Lean Leadership for Healthcare: Approaches to Lean Transformation

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Prevent Injuries and Save Time by Reducing Motion Waste in motion occurs whenever hospital workers perform movement within their workspace that does not add value for patients. Reaching or stooping for frequently used supplies and equipment, increased walking due to poor building design, or non-ergonomic patient transfers between beds, wheelchairs, or operating tables are potential instances of motion waste.

Maximize Resources by Minimizing Healthcare Overproduction Overproduction waste entails redundancies, creating too much of something, or creating it at inappropriate times. Preparing medications for a discharged patient, duplication of tests, or extending hospital stays beyond medical necessity are all examples of overproduction that healthcare organizations can tackle. Remove Waste from Over-Processing Over-processing occurs when unnecessary work goes into treating patients.

Lean Leadership for Healthcare: Approaches to Lean Transformation - Ronald Bercaw - Google книги

Needless tests, filling out different forms with the same information, and performing data entry in more than one system are examples. When time, effort, and resources do not add to the quality of care or improve patient outcomes, it has the potential to be changed or eliminated through lean analysis. By viewing all processes through the lens of lean healthcare, staff can help identify repetitive, redundant, or less than valuable processes to save time and money. Waste in healthcare detracts from time that employees could use for educational pursuits, building relationships with patients, or implementing systems-based improvements.

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Adopting a lean culture not only leads to improvements in care quality and decreased cost, it also leads to improved employee morale and commitment. Lean Healthcare Examples Improving patient satisfaction, scheduling appointments, decreasing overtime work, processing paperwork, and increasing clinic revenues are just a few of the areas where hospitals and other healthcare facilities are implementing lean principles.

Additionally, patient safety was improved by equipping rooms with ceiling lifts, beds with alarms and scales, and other equipment. Reported concerns are quickly investigated, and interventions are promptly implemented. Implementing Lean Principles in Healthcare Since the first pioneers shared their learnings at the Global Lean Healthcare Summit in , more and more healthcare organizations have implemented lean methods in their mission to gain control over costs while improving care quality and outcomes. NEJM Catalyst. Sorry, comments are closed for this item. Call for submissions: Now inviting expert articles, longform articles, and case studies for peer review.

More From Care Redesign. Do Hospitals Still Make Sense? Wiler, Nir J. Zane The future is here: moving care out of the hospital and into the home and community. Frustrated with Your EHR? Sittig Two informatics experts urge individuals and organizations to work together toward safer EHR-enabled patient care.

Article by Mark R. A minimum of three attempts were made to contact each individual and an alternate list of potential participants was requested when there was insufficient participation from the original list. A total of 26 face-to-face and one telephone interview were conducted. These were comprised of: six participants from the large urban region; seven from one small urban region and eight from the other small urban region; and six from the northern region.

Use of the realist coding matrix was helpful in directing attention to emerging CMOCs, although the nature of the questions meant that that much of the interview data related fairly specifically to the interim outcomes in which Lean implementation was occurring rather than to mechanisms and outcomes. However, triangulating interview data with our other sources of data key informant interviews, stakeholder consultation and Lean program documentation allowed us to develop a detailed theory diagram Fig.

The following discussion describes the evidence on which each of the hypotheses were based and draws primarily from the interviews. Quotes from the interviews are italicized. Participants are identified first by letter, denoting health region, and then by number, denoting order of interviews. Hoshin Kanri is a strategic planning system that was designed to be consistent with Lean.

It has been implemented alongside Lean in Saskatchewan. While a detailed program theory diagram has not been developed for Hoshin Kanri to date, our overarching program theory identifies it as the key strategy which is intended to generate a single, coherent, system-wide strategic plan. Concurrent implementation of Lean and Hoshin Kanri should, in theory, enable leaders across the system to work towards the goals established through the Hoshin Kanri process.

There was some evidence in the interviews to suggest just how this might happen. There was widespread agreement among participants that efforts to improve health care quality were badly needed. A disadvantage, though, was the need to attend meetings in person, which added the burden of significant travel for health regions located outside major urban centres.

