quality improvement (CQI) is part of its organizational culture. The parent organization has benchmarked companies like 3M and General Motors in the private sector, and one of the aspects they share is a systems approach to process improvement. The parent organization chose DMAIC (Define, Measure, Analyze, Improve, Control) as the overall or "generic" approach to QI systemwide because it would allow staff to incorporate several tools, including Lean and Six Sigma, into improvement work.

The first course offered by the parent organization's corporate QI training institute was the training course on DMAIC. This is a 10-day course on total quality management (TQM), Lean tools and principles, Six Sigma, and aspects of project management and change management. In addition, the institute offers many other  individual level courses to employees through traditional face-to-face classroom delivery and online training. Project based collaborative workshops organized around a specific topic, such as heart failure, are also held periodically.

Training on quality management and process improvement is offered to employees, including physicians, through the parent organization's training institute. Training is delivered by quality and process improvement practitioners, and largely resourced through the Quality Management Services Department, and the S&P Department at each site. Additional trainers are available from one of the campus as needed.

Many of the senior leaders and management staff at Grand have attended the institute's Teams' training course and completed projects applying the DMAIC methodology. Classes and sessions continue simultaneously with the Lean training and projects at Grand. Many interviewees felt that the DMAIC principles were not identical to Lean, yet had a great deal of overlap. One Lean participant noted that Lean efforts were more concentrated and visible than those related to DMAIC. As such, they allow Lean project teams to focus on particular opportunities and solutions, and partly due to increased visibility, managers and senior leaders may be more supportive of these efforts.

In addition to ongoing training, the medical clinic undertakes enterprise-wide priority projects that focus on core measures determined by the parent organization for all locations. Areas of focus in previous years have included obstructive sleep apnea, high-risk medications, and mortality. The enterprise priority projects are the main focus of the Quality Management Services Department. There were approximately 10 QI projects for Grand in 2010.

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Initiation of Lean at the Organization

Prior Organizational Experience with Lean

At the parent organization, Lean is viewed as a specific approach to streamlining care delivery processes and as a way to identify waste and define solutions within a larger context of QI. The organization as a whole became interested in expanded applications of Lean principles in late 2003, based on positive feedback and results obtained in pockets of the organization that implemented Lean to streamline their operations and improve the patient and staff experience.

For training purposes, in particular, the parent organization opted to merge concepts and tools from Lean with Six Sigma and various management approaches, as discussed above. Since 2006, the organization has standardized process improvement training under the auspices of the corporate QI training institute, which provides "Lean Sigma" training to Lean project team members, their project champions (which include physicians and administrators), and individual employees.

In late 2006, a member of the training institute visited Grand to provide the department charged with process improvement—Systems and Procedures—with an overview of Lean, but a specific Lean program was not put into place at that time.

Financial Losses and a New CEO Drive the Need for Change

In 2008, following a $38 million loss by Grand, the parent organization sent a team to the site to conduct an assessment of operational improvement opportunities. Based on the assessment and previous experience with Lean at two other sites, the executive leadership of Grand decided to implement Lean as part of a larger strategic plan to make improvements in the organization. The strategic plan included reducing administrative costs, filling only essential new and vacant positions; placing constraints on capital spending, streamlining of business processes to improve efficiency; and restructuring of employee pension and postretirement plans in addition to implementing Lean. Although other process redesign approaches were considered, Lean was selected because of its focus on identifying and eliminating waste and empowering frontline staff to formulate solutions. Additionally, the leadership felt that Lean would allow staff to see quick positive results, thus increasing buy-in from staff.

Lean is generally implemented using the corporate QI training institute across the parent organization's system. However, at Grand, the executive leadership stressed the urgency of the issues facing the site, and from 2008–2010 was able to hire an external consultant to focus Lean training and accelerate the change process. The consultant had previously worked with the executive leadership at the other sites under the organization's umbrella to implement Lean. The training institute staff and the outside consultant worked together to train and mentor Grand's Systems and Procedures' staff as Lean coaches and facilitators to transition Lean to an internal effort. Day-to-day management of Lean at Grand is the responsibility of analysts from the Systems and Procedures (S&P) Department who serve as internal consultants and collaborate in training Lean teams.

Conceptualization of and Goals for Lean

According to statements by nearly all interviewees, Grand uses Lean as a mechanism to reduce waste and improve processes. In addition to the focus on identifying and eliminating waste, Lean also empowers frontline staff to formulate solutions, thereby reinforcing a culture of QI. Nearly all interviewees recognized that these goals for Lean were strongly driven from the senior leadership, specifically the CEO.

Exhibit 3.6 lists the goals for Lean at Grand expressed by staff at various levels of clinical and administrative responsibility in the organization. Although there is some agreement (e.g., all five employee categories agree on waste reduction as goal), there is also important variation (e.g., only department leaders and nurses and other frontline staff cited QI). Summarizing these goals across all labor categories suggests that, at a broad conceptual level, Lean at Grand is intended to improve efficiency, improve quality, enhance the QI skills of staff, and engage the entire staff in these efforts. In addition, members of the senior leadership team indicated that Lean is also intended to change the organizational culture. 

"The overall goal is that we have to become more efficient and to be able to sustain financially and sustain the quality in our current reimbursement system, or possible future reimbursement system. We have to find a way to do things better and smarter to be here 10 years from now." —Department lead

Reduce or eliminate waste. Nearly all staff across all levels of the organization indicated some form of waste reduction as an organizational goal for Lean. Individuals believe that Lean will allow the organization to "do less with less," meaning that Lean will remove undue burden on staff by finding and removing waste within existing processes. Related to waste reduction, a few interviewees noted that a key goal of Lean is to reduce costs or save money.

Develop improvement skills. Reflecting an interest in increasing the capacity of the organization to implement Lean, several senior executive and department leadership interviewees mentioned that a goal of Lean is to provide new skills in process improvement to Grand's staff. The CEO hopes that staff will continue to use these skills after their participation in formal Lean projects ends.

Change organizational culture. Two senior executive staff noted that organizationally, they hope that Lean will be hard-wired into the organization's culture. As stated by the CEO, after Lean implementation, staff at Grand will never stop finding ways to improve processes. Further, the CEO noted that he hopes that as a result of Lean, staff will not be afraid to try something new through a rapid test of change.

Improve quality of care. Several interviewees, primarily department leads but also nurses and other frontline staff, described improvement in quality of patient care as a goal of Lean. Several of the Lean projects at Grand focused on processes that will improve the quality and experience of care for the patient.

Promote participation of all staff. One interviewee from the S&P department and the CEO hope that Lean will be adopted throughout the organization.

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Alignment of Lean and Quality Improvement Efforts

Even among staff who did not include QI as a Lean goal, Lean and QI are seen as complementary and part of a larger whole. Nevertheless, they are housed in different departments. Lean is housed in the S&P Department, reporting to the head of the Support Services Division. The Quality Management Services Department staff reports to the Division of Clinical Enterprise. These two departments are seen as having distinct goals. The S&P Department is largely in charge of process improvement, and related training, and technical assistance, while the Quality Management Services Department is responsible for the clinical quality outcome committees and submits the data required by the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission. These data include clinical process and outcomes measures, patient safety data, and patient satisfaction data. Exhibit 3.7 shows the complementary nature of the two departments.

