Lean Principles in Healthcare: 2 Important Tools Organizations Must Have

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Applying lean principles in healthcare is a goal for many health systems looking to become more efficient and effective when delivering care to patients. Manufacturing organizations like automaker Toyota, from whom a lean approach called “The Toyota Way” originated, have developed amazing sophistication by allowing frontline employees to participate in building and honing processes. Lean has become a proven, practical approach to process improvement in industries such as manufacturing and industrial engineering. Applying it to healthcare, however, can be much more difficult.

Many healthcare executives and staff have tried lean, failed to gain any sustainable benefit from it, and have come away from the process feeling frustrated.

Based on our experience in working with scores of healthcare organizations to improve processes and eliminate waste, we’ll outline what worked best and share some of the most successful applications of lean tools and principles.

A Basic Lean Principle: Intelligence on the Frontlines

Distilled down to its essence, lean is a way to counteract the common, top-down, command-and-control approach to management. Instead of relying on directives from management, lean seeks to take advantage of the intelligence an organization has on the frontlines; the employees who are engaging in the organization’s processes every day. In a lean organization, management empowers employees to define and then continuously refine processes.

It’s important to point out, however, that process improvement doesn’t become a free-for-all on the frontlines. Instead, lean organizations develop highly specified and exact processes that become standardized across the organization. The employees own it and are encouraged to review and continuously improve the process.

It’s a powerful, simple concept that can be quite difficult to apply, especially in healthcare.

The State of Lean in Healthcare

Healthcare is transitioning to value-based reimbursement, so organizations have a pressing need to fine-tune processes and work waste out of the system. Lean, touted for its ability to remove waste from processes, has obviously caught the interest of these organizations. Some health systems adopt bits and pieces of lean (value-stream maps, one-piece flow, and any number of other cool tools and techniques). Other organizations invite a lean expert to train their staff. Both approaches either temporarily translate to results or yield no results at all; hence, the skepticism about lean’s effectiveness in healthcare.

Why do so many lean implementations fail? Is it because the organizations only apply bits and pieces of lean?

The truth is, lean isn’t a magic sauce. Process improvements only take hold across an enterprise when there is a cultural paradigm shift. In other words, lean works in healthcare when it is part of a larger initiative driving real cultural change.

Incorporating Lean Principles in Cultural Change

Below are examples for how to apply lean principles as part of a greater cultural change initiative.

To be clear, healthcare organizations shouldn’t try to be lean organizations. In fact, they are well advised to avoid becoming lean purists. Instead, health systems should approach lean in a practical way, taking the pieces that work well and applying those pieces in a systematic way to help drive cultural change throughout the enterprise.

Process Improvement Goes Beyond Workflow Efficiency

Lean’s focus on workflow efficiency applies very well to some aspects of healthcare improvement, but not to others. The diagram below succinctly categorizes all of the work performed in a healthcare system. Dr. David Burton (Senior Vice President, future product strategy at Health Catalyst), in partnership with Dr. Brent James at Intermountain Healthcare, pioneered this healthcare-improvement process.

workflowDr. Burton divides healthcare into vertical processes (the ordering of care) and horizontal processes (the delivery of care). The vertical categories encompass the full spectrum of care that clinicians order for patients. The horizontal categories represent the work required to deliver the care ordered by the clinicians. Together they represent the fulfillment of care across the order-set spectrum. The mission of these horizontal support services is to deliver care in an efficient, consistent, and safe manner from patient to patient. These horizontal processes lend themselves very well to lean workflow improvement.

In contrast, improving the vertical processes requires clinicians to order the proper care for patients. Improvement initiatives in these areas don’t always lend themselves as readily to the lean approach as lean may not offer the level of precision needed to identify and develop superior treatment guidelines and protocols. Lean is more commonly used to improve the means by which diagnostic tests are performed and treatments implemented, not to improve the content of the diagnoses and treatments themselves, which is usually left to clinical researchers using rigorous statistical methods. That is just one reason why lean may not be the end-all, be-all solution for healthcare improvement.

Lean in Healthcare: Two Tools

To be successful within this healthcare context, lean is applied to improve the horizontal services. Lean is pared down to bare minimum concepts so people within the organization completely understand what to do and what goals can be expected. This approach borrows extensively from Cindy Jimmerson, the founder of Lean Healthcare West, who has helped pioneer the pragmatic simplification of lean in healthcare.