Particularly for smaller and less well-resourced health regions, however, the new unified approach also engendered significant drawbacks. Neither did the smaller health regions necessarily have the resources available to support Lean implementation: this is discussed further below. Some respondents in smaller health region also felt somewhat adrift in relation to the manner in which priorities and directions were being established.

Implications for Future Research: We postulate that, in regions where leaders verbalized loss of control, change in focus and reduced focus on local issues of concern created by centralization, there is potential to lead to alienation and possibly disengagement from this quality improvement initiative, resulting in less support and less alignment between Hoshin Kanri and regional Lean initiatives.

Evaluation of this element of program theory may assist in determining how a common set of strategic goals affect priorities at the regional and health unit level, and the linkages between those priorities, leadership engagement in Lean, leadership practices, and outcomes for staff and patients. This in turn suggests that the common goals intended through Hoshin Kanri would be more difficult to achieve.

Rather than prioritizing day-to-day management, leaders were given the legitimate authority under Lean to spend their time on quality improvement initiatives. Leaders with a significant investment in Lean also identified a change of focus as necessary — moving from focusing on discrete targets or projects, to a sustained effort to change organizational culture. Incremental change was seen as key to successful implementation of Lean.

The support leaders provided went beyond discrete tasks to recognize the struggles staff may be experiencing with the changes in process and culture brought about by Lean. Leaders often needed to deal with concerns about Lean implementation from their staff, who expressed concerns to leaders about the investment of time, energy and money into Lean.

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Leaders took on the role of educating and reassuring staff that Lean was not a passing fad. Variability in staff acceptance of and engagement in Lean implementation also required leaders to support the adoption of new attitudes, which could prove burdensome. Particularly challenging were staff who were resistant to change. New skills in change management and staff support were needed to lead implementation of Lean. Some leaders found it rewarding to witness their staff beginning to make use of Lean principles and tools. We suggest one of the key mechanisms that can underpin Lean implementation is the development of key opinion leaders within the ranks of staff.

Encouraging the participation and reinforcing the behaviors of staff who were supportive of Lean was another strategy used by leaders. Implications for Future Research: In program theory terms, we posit that authorizing attention and resources to be spent on quality improvement activities will increase the time and attention that leaders do spend on quality improvement.

This in turn will ensure that staff participate in such activities and that over time, a culture of continuous improvement is built. Furthermore, the level of managerial autonomy may also affect the extent of this shift; those with more autonomy may be less likely to persist with prioritizing quality improvement activities if the perceived benefits do not outweigh the perceived disadvantages. A realist evaluation of this element of the theory may identify whether increased leadership attention to quality improvement varies across levels of leadership and whether and in what circumstances this focus is maintained.

What Is Lean Healthcare?

It will also identify other contextual factors that are necessary in order for leaders to sustain a focus on building a culture of quality improvement. Inherent in the Lean program is an integrated set of tools for process improvement, which attempts to create structure for and instill confidence in leaders to tackle change management and legitimized leadership attention on quality-related activities.

Leaders who were early on in their Lean enculturation process, however, expressed a lack of self-confidence even after some training. Most of the leaders we interviewed valued the structure imposed by adoption of Lean. This sentiment was not, however, shared by all participants. Gaining expertise in Lean activities also provided opportunities for those not in formal leadership roles to gain some recognition as an informal leader. Implications for Future Research: Lean program theory proposes that use of a common set of Lean tools will ensure consistent quality improvement processes and practices across the province, which will in turn generate distributed quality improvement knowledge, thereby generating improved decision-making ultimately leading to better quality of care.

It further proposes that providing leaders with training in the use of all Lean tools will allow them not only to choose the right tool for the job, but also to use multiple tools simultaneously to generate quality improvement synergies. Experience in use of the tools will improve skills in inclusive leadership, while experiences of success will build belief in and commitment to the Lean approach, contributing to a virtuous cycle.


