Challenges and Lessons Learned
The project team confronted various challenges and learned many lessons as
the implementation of redesign evolved, which was to be expected when putting
a large system in motion for transformation. It is very important to
constantly monitor the progress of change so that obstacles, challenges, and
successes can be understood and addressed. This section summarizes some
of these lessons learned at the global level, value stream level, RIE level
(from the perspective of leadership and the RIE team members), and Black Belt
level.
Many of the lessons learned at the global level occurred early on during the
transformation process. There was much communication between the executive
staff, Black Belts, facilitators, RIE team members, and engineers during the
months of initial implementation. Adjustments were made in the approach
to implementation as the challenges became clearer solutions were identified
and put in place.
Global Lessons
- Lean is a tool that is applicable to health care.
- There is no existing "cook book" template for implementing
Lean in health care.
- Much of the existing published information on implementing and evaluating
the impact of Lean tools relates to non-health care industries, while relevant
is often not readily translatable to health care workers.
- Implementation of Lean is hard work.
- Implementation of Lean will not immediately provide results at the value
stream level or system level. Therefore patience and commitment at the
senior leadership level, along with executive guidance of the change process,
are all important.
- Although the Lean tools are quite intuitive, their application takes
learning and practice.
- Outside ongoing consultation is helpful for the implementation phase
of Lean.
- Commitment and intense engagement of senior leadership (executive, operational
directors, physicians and nursing) is necessary when transforming systems.
- The volume of data generated is considerable and requires disciplined
and structured organization and coordination.
- There must be a structured and systematic process established for assessing
the data.
- As there is no universal template for Lean implementation in health care,
learning must be ongoing and process flexibility is essential.
- The identification of specific individuals within the organization to
be key implementers is important. For Denver Health, these were the Black
Belts and facilitators.
- Black belts drive the concept that Lean is part of everyday work not
just an event.
- The core Lean operational structure must become part of organizational
structure.
- For transformation, Lean must be one component of a more comprehensive
strategy.
- Communication at all levels of the organization is essential.
- At some point, a tipping point occurs and system level results begin
to emerge. For Denver Health, this was about 18 months.
Value Stream Lessons
- Value streams must reflect an organization's strategic imperatives.
- Executive staff must own value streams that represent their areas of operational
responsibility.
- The most complex value streams may need several executive staff owners
who work collaboratively.
- Value streams must be manageable in scope and reflect the entire flow of
particular process.
- As processes are improved and changed within a value stream, remapping
(depiction of the process flow) of the value stream is necessary.
- Facilitators might be best deployed by value stream, becoming experts in
the processes that encompass a particular operational area.
RIE Lessons—Leadership Level
Executives
- Executive sponsors should identify RIEs at least three months prior
to being scheduled, so team members can schedule these one-week commitments
on their calendars. This is of particular importance for physician team members.
- Executives are convinced of the power of RIE process.
- Having Executive Staff lead RIEs for an entire week twice a year
sends an important message to employees regarding the value of RIEs to the
organization.
- Reporting RIE results to Executives on Friday mornings during
RIE week is valued by team members and provides an opportunity for employees
to showcase their work to executives.
Physicians
- Physician engagement is highly valued by the team members.
- Most physician and nursing leaders have embraced the RIE approach
to process improvement.
Employees
- Employees appreciate the opportunity to get together for a
week to focus on a process that all see needs to be improved. It is
much more efficient to focus the time for making an improvement in 1 week
than having monthly meetings over a 6-month or year period, where all the
employees involved in a process may not be available to make decisions.
- It is important to have a wide spread of employee involvement
in change for the culture to embrace rapid improvement approach to change.
Implementation
- In order for an RIE to be successful, it is key to clearly
identify and limit scope of the RIE so that team members are clear on their
purpose for the week and that it is doable.
- Creating the appropriate team size and composition are critical to a successful
RIE. Team size is ideally eight where other employees that may be involved
in a process can be pulled in as needed at specific times. Teams should
be composed of a facilitator, team leader (not part of the process), process
owner, and other team members involved in the relevant process. There should
be never more than one-third of the team new to process. There should always
be team members that are "new eyes" to the process—that
is, people who have had no involvement with process.
- It is important to have all key personnel involved with a process on the
RIE team.
- Starting with processes at the downstream end (i.e., patient discharge)
of a process are preferred over processes at the upstream end (i.e., patient
admissions), because a bottleneck in flow will be created until the farthest
process downstream is reached.
- It is a greater challenge to improve processes that cross departments.
In these cases it is important to have direction from executive sponsors.
- After RIE, momentum can be lost and process can return to the "old" approach. It
is important for teams to develop communication plans for post-RIE and to
identify responsible parties for followup.
- It was necessary to hire external expertsm to
motivate staff and provide momentum and structure for implementing RIEs.
