The Missing Link of Lean in Healthcare

But we are a long way away from lean becoming mainstream in healthcare.   One reason is that only a fraction of the 5,000 plus healthcare organizations in the country have adopted lean, but a more significant reason is achieving sustainability has proven elusive for many organizations.

From my personal experience, and from the many conversations I have had with healthcare leaders through my work at the ThedaCare Center for Healthcare Value (Center), some of the more common reasons why healthcare organizations are unable to fulfill the promise of lean to deliver improved value for patients include:

• The lack of full commitment by senior leaders and Board members
• The concentration of lean knowledge and practice in the hands of a few leaders and ‘experts’
• The optimization of work systems at the expense of management systems
• The delegation of lean as a “project” for middle managers
• The use of tools without the deeper understanding of the thinking behind lean

While all are important to address, I will focus on the third factor, the lack of a management system.  For this is a critical system to achieve sustained improvement over time and to develop a community of problem solvers.  Also, as a lean coach and operations leader at ThedaCare, a 7,200-employee healthcare system in northeast Wisconsin, I experienced firsthand the optimization of work systems in the absence of complementary management methods.

For almost five years, tool-based improvement at ThedaCare resulted in a whirlwind of endless improvement activity, such as value stream mapping and kaizen events, which competed for time and resources with daily operations and the implementation of strategic initiatives.  Over time, it became evident that both the pace of improvement and the outcome of these efforts were difficult to maintain over time.   Soon after a new process was introduced, variability would creep in, as staff did their best to do things differently without proper training or support.  In addition, operation leaders, overwhelmed by the flurry of activity, were helpless to prevent the slide back to old ways and unable to prioritize their efforts.

This situation might sound familiar to some of you.  It was at this point that it became obvious to ThedaCare that the organization needed to apply the tools they had become so adept at to develop a different way to manage.   The story of how this happened is told by Kim Barnas, in her newly published book, Beyond Heroes.    In the book Kim describes among other things, how the system that resulted from these efforts was painstakingly tested, and how it was spread throughout the organization, only after this phase was completed.  The system for spreading to other units was also carefully thought out, engaging those who came before to train and coach those that followed.  And the practice of deep reflection was incorporated for more effective learning by all leaders involved.

Initial results showed employee engagement improvement in 83% of hospital units, safety and quality driver metric improvement in 83% of units, customer satisfaction improvement in 85% of units, and productivity increase in 43%.    

The Business Performance System (BPS), as ThedaCare calls its management system, is a comprehensive set of tools and processes that enables the flow of information within the organization from strategic imperatives to the front-lines, and back to the senior leadership team.  It encompasses the key connecting points between levels of the organization that enable daily problem solving, catch ball of priorities, work system sustainability, teamwork, and the application of the scientific method to improve and capture the knowledge and expertise of front-line staff.

To date, more than 250 organizations have been exposed to the BPS model through the Joint Commission Journal on Quality and Patient Safety article, “Developing a Business Management System for Continuous Daily Improvement”  published in 2011 and through education from the  Center.  Fifteen organizations have also successfully adapted the system to meet their needs with the help of faculty from the Center who still practice at ThedaCare.  The white paper “Collaborative Approach to Healthcare Improvement” outlines the experience of organizations in Ontario, Canada with this program.

For those of you thinking that the cost of entry to practice lean in healthcare is high or that the efforts required for sustaining it over time are substantial, there is one thing you can do to shorten your learning cycle:  learn from those that came before and borrow their learning curve.  You can do this in many ways; don’t forget about the potential pitfalls that have stranded others.  And among those, remember that the management system is the missing link to success in lean healthcare.