Improving Care Delivery Through Lean: Implementation Case Studies

Organizational Background 

Suntown Hospital, a critical access hospital (CAH), is located in a rural community in a Western State. It has a total of 45 acute and long-term care beds and an outpatient clinic. Two projects, Urinary Tract Infection Prevention (UTI Prevention) and Redesigning the Process for Electronic Prescribing (E‑Prescribe), were selected for prospective study from this organization. The case study methods, including selection criteria for projects to be analyzed, have been described previously in this report. For this case, we conducted 28 interviews with 13 individuals. Their roles and positions at Suntown Hospital varied, as described in Exhibit 4.1.

Description of the Health Care Organization 

Suntown Hospital is part of a public hospital district. It comprises three distinct units that provide nonspecialty care: long-term care, outpatient services, and acute care inpatient services. In addition, it offers primary care at a medical clinic, emergency services, diagnostic lab and radiology, and therapeutic services (physical therapy, massage therapy, dietary counseling, speech therapy, and telehealth). It is the primary source of health care for the entire surrounding community (Exhibit 4.2).

Definition of Public Hospitals Public hospitals in this state were defined as "community created governmental entities authorized by State law to deliver any services which might be reasonably expected to improve the health of the district's residents and others in the district's market areas."

Suntown Hospital can be categorized as both a public hospital and a CAH. As a public hospital, it is subject to the Public Records Act and the Open Public Meetings Act, which require the hospital to make meetings, documents, and presentations transparent and open to the public. Many interviewees commented that this context defines the culture at Suntown Hospital, as there is a level of transparency to foster public trust. Further, Suntown Hospital receives a regular maintenance and operating levy from the community. Suntown collects approximately $70,000 per year from this levy. Additional funds are voted on through community ballots. However, in 2008, personnel issues and delays in accounts receivable affected taxpayer trust, and new funds were not approved. Accordingly, increasing public trust was a major organizational goal for the hospital in 2009. Management leaders and employees universally participated in a voluntary furlough and in wage reduction in order to achieve a balanced budget. That same year, Suntown Hospital filled the chief medical officer (CMO) position, which had been vacant for 2 years.

Definition of a Critical Access Hospital Critical access hospitals are defined by the American Hospital Association as "rural community hospitals that receive cost-based reimbursement (American Hospital Association, 2011)."

As a county hospital, Suntown is governed by five publicly elected commissioners who have authority over the district. This Governing Board of Commissioners appoints the CEO, assures compliance with national regulations, and monitors performance. 

Suntown Hospital has 25 swing beds, which can be used as needed to furnish acute or skilled nursing facility-level (SNF-level) care. It has an additional 20 long-term care (LTC) beds. In an average month, Suntown sees approximately 30–50 patients through the emergency room and has a nursing home census of between 4 and 14 patients. There are relatively few inpatient stays, about 1–5 patients per month. Suntown Hospital has approximately 110 employees and four medical providers who serve the needs of all patients: one physician who is the medical director (full time), two nurse practitioners, and one physician assistant (PA). According to some interviewees, the organization is largely nurse-driven. Suntown also experiences a relatively high employee turnover rate, averaging about 30 percent per year. Further, it has faced challenges in hiring new staff, evidenced by the CMO position remaining vacant for nearly 2 years. Exhibit 4.3 shows descriptive characteristics of this organization based on the case-selection criteria.

The governing board and hospital leadership establish the strategic plan for the organization. Suntown adopted a strategy map in 2003, the same year Lean implementation began. Suntown's key strategic objectives are culture change, public education, and clinical outcomes. These objectives are built upon core values of the organization: caring, quality, loyalty, safety, and family.

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Other Environmental Context

Local Competition

According to interviewees, the hospital operates in a fairly competitive market, competing with several neighboring hospitals; however, it is over 30 miles from the nearest competing facility. Interviewees noted that long-term care services are extremely competitive, as patients have many choices for this type of service in the surrounding areas. Interviewees noted that Suntown's commitment to quality improvement (QI) is believed by interviewees to give them the competitive edge over other hospitals and long-term care facilities that struggle with QI initiatives, such as Six Sigma. The CEO noted that the waste reduction from Lean reduces time spent across all business processes and reduces costs, giving the hospital the ability to do things for customers that competitors cannot afford.

Funding and Payers

Similar to other public hospitals, the vast majority of income is derived from patient services, in addition to levies and funding from the community. Approximately half of the total revenue comes from outpatient services. Medicare and Medicaid are major sources of revenue with Medicare, accounting for 98 percent of the acute-care payer mix and 44 percent of the outpatient mix in 2010. Medicaid accounts for about 70 percent of long-term care revenue.

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Lean and Quality Improvement at the Organization 

In this section, we discuss the history of Lean and QI at Suntown Hospital. Exhibit 4.4 outlines the overall timeline for Lean initiatives at the hospital. The specific activities noted in the timeline are discussed throughout this report.

History of Quality and Efficiency Improvement Efforts at the Organization

According to one senior executive, the hospital has a long history of participation in QI activities. However, nearly all interviewees who worked there before Lean noted that its QI efforts before Lean had been largely informal and unstructured. These interviewees also described Suntown's previous QI activities as having been "disorganized," "reactive," and "ineffective." Coordination of QI across activities had been very loose, and QI had been instituted as a result of an issue or problem. With the hiring of a new CEO in 2000, Suntown began a more formalized implementation of QI.

The hospital is governed by an elected Board of Commissioners and a CEO. The quality team reports to the CEO but has no leader. Its members include system leaders, performance leaders, and process leaders, who are all regarded as equal members. The quality team supports the mission of the county hospital district by overseeing quality assurance and improvement processes for the system on behalf of the Board of Commissioners. The quality team is responsible for enhancing quality across the system, focusing on clinical processes and the service experience. The quality team includes senior staff and frontline staff, as well as members of the board. This team meets weekly, and meetings are open to all staff regardless of whether they are official members of the team. The Board of Commissioners plays a large role in QI. As noted by the CEO, the board is extremely interested in participating in the quality team and is "pushing the organization" to improve quality.

Concurrent to Lean implementation, Suntown participated in a series of initiatives and collaboratives to improve clinical quality for the care of various conditions, including diabetes, congestive heart failure, and myocardial infarction. The hospital also participated in the Institute for Healthcare Improvement's (IHI's) 5 Million Lives Campaign,^u which deployed rapid-response teams at the first sign of patient decline, and medication-reconciliation and patient-safety activities.

The hospital also has some experience collecting and reporting metrics related to hospital performance. For example, it currently has an organizational scorecard that mostly consists of utilization data. In 2007, it deployed three surveys to assess patient experiences and satisfaction: one with inpatients using the CAHPS^® Hospital Survey,^v one in the long-term care unit and one with outpatients. The CEO noted that Suntown does not invest funds in continuously assessing patient experiences because the feedback from the initial assessment was positive.

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Initiation of Lean at the Organization

As noted above, in 2003 the newly hired CEO sought to formalize the vision for and implementation of QI processes. The CEO reviewed many different QI tools and processes available through State collaboratives and QI resources. After this review, the CEO determined that the Lean tools were the most applicable and valid compared to other QI tools and methods. The CEO noted that Lean is "where the rubber meets the road" and that it provides a mechanism for realizing organizational goals while gathering information through process measures. The inception of Lean marked the first organized approach to QI in Suntown's history. The first Lean project kicked off in 2003 with a rapid cycle event (RCE) looking at the current physical layout and design of the hospital and clinic.

"Before, I think everything was done in-house. We saw an issue, we took care of it and we reported. But we really didn't have a structured process, so we got Lean." —Department lead

When Suntown began working on Lean in 2003, it employed the services of outside consultants. These consultants trained 12 senior leaders and management staff in Lean principles. However, use of consultants was discontinued the following year and all Lean activities were internalized.