"We're giving new skills and then, we expect you to use them after you're done with the wave. Because—then you should be able to put together your own team and just go. The first three waves, four waves are teaching new skills to people. Once they've got that down, they should be able to go do it by themselves." —Executive leadership

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Process for Implementing Lean

Exhibit 3.8 depicts the key steps involved in Grand's Lean implementation process, including planning, project selection training, project implementation (including how the project and team are structured), monitoring and control, and sustainment of project results. Each of these steps is described in more detail in this section.

Planning Implementation of Lean

Lean has been implemented at many levels and is viewed as an organization-wide initiative. This initiative began with the leadership studying the whole organization, defining priorities, identifying departments for inclusion, and selecting Lean project teams; those teams then carried out their projects. Grand's implementation model relies on the principles of adult learning and uses specific Lean projects to train staff, implement Lean tools, and routinize Lean into everyday work.

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Lean Project Selection Process

The first wave of Lean projects, April-August 2009, was selected by the center's Executive Operations Team (EOT). The EOT is composed of the CEO, CAO, and other organizational leaders nominated by the CEO and approved by the center's Board of Governors. EOT members were required to complete Lean project team training and define a topic to be addressed with Lean methodology. The initial projects and training heavily emphasized processes that could reduce costs in the short term, in response to a $38M loss registered in 2008.

For the second wave of Lean, August—December 2009, the EOT sent out a general announcement requesting staff to submit ideas for Lean projects, resulting in a relatively large number of applications. One senior leader thought that many teams volunteered because "the word was out there that Lean was something that would have a 'halo' effect if you [participated]." For the third wave in February—March 2010, the EOT established an application process that required teams to write a charter and collect baseline data. The winning applications were selected by the EOT—six for the second wave and six for the third wave.

Across all waves, there was a deliberate selection of both clinical and administrative projects. The EOT looked for cost-savings but also for projects that could improve health care quality, including patient safety, patient experience, and clinical quality outcomes. Thus far, the EOT has steered away from projects requiring a large information technology (IT) component because the electronic health records system and other components were being upgraded as part of a continuing enterprise-wide effort in summer 2010.

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Lean Training

In 2009 and 2010, Lean training at Grand was conducted by an external consultant (Exhibit 3.9). The consultant-led training program had been used at three other sites under the parent organization before it was customized and used at Grand. In 2011, after four waves of training, responsibility transitioned to the S&P Department. There are two levels of Lean training: (1) just-in-time project-based training, and (2) advanced Lean training. A complementary, but independent data analysis course is also offered.

Project Team Training

Training on Lean principles and initiation of Lean projects are fully intertwined. Once projects are selected, staff are required to participate in training as a team. For 2 years, from 2009–2010 training was conducted by a private, outside consultant who also advised Grand on Lean as a whole. Each training wave included six teams, comprising upwards of 60 staff. The training lasted 4.5 days divided over three 1.5 day sessions. During the 3- to 4-week period between sessions, teams worked on their specific projects, applying what was taught during the previous session.

In most cases, after an application is approved, staff are assigned to participate in a particular Lean training by a manager or supervisor depending on the topic of interest and their organizational role. Staff participating in the training are provided with release time to attend the training. However, many staff reported that they needed to work on the Lean project before or after hours in order to meet the requirements of their regular duties.

Other Training

Advanced Lean Training was offered at Grand for the first time in January 2010 (Exhibit 3.10). The purpose of this training was to certify individuals as "Lean Specialists." This training was targeted to S&P Department staff (analysts) and organizational leaders. As of January 2011, 21 individuals at Grand had participated in the advanced training. While interviewees did not discuss the content of this training in detail, it included site visits to other organizations in the area that are implementing Lean.

Mp> In addition, a data analysis course was offered by the external Lean consultant and a statistician at Grand. This training was independent of the Lean trainings offered but highly recommended as Lean training did not include data analysis methods and reporting. These skills are often needed to define, monitor, and sustain Lean projects. The data analysis training is a 4-day course covering aspects such as charting, graphing, and data analysis using Excel (Microsoft Corporation, 2003). This training course was offered five times in 2009 - 2011. As of January 2011, approximately 50 staff had attended the training; 80 percent of them had experience with Lean projects.

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Process for Lean Projects

All Lean projects at Grand Hospital Center follow a process established with the consultant at the inception of Lean. Prior to the start of the training and projects, the director of the S&P Department meets with the project leadership. The activities conducted to prepare for upcoming Lean training are presented in Exhibit 3.11.

In addition to the formal activities listed above, teams are encouraged to meet on a regular basis to work on their projects.

Project Organizational Structure and Roles

Lean project teams generally have 10-12 participants, four of whom play champion, coach and team lead roles. Grand has identified four formal roles for Lean teams (Exhibit 3.12).

Physician and administrative champions. Assigned to each Lean team, champions are usually the physician department chair and the operations administrator for the department. Their major responsibilities include assuring Lean activities are linked to the organizational strategy, serving as a liaison to the EOT, helping to select team members, working with the team leader and coach throughout the process, and keeping the team focused.

Coach. Staff from the S&P Department serve as the project team coaches. The coaches can assist with facilitating meetings, educating team members on Lean tools and measures, and monitoring team progress.

Team lead. The team lead is responsible for managing the day-to-day aspects of the Lean project, including meetings between training sessions, data collection, and data analysis.

Team members. Staff at every level, including both clinical and administrative staff, may participate in a Lean project. It is a priority that physicians be involved in all clinical projects (as a physician champion and/or team member). Physicians are also encouraged to participate in administrative projects that might affect their work. Initially, the EOT directly selected the staff for Lean teams. Now, the department leadership champions for the project select staff as part of the project charter and the application process.

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Monitoring, Control, and Sustainment

Project monitoring occurs throughout the first 100 days through formal report-outs during each session of the Lean training. Teams may also post interim data on a bulletin board, located where team members can view it. The team leader, with support from the physician and administrative champions, monitors the project after the process changes are implemented. Specifically, team leads collect and monitor the data on the specific metrics related to the project. Of note, interviewees indicated that it is often challenging to obtain needed financial data unless a member of the finance department is on the team or the champion facilitates access.

Data are collected from available systems, including electronic health records (EHR) and scheduling systems when possible. Most often, data are collected manually because the systems are not set up for easy extraction of the data, or data are not collected in the form required for the project. In 2010, during the time that this case study was conducted, the parent organization was updating the EHR system enterprise-wide, in part so that it would be compatible across the organization's campuses. As a result, there was a moratorium on requests that would require modifications to the EHR system or other IT systems at either campus.

At the end of the training, each team conducts a "100-day report-out" to the EOT on results. If the project has achieved its goals, it enters the "sustainment phase" (described in the next section). If the project goals have not been achieved yet, the team continues the implementation process, described previously.

