Use of Lean and Related Transformational Performance Improvement Systems in Hospitals in the United States: Results From a National Survey

Designing an integrated care pathway for spondyloarthritis: A Lean Thinking approach

INTRODUCTION

Integrated care pathways (ICPs) are crucial for delivering individualised care. However, the development of ICPs is challenging and must be well designed to provide the expected benefits. Regarding this, healthcare organisations are increasingly adopting management systems based on Lean Thinking to improve their organisational processes by eliminating non-value-added steps. This study elucidates the process and evaluates the impact of applying Lean Thinking to redesign an ICP for patients with spondyloarthritis, a chronic inflammatory disease affecting young adults.

METHODS

A multidisciplinary team was assembled and trained in Lean Thinking. Patient's perspective was gathered through a focus group. Guided by an expert methodologist, the team constructed a value stream map of the entire care pathway and analysed each step. Five work streams were defined to increase value at each step, leading to targeted process improvements. Key process and outcome metrics were collected and compared in 2-month baseline and post-implementation audits.

RESULTS

A total of 118 patients were included in the baseline audit (September-October 2022), and 116 in the post-implementation audit (January-February 2023). Process redesign resulted in statistically significant improvements (p < 0.05), including a reduction in the mean number of hospital visits per patient over a 2-month period from 2.54 (SD = 0.93) to 1.84 (SD = 0.79), an increase in complementary exams scheduled on the same day (81.4% to 94.8%) and an increase in baseline disease and treatment education (from 22.2% to 84.2% and from 18.2% to 84.6%, respectively). Regarding standardisation of clinical practice, there were significant increases in collecting data for medical records on composite activity indices (76.3% to 95.7%), reporting of pharmacological treatment adherence (68.6% to 94%) and providing nonpharmacological recommendations (31.3% to 95.7%).

CONCLUSIONS

The application of Lean Thinking to redesign the spondyloarthritis ICP led to significant improvements in outpatient appointment scheduling, reduced patient hospital visits, improved interdepartmental coordination and standardised clinical practice.

Pioneering the Use of Tracker Data to Evaluate Lean-Led Hospital Design

OBJECTIVE

This study aims to examine how we can effectively and affordably evaluate the impact of design concepts such as Lean-Led Hospital Design (LLHD) on the allocation of nurses' time spent at different locations. Particularly in patient rooms, as this can be seen as value-adding time.

BACKGROUND

LLHD aims to create a hospital environment that supports value creation for patients and reduces waste. However, only a few studies measure its' effects. One of the reasons for this absence is the lack of an adequate and affordable way to evaluate.

METHOD

Nurses' time spent in patient rooms was used as a proxy for value-adding time. Through studying a pioneering case of LLHD, and drawing on a pre-/postoccupancy evaluation approach, this study used an innovative methodology utilizing mobile tracking devices to adequately provide reliable data about the time nurses spend at specific locations.

RESULTS

Our analysis reveals that the answer to the question concerning the impact of LLHD, as advocated by its proponents, on nurses' allocation of time for value-adding activities versus waste time remains inconclusive. Our findings indicate no discernible difference in the amount of value-adding time nurses spent in the old facility compared to the new one.

CONCLUSION

Our experience suggests that mobile tracking devices offer an affordable, efficient means of collecting data that produces objective measurements. Nevertheless, the interpretation of this time-based data necessitates the inclusion of supplementary qualitative information.

Lean Performance Indicators and Facilitators of Outcomes in U.S. Public Hospitals

GOAL

This study investigated the association between Lean and performance outcomes in U.S. public hospitals. Public hospitals face substantial pressure to deliver high-quality care with limited resources. Lean-based management systems can provide these hospitals with alternative approaches to improve efficiency and effectiveness. Prior research shows that Lean can have positive impacts in hospitals ranging in ownership type, but more study is needed, specifically in publicly owned hospitals.

