Adoption of Lean management and hospital performance: Results from a national survey

Associations Between Lean IT Management and Financial Performance in US Hospitals

BACKGROUND AND OBJECTIVES

To understand the relationship between Lean implementation in information technology (IT) departments and hospital performance, particularly with respect to operational and financial outcomes.

METHODS

Primary data were sourced from 1222 hospitals that responded to the National Survey of Lean (NSL)/Transformational Performance Improvement, which was fielded to 4500 general medical-surgical hospitals across the United States. Secondary sources included hospital performance data from the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS). We performed 2 sets of multivariable regressions using data gathered from US hospitals, linked to AHRQ and CMS performance outcomes. We examined 10 different outcomes measuring financial performance, quality of care, and patient experience, and their associations with Lean adoption within hospital IT departments. We then focused only on those hospitals that adopted Lean in IT to identify specific practices associated with performance.

RESULTS

Controlling for other factors, adoption of Lean IT management was associated with lower length of stay (b = -0.098, P = .018) and inpatient expense per discharge (b = -0.112, P = .090). Specifically, use of visual management tools (eg, A3 storyboards, status sheets) was associated with lower adjusted inpatient expense per discharge (b = -0.176, P = .034) and higher earnings before interest, taxes, depreciation, and amortization margin (b = 0.124, P = .042). Such tools were also associated with hospital participation in bundled payment programs (odds ratio = 2.326; P = .046; 95% confidence interval, 0.979-5.527) and percentage of net revenue paid on a shared risk basis (b = 0.188, P = .031).

CONCLUSIONS

Lean IT management was associated with positive financial performance, particularly with hospital participation in value-based payment. More detailed study is needed to understand other influential factors and types of work processes, activities, or mechanisms by which high-functioning IT can contribute to financial outcomes.

Unveiling the Impact of Lean Leadership on Continuous Improvement Maturity: A Scoping Review

Purpose

Lean Management (LM) is a process improvement approach with growing interest from healthcare organizations. Obtaining a culture of continuous improvement is a primary objective of LM, and a culture of continuous improvement indicates a mature LM approach, and here leadership plays a central role. However, a comprehensive overview of leadership activities influencing LM maturity is lacking. This study aims to identify leadership activities associated with continuous improvement and, thus, LM, maturity.

Methods

Following the PRISMA guidelines, a scoping literature review of peer-reviewed articles was conducted in twenty healthcare management journals. The search provided 466 articles published up until 2023. During the selection process, 23 studies were included in the review. The leadership activities related to continuous improvement maturity were identified using the grounded theory approach and data coding.

Results

The analysis highlighted a total of 58 leadership activities distributed across nine themes of LM leadership. Next, analysing leadership activities concerning the different maturity levels revealed three maturity stages: beginner, intermediate, and expert. Based on the findings, we propose a framework that guides suitable leadership activities at the various stages of LM maturity. The framework provides leaders in healthcare with a practical overview of actions to facilitate the growth of the LM approach, and the related propositions offer academics a theoretical basis for future studies.

Conclusion

This review presents the first comprehensive overview of LM leadership activities in relation to continuous improvement and LM maturity. To enhance LM maturity, leaders are encouraged to consider their leadership style, (clinical) stakeholder involvement, alignment with the organizational strategy, and their role in promoting employee autonomy.

What are barriers and facilitators in sustaining lean management in healthcare? A qualitative literature review

BACKGROUND

Lean management (LM) is a continuous improvement methodology originating from manufacturing and is widely adopted in healthcare to improve processes. LM shows promising results in healthcare and research on the topic is increasing. However, it can be difficult to sustain LM over time, and an overview of facilitators or barriers that influence the sustainment of LM in a healthcare context is unavailable.

METHODS

Prior to search, five inclusion and exclusion criteria were defined to establish suitability of identified articles for our research question. This study was based on 24 selected peer-reviewed studies that reported on the sustainment of LM in healthcare organisations, published in the last five years. Following the Preferred Reporting Items for Systemtic Reviews and Meta-Analyses (PRISMA) guidelines, all articles were scanned, retrieved for full-text and analysed thematically.

RESULTS

Following thematic analysis, we identified four overarching themes: Mobilising Employees, Guiding Change Efforts, Methods, and Local Context. Key facilitators for supporting LM are fostering an improvement culture and learning culture, providing professional development opportunities, assigning more responsibilities to employees in decision making processes and appointing change agents to act as local LM leaders. Key barriers for sustaining LM include overburdening employees with responsibilities, omitting staff involvement during LM implementation, lack of patient engagement, lack of resources to engage with LM, a lack of leadership commitment and follow-up on projects, and a lack of knowledge of LM among leaders.

CONCLUSION

Overall, studies emphasise the importance of actively involving and engaging the workforce to embed LM into organisational culture. Reflecting on the origins of LM, healthcare organisations can find inspiration in the virtue of respecting people in their journey to sustain and cultivate an improvement culture. LM provides potential to change healthcare for the better and could help healthcare organisations to cope with increasing external pressures.

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.

Managing Through a Pandemic: A Daily Management System for COVID-19 Response and Recovery

GOAL

This study explored the use of a Lean daily management system (DMS) for COVID-19 response and recovery in U.S. hospitals and health systems. Originally developed in manufacturing, Lean is an evidence-based approach to quality and process improvement in healthcare. Although Lean has been studied in individual hospital units and outpatient practices, it has not been examined as a whole system response to crisis events.