- Some process changes are readily transferable, such as replicating an improvement
from one clinic to another, where other process changes require "tailoring" to
the specific environment and culture.
- Tuesday is the most difficult day during RIE week.
- It is difficult for RIE teams to identify people whose work is not value-added, and therefore elimination of positions is rare.
- As the Lean philosophy took hold throughout the organization, it was necessary
to create an organizational structure to support Lean and RIEs.
- This structure was created by establishing a Lean department and by hiring
additional facilitators. With the creation of this department, employees
understood that Lean was no longer "an experiment" but a way
of life.
Evaluation Structure
- At the RIE level, data collection can be a challenge even when responsible
parties are identified. The easier the data are to collect, the more
readily they will be collected.
- The most successful RIEs have included the clear identification of the
problem, the relevant metrics, and the collection of data at least 1 to 2
months in advance of RIE week.
- Metrics are not something that most health care workers understand and
therefore guidance by experts is necessary.
- Visual production boards posted in each operational area affected by an
RIE are important. Through the display and monitoring of RIE metrics,
improvement challenges are readily visible and improve the ability to sustain
these process improvements.
Communication
- Continuous communication to employees about the progress of Lean
is critical. Denver Health developed a new internal publication to communicate
to employees called the "Getting It Right" newsletter.n
RIE Lessons—Team Member Level
At the end of each RIE week, individual participants describe their lessons
learned and accomplishments. The following list is a summary of the feedback
from over 200 participants in 59 RIEs over an 18-month period. Through
the application of formative methods, this summary categorizes responses by
common themes.
Preparation
- The 3-week preparation time for the RIEs is very important.
- Pre-event work is critical to RIE success (data collection, team identification,
and meeting 1 week ahead).
- There is a need to collect data in advance.
Data
- Information technology input and assistance are invaluable.
- Baseline metrics are very important to gauge success.
- Teams have a lot of data but they are not readily available or usable.
- Data should be used during the RIE week rather than preconceived beliefs
about the proposed change.
Preconceptions
- A seemingly simple problem can be very complex.
- Processes that initially seemed complex can be simplified.
- There was a continued need to work harder to remove preexisting agendas
from the RIE process.
Communication
- Communication must be reinforced.
- Communication between areas that could resolve errors is lacking.
- Not everyone in the organization is informed about the RIE process.
- Expanded knowledge of each other's processes was invaluable.
Buy-in
- It takes courage and buy-in to successfully transform the current state.
- Team buy-in is essential for success.
Team
- A "no show policy" should be enforced.
- It is important to have the right mix of people on the RIE team.
- It is important to involve the entire team in the RIE process, both during
the RIE and during the sustainment period.
- Strong team membership with appropriate expertise was crucial to success.
Executive Sponsorship
- Executive sponsorship is vital for RIEs to be a success.
- There is great value in having the executive sponsor meet with the team
at the start of each day and each afternoon before the daily recap so that
the team could benefit from their knowledge of Lean practices.
Lean Training
- The introductory meeting covering the Lean process and RIE basics was invaluable.
- There is a need to educate general staff more on what Lean/RIEs are before
the event and to promote Lean.
Iteration
- Change is a continuous process and feedback must be implemented.
- It helps to constantly revisit the future state so that daily adjustments
can be made.
Standardization
- There are benefits to the standardized work process.
Black Belt Lessons
- The Black Belt concept (training mid-managers in Lean throughout the organization
and expecting them to apply Lean tools in everyday work) does not appear
common in Lean implementation in health care.
- The development of the Black Belt layer for implementing Lean tools was
effective both in creating a culture of Lean as a way of doing everyday work
and for improving financial outcomes.
- The Black Belts value their role.
- In the beginning stages of implementing Lean, there has been more work
for managers that were Black Belts (i.e., dual job responsibilities).
- Monthly Black Belt reports to CEO encourage them to apply Lean tools daily.
- There is variability in the ability of Black Belts to apply Lean tools.
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Intersection of the Construct's Process Improvement Component
With Other Components
One of the important lessons for developing an approach to system transformation
was that the right pieces to the puzzle are in place. All five pieces are important
and are truly integrated when information technology helps with integrating
each piece. For instance the right physical environment was promoted not only
through the construction of new buildings but through the application of Lean
tools. Lean was used to map the work process within the new physical
environment prior to moving into the newly constructed space.
A Lean tool variant of 3Po was
applied to assist with planning a move to a new wing of the hospital. Through
the application of this tool, it was demonstrated that the obstetrics staff
walk fewer steps each day to complete their job tasks. The project team has
also been able to demonstrate that, through the use of this tool, patients
who use these services travel faster through the hospital, creating improved
throughput (flow) in the new buildings compared with throughput in the older
buildings.
