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Organisational readiness and Lean Thinking implementation: Findings from three emergency department case studies in New Zealand Gareth H Rees Health Serv Manage Res published online 7 May 2014 DOI: 10.1177/0951484814532624 The online version of this article can be found at: http://hsm.sagepub.com/content/early/2014/05/06/0951484814532624
Published by: http://www.sagepublications.com
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Health Serv Manage Res OnlineFirst, published on May 7, 2014 as doi:10.1177/0951484814532624
Primary Research
Organisational readiness and Lean Thinking implementation: Findings from three emergency department case studies in New Zealand
Health Services Management Research 0(0) 1–9 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0951484814532624 hsm.sagepub.com
Gareth H Rees
Abstract This paper describes and contrasts the implementation of Lean Thinking – a quality methodology that emphasises waste reduction and performing at higher levels of productivity with the same or less resources – into New Zealand’s healthcare system. As the field is relatively new, three literature-based exemplar cases were developed to provide an analysis framework to analyse the three New Zealand research sites, which had activities, teamwork, leadership and sustainability as its core themes. Each research site’s case was developed from primary data gathered through interviews, augmented by secondary data from project reports, District Health Board websites and media stories. The results highlight the benefits of a supportive quality-focussed organisational culture, executive management involvement and cross-functional teams as enablers. Further, work intensification and workplace resistance were also evident in varying levels within the sites. The study, while reiterating the problems of introducing quality methods from other domains into healthcare, presents the New Zealand context and reinforces that organisational preparedness as a significant factor which contributes to implementation success. This study goes beyond investigations of the use of Lean tools, changing improvement metrics and descriptive statistics to identify the contexts and variables which surround quality and process improvement implementations.
Keywords healthcare, Lean Thinking, New Zealand, organisational readiness, process improvement, quality implementation
Introduction Lean Thinking is the generic label given to the Toyota Production System’s combination of management philosophy and activities1 and it is being introduced into healthcare systems across the globe as a solution for the problems of quality and costs.2–4 In 2008, the New Zealand government introduced Lean Thinking to its health system through a series of projects, which included emergency departments (EDs). EDs have become topical for healthcare performance and quality improvement as they signal a hospital’s ability to respond to demand within the context of the worldwide phenomenon of ED overcrowding, which is due to reasons both within and outside of the organisation.5 Lean Thinking has been found to have positive impacts on both patient quality and safety in ED’s6 contributing to reductions in overcrowding by enhancing patient management and flows.7
This paper presents the experiences of three ED Lean Thinking implementations that took place in New Zealand hospitals from 2008 to 2010. Since 2008, New Zealand’s largely publically funded health care system, which delivers care to its population of 4.1 million people, has been directed to focus on frontline services, quality and service integration. Hospitals are operated by 20 democratically elected District Health Boards (DHB) to provide services to regional populations guided by a set of national performance targets. The recent changes also have resulted in the recentralisation of certain functions, including national Centre for Health Systems, Department of Preventive and Social Medicine, University of Otago, New Zealand Corresponding author: Gareth H Rees, Centre for Health Systems, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. Email: [email protected]
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oversight of information technology, workforce forecasting and system quality.8 The paper contributes to the literature, first, by adding another country’s experiences to the emerging Lean implementation literature, a country whose system has reputation for regular and wide ranging system change.8 Second, through cases developed from the extant literature that enable identification of key analytic themes, the study’s analysis extends the investigation beyond Lean tools, improvement metrics and descriptive data to include the contexts and factors that determine implementation success.9 Thus, academic insight is offered regarding the introduction of Lean tools and techniques in healthcare and provides further evidence of the importance of organisational readiness as a precursor for healthcare organisational innovation.10