Conceptualization of Lean

The formal plan for QI at Suntown encompasses three levels: the system level, the process level, and the performance level. Quality at the system level is defined by the Baldridge criteria, an integrated framework for managing an organization that helps organizations assess their improvement efforts, diagnose their overall performance management systems, and identify their strengths and opportunities for improvement.^w The process level is organized using the Planned Care Model, which includes six fundamental areas (self-management, decision support, delivery system design, clinical information system, organization of health care, and community) on which organizations should focus to provide high-quality chronic disease care.^x Suntown has extended this chronic care model to its entire system of care. Lean is the primary approach to QI at the organization.

Lean methodology at Suntown is modeled after Lean in the industrial engineering sector. It is characterized by "learning by doing" in levels across the organization. The CEO at the hospital notes that their approach to Lean has been similar to that of Toyota and Boeing, and, in health care, to Virginia Mason Medical Center in Seattle.

"It's not by accepting the status quo, but by constantly saying, "OK, why are we doing it this way? What can we do different? What can we do better in living that out in what we do every day?" —Senior executive

Lean at Suntown is nearly synonymous with RCE. RCE is based on the Lean Processing Framework, which identifies and eliminates waste from processes. Suntown primarily uses RCE as the formal approach to improving processes throughout the organization. In each RCE, it uses a specific set of Lean tools. According to one senior executive, Suntown intentionally uses only specific Lean tools to fit the needs of its organization. These tools are discussed in the next section, Process for Implementing Lean. 

According to one senior executive, Lean and RCEs are "flat" in that everyone's ideas and voices are heard equally. He sees this characteristic of Lean and RCEs to be similar to the organization of the quality team at Suntown. One department leader also noted that all participants in Lean projects have a voice and can provide input into solutions.

Goals for Lean 

The goals for Lean at Suntown are to reduce waste, change organizational culture, improve quality of care, and improve patient safety (Exhibit 4.5). These goals were discussed both in terms of organizational goals and project-specific goals. A number of interviewees, mostly providers and frontline nurses, described the goals of Lean only in terms of the specific Lean projects in which they participated. These project-specific goals are discussed in the Lean Projects Studied section of this report. Each of the organizational goals of Lean noted by interviewees is discussed in more detail below.

Improve organizational culture. Only a few interviewees described the organizational goals for Lean in terms of culture change. One senior executive noted that Lean has brought a change in thinking; staff have stopped saying "we can't" and started looking for ways to improve. This senior executive also noted that Lean focuses on key values of the organization and, therefore, is a primary means to change culture. However, most staff do not recognize Lean as a cultural-change mechanism; instead, they associate Lean with improving specific care processes or with specific RCEs.

Reduce waste and improve quality of care and/or patient safety. Several interviewees across all levels of staff noted that the improvement of processes through Lean leads to reduction of waste and/or improvement in the quality of care provided to patients. While some interviewees tied these goals to specific projects, others—mostly departmental leaders or providers—indicated that Lean reduces waste and improves quality at the organizational level. These individuals noted that because Lean focuses on every step of the process, individuals can improve the process by making it more efficient and patient-centered.

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Process for Implementing Lean 

This section describes key aspects related to Lean implementation, including training in Lean, the process for selecting Lean projects, the process of Lean implementation at the project level (including how the project and team are structured), and aspects related to monitoring and sustainment of project results (Exhibit 4.6).

Planning for Implementation of Lean

Lean is viewed as an organization-wide initiative. This initiative began with the leadership studying the whole organization, identifying the value streams, and selecting facilitators. Topics for Lean projects can be proposed by anyone. For example, the ePrescribe project that is described later in this report was initiated by a physician's assistant. The CEO and quality team determine the projects to be undertaken. In terms of criteria for selection, projects should align with the organization's strategic objectives. The number of projects to be undertaken in a year is determined by the CEO and is generally limited to four, in consideration of staff capacity. The CEO selects the facilitator for each Lean project.

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Lean Project Selection Process

Lean projects are proposed by hospital staff, including the CEO, providers, nurse managers, and frontline personnel. However, two interviewees—including the CEO—noted that frontline staff do not often suggest ideas for Lean projects, suggesting that most come from senior staff. The quality team, which includes clinical and nonclinical staff from all levels of the organization, selects the projects from among those proposed. After being selected and approved by the quality team, each Lean project, or RCE, needs a charter; the staff member who proposed the project often undertakes this step. Lean projects generally align with one or more of the three organizational strategic objectives—culture change, community education, and improved clinical outcomes.

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Lean Training

Project Team Training

Suntown Hospital offers voluntary and interactive training modules to all staff. One example is the quality module, which contains the following information:

• Overview of the Baldridge criteria.
• Discussion of quality processes unique to the hospital, specifically the three levels (system, process, performance).
• Discussion of the principles of Lean.
• Description of value stream.
• Discussion of outcome and process measures.
• Example/exercise in Lean.  

The entire quality training module is about 5 hours long, with 4 of the hours focusing on Lean. Though this training is optional, over half of the staff have completed this module, including most interviewees who participated in a Lean project. According to the CEO, the purpose of this module is to give staff a foundation on Lean for participating in Lean projects or assisting co-workers with Lean projects. (Exhibit 4.7)

Other Training 

When Lean was first introduced to the organization, a consulting organization trained senior-level staff and managers on Lean principles. This group also attended an outside Lean training event, where the Lean process was further expanded, and they visited another health care facility to see the Lean process. However, only two staff who participated in those early training sessions are still with Suntown Hospital. (Exhibit 4.8)

Process for Lean Projects

All Lean projects at the hospital follow a similar process and generally revolve around an RCE. Most of the preparation and baseline assessment is included in the RCE, and little preparatory work is done prior to the RCE. Before the event, one person, usually the CEO, sends an email to the team (typically 8–10 people) describing the goal of the project. 

Suntown developed a 10-step process to implement the RCE. These steps, described in Exhibit 4.9, provide a structured process for all Lean teams to follow. After the RCE, Lean teams follow an action plan generated during the RCE.

For issues and processes that are smaller in scope, involve only one department or unit, and are more focused, Suntown Hospital Center created a secondary process called the "quick" Plan-Do-Study-Act (PDSA). The quick PDSA follows Lean principles but is at the discretion of the department manager and usually lasts only a few hours. The quick PDSA involves a shorter process, including identification of the problem, a simple root-cause analysis (i.e., asking "why" five times to get to the root of the issue), generating/selecting a solution to the problem, implementing the solution, studying what happened, and finally, determining what to do next.

Project Organizational Structure and Roles

Staff from all levels are involved in Lean projects at Suntown. A facilitator, often the CEO or senior-level staff or manager, leads each RCE. The facilitator does not receive formal training but is often coached by a more experienced facilitator during an actual RCE.

A process owner is also involved with each Lean project. This individual is responsible for coordinating the followup activities and action plan following the RCE and reporting on progress to the quality team. This individual may also provide communication or in-service training related to the changes made during the Lean process. For larger projects with multiple processes, there may be co-process owners. 

The composition of the Lean team varies, depending on the scope of the project (typically 8–10 members). Team members are staff members with knowledge of the target processes and those impacted by the processes. These team members may include senior-level staff, providers, nurse managers, nurses, or other clinic support staff (e.g., housekeeping). Exhibit 4.10 illustrates the relationship between Lean project roles and typical job roles. Additionally, because Suntown is a public hospital in a small county, Lean teams also frequently include community members. While Suntown does encourage the participation of individuals from all levels of the organization in Lean events, many of the same staff tend to participate in multiple events. Further, these individuals are more often senior leaders and nurse managers, rather than true frontline staff.