After the project has met its goals and entered the sustainment phase, the team lead is required to submit a quarterly report to the EOT on the project's progress. The quarterly reports provided by all completed Lean projects are the primary means for monitoring overall implementation of Lean.

The team leader, the project champions, and/or sponsors ensure that the project continues to be monitored. These individuals must also ensure that improvements are sustained and that staff are taking ownership of these changes. If progress slips, one of these individuals, usually the team lead, alerts the others and seeks a solution.

At the project team level, the ongoing monitoring and sustainment are highly dependent on the project. For example, daily monitoring may be necessary for projects that examine scheduling and patient flow issues. Other projects may require less frequent monitoring—perhaps on a weekly, monthly, or quarterly basis. Monitoring may require an audit of a patient's record or other documentation to show process compliance. Examples of other metrics include: turnaround time, number of procedures, cost reports, or frequency of falls or pressure ulcers.

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Dissemination and Spread of Findings

Spread of Knowledge and Findings Across Grand Hospital Center

As discussed earlier in this section, during the study period, there were three waves of Lean training and 18 participating teams. As of April 2011, two additional waves of training were completed, one in late 2010 and another in early 2011; executives interviewed estimated that 10-15 percent of the organization's staff had participated in Lean. Among those trained in each wave, about half were people who had no previous Lean exposure. Given the level of Lean penetration within the organization, executive staff and process improvement staff noted that they expect that departments will begin initiating Lean projects and using Lean tools in a more organic fashion in the near future.

As shown in Exhibit 3.13, Grand Hospital Center also disseminates and promotes findings from Lean projects across the organization, but the impact of these efforts is unknown.

Sharing with Other Entities in the Organization

Many interviewees noted that the efficiency gains and other improvements resulting from the academic medical center's Lean projects could be replicated across other hospitals in the parent organization's network, leveraging the work done by the project teams for systemwide improvements. It is expected that the Hip and Knee Replacement Costs project will be spread to orthopedics groups at other organization hospitals. In general, if a project goes well, team members may be asked to share their Lean redefined processes and results for broader dissemination. For example, results from the Hip and Knee Replacement Costs project were shared with the specialty counsel, which operates enterprise-wide to ensure consistency in care and patient experience.

External Dissemination

In 2009, Grand Hospital Center joined a local Lean consortium, which is a cross-industry group of more than 50 area organizations implementing Lean, including health care providers, an insurance provider, and aerospace manufacturers. As described earlier (see Other Environmental Context), this group seeks to collaborate to improve the performance of businesses and other organizations by becoming more efficient, more profitable, and therefore, more competitive in the global marketplace. The consortium offers the academic medical center a place to share Lean experiences and findings as well as gain new insights and ideas.

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Lean Projects Studied

We selected two Lean projects that focus on processes relevant to frontline staff to facilitate comparison of findings across the multiple organizations included in our study. For Case 3, the two projects studied were: Hip and Knee Replacement Costs (retrospective) and Cardiology Follow-Up Appointment Scheduling (prospective). 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).

Hip and Knee Replacement Costs

Project Goals

The focus of the Lean orthopedics project was to bring actual expenses in line with Medicare reimbursement rates for total hip and knee replacements. This project was part of the first wave of projects (April—August 2009) at Grand Hospital Center, many of which focused on cost containment.

Implementation in the Orthopedic Surgery Department

This project was implemented in the Orthopedic Surgery Department. The department has a high volume of patients and procedures and had performed more than 600 knee and hip replacement surgeries in the year preceding the project. The physician department chair, who was also the clinical project champion, was highly involved in the project from the start and took personal responsibility for leading the team and ensuring that project objectives were accomplished.

Project Selection

The high volume of surgeries combined with financial losses due to a gap between Medicare reimbursement rates and actual costs made this project a priority for cost containment.

Project Staffing 

The EOT selected the members for the project team as part of the first wave of projects (Exhibit 3.14). The project leadership included the department chair (who was the physician champion); a coach from the S&P Department; and the department's operations administrator, who was designated as the formal project team lead. Commonly, the operations administrator serves as a champion, but given the nature of the project, the executive leadership team felt that it would be more appropriate if the operations administrator served as the team lead.

The project team included other members from the orthopedics department and a member from the financial analysis and planning department, given the focus on expenditures.

Planning and Implementation

As part of the planning process, the team collected baseline data on the gap between costs and Medicare reimbursement for hip and knee replacements in 2007, 2008, and the first quarter of 2009. Using this information and the tools from the Lean training, the team began looking for ways to decrease costs to better align with Medicare reimbursement rates. The specific tools used and activities completed by the project team were:

• Current state maps for preparing a patient for surgery, performing the surgery, recovery in the post-anesthesia care unit, inpatient care, and medication use. The team identified opportunities for "quick fixes" in the current state maps and focused on two general processes: performing surgery and inpatient care.
• Future state maps of performing surgery and inpatient care.
• Spaghetti map^s of the physical therapy services performed on the first day post-surgery
• Identification of waste to help cut costs for surgery and inpatient care. The team addressed several areas of waste, including supplies used for inpatient care after surgery. They examined the use and effectiveness of the hip abduction pillow and determined that generic pillows could be used instead at a lower cost. In the long term, the team planned to renegotiate contracts with the implant providers to further reduce costs.
• Workplace organization (5S) on storage areas to reduce inventory waste.
• PDSA (Plan-Do-Study-Act) on discharge time to identify opportunities to streamline the discharge process.
• Rapid test of change using a whiteboard to record notifications of the time of the next surgical case with the purpose of reporting and recording operating room changeover time (the period of time between surgeries required to prepare the operating room for the next patient).

Monitoring, Control, and Sustainment

During the 100-day implementation period, the team met on a weekly basis for an hour before the surgical schedule started. This process helped keep the project moving forward.

The team periodically collected updated data from the Financial Services Department on the total cost of hip and knee replacement surgeries and the gap in Medicare reimbursement. In addition, the team monitored data on operating room changeover time^t and discharge time using information technology software that routinely tracks this information. Decision Support System (DSS) data, as well as medical and surgical records, were used to examine anesthesiology costs, supply costs, and resource costs from other medical specialty departments. Further, staff conducted rounds to monitor use of unnecessary supplies.

Once the 100-day monitoring period was complete, the team lead and team champion revisited the project on a quarterly basis to examine whether new processes established to decrease changeover and discharge time, along with costs (for example, review of surgical supplies being used), were being maintained. A quarterly update comparing Medicare reimbursement to costs incurred, both for total volume of hip and knee replacements and on a per case basis, was compiled and provided on an ongoing basis to the EOT. In addition, the team monitored special orders per case; a special order indicates that special and expensive equipment that is not part of the plan is being purchased. The team also continued examining ways to save costs; some were implemented as described in the next section. The primary physician who played a role sustaining this project after the 100-day report out was the department chair and physician champion.

Project Outcomes

Nearly all project team members and senior executive staff indicated that this project was considered to have been highly successful. A summary of the project outcomes can be found in Exhibit 3.15.

