Lean toolkit

The Lean toolkit has been discussed extensively in the medical literature, but can be summarised as a focus on the identification and elimination of waste from healthcare delivery processes. Waste is defined as any product or activity that does not add value for the patient.6 ,7 Processes are standardised, and variability is reduced through dedicated ‘Kaizen’ quality improvement activities and Plan-Do-Study-Act cycles. Lean tools supporting these efforts include Value Stream Maps, Andon indicators for process control, Kanban cards for inventory control, and Jidoka or human supervised automation.5 ,8 These Lean tools and events can lead to significant improvements in processes throughout the healthcare enterprise.9–11 However, the Lean toolkit alone is insufficient for transformational change leading to sustainable success in improving quality and lowering costs.

Management system

Success in improving quality in a healthcare organisation requires the understanding that quality improvement should not exist as an isolated silo or add-on, but must be the foundation for all management activities, including day-to-day operations. By identifying VMPS as a management system early on, we took ‘project based’, ‘opt-in/opt-out’, off the table. All activities from supply chain to operative procedures to primary care visits are based on VMPS value streams, and changes are effected through Lean process improvement workshops and activities. In effect, all management activities are focused on quality improvement; doing the work becomes inseparable from improving the work. This required development of an educational infrastructure to train providers and staff at all levels complemented by a quality improvement division of specialists with deep expertise and full-time work focusing on improvement. It should be emphasised, however, that the quality improvement specialists do not work in isolation but rather in collaboration with operational leaders who have also been through VMPS training.

As an example, to enable important early fluid resuscitation in patients with sepsis, we held a VMPS 2-day improvement event physically on an intermediate care unit, with front-line nurses, physicians and quality improvement specialists together contributing to immediate changes. By the conclusion of the event, the changes had become part of day-to-day operations, with the improvement team now being the management team using the Lean toolkit for implementation. In this way, having VMPS as a management system provides the continuity to help address the challenge of sustaining improvements.

Not every improvement proceeds from a formal workshop. Fundamental to VMPS is empowerment of and respect for the front line workers, who are uniquely positioned to inspect for quality and contribute improvement ideas. Leaders are expected to convene daily team huddles on the work floor allowing for constructive bidirectional feedback. Further, all employees undergo basic Lean training, starting on the first day of work. It is not unusual to overhear conversations between staff, such as two transporters in the elevator talking about mistake-proofing their work.

Institutional culture

Institutional culture is critically important12 and probably the most elusive aspect of VMPS. Foundational to institutional culture is the shared vision that value to the patient is the focus of all activities. This does not mean simply that care is respectful and responsive to individuals, but rather, that all measures of quality (including efficiency, effectiveness, equity, safety, timeliness and outcomes)3 are viewed from the perspective of the patient. In reality, most healthcare delivery is built around the needs of the doctors, nurses and managers, rather than around the needs of the patients. The simplest example of this is patient waiting rooms. Worldwide, we spend hundreds of millions of dollars building waiting rooms, so that patients can hurry up, be on time and wait for us in what are, in essence, large holding tanks. This extreme waste from the Lean perspective is the antithesis of efficient and timely care from the patient's perspective and representative of the scale of transformation required to truly become ‘patient driven’ in healthcare. Through VMPS, we have achieved incremental and breakthrough tangible gains in redesigning care around our patients, including opening a clinic with no waiting rooms, and reconstructing our care delivery for conditions like low back pain, headache and breast concerns around same day access and patient needs. Celebrating these patient-focused gains within the organisation reinforces the VMPS institutional culture.

Physician culture at VM also had to adapt to the VMPS. Traditional models of healthcare delivery that feature physician hierarchies separate from that of nurses, support staff and administrative personnel, do not support efficient patient-focused care. Customary physician expectations of autonomy, protection and entitlement can conflict with care quality, safety and patient-centeredness. To address physician culture, we engaged in a year process led by front-line physicians to formulate a new physician compact, a reciprocal agreement between providers and the organisation.13 Provider's responsibilities include implementing evidence-based practice, respecting all team members, and willingly embracing innovation and organisational change. Organisational responsibilities include providing tools and information necessary to improve practice, supporting career development and professional satisfaction, and being transparent about organisational priorities and business decisions. The compact defines the relationship between organisation and physicians and is incorporated into provider orientation, performance management and annual review.

Cultural change is not rapid, and requires constant commitment from leadership. Not everyone at VM was initially accepting of VMPS, and evolution in the institutional culture required time. There was resistance, particularly early on, to change in general, and to the concept of using a manufacturing approach in healthcare, as ‘patients are not cars.’ Acceptance increased gradually, prompted by trips to Japan and other industry visits for many leaders, and by gradually increasing visibility of VMPS successes. A small number of providers left as a consequence of VMPS, but at the same time, others came to VM specifically because of the institutional focus on quality and safety.

Leadership for implementation

Leadership is required for a quality healthcare system. At its core, quality improvement is about change, and the large-scale and transformational changes required in healthcare can only be achieved with active, unwavering leadership. At Virginia Mason, the entire executive team, including the board of directors is required to undergo deep training in VMPS, and to participate in training trips to Japan for in-depth study of Toyota and other Lean companies. All leaders undergo formal training in VMPS, and are expected to use the tools to lead events and to support teams, through daily management. This ensures consistency in leadership throughout the institution, that is not dependent on any one individual.

VMPS also requires leaders to move from the ‘hero mentality’ of problem solvers to being coaches who build learning teams that use VMPS for long-term improvement. This implies a change from the usual physician or administrative leadership model with its silos and advocacy for one's own chain of control to transparency and systems-thinking. At Virginia Mason, we developed a uniform ‘standard work for leaders,’ a series of tools and processes designed to improve communication between leaders and staff (daily huddles and leadership rounds), to increase the visibility of the daily work and goals (production boards and visual controls), to enable early identification of problems in daily work (dashboards and root cause analysis), and to improve accountability of leaders and staff (leadership checklists and Genba observations). All leaders learn standard work for leaders as part of their VMPS training, and the uniform application of these tools promotes transparency and accountability. As a consequence, teams learn to identify and solve problems on their own, and leaders become managers of the system rather than problem solvers. The visibility of leaders deploying VMPS also contributes to the institutional culture.

Our journey was not without challenges. Early on, we focused too much on the Lean toolkit, and teams equated success with use of the tools alone. This misinterpretation led to overzealous regimentation by a few managers. We also overestimated the scale of change from a quality improvement event, expecting instant transformation rather than iterative improvement. Finally, we underestimated the challenges in leading people through change. Simply developing solutions in Lean quality improvement events did not equate with long-term improvements. Instead, to implement and sustain improvements, we rely on the key strategies discussed above throughout the institution (table 1).