Monitoring, Control and Sustainment

At Suntown, the monitoring phase occurs once all Lean changes are made. The process owner, usually with support from the CEO, monitors the project after the action plan items are implemented. Often, after the Lean project ends, the process owner "re-walks" the processes to determine whether and where improvements have been made. These re-walks should occur 30, 60, and 90 days after the project ends; however, these activities do not always take place because of time and resource constraints. Process data are also collected during this period, and at a minimum, staff report on the Lean project at the weekly quality team meetings.

The hospital does not have a strong focus on collecting data; therefore, monitoring activities are often implemented inconsistently. The CEO noted that data collection has always been a struggle for the organization, mostly because data are collected manually and staff resources are limited.

The sustainment phase is often intertwined with the monitoring phase of each RCE. During these phases, processes are re-examined, and compliance with changes related to the Lean project is monitored. Process data or other data related to the Lean project might be collected.

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Dissemination and Spread of Findings

Spread Across the Organization

Thus far, Suntown has engaged in approximately four to six Lean projects per year, including administrative processes, such as central supply and billing, and clinical processes, such as the reduction of UTIs across all three of the hospital's units. According to the CEO, approximately one-third to one-half of the organization's staff have been involved in Lean projects. The only interviewee who reported having a complete understanding of all current and completed Lean projects since inception was the CEO. Interviewees reported that the quick PDSA has been adopted by many staff and, according to one interviewee, is very popular with nurses and in the long-term care unit.

Dissemination of Findings to Others in the Organization 

Suntown has several methods to share outcomes and findings from Lean projects with staff across the organization and with the Board of Commissioners. These methods are shown in Exhibit 4.11.

Despite these dissemination methods, several interviewees, including those who were part of the Lean teams, indicated that they did not know about the results of the Lean projects. For example, many of the interviewees were unsure of the UTI rates and whether Lean had improved these rates. One interviewee, who was a process owner for Lean projects not part of the scope of this project, noted that she did not take ownership of reporting outcomes to the staff because of other competing priorities.

External Dissemination

The CEO noted that he informally discusses Lean with other hospital and health care administrators. He stated that because he believes so strongly in Lean, and because other organizations have a less formal approach to QI, he "talks up Lean a lot." The CEO makes formal presentations about Lean at rural hospital committee meetings or rural hospital retreats. He is also asked to present at other conferences and to local hospitals.

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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 4, the two projects studied were urinary tract infection (UTI) prevention and reduction (prospective) and redesigning the outpatient medication prescribing process (prospective). Prospective projects were from the initial training and project implementation to sustainment.

Urinary Tract Infection Prevention and Reduction

Project Goals

The goal of this project was to reduce the rate of new and recurring UTIs. One nurse manager reported that the goal was to reduce the current 9 percent UTI rate to the national goal of 5 percent or less; however, none of the other staff stated such a distinct, clear goal.

Long-Term Care and Acute Care Unit

This project was implemented in both the long-term care and acute care (hospital) units.

Project Selection

According to senior executives and nurse managers, UTIs have been a longstanding issue at Suntown, with a peak of infections in 2009 at about 9–10 percent, as reported by two nurse managers. Most of the nursing staff interviewed viewed UTIs as an important clinical issue. Before the RCE, as part of activities for a larger collaborative they were working on with other hospitals, Suntown staff began administering cranberry capsules and vaginal estrogen cream as UTI prevention measures. The CEO proposed the project as well as five others to the quality team. The UTI prevention project was selected by the quality team based on the existing collaborative and the importance of the issue as deemed by nurse managers.

"It's tough on the facilitator. And then on top of it we had a green facilitator—the person who was a process champion who was facilitating…. So [the nurse manager] was coaching her as a facilitator at the same time we're having this really very complex discussion." —Senior executive

Project Staffing 

The CEO selected the team members for the UTI project (Exhibit 4.12). The process owner—a nurse manager—also provided input on team staff selection. Because the issue of UTIs was believed to cut across multiple departments that include clinical and nonclinical support staff, the process owner suggested including staff from environmental services (i.e., housekeeping) and the dietary department. Other team members included nursing staff from long-term care (LTC) and acute care services and the chief nursing officer (CNO). The facilitator for the event was a nurse manager who had not previously facilitated an RCE on her own but had co-facilitated and participated in numerous RCEs. An executive who is also an experienced facilitator was present during the event but describes his involvement as a "casual observer."

Planning and Implementation

The facilitator reported that she prepared to implement the 10-step process, but other staff said there was little to no planning before the Lean event. However, baseline data for the event were available because Suntown routinely collects infection rates as a required patient safety indicator, including UTI rates that are reported at monthly quality team meetings. After beginning the RCE and mapping the process, the team realized that there were several sub-processes requiring attention. An executive and nursing manager described the project and process as being the most complex project they had attempted at Suntown.

After the first day, interviewees said that the team regrouped and divided into two separate teams to, in a more targeted way, review and walk through the processes believed to affect UTI rates. The first team with the residential care advisor as the process owner was a care team that focused on nursing care: perineal care, incontinence and toileting, and urinary catheter care. The second team was an environmental team focused on hydration, cleaning hard surfaces, cleaning bathrooms, and hand washing. This team was led by the nurse manager who was also the quality assurance coordinator. Several of the interviewees reported that the team was frustrated after the first day when the project scope seemed overwhelming. However, after re-scoping the project on the second day to create the two separate teams (each responsible for four sub-processes), team morale improved, and the team was able to complete the RCE in 3 days.

As discussed above (Process for Lean Projects section), the team walked through Suntown's 10-step process and implemented each tool:

• Step 1: Choose priority process. On the first day, the team worked to scope the project and discussed the start and end points of the process, the customers, the products, the expectations for the products, and the measures. Nearly all of the first day was spent on this step. It was at this point that the team began to list all of the factors and processes that might influence UTI rates. Since the purpose of this project was UTI prevention, as opposed to treatment, several preventive sub-processes were uncovered. 
• Step 2: Identify and choose priority problems. Given the eight separate sub-processes that were discovered, the team decided to split the processes into two priority areas: (nursing) care processes and environmental processes. Care processes included toileting, perineal care, incontinence, and urinary catheter care. Environmental processes included cleaning the bathroom and hard surfaces, hydration, and hand washing (Exhibit 4.13). 
• Step 3: Write a problem statement for this project. Given the change in scope from the first day, and following the 10-step process, the team came up with a problem statement (Exhibit 4.14) identifying which issue or process they were working to improve: in this case, to reduce the UTI rate in the LTC unit by addressing eight care and environmental processes. Dehydration was added as a problem to address.
• Step 4: Assign team members. Though team members were already selected, this step was revisited when the process was broken into two smaller teams; in addition, a second process owner was selected. One process owner oversaw the care processes while the second focused on environmental processes.
• Step 5: Physically walk the processes under examination. The eight care processes were walked and mapped out using sticky notes to examine opportunities for efficiencies and quality. These processes were toileting, toileting with peri-care, toileting with incontinence, catheter care, hydration, hand washing, cleaning hard surfaces, and (cleaning) sinks and toilets.
• Step 6: Create a value-added timeline. After mapping out each process, the two smaller teams identified value-added and non-value-added steps.
• Step 7: Identify ways to eliminate waste and process variation. The teams began developing new policies and procedures to reduce variation for perineal care for patients with urinary catheters, perineal care for patients without urinary catheters, hard surface cleaning, toileting, and toilet cleaning. However, the policies and procedures were not finalized during the RCE. To eliminate waste, participants proposed changes to the physical layout and additional equipment to reduce the number of physical steps a staff member had to take to provide the care the team believed was relevant to preventing UTIs. For example, new trash cans and cabinets located closer to the patient were proposed. The team targeted hydration in LTC residents whose intake was poor by setting fluid intake goals for these patients, tracking fluid intake in the chart, and educating the certified nursing assistants (CNAs) about the importance of hydration. Blue-rimmed glasses and blue trays signaled to CNAs that they should encourage fluids in at-risk patients. The CNO monitored charts each week to determine if hydration goals were met.
• Step 8: Flowchart new process steps. The team revisited the process maps for each of the eight processes and, using a flow chart, mapped the future state. The new map attempted to showcase the revised policies and procedures discussed as part of Step 7.
• Step 9: Identify outcomes and process measures. The team determined that the UTI rate would be the key project measure; however, some information was also collected during the RCE (e.g., number of steps, time required, hand-offs related to toileting and perineal care).
• Step 10: Develop an action plan. The action plan of activities to complete after the RCE ended primarily focused on finalizing the new policies and procedures; selecting, purchasing, and implementing new equipment; and training the staff on the new policies and procedures.