Lean in healthcare The term ‘Lean’ describes the manufacturing methods used by the Toyota Motor Corporation specifying value in terms of the customer and identifying elements to maximise that value through processes such as work streams and process flows.1 Performance and quality improvement are achieved by activities or tools1 such as Plan-Do Study-Act (PDSA) improvement cycles, the 5S visual work organisation method, A3 problem solving and value stream mapping; some of which may be used as part of structured or cyclical improvement events.11 Although, as the tools were developed in the manufacturing environment, they may not be directly transferable to service industries.12 Lean provides a philosophy, a management system and a toolset for healthcare organisations to use to lessen error rates, improve quality care and reduce wait-times for patients.13 It is these processes which are credited with savings and cost reallocations.13 Improvements can be achieved by reevaluating patterns of demand and redesigning the processes and work spaces,14 which have been identified as viable alternatives to traditional hospital quality problem solving methods.7 However, despite the benefits, few healthcare institutions are undertaking systematic organisation wide Lean implementations4 with Lean many times being introduced as independent initiatives or as unconnected multiple projects.15 Introducing Lean to a healthcare environment requires a certain sensitivity to the interplay between the operational and professional domains in healthcare.16 Similarly, unlike value identification in manufacturing, healthcare customer value depends on who the customer is9 and the customer’s expectation of value is then dependant on their identity and position within the health system.17 As a result, Lean efforts in
hospitals may not be directed towards organisational performance objectives, but more pragmatically to those outcomes with which most actors can align.17 It is therefore preferable that Lean is part of an organisation’s strategy leading to sustainable continuous improvement.18 Moreover, Lean should not be used as a cost elimination methodology,18 particularly if the organisation is seeking cost control rather than service innovation or improvement14 – for in times of financial constraint, it can be difficult for healthcare leaders to change their view of their workplace’s systems.19 Managers and staff implementing Lean should receive training not only to be able to undertake the new techniques but also to prevent a return to their past behaviours.20 Lean healthcare is generally executed by teams operating in a participative environment and organised across administrative or functional boundaries.21,22 The role and the style of a Lean team leader are required to be more functional than authoritarian utilising facilitation skills and creating a climate of encouragement23,24 by mitigating power differentials between staff to ensure inclusion, encouraging innovation and sustaining new work routines.22 These attributes are more important since the ‘hero clinician’ is less relevant as patient pathways become the operational norm.21,24 Top management and leadership,25,18 as well as the engagement of the hospital’s senior doctors,26 provide vital support to Lean initiatives. However, clinical engagement may be restricted to those who have been ‘converted to Lean’27,p.1339 or to occupational groups whose work organising principles are similar to Lean approaches.19,22 There are few reports that include the examination of Lean’s effects on the health workforce23 or its contribution to the intensification of work as found in manufacturing.28 Although O’Donnell29 and Willis30 found indications of work intensification in organisations following some Australian Lean healthcare implementations, Waring and Bishop27 provide insight into the issues of social organising within a UK hospital.
Research context As Lean Thinking has only recently been introduced into the New Zealand healthcare system, it is relevant to seek to understand how it is being implemented as New Zealand EDs. By uncovering the outcomes and by situating the implementation within the hospital’s contexts the factors for success can be determined.9 To provide an analysis theme and the framework for content analysis and to enable transferability of findings, three exemplar cases were composed from the literature. These exemplars, Virginia Mason Medical Centre, Seattle, USA, Royal Bolton Hospital, Bolton,
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UK and Flinders Hospital, Adelaide, Australia, were chosen due to their frequency of appearance and referral in the general Lean healthcare literature and having become known as ‘celebrated examples’.9,p.364 The exemplar cases were analysed using content analysis, a research method that enables researchers to make valid inferences from text,31 resulting in a set of implementation indicators, which are summarised in Table 1. These indicators appear later in the results section, where they are used as the study’s analytic themes.