The simplified application of lean involves at least two key tools:

  • Value-stream maps. A lean expert from the manufacturing industry might not recognize the value-stream maps often used in healthcare. Healthcare organizations usually employ a simplified version of those seen in manufacturing. These process maps (for example surgery workflow) are reviewed at a high level to identify the best opportunities for workflow improvement. There is some focus on the transitions between departments because this is where most delays tend to occur. Key stakeholders involved in the workflow process assist in building the value-stream map and provide insight into improvement opportunities. The value-stream map is best created while observing the actual process firsthand or immediately after observing it.

Value stream map for inpatient surgery(Value Stream Map. Click graphic to enlarge.)

  • A3 diagrams. Once an improvement opportunity is identified, the team creates an A3 diagram. A3 diagrams (named for the paper size used by Toyota to create them) are a simple problem-solving tool designed for all to use—experts in process improvement and non-experts. A3 diagrams are recommended particularly for teams seeking to improve workflow, but the diagrams can be used for virtually any process improvement.

The Successful Approach to Cultural Change in Healthcare

Although lean is a sound approach to management, a broader healthcare-improvement methodology is necessary for organizations.

This approach can share many key philosophical elements with lean:

  • Highly specified processes
  • A bottom-up approach drives the change
  • Continuous process improvement
  • The expectation that everyone works to update processes
  • Servant leadership

Most significantly, this approach emphasizes a shift away from functional and departmental silos to one of permanently integrated teams of clinical and non-clinical subject-matter experts and technical people working together to drive sustainable change.

Lean, like so many other process-improvement frameworks, is usually implemented as a set of tools and techniques, but the tools and techniques have only local, short-term success without the foundational principles that produced them (such as those listed as “philosophical elements” above). Without organizational and cultural adoption of these principles—including the full and active support of senior management—lean is no more effective or enduring than any temporary initiative. Likewise, this approach focuses first on the cultural adoption of success-enabling principles.

Permanent teams organized around a particular clinical or non-clinical domain—rather than around a project—can truly improve care and sustain improvements over the long term. These teams create a continuous-learning environment for each clinical domain. As new knowledge is acquired, it can be integrated into care delivery.

The truck-bed illustration below shows the optimal organizational team structure to drive sustainable improvement:

clinical care truck bed

The flatbed of the truck in this example represents the five process-improvement implementation teams in the Clinic Care support service. A guidance team with clinical and operational leads drives the truck and guides the process-improvement teams. This guidance team is ultimately accountable for the success of the initiative and has the authority to prioritize resources for each of the five process-improvement teams.

One of the principal resources to be allocated by the guidance team is represented by the wheels on the truck; i.e., the technical support staff. These are the knowledge managers (data stewards, data-quality experts), data architects (data-provisioning experts), and application administrators (IT personnel with expertise in data capture) who assist the team in utilizing the data to identify opportunities for process improvement and measuring changes resulting from clinical interventions.

The knowledge manager is generally a clinician with a significant technical background. The data architect knows SQL, translates the aim statements into metrics, and builds the reports and dashboards used by the team to report results to leadership. The application administrator can actually make changes to the transactional system (e.g., EMR) when needed (for example, changing the standard order set in the EMR based on the team’s recommendations or reconfiguring screen layout to ensure data capture).

These three technical roles support the physician, nurse, and operational leaders of each team as they work to redesign care delivery and eliminate waste.

Integrating technical and clinical teams and making them permanent is the key to achieving and sustaining better outcomes. For a more in-depth explanation of this approach, we recommend this webinar by Dr. Burton (available as slides and a transcript as well as a full recording).

Sustainable Healthcare Improvement: Commitment and Dedication

As the industry transitions from fee-for-service to value-based reimbursement, many healthcare organizations are attempting to leverage lean principles and processes in a concentrated effort to remove waste as part of their improvement initiatives. These organizations are learning that lean isn’t a magic elixir and must be part of a larger cultural change initiative. Most importantly they are beginning to understand that true, sustainable change will never become a reality without a committed organization dedicated to making it a reality.


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