The team succeeded in greatly reducing costs for hip and knee replacements, though not enough to match Medicare's reimbursement rate. The team was able to identify $656 per case in "quick hit" savings from reductions in supplies or services. After the formal project ended, the team implemented additional changes identified during the project and reduced the gap between actual costs and Medicare reimbursement to just $300-$400 per case compared to the initial $845 gap for total hip replacements and $2,357 gap for total knee replacements. Savings were accounted for by:

• Decreasing supply costs: The team evaluated all of its supply costs, from IV tubing to surgical supplies, to determine where efficiencies and cost-savings could be achieved without sacrificing patient care. For example, at the outset of the project, IV tubing used in the operating room was replaced once the patient left the surgical recovery room. To decrease costs, the Lean project team identified alternative types of tubing that could be used in both the OR and other inpatient units. The project also led to the substitution of the abduction pillow used by hip replacement surgery patients with an equally effective, but less costly, pillow, thereby saving $32 per patient.
• Decreasing implant costs: The cost of the actual hip or knee replacement implant is a major expense. Working with the Orthopedics Specialty Council, Grand's surgeons agreed to reduce the number of vendors supplying the hospital with these implants. Ultimately, the Lean team reduced the number of vendors, purchased more cost-effective implants, and obtained a higher volume discount, saving 20-30 percent on the overall cost of implants.
• Decreasing other resource costs: Typically, patients received their first physical therapy on the same day as the surgery. Since only 2–5 percent of patients received a significant benefit from this day 1 session, the Lean team piloted a program to replace same day physical therapy with a more intensive therapy session the day after the surgery, which resulted in a savings of $200 per patient.

In addition to these cost savings, the project accomplished other gains by reducing waste:

• Reduced discharge time by 3.5 hours.
• Discontinued blood typing and screening on the day of surgery, since very few patients required blood transfusions.
• Assigned rehabilitation therapists and aides to specific floors to avoid the need for physical therapy staff and tools to travel across the hospital.

Though there were significant reductions in cost and wasted resources as a result of this project, team members indicated that there were no impacts on other outcomes. Of note, interviewees did not mention improved patient satisfaction as a specific result of this project. In addition, some team members felt overshadowed by the role of the physician champion and therefore were not empowered to participate. This finding may indicate that this project did not affect employee satisfaction. In contrast, one mid-level provider team member believed that camaraderie and teamwork improved as a result of the multidisciplinary teams.

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Cardiology Follow-up Appointment Scheduling

Project Goals

The Cardiology Follow-up Appointment Scheduling project was implemented in January–June 2010. The goal of the project was to increase continuity of care for cardiology patients transitioning from inpatient to outpatient care. According to the project champions and team lead, the main objective was to increase the proportion of patients who receive an "accurate" followup appointment on discharge from the inpatient cardiology unit to the outpatient cardiology unit, defined as the followup appointment made within 1-2 days of request, with the right provider, within the time period specified for followup. The goal was to achieve 80 percent accuracy on this measure. This project targeted the approximately 25 percent of patients discharged from the inpatient cardiology department who require followup in the outpatient cardiology department; the remaining 75 percent of cardiology patients discharged are referred to other departments (e.g., internal medicine, cardiothoracic surgery, and transplantation) and were not targeted for this project. As a secondary outcome, the project champion and team lead believed that this project could improve efficiency for physicians, since followup visits can be quicker and more streamlined when physicians are familiar with patients and their care history. A third desired outcome mentioned by interviewees was to increase patient satisfaction as a result of correct itineraries and a followup visit with a familiar provider.

Implementation in the Cardiology Department

This project involved the cardiology inpatient and outpatient departments. The physician champion was the chair of the cardiology department (including both inpatient and outpatient care). Staff involved in and/or affected by the project included physicians, medical residents, advanced registered nurse practitioners (ARNP), and schedulers based in the inpatient and outpatient departments. The same providers tend to see patients in both inpatient and outpatient departments to allow for continuity of care and consistent coverage.

Project Selection

The team initially applied for participation in the second wave of Lean projects (August 2009) and submitted their charter for review. The project was not accepted at that time, but the team revised and resubmitted it for wave three, and it was accepted for a February 2010 start date. One interviewee, a manager in the department, believed that the aims of the charter as originally submitted were too broad, and that the narrower scope in the revised charter submitted for the wave three application process made it a more feasible project. All interviewees from this team agreed that the project goal was to improve patient experience and quality of care by creating better continuity between the cardiology inpatient and outpatient departments.

Project Staffing

As with all projects at Grand, the project leadership included the clinical department chair as the physician champion, the department operations administrator as administrative champion, a coach from the S&P Department, and a team lead (Exhibit 3.16).

The team lead for this project was an advanced registered nurse practitioner (ARNP) because they are responsible for the bulk of the patient care in the inpatient setting. This specific ARNP was selected because she had the most experience working in both the inpatient and outpatient departments. In addition, team members included five nurses from the cardiovascular lab, clinical services, and hospital services; a scheduler; a physical therapist; and a representative from the medical education department. Other staff, such as the surgery scheduler and residents, were brought in on an ad-hoc basis to provide input.

Planning and Implementation

In advance of the training, the project team collected baseline data on the accuracy of the followup appointments, defined as getting an appointment with the right provider within the right timeframe, meaning within 1-2 days of request. The baseline rate for an accurate followup appointment was 41 percent at the start of the project in January 2010, and the initial objective defined by the Lean project team was to increase it to 80 percent by the end of June 2010.

Using this information and the tools from the Lean training to design the project, the team began looking for ways to increase the efficiency of the inpatient cardiology discharge process and the accuracy rate for followup appointments. The specific Lean tools used and associated activities included:

• Voice of the customer interviews with patients and department staff verified hypothesized gaps in service and followup that needed to be addressed as part of the project.
• Swim lane flow chart of the cardiology inpatient discharge process identified process responsibilities by role.
• Seiketsu (standardization): changes were made to the scheduling process and template, and to staffing assignments, including shifting to a single scheduler handling the followup appointments.
• Initially, two rapid tests of change were conducted to see if the changes to the schedule process were effective.
• Using "mistake proofing," it was detected that 75 percent of medical residents' discharge orders contradicted the scheduling guidelines proposed as part of this project.
• A third rapid test of change was completed to correct for issues discovered in the mistake proofing process.
• Quick changeover: To improve the efficiency of the process, the team implemented an instant messaging program between the inpatient and outpatient staff handling discharge and followup scheduling, respectively.
• Using visual management techniques, the team created a cardiology discharge checklist for use on the inpatient floor.

The project team lead reported that the department chair (the physician champion) set broad goals for improving patient experience in the transition from cardiology inpatient to cardiology outpatient care. He was described as being accessible, collaborative, and easy to talk to. The chair was instrumental in selecting the scheduler, a key member of the team who was critical in being able to put in place the new scheduling system from the inpatient side.