Research method The case study is a methodology that lends itself to examining new phenomena,32 using quantitative and qualitative data to develop an answer to a given research question – particularly when a ‘how’ or ‘why’ question is being posed.33 A weakness of the case study method is the difficulty to generalise the results into other cases or situations;33 in particular, a situation that exists for healthcare quality,3 leading authors suggest more rigorous research to expand on the exploratory and descriptive nature of the Lean healthcare cases published so far.2,3,23 For this study, three ED sites from three different DHBs were used. Table 2 provides outlines of the case study sites and the outcomes of their Lean activities. The study’s approach and instruments were tested at Site A to validate the analytic themes in terms of
their relevance to New Zealand’s hospital system and to provide improved confidence for case replication.33 Secondary data were gathered from a range of sources and were used to triangulate aspects of the implementations, their foci and evidence of process improvement. Hospital statistics and population data were found in national health reports, DHB annual reports and from the respective DHB websites. Summary and periodic progress reports of the implementations provided details of the activities, timelines, outputs and efficiency measures. Internal memos and staff newsletters provided additional evidence surrounding implementation progress. Primary data collection consisted of a series of semistructured interviews that were conducted with respondents at each site. A total of 28 interviews were undertaken. Access was gained through a key site respondent, who assisted with scheduling respondent interviews, provided access to internal data and introduced the researcher to the respondents. Respondents were selected from the pool of staff involved with the Lean implementations to provide some symmetry of occupation and numbers across the sites. Respondents were provided with alpha numeric codes to ensure anonymity. Table 3 provides respondent data. No approached respondents refused to take part in the ethically approved research project. Respondents who were unable to attend the scheduled interviews were later contacted by telephone and interviewed using
Table 1. Lean implementation indicators identified from the three exemplar cases. Activities undertaken
Leadership involvement
Team development
Sustainability
Similar Lean tools were used across the sites, including PDSA cycles, value stream mapping, 5S and standardisation of work and processes. Tools and measures were adjusted or amended to better calculate and monitor changes of hospital processes.
There was an identified problem and an agreed commitment to have it addressed by not using or continuing to use the tools and techniques that were failing to deliver. The requirement for new skills and knowledge coupled with new orientations for managers or supervisors was also alluded to. Visible affirmation by senior leadership was a case feature as with the acknowledgement that to improve work or processes is achieved by those who do the work and know it best. The changes were led from the top and once agreed upon were implemented.
Outside support and technical input assisted the initial stages of implementation. An internal team was tasked with facilitating and developing staff awareness and understanding assisting with training and dissemination. Teamwork and the involvement of all staff to redesign processes and provide insights into waste and improved flow that improves acceptance of Lean and change and optimises interpersonal and professional relationships. It is acknowledged that organisational change is not easy to achieve.
A key feature of the cases was the implementation to effect continuous improvement, by either setting a cycle or programming for the next unit on the patient journey to undertake Lean activities. Progressing Lean across the organisation to capture the patient journey end to end, with the units undertaking Lean activities as part of their daily work. The importance of a new culture, with all of the cases branding ‘their’ improvement methodology.
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Table 2. Summary of case study organisations and Lean activities. Hospital
Organisation type
Lean activities
Site A
A 388-bed hospital providing secondary and tertiary services. 21-bed ED ED volume 37,000 per annum with a 25–30% admission rate (11,100) Mainly urban population
Site B
A 260-bed hospital providing secondary and tertiary services. 14-bed ED. ED volume 40,000 per annum with a 23% admission rate (9200). Mainly urban population. A 200-bed regional hospital providing secondary services. 14-bed ED. Ed volume 28,000 with 30% admission rate (8400). Mix of rural urban population.
X-ray pathway: Before: 0:44 h. After: 0:26 h. Fast Track low acuity stream: Before: 3:20 h. After: (November 2008) 2:16 h: (May 2010): 1:56 h. Reduced non-urgent ED attendances. Reduced Rework and checking Pharmaceutical savings. New procedures developed. Patient admission/transfer times. Before >1:00 h. After (average)
Organisational readiness and Lean Thinking implementation: Findings from three emergency department case studies in New Zealand Gareth H Rees Health Serv Manage Res published online 7 May 2014 DOI: 10.1177/0951484814532624 The online version of this article can be found at: http://hsm.sagepub.com/content/early/2014/05/06/0951484814532624
Published by: http://www.sagepublications.com
Additional services and information for Health Services Management Research can be found at: Email Alerts: http://hsm.sagepub.com/cgi/alerts Subscriptions: http://hsm.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - May 7, 2014 What is This?