A realist evaluation will investigate to which, and the circumstances in which, this program theory plays out in practice. Leaders who value the structure Lean provides are more likely to trial a wider range of tools. As a result of trialing more tools, the leaders are more likely to achieve success in meeting their objectives and therefore more likely to establish the virtuous cycle. Leaders with high levels of autonomy are more likely to choose tools that they believe are appropriate to local issues.

In circumstances where there is agreement between different levels of leadership about the more important issues to address, the most appropriate tools are likely to be selected, successes are most likely to be achieved, again establishing a virtuous cycle. Lean espouses particular roles and management styles for leaders. They are intended to develop inclusive approaches that both inform and seek input from all members of teams, thus creating a culture in which it is safe for any staff member to speak up about issues or offer ideas.

The importance of having strongly supportive leadership in Lean implementation was clearly articulated by participants. They also muster the human and material resources to the extent of their authority required to support the implementation of Lean initiatives. In discussing the unsuccessful introduction of Lean in a previous workplace, a staff member noted that there had been very little information provided to staff by management.

These changed practices by leadership are a critical aspect of the program theory for Lean , not least because they contribute to empowerment of staff to play their intended roles. Leaders being present at the work site also conveys that they are willing to witness and to participate in the day-to-day realities and demands to which workers are subjected, which in turn can help leaders account for these realities in their own decision-making.

However, some leaders reported major discrepancies between implementation processes they experienced and the espoused values of Lean. They reported lack of clear information even when it was specifically requested, lack of ability to set local priorities, and lack of flexibility to adapt tools to local contexts.

Implications for Future Research: We hypothesize that leaders are less likely to adopt prescribed new leadership styles or they may be more likely to revert to previous styles of leadership if they perceive either of the following: a the lack of centralized support to support the prescribed management style: or b the failure of central authorities to accept situations where the leadership style may need to be modified to reflect local contexts.

Leaders commonly demonstrated a high level of commitment to ensuring the success of Lean implementation and felt accountable to do their best, particularly with regards to removing barriers to quality improvement initiatives.

Lean Leadership for Healthcare

The personal contribution of leaders was recognized as critically important to success of Lean , but also more broadly to the salvation of health care in the province. The focus on the individual accountability of each was intensified as Lean was implemented.

This accountability extended to ensuring that those in leadership positions were in fact committed to its implementation. Intense training is provided through Lean which is intended to ensure that leaders have the skills they need for the role and a deep understanding of how the various components of Lean fit together to generate change. However, the very intensity of that training was problematic for some.

In spite of the intense training, some managers still felt unprepared to lead Lean activities. While leaders had an increased level of accountability, the resources needed to do the work were not always available, particularly in smaller health regions. Supports such as IT resources to pull required data and team level supports to help run the Lean projects were not uniformly available and created additional pressure on leaders.

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Several leaders remarked on the lack of role clarity and ambiguous nature of accountability for some activities. Implications for Future Research: Increased levels of staff and patient participation in improvement activities and increased visibility of leaders all contribute to increasing transparency, which in turn acts to hold leaders accountable for improvement. Our program theory suggests that leaders are more likely to implement Lean effectively, and adopt the desired management styles, when they themselves are empowered, having the appropriate autonomy, information, support, access to resources and access to professional development.

Lean management is predicated on high visibility and better use of better data. It requires leaders to collect and display locally relevant data using techniques such as data walls, and to design quality improvements to address the problems identified through their data. Use of the appropriate Lean tools then means that the causes of safety problems are addressed, which contributes to improved patient safety. Data also works to hold leaders accountable for safety and quality improvements.

Measurement was valued by front line, physician and leader respondents. The data generated through Lean activities was a tool seen by some leaders as a means to promote fairness in decision-making. Leaders also saw the value of measurement in providing irrefutable evidence about why change was necessary to staff and to assure themselves that change was necessary. Physicians also appreciated, and were reported by others to appreciate, the objective nature of the evidence provided by Lean activities. This is important because physician engagement was described as necessary for specific changes to be implemented and valued.