METHODS

We performed multivariable regressions using data from the 2017 National Survey of Lean/Transformational Performance Improvement. The data were linked to publicly available hospital performance data from the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services. We examined 11 outcomes measuring financial performance, quality of care, and patient experience and their associations with Lean adoption. We also explored potential drivers of positive outcomes by examining Lean implementation in each hospital, measured as the number of units using Lean tools and practices; leader commitment to Lean principles; Lean training and education among physicians, nurses, and managers; and use of a daily management system among C-suite leaders and managers.

PRINCIPAL FINDINGS

Lean adoption and implementation were associated with improved performance in U.S. public hospitals. Compared with hospitals that did not adopt Lean, those that did had significantly lower adjusted inpatient expenses per discharge and higher-than-average national scores on the appropriate use of medical imaging and timeliness of care. The study results also showed marginally significant improvements in patient experience and hospital earnings before interest, taxes, depreciation, and amortization margins. Focusing on these select outcomes, we found that drivers of such improvements involved the extent of Lean implementation, as reflected by leadership commitment, daily management, and training/education while controlling for the number of years using Lean.

PRACTICAL APPLICATIONS

Lean is a method of continuous improvement centered around a culture of providing high-value care for patients. Our findings provide insight into the potential benefits of Lean in U.S. public hospitals. Notably, they suggest that leader buy-in is key to success. When executives and managers support Lean initiatives and provide proper training for the workforce, improved financial and operational performance can result. This commitment, starting with upper management, may also play a broader role in the effort to reform healthcare while having a positive impact on patient care in U.S. public hospitals.

Transformational Performance Improvement: Why Is Progress so Slow?

In this chapter, we identify three distinct transformational performance improvement (TPI) approaches commonly used to redesign work processes in health care organizations. We describe the unique components or tools that each approach uses to improve the delivery of health services. We also summarize what is empirically known about the effectiveness of each TPI approach according to systematic reviews and recent studies published in the peer-reviewed literature. Based on examination of this research, we discuss what knowledge is still needed to strengthen the evidence for whole system transformation. This involves the use of conceptual frameworks to assess and guide implementation efforts, and facilitators and barriers to change as revealed in a recent evaluation of one major initiative, the Lean Enterprise Transformation (LET) at the Veterans Health Administration. The analysis suggests ways in which TPI facilitators can be developed and barriers reduced to improve the effectiveness and sustainability of quality initiatives. Finally, we discuss appropriate study designs to evaluate TPI interventions that may strengthen the evidence for their effectiveness in real world practice settings.

Effects of Lean Interventions Supported by Digital Technologies on Healthcare Services: A Systematic Review

Despite the increasing utilization of lean practices and digital technologies (DTs) related to Industry 4.0, the impact of such dual interventions on healthcare services remains unclear. This study aims to assess the effects of those interventions and provide a comprehensive understanding of their dynamics in healthcare settings. The methodology comprised a systematic review following the PRISMA guidelines, searching for lean interventions supported by DTs. Previous studies reporting outcomes related to patient health, patient flow, quality of care, and efficiency were included. Results show that most of the improvement interventions relied on lean methodology followed by lean combined with Six Sigma. The main supporting technologies were simulation and automation, while emergency departments and laboratories were the main settings. Most interventions focus on patient flow outcomes, reporting positive effects on outcomes related to access to service and utilization of services, including reductions in turnaround time, length of stay, waiting time, and turnover time. Notably, we found scarce outcomes regarding patient health, staff wellbeing, resource use, and savings. This paper, the first to investigate the dual intervention of DTs with lean or lean–Six Sigma in healthcare, summarizes the technical and organizational challenges associated with similar interventions, encourages further research, and promotes practical applications.

What Does a Systems Approach to Quality Improvement Look Like in Practice?