Downloaded from hsm.sagepub.com at UNIV OF NEW MEXICO on November 27, 2014
XML Template (2014) [29.4.2014–12:30pm] //blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/HSMJ/Vol00000/140006/APPFile/SG-HSMJ140006.3d
(HSM)
[1–9] [PREPRINTER stage]
Health Serv Manage Res OnlineFirst, published on May 7, 2014 as doi:10.1177/0951484814532624
Primary Research
Organisational readiness and Lean Thinking implementation: Findings from three emergency department case studies in New Zealand
Health Services Management Research 0(0) 1–9 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0951484814532624 hsm.sagepub.com
Gareth H Rees
Abstract This paper describes and contrasts the implementation of Lean Thinking – a quality methodology that emphasises waste reduction and performing at higher levels of productivity with the same or less resources – into New Zealand’s healthcare system. As the field is relatively new, three literature-based exemplar cases were developed to provide an analysis framework to analyse the three New Zealand research sites, which had activities, teamwork, leadership and sustainability as its core themes. Each research site’s case was developed from primary data gathered through interviews, augmented by secondary data from project reports, District Health Board websites and media stories. The results highlight the benefits of a supportive quality-focussed organisational culture, executive management involvement and cross-functional teams as enablers. Further, work intensification and workplace resistance were also evident in varying levels within the sites. The study, while reiterating the problems of introducing quality methods from other domains into healthcare, presents the New Zealand context and reinforces that organisational preparedness as a significant factor which contributes to implementation success. This study goes beyond investigations of the use of Lean tools, changing improvement metrics and descriptive statistics to identify the contexts and variables which surround quality and process improvement implementations.
Keywords healthcare, Lean Thinking, New Zealand, organisational readiness, process improvement, quality implementation
Introduction Lean Thinking is the generic label given to the Toyota Production System’s combination of management philosophy and activities1 and it is being introduced into healthcare systems across the globe as a solution for the problems of quality and costs.2–4 In 2008, the New Zealand government introduced Lean Thinking to its health system through a series of projects, which included emergency departments (EDs). EDs have become topical for healthcare performance and quality improvement as they signal a hospital’s ability to respond to demand within the context of the worldwide phenomenon of ED overcrowding, which is due to reasons both within and outside of the organisation.5 Lean Thinking has been found to have positive impacts on both patient quality and safety in ED’s6 contributing to reductions in overcrowding by enhancing patient management and flows.7
This paper presents the experiences of three ED Lean Thinking implementations that took place in New Zealand hospitals from 2008 to 2010. Since 2008, New Zealand’s largely publically funded health care system, which delivers care to its population of 4.1 million people, has been directed to focus on frontline services, quality and service integration. Hospitals are operated by 20 democratically elected District Health Boards (DHB) to provide services to regional populations guided by a set of national performance targets. The recent changes also have resulted in the recentralisation of certain functions, including national Centre for Health Systems, Department of Preventive and Social Medicine, University of Otago, New Zealand Corresponding author: Gareth H Rees, Centre for Health Systems, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. Email: [email protected]
Downloaded from hsm.sagepub.com at UNIV OF NEW MEXICO on November 27, 2014
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oversight of information technology, workforce forecasting and system quality.8 The paper contributes to the literature, first, by adding another country’s experiences to the emerging Lean implementation literature, a country whose system has reputation for regular and wide ranging system change.8 Second, through cases developed from the extant literature that enable identification of key analytic themes, the study’s analysis extends the investigation beyond Lean tools, improvement metrics and descriptive data to include the contexts and factors that determine implementation success.9 Thus, academic insight is offered regarding the introduction of Lean tools and techniques in healthcare and provides further evidence of the importance of organisational readiness as a precursor for healthcare organisational innovation.10
