Health Services Research & Development

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Commentary

In its landmark report, “Crossing the Quality Chasm: A New Health System for the 21st Century” the Institute of Medicine (IOM) provided a framework for the development of an improved U.S. health care delivery system. The IOM based this framework on the key tenets of providing health care services that are safe, effective, patient-centered, timely, efficient, and equitable.

In the more than 13 years since publication of the IOM report, enterprise-level deployment of the U.S. translation of the Toyota Production System—widely known as ‘Lean Enterprise Transformation’—has been promoted as a means of transforming health care organizations. Much of this movement is a direct result of the success of Lean transformation efforts within manufacturing companies (Toyota, Ford, Dell) and the highly publicized application of these methods within key health care organizations (Thedacare, Virginia Mason, Denver Health).

However, the implementation of Lean enterprise methods within health care systems often fails to result in long-term, sustained organizational transformation. In fact, according to a 2009 study by the American Society for Quality, it seems that failure is much more likely than success. Researchers have found that the application of Lean in the health care sector often fails when implementation focuses on limited application of Lean tools and methods with little or no emphasis on the cultural transformation necessary to sustain results over time. Furthermore, as one of the basic tenets of the Toyota Production System is maximizing value for the customer, the complexity of the health care value proposition may limit the direct translation of Lean strategies, and impact sustainability and diffusion of these strategies throughout health care systems.1

Why is the value proposition within health care so complex? As is the case within other service industries, the definition of value within health care is based on the experience of the customers (both patient and staff) as they engage with health care systems and processes. Thus, value is often dependent on an individual’s norms, attitudes, and beliefs, which may change over time. This evolution requires continuous assessment and improvement of systems and processes to ensure that the potential for the customer to extract value from the system is optimized. Additionally, organizations must assess and manage any tension between customer expectations and other aspects of patient care to ensure that the basic tenets of safe and high quality care are not violated.

Given these challenges, it becomes clear that the large-scale deployment of Lean enterprise strategies within health care systems requires translation of the existing evidence base into deployment models that are health care-based, support continuous improvement of processes and systems, and are established on the foundational elements of patient safety and high quality of care. This is a critical concept; if clinicians feel safety is being sacrificed for efficiency, cynicism and resistance will follow.

In 2012, the VA Center for Applied Systems Engineering (VA-CASE) initiated a formal review of the strategies utilized by multiple U.S. health care organizations that have been recognized as successful in enterpriselevel transformation through the application of Lean transformation efforts.2 The review found that successful organizations utilized dynamic deployment cycles with a focus on three strategies key to their transformation efforts: (1) respect for people; (2) strategic alignment; and (3) strategic deployment. These three strategies are often bundled together under the term "Lean Management System."

How do these strategies work together to enable transformation? An organizational culture supporting respect for people ensures that internal capacity and capability is developed at the staff, mid-management and leadership levels, thereby enabling continuous focus on creating and maintaining value for both patients and employees. Strategic alignment methods provide transparency throughout the organization with respect to goals and metrics. A balanced portfolio between large-scale, system-level initiatives and small-scale, unit-level initiatives ensures that program results are sustained without significantly increased complexity. Strategic deployment mechanisms (such as daily improvement huddles and area improvement centers) ensure that the transformational initiatives are tangible and relevant to the front-line staff members and support continuous daily improvement of processes.

Based on these findings, the VA Center for Applied Systems Engineering developed a VHA translation of the Lean Management Systems and initiated deployments in six VHA Healthcare Systems in 2011 and 2012. Of the initial six health care systems participating in this initiative, five continue to demonstrate successful deployment.

The Palo Alto and Indianapolis VA Medical Centers and FHCC Lovell Medical Centers are the longest running of the initial sites, now in their third and fourth years of deployment, respectively.

To date, fifteen VA Healthcare Systems have initiated the journey to organizational transformation through implementation of VHA's translation of the Lean Management System. In March 2015, the VHA National Leadership Council formally adopted Lean Management as the foundation for a standard VHA quality improvement strategy, opening the doors for deployment of Lean Management throughout VHA.

In May 2015, the Veterans Engineering Resources Center (VERC) program, in collaboration with the VA Quality Enhancement Research Initiative (QUERI), initiated a Partnered Evaluation Center (PEC) to conduct a formative evaluation of VHA Lean Management Systems deployment. The overarching objective of this evaluation is to understand which strategies interact to ensure successful, sustained transformation efforts and investigate how current Lean Enterprise deployment strategies can be improved. This evaluation is just a start, however, and there are many other aspects of the Lean Management System integrated within VHA that can and should be studied by the HSR&D/QUERI Community.

1. Radnor, Z. et al. "Lean in Healthcare: The Unfilled Promise?" Social Science and Medicine; 74, p. 364-71.

2. Woodward-Hagg, H. et al. (2014). Large Systems Transformation within Healthcare Organizations Utilizing Lean Deployment Strategies. Proceedings of the Industrial and Systems Engineering Research Conference (ISERC). Montreal, Canada