Right people are the key to process improvement and in identifying the right
process. By recruiting and hiring people with talents that are the best fit
for a position, the workforce is more likely to participate in innovative approaches
to improvement. For example, phlebotomy used the talent profiling hiring tool
to hire phlebotomists; the same number of phlebotomists is able to fulfill
the needs of the hospital, including the new wing. Through the use of
talent profiling and hiring appropriate staff, the new staff was more efficient
in providing phlebotomy services.
Right communication represents the correct flow of information and therefore
reflects the concept of barrier free flow. For example, Denver Health has implemented
the use of a structured communication tool between physicians and nurses within
the acute care setting. Through the application of this tool, there has
been a reduction in the number of communication steps between physicians and
nurses that relate to patient care. The removal of non-value-added steps
to communication is linked with creating improved processes, and this improved
communication also promotes patient safety and enhances employee engagement.
Right incentives reflect the observation that people will do what is they
have an incentive to do. Team-based incentives which emphasize the team
concept applied by Lean have been developed. To date 22 teams have been paid
for Lean projects through the team incentive award program, and the number
of Lean teams that are applying for these awards is rapidly growing.
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Communication and Knowledge Transfer
Internal
Numerous approaches that were developed to communicate the coordination, implementation,
and evaluation of the RIEs include the following:
- "Getting It Right" newsletter.
- Screensaver.
- Friday out-briefings to leadership (during RIE week).
- Facilitator sharepoint (intranet) site.
- Black Belt quarterly meetings.
- Employee engagement in rapid improvement events.
- Incentive system.
The "Getting It Right" newsletter is published monthly by the
Denver Health Public Relations Department. This newsletter highlights
process improvement projects, particularly RIEs and Black Belt projects, through
staff interviews and by identifying the staff engaged in these events. It
also offers a communication link to all 4,300 Denver Health employees about
the system transformation efforts, as this newsletter is readily available
on the internal Denver Health Web site.
Denver Health has developed a common employee screensaver that activates when
employees are inactive at their computer for a specified length of time. This
screensaver is changed at least twice monthly and provides a forum for communicating
information throughout the health care system. Numerous screen
savers have been developed to communicate the Lean philosophy and how it applies
to Denver Health and employees in their everyday work environment.
During the 1-hour Friday morning out-briefings during RIE week, each of the
five teams has the opportunity to report on the purpose, scope, Lean method,
and results of their projects to executive staff, other teams, and Black
Belts. This has provided an opportunity for all employees to communicate
with executives and other operational leaders.
The facilitator sharepoint site, a Microsoft® intranet site for sharing
documents and information, provides a forum for facilitators to communicate
with each other. As the RIE approach to continuous improvement is a standardized
process, the sharepoint site reinforces the standardization of implementation
through this communication tool.
Black Belt quarterly meetings provided a forum for Black Belts to discuss
their projects with each other and to learn from each other. During these
meetings leadership also received feedback regarding the progress of RIEs and
the challenges Black Belts face applying Lean tools as part of their daily
work.
The number of employees directly and indirectly engaged and affected by RIEs
continues to grow. The spread of engagement to more and more employees
located throughout the health care system assists in creating a culture of
continuous process improvement through the application of Lean principles.
With an incentive system that rewards a team approach to process improvement,
the culture reinforces communication and collaboration among employees.
External
The results of this study have been presented to many groups, including:
- National Association of Public Hospitals and Health Systems.
- Business and community leaders.
- Other hospitals.
- Institute for Healthcare Improvement annual meeting.
Denver Health also received support from AHRQ to sponsor a national Lean training
conference that focused on communicating Lean tools as applied in health care
to safety-net hospitals.p Other
hospitals have also requested an opportunity to observe and participate in
RIEs. External Advisory Committee members have also shared process development
with other industries.
Finally, the following journal articles have been published or in process:
- Gabow PA, Karkhanis A, Knight A, Dixon P, Eisert S, Albert RK. Observation of residents' work activities for 24 consecutive hours: implications for workflow redesign. Academic Medicine 2006 August;81(8):766-75.
- Gabow PA, Eisert SL. A construct for transformation of a health system. Under review.
- Gabow PA, Kaufman L, Wilson M, Goodman P, Albert R, Karkhanis A, Husby B. Applying the Lean tool 5S in a health care system. Under review.
m. Denver Health refers to these experts as "sensei."
n. Additional activities and methods relating to internal communication are described in "Communications and Knowledge Transfer" (below).
o. "3P" (that is, Production Preparation Process) focuses on eliminating waste through product and process design.
p. "Getting Lean: Health Care's Challenge" was held in Denver, CO, on October 19-21, 2005, The conference agenda can be accessed at http://www.denverhealth.org/gettingLean/.
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Current as of September 2007
AHRQ Publication No. 07-0074-EF
Internet Citation:
Managing and Evaluating Rapid-Cycle Process Improvements as Vehicles for Hospital System Redesign. AHRQ Publication No. 07-0074-EF, September 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/rapidcycle/