The team ran into structural challenges related to scheduling and had to adjust the project plan. There were not enough followup slots in the timeframe needed to meet patient safety requirements, or there were slots available but they were not for the right type of appointment. The team made some small changes to the physician scheduling templates but could not implement all the changes proposed because of a freeze on changes to Grand's IT system. In the meantime, the team found a workaround that allowed certain staff to make changes to the template on an as needed basis.

In addition, the project team changed the scheduling process dramatically, shifting the responsibility from a group of schedulers in the inpatient area to a single scheduler in the outpatient area. To make this change work, the team lead worked with scheduling supervisors to get approval and educated all of the schedulers on the new process. However, when the scheduler responsible for followup appointments is out of the office, the scheduling process is put on hold or reverts back to the inpatient schedulers (the process in place prior to Lean improvements). Therefore, the continuity of the new process hinges upon a single individual and has not been institutionalized. This is partly due to limitations in modifying the scheduling system, given the moratorium on IT system changes.

Monitoring, Control, and Sustainment

During the 100-day project implementation, the team lead and the administrative champion met weekly to discuss project progress. The team lead performed a monthly audit to monitor the followup appointment process by reviewing a subset of charts from the inpatient department. This process was completed by hand, and data were entered into an Excel (Microsoft Corporation, 2003) spreadsheet on a monthly basis by the team lead. Information collected includes whether the followup appointment:

• Was made within 1-2 days of the discharge order request.
• Was scheduled with the right provider.
• Was scheduled for the specified time period.

After the project ended, the team continued to audit charts manually and report findings to the EOT on a quarterly basis. The team lead left the organization a few months after the project ended but transitioned sustainability monitoring responsibilities to another member of the project team.

Project Outcomes

Overall, the Cardiology Follow-up project was regarded as moderately successful by the team members. The project team was able to achieve their goal of 80 percent accuracy in scheduling cardiology followup appointments, doubling the initial 40 percent accuracy rate. The accuracy rate ranged between 72—80 percent as the project moved into the sustainment phase. This progress is impressive in the face of structural challenges. The project team created temporary workarounds to implement their solutions, but they may be able to shift to more permanent solutions as the freeze on changes to the IT systems ends. As new computerized discharge orders can be built and scheduling templates for appointments are revised, the team lead stated that it would be easier to schedule followup visits, since more of those slots would be open rather than being assigned as new patient slots.

Improved communication and teamwork was mentioned as an outcome by several Cardiology Follow-up team members. One team member specifically noted that the Lean process and common language promoted collaboration and communication between team members. Another nurse manager and a frontline staff person indicated that this improved communication was facilitated by the instant messaging system implemented as part of this project.

Several interviewees reported that the project had positive effects on patient satisfaction as expressed by patients in interviews when asked about the discharge process and the transition from the hospital to the clinic. Patient survey results showed an increase in satisfaction with the discharge process in the first quarter after the project, but there was a decrease in the second quarter after the project (the last time period for which data were available at the end of the study). Interviewees did not provide suggestions as to why this decrease may have occurred.

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Outcomes of Lean

In this section, we discuss the outcomes of the Lean initiative at Grand Hospital Center based on interviews with staff and materials provided by the organization. Overall, the center experienced significant gains in efficiency and moderate improvements in employee satisfaction and culture change. Improvements in clinical quality and patient safety were also reported, primarily in conjunction with the Cardiology Follow-up project discussed above.

The discussion of Lean outcomes in this report is organized into two major categories, based on our conceptual framework: intermediate outcomes and ultimate outcomes. As described previously and shown in Exhibit 3.17, intermediate outcomes include culture change, employee satisfaction, change in Lean knowledge and skills, Lean routinization, and dissemination. Ultimate outcomes include impacts on efficiency, patient satisfaction and experience, clinical process and outcomes assessments, and patient safety.

The findings reported here are mainly based on qualitative reports from staff, since they had difficulty identifying specific quantitative data that addressed the effectiveness of Lean for these two projects. We found that managers and frontline staff agreed that Lean activities had contributed to desirable outcomes, but they struggled to attribute specific outcomes to Lean activities. The importance to Grand of directly attributing results to Lean is not clear, but it seems likely that the long-term viability of Lean as a valid approach to reducing waste and improving performance will be limited without data specifically linking Lean implementation to cost savings, QI, or other goals.

"At the end of the day, it doesn't matter to me much that, let's say, there was $2,000 savings, [where] the $1500 came from Lean and $500 came from other areas." —Executive leadership

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Intermediate Outcomes

In our conceptual framework, intermediate outcomes refer to organizational culture, employee satisfaction, increased Lean knowledge and skills, routinization of Lean, and dissemination of Lean, both within the organization and externally. These intermediate outcomes are in turn linked to ultimate outcomes—efficiency, value, and quality—as defined in the conceptual framework and discussed in the next section. Interviewees reported progress in the areas of culture change and employee satisfaction. However, Lean seems to have relatively less impact on increased Lean knowledge and routinization.

"Two years ago... 280 people told me, 'We're already Lean.' Now, the most common comment I get is, 'Oh, my God. I didn't realize we had so much waste. 'That's followed by at completion of the project saying, 'We just scratched the surface.' I think that's been caught up in the culture now, finally—[that] there is waste." —Executive leadership

Organizational Culture Change

Nearly half of the interviewees noted significant changes in organizational culture. Those individuals indicated that Lean has improved teamwork, empowered staff to attempt change, and improved communication and openness.

"I'm getting to know more of the physicians, the residents, the fellows. I enjoy working with them. I feel like I am doing a good deed for them and for the patients." —Frontline staff

Improved teamwork and collaboration among staff. Many interviewees mentioned that the culture at Grand reflects improved teamwork and collaboration. For example, one interviewee specifically noted that connecting frontline, administrative, and clinical staff has been very valuable. Another frontline staff member noted that getting everyone in the same room has fostered communication that will last beyond the Lean project. One Hip & Knee replacement project team member noted that as a result of Lean, the physician champion (and department leader) discussed process improvements with the physical therapist (a frontline staff person).

"I think the other shift is that the CEO is saying, 'It's OK to fail, just try something.' You know, before it was, 'That was bad.' If you try something, and it didn't work, then your credibility was shot. Now he's saying, 'No, it's only a failure if you don't learn from it and try something different.'" —Analyst

Empowering staff to try new ideas. The second major cultural shift included empowering the staff to try out new ideas (using rapid tests of change) and implement appropriate improvements without having to run these ideas through committees or obtain unnecessary approvals. This shift was attributed to the executive leadership's decision to use Lean to engage frontline staff in process change and to dissolve many decisionmaking committees. According to one S&P interviewee, the rapid test of change—the notion that individuals can try something new and move forward with an idea—is the most important outcome of Lean.

Recognition of waste. One S&P analyst and one senior executive noted that Lean is showing staff new forms of waste and allowing them to recognize more waste in the workplace. As noted by the CEO, prior to Lean, many staff believed that they were already "lean" and did not have waste in their processes. With the initiation of Lean, staff are realizing that waste exists in their processes.