Universally improving healthcare systems is difficult to achieve in practice with organisations implementing a range of quality improvement (QI) approaches, in varying and changing contexts, and efforts ranging from project-based improvements to whole system change. This study aimed to identify how organisations overcome the challenges to improving the quality of the services they deliver. Drawing on the eight challenges from the ‘Quality and Safety in Europe by Research (QUASER) hospital guide, we assessed eight cases reported by the UK-based regulator Care Quality Commission as improving their performance. A thematic analysis of these secondary data established that all eight challenges had been addressed or considered in varying degrees. Education and physical and technological challenges seemed less prominent than developments made to address other challenges such as developing leadership, structure, and culture to support improving quality. This paper relies on the analysis of secondary case data and one framework to assess improvement efforts. Further research is required to consider other models and frameworks and to collate longitudinal data to capture the dynamics and increasing the maturity of improving healthcare systems in practice.

Validation of the Lean Healthcare Implementation Self-Assessment Instrument (LHISI) in the finnish healthcare context

BACKGROUND

Lean management is growing in popularity in the healthcare sector worldwide, yet healthcare organizations are struggling with assessing the maturity of their Lean implementation and monitoring its change over time. Most existing methods for such assessments are time consuming, require site visits by external consultants, and lack frontline involvement. The original Lean Healthcare Implementation Self-Assessment Instrument (LHISI) was developed by the Center for Lean Engagement and Research (CLEAR), University of California, Berkeley as a Lean principles-based survey instrument that avoids the above problems. We validated the original LHISI in the context of Finnish healthcare.

METHODS

The original HISI survey was sent over a secure organizational email system to the over 26,000 employees of the Hospital District of Helsinki and Uusimaa in March 2020. The data were randomly split with one part used to carry out an exploratory factor analysis (EFA), and the other for testing the resulting model using confirmatory factor analysis (CFA).

RESULTS

A total of 6073 employees responded to the LHISI survey, for an overall response rate of 23%. The results indicated that the 43 items used in the original LHISI can be reduced to 25 items, and these items measure a five-dimensional model of the progress of Lean implementation: leadership, commitment, standard work, communication, and daily management system. In comparison with a single-factor model, the fit measures for the 5-factor model were better: smaller X2, larger comparative fit index (CFI), smaller root mean square error of approximation (RMSEA), and smaller standardized root mean square residual (SRMR).

CONCLUSIONS

The 25 item LHISI is valid and feasible to use in the context of Finnish healthcare. The LHISI allows the organization to self-monitor the progress of its Lean implementation and provides the leadership with actionable knowledge to guide the path towards Lean maturity across the organization. Our findings encourage further studies on the adoption and validation of the LHISI in healthcare organizations worldwide.

Evaluation of an Access-Risk-Knowledge (ARK) Platform for Governance of Risk and Change in Complex Socio-Technical Systems

Three key challenges to a whole-system approach to process improvement in health systems are the complexity of socio-technical activity, the capacity to change purposefully, and the consequent capacity to proactively manage and govern the system. The literature on healthcare improvement demonstrates the persistence of these problems. In this project, the Access-Risk-Knowledge (ARK) Platform, which supports the implementation of improvement projects, was deployed across three healthcare organisations to address risk management for the prevention and control of healthcare-associated infections (HCAIs). In each organisation, quality and safety experts initiated an ARK project and participated in a follow-up survey and focus group. The platform was then evaluated against a set of fifteen needs related to complex system transformation. While the results highlighted concerns about the platform's usability, feedback was generally positive regarding its effectiveness and potential value in supporting HCAI risk management. The ARK Platform addresses the majority of identified needs for system transformation; other needs were validated in the trial or are undergoing development. This trial provided a starting point for a knowledge-based solution to enhance organisational governance and develop shared knowledge through a Community of Practice that will contribute to sustaining and generalising that change.

Implementing lean-led hospital design; lessons gained at a pioneer

PURPOSE

The aim of this study is to document and analyze experiences with building a new hospital guided by lean-led hospital design (LLHD) (Grunden and Hagood, 2012) and to investigate key mechanisms enhancing healthcare professionals' participation and collaboration in implementing this innovative approach.

