May 2018 Leaning in to Succeed in Public Hospitals A s first responders for medical care, behav- for these organizations, helping eliminate compla- ioral health, and other urgent community cency and harness the energy of frontline staff and needs, California’s public hospital systems managers. serve a disproportionate share of uninsured people and patients with complex health care needs. These institutions are inherently vulnerable to the shifting Lean and Health Care needs of local, state, and federal forces. Public hos- Lean has been written about extensively as a phi- pitals must balance their responsiveness to often losophy and management system embedded in a divergent and emergent requirements with vigilant culture of continuous improvement and learning. attention to their core mission. Initially employed to transform Toyota, Lean includes tools such as value stream mapping, rapid cycles Seeking an enduring way to thrive in an increasingly of improvement, mistake proofing, level loading, competitive marketplace, Zuckerberg San Francisco standard work and 5S methodologies, and setup General Hospital (ZSFGH) and San Mateo Medical reduction — all aimed at involving staff at every level Center (SMMC) adopted Lean methodologies sev- in organizational change. eral years ago. Through the application of Lean principles, practices, and tools, these organizations Denver Health began adopting Lean in 2005, mak- have embedded the systems and infrastructure ing it one of the first hospital systems to do so.1 needed to stabilize and align resources to achieve Since then, more than 2,000 of its employees have strategic goals. When it comes to engaging the been involved in Lean improvements. Denver Health workforce in finding and eliminating waste and teaches Lean methods to health care leaders and improving quality, safety, throughput, and financial staff through its Lean Academy, which operates in health, these hospitals serve as examples of “what collaboration with Healthcare Performance Partners.2 good looks like.” On the East Coast, New York City Health + Hospitals (NYC H+H) adopted Lean in 2007, and has since Most recently, the development of daily manage- deployed techniques to make ongoing improve- ment systems and the standardization of work ments to patient care. In one example, it focused processes have been called out as game changers on surgical services at its Jacobi Medical Center and Issue Brief achieved both a 22% increase in surgeries and an 11% reduction in turnaround time using value stream Zuckerberg San Francisco years before they embarked on an organization-wide strategy deployment. They created systems for daily analysis and other Lean technologies.3 Nationally, the General Hospital and San management that engage “everybody every day” in US Department of Veterans Affairs (VA) is implement- ing Lean’s Six Sigma practices “to optimize the rate Mateo Medical Center problem solving to demonstrate how each person in the hospital contributes to the achievement of stra- at which the VA can treat veterans, as well as boost Leaders at ZSFGH and SMMC described their tegic priorities. Their journey toward zero defects has the overall quality of the treatments and services.”4 improvement journeys as both long-term and trans- been marked by periods of accelerating growth of A two-year study by the Association of VA Surgeons formational, acknowledging that it can take at least knowledge and receptivity interspersed with periods into the effect of Lean processes at a VA medical 10 to 15 years to fully reap the benefits of Lean. that are slower to yield results. It was these slower center showed “significant and sustained” wait list periods, the executives noted, that often fomented reduction — from 33 days to 12 days — for patients ZSFGH CEO Susan Ehrlich, MD, and SMMC CEO innovation among leaders, managers, and line staff waiting for elective general surgical procedures.5 Chester J. Kunnappilly, MD, said they are unde- as they sought a return to the pace that yielded the terred by a long incubation period. As Kunnappilly most improvement. put it: “At eight years of experimentation, including five years of intense work, we are at best toddlers More on Lean in Public Hospitals The California Health Care Foundation has in the Lean world. This means we fall down a lot, Inspiration from Lean helped fund the establishment of Lean man- and the idea is that the tools give us the resilience to get back up, keep improving, figure out what went Health Care Experts agement systems in the state’s public hospitals wrong and how to revise. This is the area of learning Ehrlich, who had been CEO of SMMC early in its since 2009. See more at: for us.” Lean journey, reflected on the importance of getting $$ Betterand Faster: How Safety-Net all leaders on board with changes. In 2013, along Providers Are