"One of the things that came out was hydration and nurses' focus on the physical care. …the time where we had a dietary representative, they were like, 'Well, are we giving them adequate fluids?' And so it just snowballed into this huge (thing) and then, 'Are the toilets being cleaned properly?' So then that went into a whole other process walk of how you clean a toilet? How you clean a sink? It just was huge. …I think we felt that it was very important that all of these aspects were discussed because of the simple fact every one of them impacted the reduction of UTIs. And good or bad, we are a very vocal group so there was so much discussion. And each person was so passionate about their little part that this huge discussion erupted. But there was value in it. It was just constantly backward and it was just keeping everybody in line and keeping everybody on point was probably the hardest for me…. I helped (the primary facilitator)…it was really hard for me to keep [the group on the topic]. It's like, 'No, let's talk about this." —Nurse Manager

After the RCE, the team interacted via email and in meetings over the course of 5–6 months to come to a consensus on and finalize the new policies and procedures. The team had difficulty agreeing on every procedure, so the process owner contacted the staff member viewed as the expert in each area in question to determine best practices, and these became the final process. Ultimately, the new policies and procedures served as "how-to" guides for best completing the eight priority processes (e.g., cleaning hard surfaces, providing perineal care with and without a urinary catheter, and cleaning a toilet). The new step-by-step procedures closely matched the processes developed by the Lean team in the RCE. Once the procedures were finalized, the process owners trained the housekeeping and nursing staff on the new procedures through one-on-one coaching and staff meetings.

The team ordered new equipment, including bathroom cabinets, to make cleaning supplies more accessible at the point of care, as well as trash cans for bathrooms and disposable cloths to provide perineal care. The procurement process turned out to be more cumbersome than originally anticipated, and the team had to wait weeks for some new equipment to arrive. Equipment was used on a trial basis in a few rooms at a time. This allowed staff to make changes, as needed. For example, the original cabinets turned out to be too big and cumbersome; thus, the team tested another type of cabinet before deciding on a final design, ultimately built by a staff member. These environmental process improvements were implemented not only in the LTC unit, but also in acute and swing beds.

Monitoring, Control and Sustainment

The process owners re-walked all processes 30 days post-implementation to check on the status of improvements; the 60- and 90-day re-walks did not occur because the care process owner left to take another position outside the State. Process owners have a major role—coordinating the followup activities and action plan, including training and communicating process changes, as well as reporting progress to the quality team. One nurse manager and project team member believed that the lack of engagement of the care process owner—who initially served as the primary process owner for the entire project—and her later resignation was one of the primary reasons the project outcomes were not sustained.

The remaining process owner also monitored compliance with new policies and procedures and provided feedback to staff who did not comply. Additionally, the remaining process owner continued to monitor the infection data shared at monthly quality team meetings. However, this process owner commented that with competing priorities, she was unable to take on the full role of the process owner after the departure of the primary process owner and did not rework the process. For example, the RCE produced better cleaning processes by replacing reusable cloths with disposable cloths. Interviewees reported that staff did seem to initially adhere to the changes and received some housekeeping education; however, relatively soon, not all staff adhered to the new rules, and no followup on compliance with the new cleaning regulations was undertaken.

The UTI infection rate initially decreased (to a rate unreported in the interviews) but then came back to pre-Lean levels (roughly 10 percent rate of infection). When that occurred, team members insisted on having two aides, rather than one, available for perineal care to ensure that the patient was properly cleaned and dry. Process owners reported on the UTI project at the quality meetings, noting what they did that week, what they learned, and what they would do next for the UTI project. However, at the close of the study, one nurse manager reported that there were plans to have an in-service with staff to reinforce the importance of good practices to control infection rates, conduct a PDSA on bladder infections, and use publicly available forms from AHRQ to monitor UTI rates. An executive stated that staff education would be implemented again to ensure that new processes would become a part of staff duties and that, because of Lean, this is an area that is now emphasized.

Project Outcomes

Perceptions about the success of the UTI prevention and reduction project varied among the staff. The resurgence in UTI rates after an initial decline frustrated some staff who participated in the RCE, and they noted that the presence of UTIs in preventable cases was a "dismal failure." Others, however, noted that the UTI infection rate needed to be taken in context; in particular, some patients have chronic infections that are less likely to respond to these measures.

A few of the nursing staff felt that this project was successful, even if this was not reflected in improvements in UTI rates. These individuals believed that the new policies, procedures, and standardization of work across units and staff were a huge improvement. Specifically, staff noted the following improvements stemming from the Lean project:

• New policies and procedures for perineal care and cleaning bathrooms were implemented.
• The number of physical steps in the general toileting process was estimated to have been reduced by 35 percent and toileting with perineal care by 43 percent.
• The acquisition and use of new cabinets, trash cans, and disposable wash cloths for housekeeping and nursing staff was expected to improve compliance with new policies and procedures.

Three senior staff mentioned the following, less-tangible aspects of this project as indicators of success:

• Staff from nursing, dietary, and environmental services were brought together to focus on all aspects of UTIs.
• The Lean team completed its most complex, challenging RCE to date, despite widespread frustration with the project's initial breadth and scope. Further, there were a few new staff members participating on Lean projects who had not previously participated in a project.
• One nurse manager stated that Lean was changing staff thinking and culture. The manager cited the fact that staff—both with and without Lean experience—discussed issues related to UTI rates in a blame-free manner.
• Finally, one senior staff interviewee felt that the attention this Lean project brought to hydration was critical to improving patient experiences and care.

"Obviously, there were some leadership issues. [We] didn't have anybody that really took ownership for it and there appeared to be some issues in that. Even though the person we assigned to it is well-educated [sic], she just wasn't very interested. So it was always a struggle. And it was assigned to her rather than she volunteered to do it, or was excited about it." —Nurse Manager

When asked if the UTI project was a success, one nurse manager maintained that, although it was not a clear-cut success, it did help the team detect and focus on areas that needed improvement. This in itself was a learning experience and an accomplishment for the team. Additionally, several practices came out of the UTI RCEs related to improved sanitation, which were learned skills for everyone, from housekeeping to the nurses.

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Redesigning the Outpatient Medication Prescribing Process

Project Goals

The goal of the Redesigning the Outpatient Medication Prescribing Process (known as E‑Prescribe) was for the pharmacists to receive a definitive script (one that is legible, timely, accurate, and covered by insurance) from Suntown's medical clinic staff the first time the script is sent.

Department Where Implemented: Outpatient Clinic

This project was implemented in Suntown's outpatient clinic.