The importance of physician engagement was highlighted in the Conference Board of Canada survey as a key success factor [ 3 , 30 ]. Engaged physicians encouraged buy-in by others and modelled new behaviors, particularly for other doctors. Implications for Future Research: We hypothesize that leaders will be more supportive of Lean initiatives in a context of timely access to meaningful data relevant to their projects. Where data is difficult to access, unavailable, perceived as poor quality or challenging to obtain or collect, leader support of Lean will be compromised.

Lean seeks to create an environment in which mistakes are opportunities for learning, with consistent implementation of no-blame approaches to mistakes and errors. Argyris ; suggests that double-loop learning is essential if practitioners and organizations are to make informed decisions in ambiguous and rapidly changing contexts [ 27 , 32 ]. Single-loop learning occurs when people search for another strategy to address the error and work with, or within, the governing variables, so that extant goals, values, plans and rule are operationalized rather than questioned.

Single-loop learning typically follows pre-set routines and plans, engendering less risk for both the person and the organization and affording greater control. Some of the Lean tools, which provide highly structured ways of addressing particular problems in very specific contexts, may be considered to support single loop learning. In contrast, double-loop learning leads to questioning of the governing variables themselves, such that governing variables may be altered and a shift in strategies and consequences occurs.

The underlying philosophy of Lean and the changes it envisages to leadership style, staff empowerment and patient-centered design of services and systems involve learning of this kind. This is more challenging for many people and might be expected to take longer to evolve. Implications for Future Research: We hypothesize that leaders will support Lean to the extent that believe that they are able to make mistakes without negative consequences for their positions within the organization.

In addition to the materials on which our program theory is based, the baseline interviews revealed perspectives on a number of other matters which are likely to affect whether, where and how Lean works. Lean as a quality improvement tool was often favorably compared with previous quality improvement efforts. Past experience with quality improvement initiatives, however, made some leaders wary of investing too heavily in Lean.

Changes in behavior that are mandated in this case, by workplace expectations that employees participate in Lean activities may lead to situations in which an individual may resolve dissonance by developing a more positive appraisal of Lean than previously held. Over time and with many individuals being exposed to Lean activities, this strategy may foster organizational change.

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Both reservations — the concern about sustained implementation and that about messaging — reflect the importance of credibility of the program to ensure sustained leadership engagement in Lean implementation. Several respondents had spent vacation time engaged in Lean activities because no other time was available.

Others reported a significant amount of personal time spent working after hours because of the demands of Lean implementation. The high demands placed upon leaders can reasonably be expected to result in changes to their level of engagement and may affect sustainability of this initiative, particularly in the long term. The positive side of rapid implementation was that those who have been trained could quickly implement their skills in Lean projects and see results in a short amount of time.

Leaders who recognize that the changes brought about by Lean have a negative impact on staff workload and morale may be required to invest additional time and resources in supporting those individuals. This would be important to nurture and sustain the efforts of staff to achieving the goals of Lean. Despite the early stage of implementation at the time these interviews were conducted, a number of interviews identified short-term outcomes from the use of Lean tools. While the implementation of Lean in Saskatchewan is at an early stage, this study has generated initial hypotheses and realist program theory that can form the basis for future evaluation of Lean initiatives.

Theoretical work on learning organizations that encompasses the notion of single and double loop learning [ 27 , 32 ] has been valuable in understanding some key components of Lean implementation, although this work may also present challenges, both to the Lean implementation strategy adopted in Saskatchewan or to the program theory we have developed to represent it. As discussed above, Lean appears to involve elements of both single loop and double loop learning encompassing — perhaps — some perceived contradictions. On the one hand, Lean uses highly structured tools and generates highly structured standard work in the local setting single loop learning.

On the other, Lean aims to build a culture that is data-based, questioning and reflective, and incorporates a responsibility to challenge peers and authority figures double loop learning. The Lean implementation process in Saskatchewan similarly incorporates particular tensions: it represents a top-down attempt to build bottom up processes of improvement. This, in turn, creates inherent tensions for leaders.