Redesigning Care The improvement tactics they deploy are modeled with other public hospital executives, she visited (www.chcf.org, 2011) on a number of Lean principles: Identify value as ThedaCare, a Wisconsin-based integrated delivery $$ Implementing Lean in a Safety-Net Clinic: defined by the customer, map the value stream in system renowned for its leadership in applying Lean A Case Study (www.chcf.org, 2012) order to deeply understand each step in the pro- methodologies. The leaders spent a week learn- $$ The Lean Way: How California Hospitals cess of creating value and eliminating waste, flow ing how to build a management system using the Are Embedding a Culture of Improvement processes smoothly with tight connections between techniques. Subsequently, coaches from Catalysis, (www.chcf.org, 2015) each step, establish pull that enables the customer a nonprofit education institute, provided daily man- $$ Hospitals Seeking an Edge Turn to Unlikely to receive a product or service on demand, and seek agement training onsite at ZSFGH and SMMC; they Adviser: A Carmaker (www.kqed.org, 2015) perfection by continuing the cycle of improvement partnered with Rona Consulting Group, which pro- $$ S.F. General Following “Toyota Way” to in the pursuit of zero defects. vided ongoing coaching to embed and spread the Efficiency (www.sfgate.com, 2013) system across the whole hospital.6 ZSFGH and SMMC took similar approaches as they established new ways of managing and operating. While in Wisconsin, Ehrlich heard a talk by John They first initiated changes through mapping and Toussaint, a Lean thought leader and CEO (now making improvements in one, then two, and then executive chairman) of Catalysis. Toussaint discussed more additional service areas over a period of several the loss of middle managers in health care due to California Health Care Foundation 2 insufficient support from executive leadership. He everyone aware of the contributions made by the of improvement or strategic initiative — provide a described this as the biggest mistake made in imple- people and processes. Unit-based interdisciplinary structure for executive sponsors of each area of work menting Lean. As a result, said Ehrlich, she has been leadership teams are learning to guide and coach to huddle with their improvement teams, usually a strongly focused on leadership development philos- teams toward daily problem solving that contributes combination of managers and line staff. During the ophy and tools. Specifically, she coaches ideal leader to strategic targets. Aligning priorities across the huddles, sponsors identify challenges that require behaviors — what leaders do every day to support hospital, huddle boards, stat sheets, and one-to- interdepartmental or interdisciplinary collaboration frontline staff and what executive staff do to support one interactions all contribute input to large visibility and demonstrate how focused work in any one area managers and supervisors. “This is about culture and walls across the whole hospital. builds toward specific strategic goals. In patient care behavior change so it takes a long time,” stressed areas, visibility boards include metrics that respond Ehrlich. Staff and leaders hold daily “stand-ups” at these to daily, and sometimes hourly, changes. Huddles at walls to get a clear view of how the facility is doing these boards allow teams to make data-based deci- ZSFGH and SMMC have maintained their commit- overall, the challenges workers face, and how execu- sions and understand at a glance if the trend is going ment to Lean, including recent work on spreading tives can enable staff to work at their highest level in in the right direction. These local boards, as is the the daily management system. At both institutions, the pursuit of organizational goals. case at ZSFGH, feed executive leader boards; they this system started as an experiment with using provide direct evidence of alignment to the institu- team-based daily improvement as a way to engage ZSFGH’s daily management system is now in place in tion’s “must-do, can’t-fail” strategic priorities. everyone. Because improvement activities had been perioperative services, an inpatient unit, the urgent limited to too few people and too few ideas, the care clinic, specialty clinics, and the emergency Kunnappilly noted that two of the most successful hospitals searched for a different approach. department. This year, ZSFGH is improving this sys- elements of the daily management system at SMMC tem and rolling it out to additional areas. Ehrlich are status sheets and huddles, which have evolved noted that this is a critical advancement as the sys- over time to focus strongly on problem solving. “Stand-Ups” and Visibility tem prepares for the launch of its enterprise-wide The daily leadership and staff huddles occur across Boards electronic