Project Selection

The idea for the project began with one provider—a physician assistant who also became the process owner for the project. When selecting this project, the hospital's medical clinic staff knew they wanted to implement electronic prescribing software and to use Lean to redesign the prescribing process so that the results could inform the selection of the software. Suntown was motivated by forthcoming mandates to integrate as part of health information technology (IT) reforms. The quality team, which was well aware that electronic prescribing would soon be mandated for all prescriptions, approved this project.

Project Staffing 

Exhibit 4.15 shows the team composition for this project. The CEO and the physician assistant who was the process owner selected the team members for the prescribing redesign project. Because most prescriptions from the hospital's medical clinic are filled by the local community pharmacy, it was important for a representative from the pharmacy to participate in this RCE. Suntown's CEO decided to serve as the facilitator for this RCE because he is the most experienced facilitator at the organization and because of staff availability. The project team included nurse managers from long-term care and acute care services and the CNO.

Planning and Implementation

This project involved all 10 steps of the RCE process and was completed in only 2 days instead of the usual 3 days. Each step progressed without delay, and few barriers were encountered in this RCE. The tools used and activities completed by the project team are described here.

• Step 1: Choose a priority process. The team narrowed the starting point of this process to the provider's decision to prescribe or refill a medication; the end point was to be when the pharmacist received the order.
• Step 2: Identify and choose priority problems. A major issue with the current medication prescribing process was the number of call-backs from the pharmacy because prescriptions were either incomplete or unclear. Further, the process involved a lot of discussion between the nurses and providers, with the nurses ultimately faxing the prescriptions to the pharmacy. This often resulted in lost prescriptions, a significant time delay, and a long turnaround time for patients.
• Step 3: Write a problem statement. The team described the problem and described the objective of this project: "for the pharmacist to receive a definitive script on the first pass [i.e., the first time it is sent]." A definitive prescription is one that is legible, timely, accurate, and covered by insurance.
• Step 4: Assign team members. To some extent this step had already been addressed, as team members were selected before the RCE, and it was clear that the physician assistant would be the process owner.
• Step 5: Physically walk the processes. The team walked the current process for writing and submitting both a new prescription and a refill prescription to the pharmacy. The total number of steps and amount of time for each process were recorded.
• Step 6: Create a value-added timeline. The team examined where value was added/not added for each step. The team concluded that there was only one value-added step in the process of writing new prescriptions (i.e., the actual writing of the prescription by the provider) and two value-added steps in the refill process (i.e., researching the refill request and writing the refill prescription). Both of these value-added steps were completed by providers. All of the other steps in the process (completed by the nurse) were deemed non-value-added.
• Step 7: Identify ways to eliminate waste and process variation. The team developed new policies and procedures to eliminate waste and reduce variation. Using a fishbone diagram, they brainstormed sources of variation in this process and noted potential forms of waste as well as solutions to the issues. A specific area of waste they identified was call-backs. Call-backs refer to the number of times the pharmacy needs to call the outpatient clinic to clarify a prescription; this speaks to the accuracy of the prescription.
• Step 8: Flowchart new process steps using future-state and process mapping. The team removed nearly all of the non-value-added steps and estimated the total time and number of steps for the revised processes. These steps were mapped out in a process flowchart.
• Step 9: Identify output and process measures. A process measure of pharmacy call-backs was used, and the team hoped to reduce this number by 50 percent.
• Step 10: Develop an action plan. A tentative decision to purchase prescribing software had been made as part of project selection. The RCE plan included activities related to purchasing the software, training/educating staff on the software and the process changes, working with the pharmacy to ensure the software matched their platform, and informing the community of these changes.

After the RCE, the CEO and the process owner handled most of the followup activities on the action plan, such as ordering the software, setting up the software for the providers and the pharmacists, and training the providers on how to use the software. To train providers, the CEO and the process owner created a video to demonstrate the new electronic prescribing software and conducted at least two training sessions with medical providers and support staff. The process owner worked with the pharmacy to iron out any software glitches in the new system. The process owner contacted other local pharmacies to let them know that Suntown was now electronically prescribing medications for outpatients. The entire implementation process lasted roughly 5 months.

Monitoring, Control and Sustainment

The process measures that were identified in the RCE included the number of pharmacy call-backs and the number of steps or time saved in the medication prescribing process. The process owner reported that initially the call-backs were tracked by having the front office log the number of pharmacy calls. However, interviewees noted that within the first 2 weeks, call-backs became so rare that there no longer seemed to be a benefit to tracking the calls.

The central monitoring activity for this project is ensuring compliance with electronic prescribing. At 3 months after the conclusion of the RCE, interviewees varied in their estimates of the number of medical providers using the electronic prescription software. The process owner/physician assistant estimated that three of the four providers were using the electronic prescription software. A nurse practitioner reported that only half of the providers were using the system because of glitches between the newer E-Prescribe software and older electronic medical record software. A third provider reported that all of the staff were using the E-Prescribe program about 50 percent of the time. Pharmacists reported receiving only 25 percent of the prescriptions from Suntown through the e‑Prescribe system. Interestingly, each of the three providers we talked to said that they themselves were using it 100 percent of the time, but that one provider who is not technologically savvy was not using the software at all.

Project Outcomes

The E-Prescribe project at Suntown's medical clinic was considered a "partial success" by most interviewees who participated in this project or who were aware of the project. The process owner felt that this project was 80 percent successful. When asked if the project was a success, one nurse manager stated that incorporation of the new technology was a success. The pharmacists were more measured, identifying gaps in knowledge and understanding of this new system among users. They felt that more training and step-by-step learning by the team was necessary for the system to be a true success.

Though this system was viewed by the process owner as simple and mostly successful, the issue of noncompliance hindered the impact on efficiency. As noted above, the interviewees estimated that only two or three of the four providers were using the electronic prescribing software and not always using it 100 percent of the time. Further, the pharmacists interviewed estimated that only 25 percent of prescriptions they filled from Suntown were being electronically prescribed.

Outcomes attributed to this project are:

• An estimated 80 percent reduction in the number of steps. These steps shifted the burden of processing the prescriptions from the nursing staff to the providers who are actually writing the prescriptions.
• Most interviewees believed that this system was increasing efficiency and that using the electronic prescribing software saved staff time and reduced costs for both staff and pharmacy. However, impacts on overall efficiency were mitigated by the fact that not all providers were using the software consistently or all of the time.

The process owner estimated that one of every 50 prescriptions required a call-back from the pharmacy, far fewer than the initial state. However, these data were collected only for the first 2 weeks post-implementation.

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Outcomes of Lean

In this section, we discuss the outcomes of the Lean initiative at Suntown Hospital based on interviews with staff and materials provided by the organization. Overall, hospital staff reported moderate improvements in employee satisfaction and culture change. Staff also believed that gains in efficiency had occurred; however, Suntown does not routinely collect data after each RCE to validate efficiency gains. As noted previously, improvements in clinical quality and patient safety were not sustained.

The findings reported here are based mainly on verbal reports from staff, since they had difficulty identifying specific quantitative data that addressed the effectiveness of Lean. We found that the measurement needed to examine progress and improvements after an RCE ends often does not occur, and actual impacts cannot be quantified; instead, hospital staff often relies on future-state mappings and predicted outcomes as part of the RCE process (see the Process for Implementing Lean section for more detail on the RCE process). The importance to Suntown of directly measuring the impact of 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 improved efficiency, cost savings, improved safety, or other goals. 

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 in the Introduction to this report and in Exhibit 4.16, 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.

Intermediate Outcomes

In our conceptual framework, intermediate outcomes refer to organizational culture, employee satisfaction, increased Lean knowledge and skills, and routinization of Lean. 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, involvement in Lean activities seems to have relatively less impact on increased Lean knowledge and routinization. In addition, interviewees are not uniform in their views of these changes. Frequently, frontline and other staff do not share as fully in the optimistic view of change compared to senior executive staff.

