ADOPTION AND IMPLEMENTATION OFLEAN PHILOSOPHY, PRACTICES AND

TOOLS IN U.S. HOSPITALS

CENTER FOR LEAN ENGAGEMENT AND RESEARCH IN HEALTHCARE (CLEAR) SCHOOL OF PUBLIC HEALTH

UNIVERSITY OF CALIFORNIA, BERKELEY

INVESTIGATORS

Thomas Rundall, PhDHenry J. Kaiser Professor of Organized Health Systems, EmeritusCo-Director, Center for Lean Engagement and Research in Healthcare (CLEAR)

Janet Blodgett, MScProject Manager and Data Analyst, Center for Lean Engagement and Research in Healthcare (CLEAR)

Stephen Shortell, PhD, MBA, MPH Blue Cross of California Professor of Health Services Research, EmeritusCo-Director, Center for Lean Engagement and Research in Healthcare (CLEAR)

ACKNOWLEDGEMENTS

Research support was provided by:• PETER KRALOVEC

EXECUTIVE DIRECTOR, AHA HEALTHCARE DATA CENTER

Funding for this research was provided by:• CATALYSIS• THE LEAN ENTERPRISE INSTITUTE• RONA CONSULTING GROUP/MOSS ADAMS

DISCLOSURES

• CLEAR receives funding from Catalysis• CLEAR receives funding from The Lean Enterprise Institute• CLEAR receives funding from Rona Consulting Group/Moss Adams• Dr. Shortell serves on the Catalysis Advisory Board• Dr. Rundall serves on the Board of Directors of John Muir Health

STUDY PURPOSE

• There is growing interest in hospitals’ application of lean management practices and tools

• There is no national data on the extent of lean adoption and implementation in hospitals

• The purpose of this study is to assess the extent to which lean management philosophy, practices and tools have been adopted and implemented in U.S. hospitals

METHODS• On-line survey of 4,500 non-federal, short-term, acute-care medical

and surgical hospitals in the United States, including pediatric general and medical hospitals

• Survey was designed to assess dimensions of the adoption and use of lean philosophy, practices, and tools described in relevant books and articles and in consultation with our strategic advisory council members

• The instrument went through multiple revisions based on feedback from pilot testing with 12 practicing lean performance improvement specialists

METHODS

• Adoption of lean management

• Extent of current use of lean management

• Model Cells• General hospital policies and

practices with respect to lean• Central improvement team• Daily management system

• Tools and methods used• Finance department• Human resources department• Information technology

department• Lean training and staffing• Self-reported performance

improvements attributable to lean

Major topics covered by survey questions

METHODS

• USPS letter with the survey’s login information was sent April 24, 2017 by the AHA to hospital CEOs with request that an appropriate staff member complete the survey

• Letter was signed by Dr. Jay Bhatt, CMO of the American Hospital Association and Dr. Stephen Shortell, Professor of Health Policy and Management, UC Berkeley

• Email reminder communications sent to the CEOs of all non-responding hospitals on May 15, June 15, July 18 (with a copy to the CMO), and August 1st

METHODS• From 6/28 – 9/8 phone calls were made to the executive and quality

department offices of multi-hospital systems asking that they encourage their hospitals to complete the survey; voice mail messages left if no answer

• All state hospitals associations received a copy of the survey along with the original cover letter, were asked to encourage hospitals to complete survey

• Hospital leaders in CA, MN, WI, and OH personally contacted the executive offices of hospitals in those states to request completion of the survey

Final date for receipt of completed surveys was September 11, 2017• Respondent sample size = 1222• Response rate = 27%

COMPARISON OF RESPONDING WITH NON-RESPONDING HOSPITALSHospital characteristic Categories Responding hospitals

(n = 1,222) n (%)

Non-responding hospitals (n = 3,278)

n (%)

Type of authority* Public 288 (23.7%) 704 (21.6%)Not-for-profit 830 (68.4%) 1928 (59.2%)Investor-owned 96 (7.9%) 623 (19.1%)

System member? Yes 751 (61.5%) 2061 (62.9%)Core-based statistical area type Metro (urban ≧ 50,000 people) 699 (57.6%) 1916 (58.9%)

Micro (urban 10,000 - 50,000 people) 208 (17.1%) 553 (17.0%)Rural 307 (25.3%) 786 (24.1%)

Medical school affiliation?* Yes 391 (32.2%) 837 (25.7%)Member of Council of Teaching Hospitals?* Yes 107 (8.8%) 150 (4.6%)Region* Midwest 317 (26.1%) 724 (22.2%)

Northeast 131 (10.8%) 418 (12.8%)South 470 (38.7%) 1528 (46.9%)West 296 (24.4%) 585 (18.0%)

Bed size* 1-99 beds 569 (46.9%) 1664 (51.1%)100-399 beds 481 (39.6%) 1298 (39.9%)400 or more beds 164 (13.5%) 293 (9.0%)

* p < .05 in Pearson's Chi-sqared test

IS YOUR HOSPITAL CURRENTLY ENGAGED IN ANY OF THE FOLLOWINGTRANSFORMATIONAL PERFORMANCE IMPROVEMENT APPROACHES?