health record in August 2019. the hospital, providing an opportunity for frequent check-ins and reflection on a wide range of opera- Initiated in 2015, ZSFGH’s daily management sys- tional topics. The huddles are only 5 to 15 minutes tem is now emerging across the hospital one unit Status Sheets and long and follow a standard format where participants or department at a time. The methodology includes daily improvement huddles by area teams at “visibil- Huddles ask: AA What safety events have occurred and what ity boards.” The huddles inform workers about how SMMC also successfully deployed the daily man- are we doing to respond? they did yesterday, prompts them through a process agement system. Key elements of the system are of identifying barriers to today’s work, and allows for in operation in the emergency department, operat- AA How are we doing on patient experience? problem solving to be initiated by frontline staff. ing room, inpatient psychiatry and medical/surgical AA What flow problems do we anticipate today? units, and in nine outpatient clinics. In addition, daily “stat” sheets provide opportunities AA What do we need to adjust? for managers and supervisors to quickly but thor- Visibility boards in SMMC’s executive suite have AA Who are we celebrating today? oughly review the issues and lessons of the day. The been used effectively for several years. These leaders note that this “engaged partnership” makes boards — essentially a wall panel for each major area Leaning in to Succeed in Public Hospitals 3 The stat sheets are connected up and down the targets that are set and measured daily by staff; the Another challenge, Kunnappilly noted, was correct- chain of command to make sure everyone is empowerment of staff to continuously improve the ing misapprehensions about standard work. “Initially, informed of the issues and responses. “The measure standard work, identify problems, and create solu- people, especially physicians, thought creating stan- of success of these tools is the tremendous pull you tions; and regular auditing by managers. dard work meant that we were taking away their see throughout the organization,” said Kunnappilly. ability to be creative, to diagnose and treat using “People observe what’s happening and working well What standard work offers is clarity, Kunnappilly their expertise and training,” he said. He pointed out in one unit, and realize they want to implement it in stressed. If adherence to standard work was found that standard work provides a baseline from which to their unit.” He added that the daily huddle connects to be falling, managers learned to coach teams to improve, the means to produce reliable and consis- employees and facilitates the development of effec- understand the cause of the breach and institute tent results, and frees everyone to use their creative tive teams. countermeasures to regain adherence. Standard skills to solve the more complex issues they experi- work allowed for repeatable, consistent processes ence every day. that improve safety, quality, and effectiveness. With Standard Work the new management system in place, the SMMC waiting list began to fall again, he said. Although ZSFGH leaders encountered similar experiences with standard work as a method for maintaining improve- and Maintaining maintaining access remains a struggle due to ments such as shortened wait times and improved increasing demand coupled with provider and staff Improvements vacancies, added Kunnappilly, standard work has processes for surgery preparation. However, while Lean accelerates changes, just sustaining the tools In 2012, SMMC — a community hospital with a enabled SMMC to prevent the waiting list from doesn’t sustain the change, Ehrlich said. It is the dis- network of neighborhood clinics — had a grow- growing to its previous levels. ciplined adherence to standard work and the more ing access problem. They determined the size of recently adopted management system that pro- the problem by creating a list of patients waiting “We’ve had a lot of gains at SMMC, including reduc- duces consistency and visibility in the work. for services across the system and found that 5,000 ing operating room cancellations and wait times people were in line. Over the next two years, as the for prescriptions,” Kunnappilly said. “In the clinics, “Standard work helps organizations address com- institution focused sharply on improving access, the we’ve made gains around improving preventative peting priorities,” Ehrlich said, by minimizing drift waiting list fell to 2,500 patients and then eventually measures, such as adult immunizations and screen- and demonstrating successes. “This continual ‘plan, to zero. ing mammograms.” Noting that some of these do, check, act’ (PDCA) cycle of improvement pro- efforts were supported by big-ticket, weeklong vides evidence that