Implementing lean: A hospital case study

An excerpt from Beyond Heroes: A Lean Management System for Healthcare.

Lean was a serious initiative from the beginning. It was energetically championed by our CEO at that time, John Toussaint, MD, who began his own lean investigations in 2002. By this time, I was a vice president with operational responsibilities in the hospitals for obstetrics, cancer care, and surgery, in addition to the philanthropic foundations, so I was involved from the beginning of our ambitious lean initiative.

Like many organizations beginning a lean initiative, we started by putting together teams to map our value streams.   First, though, we had to define “value stream.” In industry, value streams show how products and information flow through a company from raw material to fabrication and shipping. In health care, we decided, the patient was the product, and so the value stream would be the flow of a patient through a cycle of care. A cancer value stream, for instance, includes testing, diagnosis, treatment, and, some percentage of the time, hospice.

For women having babies, our obstetrics value stream began with prenatal checkups, continued through delivery, and ended with baby’s first visit with a pediatrician. In this way, we shifted our focus from organizing work around specialized departments (silos) such as pharmacy or surgery to organizing around the needs of the patient. We recognized that most patients flow through multiple value streams. Also, we learned that our first pass at any patient’s care was disease specific — not necessarily taking multiple health issues into account.

Next, we set end-to-end improvement goals in those value streams — cutting through departments and old barriers — and pushed ahead with three or four kaizen1 improvement teams operating every week across the organization. Our Friday report-out sessions were part information sharing, part tent revival. We trained more than two dozen people to become lean experts facilitating kaizen teams and then started rotating frontline leaders and executives through those facilitator positions for two-year terms.

Organizing all the work was our ThedaCare Improvement System Office, overseen by a senior vice president reporting to the CEO. We called our kaizen team weeks Rapid Improvement Events and made sure they were multidisciplinary, with nurses, patients, pharmacy technicians, family members, and doctors all joining together to solve problems. Wherever we applied lean thinking, quality was improving, costs were falling, and patient satisfaction was inching upward.

Like most of my fellow leaders, I saw the benefits of lean as the economy stagnated in the mid-2000s and cost pressures on health care increased. We had all seen plenty of improvement programs, but lean was the first that was a complete operating system, balancing the needs of patients, caregivers, and the bottom line. Lean thinking was helping us improve quality for patients, reduce costs, and engage employees like no other approach. About three years into this initiative, sometime in 2006, I was involved in improvement events in a cancer treatment value stream focusing on radiation oncology.

We were getting breakthrough results: improving labor productivity by 20%, improving same-day access to one’s doctor by 30%, and slashing the time it took to move a patient from diagnosis to treatment from weeks to days. After a slow start, physicians had become more engaged in lean and were sometimes driving improvement work. Patients were on every kaizen team, helping to shape and guide our priorities. Sustaining our improved processes was a struggle, but I was sure we would solve that problem, too. It felt like we were sailing with a strong tailwind.

Then we hit a snag that could have sunk our lean initiative. And the snag was us. What hospital executives were asking of our line managers was slowly strangling our lean improvement efforts. We were heaping on more work, expecting managers to guide lean efforts while performing the same managerial duties as before, in the same way as before. And we expected them to figure out how on their own. This was nothing new. Like our throw-her-in-the-deep-end training, these competing priorities were another strike against our leaders.  At the highest level, productivity at ThedaCare is defined as gross revenue per full-time employee equivalent. At the unit level, manager’s track worked hours per unit of service to define productivity. A unit of service might be a lab report, a surgery, or 24 hours in a medical unit bed.

One day, the very frustrated manager of a hospital intensive care unit yelled at me in my office (in a respectful Wisconsin way, of course), “You’ve changed the way our teams work, but you haven’t changed how we lead. We don’t have the tools for this.” Another manager wept in my office. Both of these were good and steady leaders, so I knew there was a real problem. I talked to other managers and to executives in ThedaCare’s two main hospitals and everyone recognized the truth of the ICU manager’s statement and acknowledged the general frustration.

Managers at ThedaCare are dead center — the bull’s-eye — of our leadership structure. They are responsible for frontline supervisors and entire units; they answer to vice presidents and other executives. New and daunting responsibilities were pressing down from above and below. It was no wonder that cracks were starting to show at this level. For nearly two years, we had been telling managers that the most important goal was improving patient experiences by improving the value streams they managed and then sustaining those improvements.

But we at the executive levels were still acting as if hitting monthly financial targets in the budget— mostly unrelated to improvement work — was the real objective. Goals were being generated in boardrooms, but these were often inconsistent with what was happening at the front line. Worse yet, we were failing to offer meaningful communication, training, or guidance to the line managers now responsible for keeping all the critical improvement work on track.

Kim Barnas is a former senior vice president, ThedaCare, and author of Beyond Heroes: A Lean Management System for Healthcare.

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