DESIGN/METHODOLOGY/APPROACH

An in-depth case study of the implementation of LLHD in a Dutch hospital was performed based on multiple data sources. The case hospital presented a unique opportunity since there was embedded access to the data by the first author.

FINDINGS

Three mechanisms supporting participation and collaboration of staff for implementing LLHD were identified. (1) Freedom in translating a concept enables managers to balance it with variations in practice at the organizational level. (2) A set of key principles governing the design process appeared an important anchor on a managerial level in a changing environment. (3) Creation of a supportive attitude toward lean and lean facility design, with co-creation as a key element of LLHD.

PRACTICAL IMPLICATIONS

By using the emerging mechanisms, managers/change agents can enlarge collaboration and participation of hospital staff when implementing organization-wide innovations.

ORIGINALITY/VALUE

This case study delivers a unique inside view on the dynamics evolving in the complex change processes at organizational, managerial and personal levels involved in implementing LLHD.

Creativity in problem solving to improve complex health outcomes: Insights from hospitals seeking to improve cardiovascular care

Introduction

Improving performance often requires health care teams to employ creativity in problem solving, a key attribute of learning health systems. Despite increasing interest in the role of creativity in health care, empirical evidence documenting how this concept manifests in real‐world contexts remains limited.

Methods

We conducted a qualitative study to understand how creativity was fostered during problem solving in 10 hospitals that took part in a 2‐year collaborative to improve cardiovascular care outcomes. We analyzed interviews with 197 hospital team members involved in the collaborative, focusing on work processes or outcomes that participants self‐identified as creative or promoting creativity. We sought to identify recurrent patterns across instances of creativity in problem solving.

Results

Participants reported examples of creativity at both stages typically identified in problem solving research and practice: uncovering non‐obvious problems and finding novel solutions. Creativity generally involved the assembly of an “ecological view” of the care process, which reflected a more complete understanding of relationships between individual care providers, organizational sub‐units, and their environment. Teams used three prominent behaviors to construct the ecological view: (a) collecting new and diverse information, (b) accepting (rather than dismissing) disruptive information, and (c) employing empathy to understand and share feelings of others.

Conclusions

We anticipate that findings will be useful to researchers and practitioners who wish to understand how creativity can be fostered in problem solving to improve clinical outcomes and foster learning health systems.

Quality improvement in general practice: what do GPs and practice managers think? Results from a nationally representative survey of UK GPs and practice managers

BACKGROUND

This paper presents the results of the first UK-wide survey of National Health Service (NHS) general practitioners (GPs) and practice managers (PMs) designed to explore the service improvement activities being undertaken in practices, and the factors that facilitated or obstructed that work. The research was prompted by growing policy and professional interest in the quality of general practice and its improvement. The analysis compares GP and PM involvement in, and experience of, quality improvement activities.

METHODS

This was a mixed-method study comprising 26 semistructured interviews, a focus group and two surveys. The qualitative data supported the design of the surveys, which were sent to all 46 238 GPs on the Royal College of General Practitioners (RCGP) database and the PM at every practice across the UK (n=9153) in July 2017.

RESULTS

Responses from 2377 GPs and 1424 PMs were received and were broadly representative of each group. Ninety-nine per cent reported having planned or undertaken improvement activities in the previous 12 months. The most frequent related to prescribing and access. Key facilitators of improvement included 'good clinical leadership'. The two main barriers were 'too many demands from external stakeholders' and a lack of protected time. Audit and significant event audit were the most common improvement tools used, but respondents were interested in training on other quality improvement tools.

CONCLUSION

GPs and PMs are interested in improving service quality. As such, the new quality improvement domain in the Quality and Outcomes Framework used in the payment of practices is likely to be relatively easily accepted by GPs in England. However, if improving quality is to become routine work for practices, it will be important for the NHS in the four UK countries to work with practices to mitigate some of the barriers that they face, in particular the lack of protected time.