persistence pays off and sets But this accomplishment was short-lived. Once a events, Kunnappilly cautioned that there can be a the groundwork for the next advance,” she said. problem is fixed, they learned, it will re-emerge problem sustaining the change. “You need a process “Standard work basically allows those using it to unless there is a buttress against the gravitational by which you are constantly going back to that stan- focus on the most important things — our true north pull of the previous state. So SMMC leaders and staff dard work,” he added. “People have a tolerance for goals and metrics.” Ehrlich pointed to one example made a deep commitment to maintaining improve- drift; you can drift for a little while before you’ll start of the results of standard work and PDCA successes: ments through the Lean methodology of standard seeing it in the data. By the time the data are worse, a sharp increase in patient load at ZSFGH’s urgent work. This includes written directions for completing you have a bigger recovery effort than if you were care clinic. tasks that are developed by the people responsible monitoring the work itself.” for the task; clearly articulated expectations and California Health Care Foundation 4 Endnotes The Role of Leaders During their ongoing Lean journeys, both ZSFGH and SMMC have encountered major disruptions that 1.Harris Meyer, “Life In The ‘Lean’ Lane: Performance Improvement at Denver Health,” Health Affairs 29, Ehrlich and Kunnappilly also deploy their own might have derailed less robust efforts. The chal- no. 11 (November 2010), www.healthaffairs.org. “leader standard work,” or a routine of behaviors lenges included significant changes in the executive 2.“About Lean Academy,” Denver Health, and activities that ensure they move through the leadership teams at both institutions, ZSFGH’s move www.denverhealth.org. work before them each day while leaving time for into a new hospital building, the imposition of new 3.“Healthcare Business Insights: Patient Care Delivery,” strategy and the people side of hospital leadership. external regulatory requirements, funding volatility, New York City Health and Hospitals Corp., January 2017, In 2016, the ZSFGH executive team identified leader and hiring delays. Despite these issues, improve- www.nychealthandhospitals.org (PDF). behaviors that support the principles of “align, ment work has continued without significant pause 4.“VA Healthcare System Adopts Lean Six Sigma,” enable, and improve” and that embody “the ZSFGH for six years at ZSFGH and eight years at SMMC. Health Care Daily Online, December 2015, way.” The institution has continued to reinforce these www.healthcaredailyonline.com. behaviors by training all leaders in “A3 Thinking” (a 5.Nakul Valsangkar et al., “Effect of Lean Processes on structured approach to problem solving), using 360- Surgical Wait Times and Efficiency in a Tertiary Care degree surveys focused on Lean leader behaviors, Veterans Affairs Medical Center,” JAMA Surgery 152, and implementing leader standard work. Authors no. 1 (2017): 42– 47. doi:10.1001/jamasurg.2016.2808. Joanna Omi, MPH, a principal with Rona Consulting 6.The California Health Care Foundation supported the trip The SMMC and ZSFGH leaders stressed that Lean Group, and Anne Boyd Rabkin, MPA, an indepen- and subsequent coaching at the hospitals. changes the role of leaders — the way they think dent consultant. and the way they act. This ultimately impacts organizational culture as skills and incentives are sys- About the Foundation tematically moved through every level of staff. For The California Health Care Foundation is dedicated example, managers are coached to develop their to advancing meaningful, measurable improvements staff members to be problem solvers rather than to in the way the health care delivery system provides look to be rewarded for their own problem-solving care to the people of California, particularly those ability. Executives regularly take “gemba walks” with low incomes and those whose needs are not (gemba refers to the place where the work occurs) well served by the status quo. We work to ensure throughout the institution, taking the pulse of the that people have access to the care they need, when hospital, asking questions, and learning firsthand they need it, at a price they can afford. what is working well and what is not. CHCF informs policymakers and industry leaders, Ehrlich acknowledged that Lean is a slow and invests in ideas and innovations, and connects with methodical process. But, she said, the CEO sees changemakers to create a more responsive, patient- that change is occurring both through the data gen- centered health care system. erated daily and by observing the unit walls as she walks the hospital. For more information, visit www.chcf.org. Leaning in to Succeed in Public Hospitals 5