Lean in healthcare The term ‘Lean’ describes the manufacturing methods used by the Toyota Motor Corporation specifying value in terms of the customer and identifying elements to maximise that value through processes such as work streams and process flows.1 Performance and quality improvement are achieved by activities or tools1 such as Plan-Do Study-Act (PDSA) improvement cycles, the 5S visual work organisation method, A3 problem solving and value stream mapping; some of which may be used as part of structured or cyclical improvement events.11 Although, as the tools were developed in the manufacturing environment, they may not be directly transferable to service industries.12 Lean provides a philosophy, a management system and a toolset for healthcare organisations to use to lessen error rates, improve quality care and reduce wait-times for patients.13 It is these processes which are credited with savings and cost reallocations.13 Improvements can be achieved by reevaluating patterns of demand and redesigning the processes and work spaces,14 which have been identified as viable alternatives to traditional hospital quality problem solving methods.7 However, despite the benefits, few healthcare institutions are undertaking systematic organisation wide Lean implementations4 with Lean many times being introduced as independent initiatives or as unconnected multiple projects.15 Introducing Lean to a healthcare environment requires a certain sensitivity to the interplay between the operational and professional domains in healthcare.16 Similarly, unlike value identification in manufacturing, healthcare customer value depends on who the customer is9 and the customer’s expectation of value is then dependant on their identity and position within the health system.17 As a result, Lean efforts in
hospitals may not be directed towards organisational performance objectives, but more pragmatically to those outcomes with which most actors can align.17 It is therefore preferable that Lean is part of an organisation’s strategy leading to sustainable continuous improvement.18 Moreover, Lean should not be used as a cost elimination methodology,18 particularly if the organisation is seeking cost control rather than service innovation or improvement14 – for in times of financial constraint, it can be difficult for healthcare leaders to change their view of their workplace’s systems.19 Managers and staff implementing Lean should receive training not only to be able to undertake the new techniques but also to prevent a return to their past behaviours.20 Lean healthcare is generally executed by teams operating in a participative environment and organised across administrative or functional boundaries.21,22 The role and the style of a Lean team leader are required to be more functional than authoritarian utilising facilitation skills and creating a climate of encouragement23,24 by mitigating power differentials between staff to ensure inclusion, encouraging innovation and sustaining new work routines.22 These attributes are more important since the ‘hero clinician’ is less relevant as patient pathways become the operational norm.21,24 Top management and leadership,25,18 as well as the engagement of the hospital’s senior doctors,26 provide vital support to Lean initiatives. However, clinical engagement may be restricted to those who have been ‘converted to Lean’27,p.1339 or to occupational groups whose work organising principles are similar to Lean approaches.19,22 There are few reports that include the examination of Lean’s effects on the health workforce23 or its contribution to the intensification of work as found in manufacturing.28 Although O’Donnell29 and Willis30 found indications of work intensification in organisations following some Australian Lean healthcare implementations, Waring and Bishop27 provide insight into the issues of social organising within a UK hospital.
Research context As Lean Thinking has only recently been introduced into the New Zealand healthcare system, it is relevant to seek to understand how it is being implemented as New Zealand EDs. By uncovering the outcomes and by situating the implementation within the hospital’s contexts the factors for success can be determined.9 To provide an analysis theme and the framework for content analysis and to enable transferability of findings, three exemplar cases were composed from the literature. These exemplars, Virginia Mason Medical Centre, Seattle, USA, Royal Bolton Hospital, Bolton,
Downloaded from hsm.sagepub.com at UNIV OF NEW MEXICO on November 27, 2014
XML Template (2014) [29.4.2014–12:30pm] //blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/HSMJ/Vol00000/140006/APPFile/SG-HSMJ140006.3d
(HSM)
[1–9] [PREPRINTER stage]
Rees
3
UK and Flinders Hospital, Adelaide, Australia, were chosen due to their frequency of appearance and referral in the general Lean healthcare literature and having become known as ‘celebrated examples’.9,p.364 The exemplar cases were analysed using content analysis, a research method that enables researchers to make valid inferences from text,31 resulting in a set of implementation indicators, which are summarised in Table 1. These indicators appear later in the results section, where they are used as the study’s analytic themes.