Assessing the relationship of the human resource, finance, and information technology functions on reported performance in hospitals using the Lean management system

BACKGROUND

Given pressures to control costs and improve quality of care, one of the most prevalent transformational performance improvement approaches in health care is Lean management. However, the roles of support functions such as human resource (HR), finance, and information technology (IT) in Lean management and the relationships of these support functions with performance are unknown.

PURPOSE

The aim of this study was to examine the relationships between the HR, finance, and IT functions, overall Lean implementation, and self-reported performance improvement in hospitals that have implemented Lean.

METHODOLOGY/APPROACH

Data from a national survey of Lean in U.S. hospitals (N = 1,222; 847 reported using Lean) were analyzed using multivariable regression and bootstrapped mediation analysis. The extent to which HR, finance, and IT functions support Lean management was measured using indices including six, three, and six items respectively. Lean implementation was measured by the number of units doing Lean (up to 29) and by a four-level self-reported maturity scale. Performance improvement was measured using an index of self-reported achievements (ranging from 0 to 16).

RESULTS

There were significant positive associations between Lean HR, finance, and IT functions and self-reported performance impact (controlling for organizational and market variables). Tests of mediation indicated that the associations of HR, finance, and IT functions with self-reported performance were significantly mediated by the number of Lean units (mediated proportion ranging from 40% to 73%), and HR function was also mediated by self-reported maturity (61% mediated). There were no moderating effects.

CONCLUSION

HR, finance, and IT functions are positively associated with self-reported Lean impact on performance and primarily explained by the overall degree of Lean implementation.

PRACTICE IMPLICATIONS

Efforts to align HR, finance, and IT functions with overall Lean implementation can help to ensure that frontline caregivers and managers have the data and skills required to meet transformational improvement goals.

Benchmarking outcomes on multiple contextual levels in lean healthcare: a systematic review, development of a conceptual framework, and a research agenda

BACKGROUND

Reliable benchmarking in Lean healthcare requires widely relevant and applicable domains for outcome metrics and careful attention to contextual levels. These levels have been poorly defined and no framework to facilitate performance benchmarking exists.

METHODS

We systematically searched the Pubmed, Scopus, and Web of Science databases to identify original articles reporting benchmarking on different contextual levels in Lean healthcare and critically appraised the articles. Scarcity and heterogeneity of articles prevented quantitative meta-analyses. We developed a new, widely applicable conceptual framework for benchmarking drawing on the principles of ten commonly used healthcare quality frameworks and four value statements, and suggest an agenda for future research on benchmarking in Lean healthcare.

RESULTS

We identified 22 articles on benchmarking in Lean healthcare on 4 contextual levels: intra-organizational (6 articles), regional (4), national (10), and international (2). We further categorized the articles by the domains in the proposed conceptual framework: patients (6), employed and affiliated staff (2), costs (2), and service provision (16). After critical appraisal, only one fifth of the articles were categorized as high quality.

CONCLUSIONS

When making evidence-informed decisions based on current scarce literature on benchmarking in healthcare, leaders and managers should carefully consider the influence of context. The proposed conceptual framework may facilitate performance benchmarking and spreading best practices in Lean healthcare. Future research on benchmarking in Lean healthcare should include international benchmarking, defining essential factors influencing Lean initiatives on different levels of context; patient-centered benchmarking; and system-level benchmarking with a balanced set of outcomes and quality measures.

Lean management in health care: a review of reviews of socio-technical components for effective impact

PURPOSE

The aims of the implementation of lean management in health care are to improve quality of care, to eliminate waste and to increase efficiency. The purpose of this study is to contribute to the advancement of knowledge by investigating which main socio-technical factors are considered to be effective for the implementation and management of lean initiatives.

DESIGN/METHODOLOGY/APPROACH

A systematic review of literature reviews on lean management in health care was conducted. The components of the socio-technical system are identified by moving from the socio-technical drivers that support organization-wide quality improvement practices and the lean implementation process in health care. The impacts of lean management are classified using the internal processes, patient, learning and financial dimensions.