Employee Satisfaction

About half of interviewees reported changes in employee satisfaction as a result of Lean implementation. Most of these interviewees attributed increased satisfaction to improved communication and collaboration, as discussed above. In addition, several interviewees also attributed improvements in employee satisfaction to process improvements and efficiency gains. According to senior executives, the nurses' jobs are improving because they have more time for patient care as a result of Lean.

"It's nice to be able to work with people on something that isn't directly related to something you always do. You know, it's nice to be working with anesthesia and to find out what their opinion of the whole thing is and to work, you know, with the actual surgical techs, you know, find out what their opinion is of the whole thing." —Physician assistant

Only one interviewee suggested that employee satisfaction may be decreasing. Specifically, one department leader noted that Lean may be having negative impacts on staff satisfaction, particularly for physicians. She noted that the increased responsibility placed on physicians, paired with the current staffing issues, may be causing some dissatisfaction.

Lean Knowledge and Skills

Through three waves of training, over 60 staff in 18 teams participated in Lean. Waves were completed in April–August 2009, August–December 2009, and February–March 2010. Although a number of tools, concepts, and techniques were introduced to the staff through Lean training, only a few interviewees mentioned increased knowledge or skills as an outcome. The CEO and department leaders noted that certain Lean tools—particularly white boards which display metrics being measured—were being used in several departments.

Many interviewees, including department leaders and frontline staff, reported liking the Lean training and finding the sessions valuable. Some individuals found the training sessions valuable because they were able to collaborate with staff from other departments or disciplines, while other interviewees enjoyed learning about specific Lean skills and tools.

Lean Routinization

A few individuals, namely department leaders and a senior executive, indicated that Lean was becoming a problem-solving method for staff. These individuals felt that Lean provided a structure and a mentality to address multiple types of problems.

Critical to routinization of Lean at Grand Hospital Center is the shift for frontline and departmental staff to learn data collection and analysis skills to measure and monitor their Lean projects. Though S&P staff usually support this analysis at the center, they reported it was difficult for them to pull back from their normal role to allow staff to learn the skills necessary to own the project.

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Ultimate Outcomes

Information is available for three of the ultimate outcomes: efficiency, value (business case), and, within quality, patient experiences of care. Based on interviewee reports, Grand Hospital Center has realized significant cost savings as a result of Lean, and patient experiences and quality of care have improved.

Efficiency

Interviewees had quite a bit to say about improvements in efficiency. Overall, nearly all staff at all levels, from senior management to frontline staff, reported improvements in efficiency as a result of Lean.

Organizational Level

A few executives at Grand reported that Lean may have helped the organization overcome their $38M loss in 2008 and achieve a $48M gain in 2009, although they could not attribute the savings directly to Lean. There are many other factors that may have led to this financial turnaround, including making expense management a high priority; reducing administrative costs and filling only essential new and vacant positions; placing constraints on capital spending and streamlining of business processes to improve efficiency, including improved patient access; and restructuring of employee pension and postretirement plans.

Project Level

The following impacts on efficiency were linked directly with specific Lean projects. Although several of these impacts were discussed earlier, we are repeating them here to highlight the totality of impacts on this area.

Hip and Knee Replacement Costs:

• On the Hip and Knee Replacement Costs project, rehabilitation therapists and aids were assigned by floor to avoid having staff and tools traveling across the hospital.
• The team discontinued blood typing and screening on the day of surgery, since very few patients required blood transfusions, resulting in time saved.
• Cost savings for the Hip and Knee Replacement Costs project averaged $656 per case and reduced the gap between actual costs and Medicare reimbursement to just $300-$400 per case. Savings were achieved by decreasing supply costs, implant costs, and resource costs.

Cardiology Follow-up Appointment Scheduling:

• On the Cardiology Follow-up Appointment Scheduling project, the team streamlined the process by consolidating the scheduling activity to a single scheduler, which increased accuracy of followup appointment scheduling from 40 to 80 percent.

Other Lean projects:

• In the clinic laboratory area, the Lean project team reduced patient wait times by increasing use of early morning appointment times.
• The transplant team reduced their time to evaluate a kidney transplant from 60-70 days to 9 days.
• Adjustments made to the lab process increased capacity to see patients by 50 percent and did so with fewer staff. This change allowed one physician to leave the lab and see more patients, while eliminating the need for an additional staff member (a secretary) that had been requested.
• The neurology lab project reengineered their processes and withdrew their prior request for additional space and staff.
• An executive team member reported that Grand reduced its allocated expenses by $5-7M by doing Lean process reengineering in the financial/administrative area of the organization.
• In the orthopedics department, the team reduced discharge time by 3.5 hours, a change that may ultimately reduce the charge to the patient because the patient is released before incurring charges for an extra day's stay.

Patient Experience

Improved patient experience and satisfaction is one of the key outcomes that Grand seeks to achieve with any Lean project. Several interviewees across all levels of the organization referred to a variety of Lean projects that were expected to result in better patient experiences, some of which were confirmed through patient surveys and other data. Most of the information regarding improvements in patient experience comes from the Cardiology Follow-up project. Specifically, interviewees noted:

• An increase in the proportion of patients receiving an accurate followup appointment prior to discharge from the hospital.
• Patients' accounts of being satisfied with the discharge process and the transition from the hospital to the outpatient clinic as reflected in patient interviews.
• Mixed results in terms of scores for patient satisfaction with discharge as reflected in patient surveys, which increased in the first quarter after the cardiology project but decreased in the second quarter.

Further, senior executives described how Lean was affecting patient experience and satisfaction in other areas of the hospital where Lean was implemented. They specifically pointed to improved satisfaction due to decreased patient wait times in the laboratory area achieved by reducing overbooking and establishing earlier time slots for appointments; they also noted increased patient satisfaction scores in the context of a hospital department that had achieved reduced pain scores.

Clinical Process/Outcomes Assessment and Patient Safety

Overall, about one-half of interviewees reported improvements in clinical process and patient safety as a result of Lean implementation. As with patient experience outcomes, these impacts are mostly linked to specific Lean projects; nearly all of the interviewees from the Cardiology Follow-up project noted an improvement in clinical process attributed to the increase in patients being discharged with a followup appointment. As the team lead noted, continuity of care through followup appointments is critical in ensuring patients receive the followup care they need. Thus, the improvement in scheduling of followup visits enhanced clinical process and safety in addition to enhancing the patient experience of care, as noted previously.

The CEO also described another Lean project where clinical guidelines and patient safety guidelines were integrated into a process for rounding (i.e., visiting the patient's room) developed as a result of a Lean project. This process ensured that a staff person visited each patient at least once every hour to check on the patient's pain scores, the cleanliness and safety of the room, and the position of the patient. The CEO reported patient safety improvements as a result of this process and also noted that phone calls from patients to nurses decreased as a result of this new process.