Research method The case study is a methodology that lends itself to examining new phenomena,32 using quantitative and qualitative data to develop an answer to a given research question – particularly when a ‘how’ or ‘why’ question is being posed.33 A weakness of the case study method is the difficulty to generalise the results into other cases or situations;33 in particular, a situation that exists for healthcare quality,3 leading authors suggest more rigorous research to expand on the exploratory and descriptive nature of the Lean healthcare cases published so far.2,3,23 For this study, three ED sites from three different DHBs were used. Table 2 provides outlines of the case study sites and the outcomes of their Lean activities. The study’s approach and instruments were tested at Site A to validate the analytic themes in terms of
their relevance to New Zealand’s hospital system and to provide improved confidence for case replication.33 Secondary data were gathered from a range of sources and were used to triangulate aspects of the implementations, their foci and evidence of process improvement. Hospital statistics and population data were found in national health reports, DHB annual reports and from the respective DHB websites. Summary and periodic progress reports of the implementations provided details of the activities, timelines, outputs and efficiency measures. Internal memos and staff newsletters provided additional evidence surrounding implementation progress. Primary data collection consisted of a series of semistructured interviews that were conducted with respondents at each site. A total of 28 interviews were undertaken. Access was gained through a key site respondent, who assisted with scheduling respondent interviews, provided access to internal data and introduced the researcher to the respondents. Respondents were selected from the pool of staff involved with the Lean implementations to provide some symmetry of occupation and numbers across the sites. Respondents were provided with alpha numeric codes to ensure anonymity. Table 3 provides respondent data. No approached respondents refused to take part in the ethically approved research project. Respondents who were unable to attend the scheduled interviews were later contacted by telephone and interviewed using
Table 1. Lean implementation indicators identified from the three exemplar cases. Activities undertaken
Leadership involvement
Team development
Sustainability
Similar Lean tools were used across the sites, including PDSA cycles, value stream mapping, 5S and standardisation of work and processes. Tools and measures were adjusted or amended to better calculate and monitor changes of hospital processes.
There was an identified problem and an agreed commitment to have it addressed by not using or continuing to use the tools and techniques that were failing to deliver. The requirement for new skills and knowledge coupled with new orientations for managers or supervisors was also alluded to. Visible affirmation by senior leadership was a case feature as with the acknowledgement that to improve work or processes is achieved by those who do the work and know it best. The changes were led from the top and once agreed upon were implemented.
Outside support and technical input assisted the initial stages of implementation. An internal team was tasked with facilitating and developing staff awareness and understanding assisting with training and dissemination. Teamwork and the involvement of all staff to redesign processes and provide insights into waste and improved flow that improves acceptance of Lean and change and optimises interpersonal and professional relationships. It is acknowledged that organisational change is not easy to achieve.
A key feature of the cases was the implementation to effect continuous improvement, by either setting a cycle or programming for the next unit on the patient journey to undertake Lean activities. Progressing Lean across the organisation to capture the patient journey end to end, with the units undertaking Lean activities as part of their daily work. The importance of a new culture, with all of the cases branding ‘their’ improvement methodology.
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Table 2. Summary of case study organisations and Lean activities. Hospital
Organisation type
Lean activities
Site A
A 388-bed hospital providing secondary and tertiary services. 21-bed ED ED volume 37,000 per annum with a 25–30% admission rate (11,100) Mainly urban population
Site B
A 260-bed hospital providing secondary and tertiary services. 14-bed ED. ED volume 40,000 per annum with a 23% admission rate (9200). Mainly urban population. A 200-bed regional hospital providing secondary services. 14-bed ED. Ed volume 28,000 with 30% admission rate (8400). Mix of rural urban population.
X-ray pathway: Before: 0:44 h. After: 0:26 h. Fast Track low acuity stream: Before: 3:20 h. After: (November 2008) 2:16 h: (May 2010): 1:56 h. Reduced non-urgent ED attendances. Reduced Rework and checking Pharmaceutical savings. New procedures developed. Patient admission/transfer times. Before >1:00 h. After (average)