FINDINGS

The 28 reviews retrieved confirm the current and increasing interest in lean management. While more than 60% of them call for a system-wide approach, system-wide implementations have rarely been observed, and, instead, adoption in isolated units or departments, or the use of single techniques and tools, prevails. The most commonly investigated socio-technical components are organizational structure, techniques and tools and organizational culture and strategic management. Significant impacts are reported for all the four dimensions. Nonetheless, the review reveals that there is still a lack of evidence on the sustainability of lean results and a need for a standardized impact measurement system.

ORIGINALITY/VALUE

This work stands out as the first review of reviews of how the socio-technical components of the lean management approach obtain positive impacts within the patient, internal processes, learning and financial dimensions.

Patient experiences after implementing lean primary care redesigns

OBJECTIVE

To examine the effect of Lean primary care redesigns on patient satisfaction with care and timeliness of care received.

DATA/SETTING

We used patient surveys and time-stamped electronic health record (EHR) data in a large ambulatory care system.

DESIGN

Lean-based changes to clinical spaces and care team workflows were implemented in one pilot site and then scaled to all primary care departments across the system. Redesigns included standardizing equipment and patient education materials in examination rooms, streamlining call management functions, co-locating physician and medical assistant dyads in a shared workspace, and creating new care team workflows. We used a non-randomized stepped-wedge study design and segmented regression with interrupted time series analysis to examine Lean impacts on patient outcomes.

DATA COLLECTION

We analyzed patient satisfaction ratings and wait times as documented by the EHR. These longitudinal data were collected for 317 physician-led teams in 46 primary care departments from January 2011 to December 2016.

PRINCIPAL FINDINGS

After implementation of Lean redesigns, patients reported a 44.8 percent increase in satisfaction with the adequacy of time spent with care providers during office visits (P < .05). They also reported 71.6 percent higher satisfaction with their care provider's ability to listen to their concerns, and a 55.4 percent increase in perceived staff helpfulness at the visit (P < .01). Based on monthly EHR data, the amount of time elapsed between a patient request for a routine appointment and the scheduled visit day decreased from baseline by an average 2 percent per month (P < .01). On the day of the visit, patient wait times to be seen also decreased gradually by an average 1.2 percent per month (P < .05).

CONCLUSIONS

Patient experiences of care after Lean implementations have not been widely studied in primary care settings. We found that Lean redesign yielded improvements that may strengthen clinical operations while enhancing value for patients.

Utilizing Lean Leadership Principles to Build an Academic Primary Care Practice of the Future

This Perspective presents a case study of multidimensional clinical transformation in an academic general internal medicine practice. In the face of increasing internal and external pressures, health systems and individual medical practices have pursued multiple strategies to improve quality, patient experience, and efficiency, while reducing staff and provider stress and burnout. We describe a Lean-informed approach that emphasizes the importance of organizational alignment in goals, evidence-based problem solving, and leadership behaviors to support a culture of continuous improvement. Our aim in this Perspective is to provide a real-world example of a feasible process for the planning, preparation, and execution of effective transformation, and to present lessons that may be useful to other academic health center practices seeking to develop innovative models to achieve the quadruple aim.

Assessing the Impact of Lean Healthcare on Inpatient Care: A Systematic Review

Healthcare services are facing challenges in increasing their efficiency, quality of care, and coping with surges in demand. To this end, some hospitals have implemented lean healthcare. The aim of this systematic review is to evaluate the effects of lean healthcare (LH) interventions on inpatient care and determine whether patient flow and efficiency outcomes improve. The review was performed according to PRISMA. We used six databases to search for studies published from 2002 to 2019. Out of 5732 studies, 39 measuring one or more defined outcomes were included. Hospital length of stay (LOS) was measured in 23 studies, 16 of which reported a reduction, turnover time (TOT) decreased in six out of eight studies, while the turnaround time (TAT) and on-time starts (OTS) improved in all five and seven studies, respectively. Moreover, eight out of nine studies reported an earlier discharge time, and the boarding time decreased in all four cases. Meanwhile, the readmission rate did not increase in all nine studies. Lastly, staff and patient satisfaction improved in all eight studies. Our findings show that by focusing on reducing non-value-added activities, LH contributed to improving patient flow and efficiency within inpatient care.