Organizational Culture Change

Senior executives and a few mid-level staff reported improvements in organizational culture because of Lean. However, frontline staff provided fewer comments on culture change as an outcome, indicating that staff did not perceive the same changes as senior leadership and management staff. According to senior executives, Lean at Suntown is an ongoing process of culture change for the organization. Overall, senior leadership and management staff reported improvements in employee attitudes because of Lean. One senior executive maintained that Lean events have challenged employees to move away from what they were familiar with and take on more responsibility. Another senior executive added that Lean is sustained by the culture change it generates: Lean promotes employee ownership and responsibility, which in turn strengthens interest in improvement.

"Data collection: you have identified our weakness. We do not have the manpower to collect data. On the front end, it's obvious that a certain process is going to be much better than the process we have. We definitely can't measure in terms of numbers of how effective that is. So, I have no idea how much cost savings I'm giving my patients…We don't have someone who can collect that data consistently and that's the problem with all of our Lean studies…You make the assumptions at the beginning that this is going to be better, but we can't prove it in the end. Everyone feels like it has in the end, but you can't prove it." —Process owner

Greater acceptance of new processes. Senior executives, one nurse manager, and one mid-level provider noted that because of Lean, staff was more willing to implement and accept new processes. According to one senior executive, "Even the most skeptical individuals on our team are converted by the end of the RCE process, that they've seen the real value in doing this." As Lean team members participate in creating, mapping, and measuring a new process, they are motivated to implement and change existing processes. Specifically, interviewees mentioned that Lean gave individuals a "license for decisionmaking" and encouraged staff to really examine processes to improve them. This motivation, in turn, fosters a culture where process changes are more accepted. Members of the E-Prescribe project noted that the community pharmacist and some of Suntown's medical clinic providers were willing to revise the way they processed prescriptions after they saw the potential benefits from the E-Prescribe RCE. However, this culture change to implement new processes has not been adapted by all clinic providers, particularly those who are not part of Lean teams. For example, one physician who did not participate in the event would not adopt the process changes resulting from the E-Prescribe project.

Improvement in employee ownership. Nearly all senior leadership at Suntown indicated that Lean is increasing staff ownership of processes and increasing the responsibility they take over their work. Because of this increased ownership and responsibility, these interviewees believe that staff are more likely to foster their own change internally and are also more likely to remain loyal to the organization. In contrast, frontline staff did not note that Lean is increasing the ownership they take over their own work, but one frontline nurse noted that Lean made her more aware of how her work could more directly improve patient clinical outcomes.

Employee Satisfaction

Whereas impacts on culture change were mostly noted by senior executive and management staff, interviewees from all levels reported that participation in Lean events resulted in improved communication with colleagues across the organization and outside of the organization and in improved job satisfaction because of waste reduction.

"It was really tough, because there were many people in the organization which were clinging to the familiar and, 'This was always the way we've done it." So it really kind of started with leadership and a core team of individuals who said, 'We've got to question. We got to start to challenge ourselves to do things differently. And we need a method for doing that." —Senior executive

Improved communication. Nearly all interviewees agreed that the Lean RCEs foster a level of open communication, discussion, and teamwork unseen before Lean was implemented. One nurse manager noted that because the RCE team differs each time, staff are able to develop a level of camaraderie with each other that may not have existed before.

Improved job satisfaction because of waste reduction and improved quality of care. In addition, several nurse managers and frontline staff said that the perceived improvements in efficiency and quality because of RCEs improved their job satisfaction. One frontline person noted that the learning environment and the perceived positive impact on patient care made her feel satisfied with the Lean process. Another nurse manager stated that after one specific RCE where a new phone system was implemented for nurses, nursing staff were pleased with the improvements and believed this new system made their jobs easier. In general, during and after an RCE event, team members believed that their jobs and the jobs of those impacted by the Lean changes improved as waste in the process was removed. This element was tangible during the E-Prescribe rapid cycle we observed: upon seeing how the new process could make the nurses' jobs easier, nurses participating in the event grew very excited at the perceived impact. According to one senior executive, employee satisfaction scores rose, then dropped a bit, then rose again. The executive felt that this occurred because employees began to recognize that there is ongoing progress towards better clinical care. 

Several interviewees also reported some initial resistance to Lean, which may negatively influence employee satisfaction. Specifically, these individuals reported that staff have been frustrated with the initial time investment and learning involved with a Lean event. However, these same interviewees indicated that staff become more optimistic about Lean and their satisfaction improves once staff see the potential for improvements or experience improvements as a result of changes implemented through Lean.

Empowerment of staff. Two nurse managers also noted that the RCE process gives all staff members a voice in improving processes. These individuals cited examples from past and current RCE projects where nurses specifically felt that they were able to speak up and provide input on how to improve processes and, in turn, the care given to patients.

Lean Knowledge and Skills

A number of tools, concepts, and techniques (e.g., process mapping, future-state mapping, fish bone diagrams, etc.) are introduced to the staff through Lean projects and through the quality module training. As such, several interviewees, namely senior executives and nurse managers, indicated that knowledge of the Lean process and quick PDSAs, the other Lean tool employed at Suntown, have penetrated the organization. One nurse manager noted that nurses in LTC often use the quick PDSA as a means to improve processes. However, other managers remain unsure about the degree of uptake and acceptance of Lean tools.

Lean Routinization

According to interviewees, Lean provides a method for problem solving. Several interviewees expressed in one way or another that Lean processes (including the RCEs and the quick PDSAs) have become "what people do" at Suntown. Another interviewee noted that because of Lean, staff no longer accept the "status quo." Along those lines, one senior executive also noted that Lean penetration at the organization has caused staff to start questioning processes.

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Ultimate Outcomes

Little information is available for the ultimate outcomes of efficiency, clinical outcomes, patient experience, patient safety, and business case (or value) at Suntown.  Staff reported perceived increases in efficiency and patient experience; however, little quantitative evidence is available to support those perceptions. As noted in the previous section, Suntown has struggled to see sustained impact on clinical quality and patient safety.

Efficiency and Standardization

Efficiency gains projected because of Lean projects at Suntown are often estimated or projected during the RCE. However, the actual decrease in the number of "steps" and in non-value-added processes is not always confirmed after the RCE event. Nevertheless, hospital staff believe that adherence to the processes outlined in the RCE will provide for such efficiency gains. Further, Suntown does not collect cost data for Lean projects, unless the metrics are clearly defined and routinely collected as part of the work process.

Efficiency. Nearly all interviewees reported that Lean projects resulted in reducing the amount of time a process takes, reassigning staff responsibilities, and using existing resources more efficiently. Further, the new processes resulting from each RCE had the potential to reduce the non-value-added steps, overall duration, and distance in terms of number of process steps. Estimated efficiency gains from administrative Lean projects not specifically studied in this project included:

• A reduction in the period for patient billing from 120 days to 50 days after an RCE event.
• Decreased time for processing long-term care admission by 60 percent, the number of steps in this process by 50 percent, and the number of handoffs to admit a patient from 15 to 4.

According to a few interviewees, the E-Prescribe team has not yet observed all of the efficiency gains expected because of some initial time sunk into improving the electronic prescribing software, debugging the system, and getting providers on board. However, one senior executive and frontline staff who were interviewed foresee great time and cost savings for the organization and the patients once providers are fully using the E-Prescribe system.

Standardization. Lean projects at Suntown may also result in new policies and procedures. As discussed previously, because of the UTI project, policies and procedures regarding hydration and cleaning procedures were standardized as a result of the RCE. 

Patient Experience

Suntown does not systematically collect information on patient experiences and satisfaction and—because of its status as a CAH—is not required to collect Hospital CAHPS data. Because of resource constraints, hospital executives have opted not to collect these types of data.