WHICH, IF ANY, OF THE FOLLOWING TRANSFORMATIONAL PERFORMANCE IMPROVEMENTAPPROACHES IS THE PRIMARY APPROACH USED IN YOUR HOSPITAL TO IMPROVE QUALITY, SAFETY,

EFFICIENCY, AND PATIENT SATISFACTION?

WHEN DID YOUR HOSPITAL FIRST BEGIN IMPLEMENTING LEAN?

• N = 778• Mean number of years since implementation: 5.2

• Standard Deviation: 3.6• Range: 0-22.5

WHICH OF THE STATEMENTS BELOW BEST DESCRIBES THE APPROACHUSED IN YOUR HOSPITAL TO BEGIN LEAN IMPLEMENTATION?

Approach N PercentSome elements hospital-wide 296 36.9%Some elements in a small number of departments 326 40.6%Some elements in a single department 48 6.0%Comprehensive DMS hospital-wide 91 11.3%Comprehensive DMS in a small number of departments 29 3.6%Comprehensive DMS in a single department 13 1.6%

DID YOUR HOSPITAL INITIATE ITS USE OF LEAN WITH ONE OR MOREMODEL CELLS?

• Yes: 542 (66.9%)• No: 268 (33.1%)

AT THIS POINT IN TIME, WHICH OF THE STATEMENTS BELOW BEST DESCRIBES YOUR HOSPITAL'SJOURNEY TOWARD OVERALL TRANSFORMATIONAL PERFORMANCE IMPROVEMENT?

WHICH OF THE FOLLOWING HOSPITAL UNITS ARE CURRENTLYUSING THE PRINCIPLES AND TOOLS OF LEAN?

Of all 29 units presented• Mean (SD): 14.2 (7.3)• Range: 0-29

HAS YOUR HOSPITAL DEVELOPED A VISION FOR ITS FUTURE THAT ISUSED AS THE "TRUE NORTH" FOR ITS LEAN TRANSFORMATION?

• Yes: 451 (58.6%)• No: 319 (41.4%)

GENERAL HOSPITAL POLICIES AND PRACTICES WITH REGARD TO LEAN

DOES YOUR HOSPITAL OR THE SYSTEM TO WHICH YOUR HOSPITAL BELONGSHAVE A CENTRAL IMPROVEMENT TEAM OR EQUIVALENT GROUP?

• Yes: 581 (75.5%)• No: 189 (24.5%)

WHICH OF THE FOLLOWING ACTIVITIES DO LEADERS ROUTINELY DO?

TO WHAT EXTENT HAS YOUR HOSPITAL IMPLEMENTED EACH OF THEFOLLOWING TOOLS AND METHODS?

APPROXIMATELY, WHAT PERCENTAGE OF YOUR HOSPITAL'S STAFF HAVE BEENTRAINED IN SCIENTIFIC APPROACHES TO PROBLEM SOLVING, SUCH AS THE USE

OF PLAN-DO-STUDY-ACT (PDSA) CYCLES?

PLEASE SELECT THE ANSWER CHOICE THAT BEST REPRESENTS YOURHOSPITAL'S STAFFING RELATED TO PERFORMANCE IMPROVEMENT (PI)

Staffing plan N PercentNo performance improvement staffing plan has been identified 88 11.9%Initial lean performance improvement staffing requirements have been identified

40 5.4%

PI trained staff members are leading A FEW improvement initiatives 263 35.5%PI trained staff members are leading MANY improvement initiatives 232 31.4%PI trained staff members are leading MOST improvement initiatives 117 15.8%

WHAT, IF ANY, PERFORMANCE ACHIEVEMENTS IN YOUR ORGANIZATIONCAN BE PRIMARILY ATTRIBUTED TO IMPLEMENTATION OF LEAN?

Of 16 achievements presented• Mean (SD): 9.0 (4.0)• Range: 0-16

NEXT STEPS

• Adding data on each hospital’s performance on processes of care, patient outcomes, and operational efficiency (hospital-wide, ER, and OR) from Hospital Compare, Medicare Cost Report, and AHRQ publicly available data sets

• Constructing indices of the central improvement team, maturity/comprehensiveness of lean implementation, use of a daily management system, the strength of development of the 4Ps, leadership commitment to lean, lean training and staffing, and other characteristics of lean deployment in hospitals

• Conducting analyses of the associations among the characteristics of lean deployment and hospital performance

• Identifying potential strategies to increase the beneficial effects of lean deployment on hospital performance

• Delivering presentations at conferences and meetings, webinars, and journal articles to relevant audiences

THANK YOU!

Stephen Shortellshortell@berkeley.edu

Janet Blodgettjanet.blodgett@berkeley.edu

Thomas Rundalltrundall@berkeley.edu