On the one hand, they are required to implement Lean : its implementation is non-negotiable despite any dissatisfaction that it or the lack of additional resourcing for implementation may generate for staff. On the other, they are encouraged to empower staff albeit only in relation to particular aspects of practice and to develop more open and responsive leadership processes.

These tensions are not, in fact, irreconcilable, but they require a degree of sophistication and skill to manage, as well as the establishment of particular cultural mores. Perhaps, however, there will need to be significant changes in both leadership and staff behaviors before such attitudinal and cultural change can be observed. If this is the case, it is likely that change evolves through multiple small feedback loops a small behavior change generated through use of a particular Lean tool generates a small attitudinal change amongst participants, which provides a more enabling context for a next behavior change which enables some further attitudinal change, and so on.

If this is the case, it has significant implications for the order in which particular indicators of change should be expected and therefore the bases on which progress towards effectiveness should be judged. It also has significant implications for the processes of planning and implementation that should be encouraged to improve patient outcomes in the longer term.

This paper has dealt specifically with the changes in leadership associated with implementation of the Saskatchewan model of Lean. Much further work remains to be accomplished in examining the impact of implementation on other key groups, such as front-line workers, patients and families.

Future challenges involve examining the way Lean is or is not embedded and integrated into health care in Saskatchewan. This research project and manuscript development has been supported by the Saskatchewan Health Quality Council Contract C We acknowledge the financial support provided for this project from the Saskatchewan Health Quality Council, and the help provided by Dr. We also wish to acknowledge the contributions of participants, who took time from their very busy schedules to share their perspectives on the implementation of Lean in Saskatchewan.

Written by a Shingo Prize-winning author and Lean sensei, Lean Leadership for Healthcare: Approaches to Lean Transformation explains how to apply Lean improvement to both clinical and non-clinical processes. It presents valuable lessons learned by the author over the years of leading improvements in this complex industry and lays out a clear roadmap for initiating your Lean improvements.

Illustrating the leadership behaviors required to achieve sustainable success, the book is ideal for leaders in the healthcare industry looking to initiate Lean improvements to clinical and non-clinical processes. It reviews the fundamentals of Lean and explains how to link a strategy of continuous improvement to corporate strategy to achieve operational excellence. It also describes how to mitigate the risk of failure when undergoing large-scale corporate change—including what can go wrong and how to prevent these failures.

The book includes case studies that share the time-tested insights of healthcare team members and leaders.

Ronald Bercaw is the president of Breakthrough Horizons, LTD, a management consulting company specializing in world-class improvement through the application of the Toyota Production System, more commonly known as "Lean. Educated at Purdue University, Bercaw learned the details and disciplined applications of Lean principles, habits, and tools from both the Shingijutsu Sensei and their first generation disciples.

Working in both shop floor and above-the-shop-floor areas, He has vigorously strived to remove waste from businesses through the involvement and ideas of the people doing the work. Bercaw has consulting experience in the healthcare sector U.

Lean Leadership for Healthcare: Approaches to Lean Transformation Lean Leadership for Healthcare: Approaches to Lean Transformation
Lean Leadership for Healthcare: Approaches to Lean Transformation Lean Leadership for Healthcare: Approaches to Lean Transformation
Lean Leadership for Healthcare: Approaches to Lean Transformation Lean Leadership for Healthcare: Approaches to Lean Transformation
Lean Leadership for Healthcare: Approaches to Lean Transformation Lean Leadership for Healthcare: Approaches to Lean Transformation
Lean Leadership for Healthcare: Approaches to Lean Transformation Lean Leadership for Healthcare: Approaches to Lean Transformation
Lean Leadership for Healthcare: Approaches to Lean Transformation Lean Leadership for Healthcare: Approaches to Lean Transformation
Lean Leadership for Healthcare: Approaches to Lean Transformation Lean Leadership for Healthcare: Approaches to Lean Transformation

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