However, several interviewees reported anecdotal evidence that Lean is improving patient satisfaction. Two nurse managers noted that after Lean projects, patients have been complaining less. Another nurse manager noted that because of streamlining processes in the long-term care unit, patients seem happier. LTC census numbers, however, have declined from a peak of 94 percent in 2007 to 83 percent in the first part of 2011.

On a larger scale, two senior executives believe Lean has resulted in positive rapport with the community because community members see Suntown as "a facility that is running smoothly and one that they can trust." Notably, one of the first Lean projects at Suntown was geared toward improving revenue-cycle management. Given that previous struggles with this issue had resulted in some distrust of Suntown in the community, the executives believe that the improvements from this Lean project were instrumental in improving the public perception of Suntown.

Clinical Process or Outcomes Assessment and Patient Safety

There is little solid evidence to support improvements in clinical outcomes associated with Lean implementation at Suntown. Several interviewees believed that in removing non-value-added steps from each process, staff, particularly nurses, would have more time to devote to patient care. For example, the E-Prescribe project removed several steps in prescribing that nurses formerly had to complete. Lean team members felt that this time would be better spent with the patient, improving patient care.

There is no evidence of improvement in patient safety associated with the implementation of Lean at Suntown. The UTI prevention and reduction project targeted the rate of UTIs in LTC. While the UTI infection rate reportedly decreased in the first 3 months after this project, the rate then returned to pre-project levels. Frontline nurses and management staff did not have a consensus about why infection rates have not decreased but believed that they had implemented better cleaning and hydration practices.

A few other RCEs at Suntown targeted and improved aspects of patient safety. For example, one RCE improved patient documentation in the emergency room so that documentation was 96 percent accurate; this was cited by one senior executive as an improvement in patient safety.

Senior executives at Suntown indicated that Lean was saving the organization time and resources; however, as noted in previous sections, this information was based on perceived or predicted outcomes from the Lean events. While Lean is the primary process-improvement tool used at Suntown, actual impacts cannot be quantified because post-implementation measurement is not done. However, interviewees believe that the revised processes are, in fact, improving efficiency, and therefore having an impact on satisfaction and cost.

Given the community's denial of supplemental funding for Suntown several years ago, all interviewees recognized the need to improve the trustworthiness of the organization in the community. As Lean is believed to have improved the organization's financial situation and also allowed it to provide better care to patients, interviewees believed that the community would be more likely to support increased funding for the organization and also would be more likely to seek care at Suntown Hospital.

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Factors that Influenced the Success of Lean Implementation 

During site visits and interviews, staff at all levels were asked to name the two or three greatest contributors to Lean's success, as well as the problems or challenges they witnessed or faced in implementing Lean at Suntown Hospital. Findings regarding facilitators and barriers are based on responses to these questions and on an interpretation of findings by the research team (Exhibit 4.17). All interviewees were asked to share their insights, that is, their lessons learned based on their experiences with Lean at Suntown. More specifically, they were asked whether and how they would change what they had done if they were to do it over again. The two cases that were studied did not produce concrete evidence of improvements (efficiency, patient experience, and patient safety); thus, evidence of Lean's success is drawn from anecdotal reports of Suntown hospital's overall experience with Lean through the years.  

Using Lean's conceptual framework, the leadership was the primary facilitator of the Lean initiative. The major barriers to implementation that staff mentioned were related to scope, pace, and coordination of the Lean events and resources; leadership (which was seen as a barrier as well as facilitator); availability of resources; staff engagement; and Lean team composition and size. It appears that factors related to the external environment and applicability and locus of Lean activities were not significant as either barriers or facilitators. This section provides a summary table of "Major Factors that Facilitate Lean Success" (Exhibit 4.18), followed by "Major Factors that Inhibit the Lean Success" (Exhibit 4.19).

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Organizing the Lean Initiative

In this section, we discuss barriers, facilitators, and lessons learned related to organizing the Lean initiative.

Internal Context

As a CAH, Suntown Hospital is a small organization with a culture that fosters openness and transparency. Numerous quality team members regard the QI structure as "flat" and nonhierarchical. As such, the existing culture and organizational structure facilitated Lean implementation because some individuals, especially nurse managers, were accustomed to bringing up issues and possible improvement ideas to the senior executives of the organization. However, this value of openness was felt less by frontline staff, who tended to be uncomfortable speaking up on quality issues before Lean. A few interviewees reported that previously they did not have a voice in QI initiatives.

Scope, Pace, and Coordination of Lean Projects

Numerous interviewees pointed to aspects of the scope, pace, and coordination of Lean as barriers to successful implementation. Specifically, all team members mentioned the scope of the UTI project as a barrier to success. As noted previously, this project was eventually broken into two separate projects, each focusing on different processes, because of the large scope. Even after the processes were broken down, several interviewees noted that the connection between process changes and impacts on UTI infection rates was unclear, and even after implementation, they did not understand where problems with the UTI rates arose. Presenting the medical evidence to identify factors demonstrated to reduce UTI rates (e.g., removal of urinary catheters) at the RCE event would have helped to focus the team on processes, with a greater likelihood of making an impact on UTI rates.

The locus of Lean activity was also reported to be a barrier by a few interviewees. Specifically, these individuals noted that sometimes processes targeted for redesign by the RCE might have made staff defensive and more resistant to addressing the problem. In relation to the UTI project, one nurse manager noted that infection control is a sensitive topic, as "no one likes to be accused of causing an infection."

"But you have to be able to prove it and you have to be able to show how you're going to implement it and add it to your current processes to bring value to it. I don't think you can do that if you skip the small steps because, you know, it just breaks down when you-—if you skip so many small steps, the whole thing is just going to break down." —Frontline staff

Interviewees also indicated that the pace of the RCE Lean events both facilitated identifying issues with processes and was a barrier to staff participation. On one hand, one mid-level provider, the nurse managers, and the frontline staff agreed that the careful step-wise examination of processes that occur in an RCE is critical to understand where and how processes can be improved. These staff noted that if a team skips examining each individual step in a process, the solutions are more likely to fail. On the other hand, according to a few nurse managers and frontline staff, this very slow pace of examination during the RCE frustrates staff. These interviewees indicated that they felt the RCE process might be too slow and could be accelerated.

"I think also what's really great about this is not management staff sitting down and making decisions about how they give care, how they do their processes. We have everybody, housekeepers, whoever. If it involves them, they are welcome to be part of this process. So then they take ownership of it and then they become very passionate about what they're doing." —Senior executive

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Implementing the Lean Initiative

In this section, we discuss barriers, facilitators, and lessons learned related to implementing the Lean initiative.

Leadership Activities and Qualities

Leadership and support was the most frequently cited facilitator to Lean. Nearly all staff across all levels noted that the CEO's outward support of Lean was a key reason the initiative was begun. A few interviewees also noted that the CEO pushes the organization forward and believes that Lean is a mechanism for doing so. According to interviewees, the CEO often mentioned Lean during meetings and gave Lean team members the opportunity to share improvements and lessons from their projects with other staff through quality team and staff meetings. Further, he attends nearly all RCEs. His leadership of the new pharmacy processes had a very positive influence on the RCE, according to frontline staff. The CEO reported taking responsibility for action items resulting from RCEs and allocating funds to purchase equipment and software requested by Lean teams—though, as noted in the next section, staff sometimes find it challenging to obtain the resources they need for Lean implementation.