Business or Strategic Case

At Grand, outcomes were often expressed in terms of their effect on the value equation, where value equals quality (e.g., clinical outcomes, patient safety, and patient satisfaction) divided by cost. Favorably affecting one if not both elements of the equation will result in added value that is not exclusively financial. The CEO and an S&P staff member noted that immediate financial paybacks might not occur, but benefits are achieved through improved patient safety, quality of care, and patient satisfaction. In one Lean project, hourly checks on all patients led to a reduction in patient calls to the nursing station and improvement in pain control. This change is an example of how replacing unplanned and reactive effort with planned and scheduled effort can improve the value proposition. Planned and scheduled effort is likely to be less expensive than unplanned sporadic effort, but even if it is not, the resulting benefits to patient experience and pain control offer the potential for enhanced benefits.

"A Lean project doesn't necessarily [save] you bottom line dollars. It could be safety or patient satisfaction [outcomes], which is not a true cost savings. We have to look at the value equation."   —Consultant

Senior and department level staff were asked about the business case for Lean. While nearly all interviewees recognized the resources required for Lean implementation, specifically in terms of staff time, nine interviewees—ranging from S&P Analysts, to department leads, to executive staff—indicated that there was a positive business case for Lean, while two indicated uncertainty. All but one interviewee attributed the business case to positive financial gains at both the project level and the organizational level. Further, these interviewees believed that a decrease in waste and improvements in productivity contributed to Lean's business case. Only one interviewee mentioned that the reduction of work silos and the increase in ownership were the primary factors in the business case for Lean.

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Factors that Influenced Success of Lean Implementation

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 at Grand Hospital Center. Findings regarding facilitators and barriers are based on responses to these questions and on interpretation of findings overall by the research team (Exhibit 3.18). As expected, barriers to implementation were identified much more often than facilitators. Further, senior executives and department leaders provided the greatest amount of information regarding these issues.

Here, we discuss the factors mentioned by interviewees, noting how they operated as facilitators and/or barriers in organizing and implementing the Lean initiative. We also link lessons learned to these facilitators and barriers.

Using the elements of the conceptual framework, facilitators related to the Lean initiative including, leadership, staff engagement, Lean team composition and size, and alignment of Lean to the organization, were the most frequently mentioned. The major barriers to implementation mentioned by staff related to staff engagement, resources, and communication about Lean. It appears that factors related to the external environment, the applicability and locus of Lean activity, and the scope, pace, and coordination of Lean were not significant either as barriers or facilitators. Lessons learned addressed staff engagement most often. We have organized this section by first providing a summary table of Major Factors that Facilitate Lean success (Exhibit 3.19), followed by Major Factors That Inhibit Lean Success (Exhibit 3.20).

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Organizing the Lean Initiative

In this section, we discuss barriers, facilitators, and lessons learned related to organizing the Lean initiative. The most important facilitators and barriers to organization of the Lean initiative, as discussed by interviewees, were related to alignment of Lean to the organization. Notably, there were very few statements related to the applicability of Lean to health care processes.

Alignment of the Initiative to the Organization

Interviewees from the S&P Department and the Quality Improvement Department noted the importance of integrating Lean into the organization from a strategic perspective. As noted previously, Grand integrated Lean into their strategic plan, a key facilitator according to senior executives and department leadership.

Interviewees also indicated that the center's culture is supportive of QI and is committed to improving patient care, and they surmised that Lean implementation was smoother as a result. The center's staff tend to be interested in professional development, seek to improve their departments through QI, and look for opportunities to improve patient care, all of which are consistent with the tenets of Lean. As part of the Lean initiative, Grand now encourages QI/Lean certification (bronze, silver, gold) and has removed several layers of decisionmaking bureaucracy to allow staff to implement the Lean rapid tests of change.

Executives mentioned the challenge of aligning the goals of Lean with the goals of Grand, as well as with the enterprise overall. These barriers were not noted by other types of staff.

"The challenge that we're finding is that our team members, all of them, are clinical staff that have clinical responsibilities every day, all day. So breaking them out of that to go to the meetings and then participate in the training, there's a lot of stuff that goes on outside of the formal training. So that has been—that's an ongoing challenge for us." —Department manager

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Implementing the Lean Initiative

Major facilitators and barriers to implementing Lean were related to leadership qualities and activities, level of staff engagement, communication about Lean, resource availability, and Lean team composition and size.

Leadership Activities and Qualities

Strong leadership at certain levels was generally regarded as the most important factor to the implementation of Lean and to the success and sustainability of changes from Lean projects. This leadership manifested itself in several ways, as described by interviewees.

As noted previously, Grand's Lean initiative was driven and heavily influenced by senior leadership. The external consultant and senior executives noted that Lean must start with leadership, and in the case of Grand, it began at the highest levels. These individuals viewed this as a facilitator to Lean implementation. Further, frontline interviewees and S&P staff interviewees also indicated that leadership involvement in Lean from the very beginning was helping to sustain the initiative. Senior executives were involved in the first Lean project. Regarding senior level leadership, the visibility of the CEO as a supporter of Lean facilitated not only the initiation of Lean at Grand, but also promoted accountability to Lean. Importantly, the CEO meets with every Lean team to discuss the progress and outcomes of the project.

Leadership at the Lean project level was also cited as a facilitator to success. Across the board, interviewees of all levels believed that Grand employs "infectious" leaders committed to the projects. The critical nature of the senior leadership's support is noted above, but these interviewees also believed that departmental leaders and processes owners also play a key role. These leaders are approachable, encouraging, and attempt to mitigate barriers to implementing Lean. Further, they show their commitment to the Lean project by motivating others to sustain changes or by putting in extra time to complete Lean activities, such as data collection. Finally, they often are the individuals who foster accountability to changes from the Lean projects. In one project, the enthusiasm and dominance of the department leader thwarted the participation of other staff and limited their role in the Lean project.

Availability of Resources

Barriers related to the availability of some form of resources were mentioned by nearly all interviewees. Nearly one-half of interviewees across all levels of staff mentioned that it was a challenge to get release time for staff to be able to do the work on the project. Although Grand ultimately supports staff's time during their participation in Lean, many interviewees noted that competing responsibilities and priorities leave individuals, mostly clinical staff, unable to participate. In general, interviewees noted that staff have little capacity for additional Lean project work.

A special resource barrier mentioned by several interviewees is the availability of IT resources. IT was a challenge because IT resources were being focused on a system upgrade and could not be allotted to making updates for Lean projects. The moratorium on IT-related solutions held up one project we studied and also meant that all projects that might have an IT component had to be put on hold. This barrier was mentioned most frequently by team members from the Cardiology Follow-up project and as the most significant barrier by the team leader.

A third barrier mentioned by several interviewees at all levels was access to data, data collection, and data analysis. While Grand employs a strong S&P Department, much of the data collection and analysis from Lean projects are completed by the Lean project team. A few interviewees expressed some frustration that data collection is time consuming and, if done manually, can introduce human error. Further, some frontline staff may not possess even rudimentary data analysis skills to support Lean projects.

