» Back to Table of Contents
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
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,
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