While the leadership and support of the CEO was a clear motivator for Lean's implementation at Suntown, other senior executives might not have been as highly engaged in the Lean process. Specifically, one senior executive noted that while he did not outwardly oppose Lean and saw value for other staff, he did not wish to participate in Lean projects or QI meetings more generally. At the time of the study, the nonparticipation of this senior executive might have had a negative impact on the E-Prescribe project but did not hamper activities on the UTI project, which focused primarily on nursing and environmental health activities. However, this barrier could have a more lasting impact as Suntown Hospital continues to tackle clinical processes that involve the providers.

"They could feel my passion about these things. So I really truly am setting the tone for the organization when I'm talking about values, when I'm talking about quality. And it's not just someone else on the team preaching the story. It's coming from the top. So I now appreciate that more than I used to. In the beginning, I was like, I got to get this off my plate. I need to turn it over to someone else." —Senior executive

Leadership at the process-owner level might also be a barrier to implementing and sustaining changes resulting from the RCE. Several interviewees across all levels of the organization noted that lack of followup and accountability from the process owner or project leader is a significant barrier. These interviewees pointed to several examples, notably the E-Prescribe and UTI projects, where staff were not held accountable for changes made by the RCE nor for completing activities on the action plan after the RCE. For the UTI project, this barrier was complicated by the fact that the process owner left Suntown shortly after the UTI RCE. Subsequent process owners were not able to "keep the momentum" on the project, contributing to its failures.

Availability of Resources

Numerous interviewees at Suntown, with the exception of the CEO, described staff availability as a barrier to participation in Lean projects. For projects involving clinical staff, such as the E‑Prescribe event, providers were often unable to attend training sessions because of their schedules. One provider expressed frustration at the length of the Lean projects, noting that she would like to have more flexible participation in Lean events. In addition, one frontline staff person described how difficult it was for staff in full-time positions to devote extra time towards Lean improvement processes, with the implementation stage being the most difficult. Even the CEO indicated that there was some frustration among staff when there was no one to cover for them while they were away at workshops. In some ways, this barrier is a result of the organization's small size and the fact that so many staff members fulfill multiple roles. Despite the challenges of finding the time to participate in Lean events, several interviewees mentioned that salaried employment at Suntown facilitated provider participation in Lean because staff can participate in training without worrying about losing money.

Lack of capacity for data collection and reporting was also cited as a major barrier for Suntown in implementing Lean. As discussed in the previous section, Suntown does not routinely collect data after the RCE event, and actual improvements are not always measured. To overcome this barrier, the plan is to hire a full-time IT staff person who will also take on a data supervisory role. One senior executive indicated that hiring this individual would help improve and streamline data collection capabilities, allowing for a point person for organizational metrics.

Several interviewees also noted that obtaining resources is a barrier to Lean implementation. Notwithstanding the support expressed by the CEO for allocating funds for Lean implementation, these interviewees reported that, because of budget constraints and existing organizational procedures for obtaining approval on purchases, purchasing new equipment to implement new processes designed in the RCE can be difficult. As the care coordinator said, "I have to go and find this paperwork. Once I find the right person who knows what the paperwork looks like then I have to get it signed by some administrator." This in turn adds to the time drain during the implementation stage. According to the quality assurance and clinical director, even when purchases are decided upon there is often a long lag time—up to 2 months—before the supplier ships the correct item.

Staff Engagement

Several staff, including senior executives and nurse managers, noted that participating in RCEs is important for facilitating staff buy-in to the Lean initiative. These individuals believed that after a staff person participated in a 3-day event and saw the potential reduction in waste, they would become believers in the Lean process. One frontline staff person whose first RCE was the UTI event also expressed this sentiment: before participating, she was confused and skeptical about Lean. Afterward, she reported that the Lean process was eye-opening, and she now saw how Lean can improve processes and reduce waste. However, according to a few interviewees, many staff who have not participated in a Lean event still remain disengaged or skeptical of Lean. Staff turnover at Suntown could also be contributing to this effect; Suntown reported an approximately 30 percent turnover over the prior year.

Suntown Hospital's previous Lean projects were viewed as highly successful, especially as these projects helped Suntown earn trust from the community and resulted in tangible changes to the organization. For example, a Lean project that focused on improving communication between nurses and providers ultimately resulted in the installation of a new telephone system. Because of these early successes, many staff members trust and believe in the Lean process.

Lean Team Composition and Size

Because Suntown is so small, many individuals are often called upon for multiple Lean projects. One nurse manager noted that she was "burned out on Lean," despite believing in the process, because she had participated in so many projects.

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Conclusions

Suntown Hospital's approach to implementing Lean was to train a core set of staff on the concepts and tools and then train frontline staff while they participated in Lean projects. The CEO views Lean as a tool for culture change and reducing waste, while the frontline staff primarily view Lean as a mechanism for improving processes to ultimately increase the quality of care.

In general, the staff have a largely optimistic view that even where Lean has not produced concrete, positive results, there have been improved clinical practices and increased staff learning. However, sustainability of RCE changes is jeopardized by a lack of reporting and accountability. Recommendations suggested below derive from Suntown's experience with Lean.

Recommendations for Similar Organizations Moving Forward

• Measure results to document the adoption and effectiveness of process changes. It is difficult to determine the success of process changes without data. Consideration should be given to identifying simple ways to collect data as part of the work flow that would not be burdensome to staff.
• Invest in sustainment. New and redesigned processes resulting from Lean events will most likely need to be refined or additional effort will need to be invested in staff training to ensure adoption and routinization of the new processes.
• The best way to learn and adopt Lean is by participating in it. In Case 4, Suntown management and staff noted that they did not truly buy into or believe in the Lean process until they participated in a project and experienced Lean first-hand.
• Early wins foster buy-in. Suntown's first Lean projects were viewed as highly successful, especially as these projects helped Suntown earn trust from the community. Because of these early successes, many senior executives and nurse managers believed in the Lean process.
• Ensure that the number and scope of Lean projects challenge staff without overwhelming and exhausting them. Small and large health care providers might experience different challenges in implementing Lean. Smaller provider organizations have the advantage of a smaller staff to train on Lean principles and tools, retrain when processes are redesigned, and engage in supporting Lean. However, staff working in smaller health care settings may be more apt to experience fatigue from taking on multiple roles within a project and being repeatedly called on to support Lean projects.
• Identify the value-added of a Lean initiative for each specific case. Lean events represent a significant investment of organizational resources; in some cases, a simpler approach might yield equal results in terms of clinical outcomes and cost savings.
• Transitioning from administrative to clinical projects might be challenging. To mitigate these challenges, ensure leadership support and follow-up procedures are in place. Suntown Hospital experienced early successes using Lean on administrative and clinical "back-office" processes. However, as they transition to improving clinical processes using Lean, they must have support from providers and nurses alike, as well as processes to ensure that staff will adhere to the new procedures resulting from Lean.
• Review the medical evidence. Reviewing the medical evidence before beginning a clinical improvement process will help in determining who should be part of a Lean project team and focus the team on processes most apt to improve clinical outcomes.
• Scope the project and break down a large process into manageable sub-processes. When faced with a large project, assigning team members to redesign specific sub-processes will make the task more manageable.

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^u. The aim of the IHI's 5 Million Lives Campaign was to support the improvement of medical care in the United States,  significantly reducing levels of morbidity and mortality over the course of the 2-year initiative (2006-2008). Go to http://www.ihi.org/offerings/initiatives/paststrategicinitiatives/5millionlivescampaign/pages/default.aspx.

^v. Consumer Assessment of Healthcare Providers and Systems, Agency for Healthcare Research and Quality, Rockville, MD. Available at https://cahps.ahrq.gov.

^w. Baldridge performance Excellence Program. Available at http://www.baldrigepe.org.

^x. Institute for Healthcare Improvement, Cambridge, MA. Go to http://www.ihi.org/search/pages/results.aspx?k=Planned%20Care%20Model.

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