Facilitators and barriers to the Lean Enterprise Transformation program at the Veterans Health Administration

BACKGROUND

The Veterans Health Administration piloted a nationwide Lean Enterprise Transformation program to optimize delivery of services to patients for high value care.

PURPOSE

Barriers and facilitators to Lean implementation were evaluated.

METHODS

Guided by the Lean Enterprise Transformation evaluation model, 268 interviews were conducted, with stakeholders across 10 Veterans Health Administration medical centers. Interview transcripts were analyzed using thematic analysis techniques.

RESULTS

Supporting the utility of the model, facilitators and barriers to Lean implementation were found in each of the Lean Enterprise Transformation evaluation model domains: (a) impetus to transform, (b) leadership commitment to quality, (c) improvement initiatives, (d) alignment across the organization, (e) integration across internal boundaries, (f) communication, (g) capability development, (h) informed decision making, (i) patient engagement, and (j) organization culture. In addition, three emergent themes were identified: staff engagement, sufficient staffing, and use of Lean experts (senseis).

CONCLUSIONS

Effective implementation required staff engagement, strategic planning, proper scoping and pacing, deliberate coaching, and accountability structures. Visible, stable leadership drove Lean when leaders articulated a clear impetus to change, aligned goals within the facility, and supported middle management. Reliable data and metrics provided support for and evidence of successful change. Strategic early planning with continual reassessment translated into focused and sustained Lean implementation.

PRACTICE IMPLICATIONS

Prominent best practices identified include (a) reward participants by broadcasting Lean successes; (b) provide time and resources for participation in Lean activities; (c) avoid overscoping projects; (d) select metrics that closely align with improvement processes; and (e) invest in coaches, informal champions, process improvement staff, and senior leadership to promote staff engagement and minimize turnover.

Practical Use of Process Mapping to Guide Implementation of a Care Coordination Program for Rural Veterans

BACKGROUND

Transitions of care are high risk for vulnerable populations such as rural Veterans, and adequate care coordination can alleviate many risks. Single-center care coordination programs have shown promise in improving transitional care practices. However, best practices for implementing effective transitional care interventions are unknown, and a common pitfall is lack of understanding of the current process at different sites. The rural Transitions Nurse Program (TNP) is a Veterans Health Administration (VA) intervention that addresses the unique transitional care coordination needs of rural Veterans, and it is currently being implemented in five VA facilities.

OBJECTIVE

We sought to employ and study process mapping as a tool for assessing site context prior to implementation of TNP, a new care coordination program.

DESIGN AND PARTICIPANTS

Observational qualitative study guided by the Lean Six Sigma approach. Data were collected in January-March 2017 through interviews, direct observations, and group sessions with front-line staff, including VA providers, nurses, and administrative staff from five VA Medical Centers and nine rural Patient-Aligned Care Teams.

KEY RESULTS

We integrated key informant interviews, observational data, and group sessions to create ten process maps depicting the care coordination process prior to TNP implementation at each expansion site. These maps were used to adapt implementation through informing the unique role of the Transitions Nurse at each site and will be used in evaluating the program, which is essential to understanding the program's impact.

CONCLUSIONS

Process mapping can be a valuable and practical approach to accurately assess site processes before implementation of care coordination programs in complex systems. The process mapping activities were useful in engaging the local staff and simultaneously guided adaptations to the TNP intervention to meet local needs. Our approach-combining multiple data sources while adapting Lean Six Sigma principles into practical use-may be generalizable to other care coordination programs.