Another resource that is critical to Lean is expertise or knowledge. Several interviewees, including nurse managers and department leaders felt strongly that training is needed prior to participation on Lean projects. These interviewees had mixed reactions on whether or not the training model used by Grand fulfilled this need: two interviewees felt that the training was excellent and gave everyone a foundation for the implementation, while another individual believed that more training on the specific Lean tools was needed. Related to Lean expertise, several interviewees, mostly senior executives and department leadership, indicated that external (i.e., external consultant) or internal (i.e., S&P staff) expertise in Lean is a key facilitator to implementation. A few interviewees noted that beginning Lean implementation with an external consultant was critical, as he fostered a sense of accountability and really helped launch Lean at the organization.

"Lean won't be sustained without a leadership team actively engaged... you can start it and do it, and experience some success with disengaged senior leaders, [but] it simply won't be sustained." —Consultant "It's hard to communicate because people are busy, they don't want to read their email. It's hard to get meetings pull together. So communication is another challenge." —Physician

Staff resources may play another role in sustaining Lean: staff turnover may make it difficult to sustain Lean changes. This aspect was noted by a few members of the Cardiology Follow-up project, including one of the sponsors, with regard to the departure of the team lead.

Communication about Lean

The quality and content of communication about Lean have had a role in the nature of the implementation of the initiative. Interviewees from Grand primarily discussed issues related to communication about Lean activities and changes resulting from these activities with staff members who were not involved in the projects. Several interviewees noted specific struggles in communicating about the removal of the hip abduction pillow as part of hip replacement surgeries. This change met resistance from the nursing staff who did not receive or absorb the communication about why these pillows were no longer needed. Although interviewees participating in the Cardiology Follow-up Appointment project also described challenges communicating about Lean to staff who had not been part of a formal project, the champion and team lead felt that encouragement of staff and emails about how changes were now part of the standard of care were sufficient in overcoming any barriers.

"[Grand] is a physician-led organization. And so if you want to be successful on any project, you need to have a physician champion or you're not going to be successful." —Department manager

Staff Engagement

Staff engagement is highly influenced by leadership and communication about the vision and goals for Lean. In addition, Lean as an approach facilitates, or more accurately requires, full staff engagement. Physicians are a particularly important constituency for Lean, given the influence they wield over both their peers and their clinical teams. Several interviewees who participated in the Cardiology Follow-up project emphasized the important role of the physician leader of their department and the clinical champion for the project, noting that he was highly engaged and very passionate about improving processes through Lean. However, not all physicians are as highly motivated to implement Lean. Physician schedules and opportunity costs might not support participating in Lean training and meetings, and several interviewees noted that a physician with a strong personality may overshadow other team members.

Physicians at Grand are salaried staff employees. The exclusive relationship between the center and its physicians may result in more effective adoption and implementation of Lean, compared to the use of more loosely coupled, independent contractors and privileged physicians who might have relationships with multiple hospitals and not be paid by the hospital. The external consultant noted that physician-led organizations are the most responsive towards Lean changes because physicians are so "highly influenced by their peers." Notably, physicians and department managers rarely mentioned the fact that the organization was physician-led or even the strong leadership in the organization as a facilitator, while this was mentioned by all others quite frequently.

Lean Team Composition and Size

Nearly half of interviewees, across all levels and types of staff, indicated that the multidisciplinary teams from all organizational levels are important facilitators for Lean projects. According to a department manager, this team composition makes for a good representation "of what goes on both on the inpatient and outpatient side," and therefore everyone potentially involved in the change is participating from the start. The executive and physician assistant both state in their own words that this type of team composition improves communication and commitment to Lean.

In addition, several interviewees noted the importance of a physician champion for each Lean project. Champions of Lean are important if any Lean project is to have a chance at being successful. As noted above, Grand staff believe that for the project to be a success, one of these champions should be a physician.

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Conclusions

Grand's approach to implementing Lean involves training senior management on the concepts and tools a priori and training frontline staff through projects paired with formal training. The CEO views Lean as a tool for culture change, empowering frontline staff to implement new solutions. Many frontline staff equate Lean solely as a tool to reduce waste in the organization. Though staff may not necessarily view Lean only as a tool and not as a mechanism for culture change, this view does not seem to be impeding staff buy-in to the Lean initiative. Overall, the staff at Grand Hospital Center seem to be concerned with their ability to collect data and positively affect the value equation. These abilities are complicated by IT issues at the organization and by lack of staff time. Recommendations suggested here emphasize the clinic's strengths and also address barriers faced.

Recommendations for Similar Organizations Implementing Lean

• Provide opportunities for staff to get involved with Lean. Allowing more staff to be involved in Lean trainings or projects will improve the dissemination of Lean knowledge and skills, and will help to accelerate culture change.
• Align incentives to encourage additional participation.Staff engagement can be a challenge. A traditionally participatory culture may encourage involvement in Lean and QI, but rewards and incentives are also needed.
• Staff learn Lean skills on their own, but they keep other priorities in perspective.Grand made a conscious decision to not let S&P staff take over staff's participation in Lean. However, there is fine line between overwhelming staff with skills in data collection and analysis as opposed to ensuring they have the basic skills needed to participate.
• Explore ways to improve communication of changes after the Lean project.Communication can be improved by finding alternate mechanisms to email and by translating results into metrics and language that will resonate with employees. For example, talking about the impact on patient satisfaction or safety might be more compelling than communicating about gains to efficiency alone.
• Leverage successes for replication. Successes achieved in both the Hip and Knee Replacement and Cardiology Follow-up projects could be replicated in similar departments of the system or other entities. Maximizing the benefits of Lean by translating key successes and minimizing the high labor costs of a Lean event may result in improved value return.
• Recognize that IT can both facilitate and hinder Lean projects.In theory, IT could assist with Lean projects by facilitating data collection and providing more efficient solutions. However, for the Cardiology Follow-up project, IT was a huge barrier. Grand Hospital Center and other organizations should try to overcome these issues and leverage IT as a facilitator to Lean.
• The executive team should be highly engaged when implementing Lean. Grand's executive team was deeply involved in learning about Lean concepts and selecting the initial Lean projects. This approach fostered support from the very top levels of the organization.
• Embed Lean in the organization's strategic plan. Aligning Lean with the strategic plan will ensure that staff understand the importance of Lean to the organization and that it is not just another "flavor of the month."
• Acquire appropriate internal or external expertise. Grand opted for an external consultant to facilitate the implementation of Lean. The major advantages of hiring an external consultant were accountability and additional Lean expertise.
• Develop a strategy for physician engagement. The Grand Hospital Center case shows that physician engagement is difficult, even when physicians are salaried or employed by the organization. A strategy that uses physician champions is necessary for Lean success.
• Collect data in order to show improvements.The ability to show results from Lean projects will foster engagement and excitement from Lean team participants.
• Be prepared for significant investment of staff resources. As noted by academic medical center staff, many of the Lean project activities were completed during "off hours." Time during the regular workday must be carved out for staff participation and followup on Lean projects.

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^s. A spaghetti map is a Lean tool that shows the flow of people or information through systems.

^t. Changeover in the OR refers to a reduction in the time between procedures, or the time required to prepare an operating room for the next patient.

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