METHODS

We conducted qualitative interviews with 46 executive leaders, clinical leaders, and frontline staff in four hospitals and health systems across the United States. We developed a semistructured interview guide to understand DMS implementation in these care delivery organizations. As interviews took place 6-8 months following the onset of the pandemic, a subset of our interview questions centered on DMS use to meet the demands of COVID-19. Based on a deductive approach to qualitative analysis, we identified clusters of themes that described how DMS facilitated rapid system response to the public health emergency.

PRINCIPAL FINDINGS

There were many important ways in which U.S. hospitals and health systems leveraged their DMS to address COVID-19 challenges. These included the use of tiered huddles to facilitate rapid communication, the creation of standard work for redeployed staff, and structured problem-solving to prioritize new areas for improvement. We also discovered ways that the pandemic itself affected DMS implementation in all organizations. COVID-19 universally created greater DMS visibility by opening lines of communication among leadership, strengthening measurement and accountability, and empowering staff to develop solutions at the front lines. Many lessons learned using DMS for crisis management will carry forward into COVID-19 recovery efforts. Lessons include expanding telehealth, reactivating incident command systems as needed, and efficiently coordinating resources amid potential future shortages.

PRACTICAL APPLICATIONS

Overall, the Lean DMS functioned as a robust property that enabled quick organizational response to unpredictable events. Our findings on the use of DMS are consistent with organizational resilience that emphasizes collective sense-making and awareness of incident status, team decision-making, and frequent interaction and coordination. These features of resilience are supported by DMS practices such as tiered huddles for rapid information dissemination and alignment across organizational hierarchies. When used in conjunction with plan-do-study-act methodology, huddles provide teams with enhanced feedback that strengthens their ability to make changes as needed. Moreover, gaps between work-as-imagined (how work should be done) and work-as-done (how work is actually done) may be exacerbated in the initial chaos of emergency events but can be minimized through the development of standard work protocols. As a facilitator of resilience, the Lean DMS may be used in a variety of challenging situations to ensure high standards of care.

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.

Lean adoption, implementation, and outcomes in public hospitals: benchmarking the US and Italy health systems

Background

Despite the growing interest in transformational performance improvement among nearly all countries, international benchmarking has rarely been used. Cross-comparative research could allow an appreciation of the extent of Lean’s use in healthcare and a better evaluation of possible cultural influences on Lean implementation. This study provides a comparative international benchmarking of Lean adoption, implementation, and outcomes of hospitals in the US and Italy.

Methods

The National Survey of Lean, developed in 2017 in the US and adapted in Italy in 2019 was used to compare the two healthcare systems along three dimensions: the maturity of adoption, the implementation approach, identifying both strategic and operational activities and tools, and the Lean performance, investigated through patients, employed, and affiliated staff, costs, and service provision areas. Descriptive statistics including T-tests were used to examine differences between the two countries on the study variables.

Results

Lean has been adopted less by Italian public hospitals (36%) than US public hospitals (53%). Each country averages 4 years of experience with Lean. Italian hospitals reported being at a higher maturity stage while the US implemented a more system-wide approach, developing Lean in more operational units. The daily management system, leadership commitment, education and training indexes were higher or the same in the US while in Italy, hospitals had a higher self-reported performance index.

Conclusion

This exploratory work is one of the first international benchmarking studies on Lean implementation in healthcare systems using a standardized survey with a common set of definitions and questions. The study identifies different forms of Lean implementation that can be adopted, both at strategic and operational levels, with related perceived outcomes. Despite the US public hospitals being more likely to report a higher number of units using Lean, a higher daily management system index and use of Lean tools, Italian hospitals report more achievements primarily due to Lean. Further research can build on these findings by examining the relationship between Lean adoption/implementation and independent, objective performance measures.

Examining the Relationship Between the Lean Management System and Quality Improvement Care Management Processes

BACKGROUND AND OBJECTIVES

The United States has an underperforming health care system on both cost and quality criteria in comparison with other developed countries. One approach to improving system performance on both cost and quality is to use the Lean Management System based on the Shingo principles originally developed by Toyota in Japan. Our objective was to examine the association between hospital use of the Lean Management System and evidence-based or recommended quality improvement care management processes.

METHODS

A cross-sectional analysis of data from 223 hospitals that responded to both the 2017 National Survey of Healthcare Organizations and Systems and the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals was conducted.

RESULTS

Controlling for hospital organizational and market characteristics, the number of years using Lean was positively associated with use of electronic health record-based decision support, use of quality-focused information management, use of evidence-based guidelines, and support for care transitions at the P < .05 level. The degree of education and training in Lean methods and processes was also positively associated ( P < .05) with greater support for care transitions. The number of years using Lean was marginally associated with screening for clinical conditions at the P < .10 level. There was an unexpected negative association between education and training scores and screening for clinical conditions.

CONCLUSIONS

Greater experience in using the Lean Management System is positively associated with several evidence-based and/or recommended quality improvement care management processes.

Quality of Care Before and After Mergers and Acquisitions of Rural Hospitals

IMPORTANCE

Rural hospitals are increasingly merging with other hospitals. The associations of hospital mergers with quality of care need further investigation.

OBJECTIVES

To examine changes in quality of care for patients at rural hospitals that merged compared with those that remained independent.

DESIGN, SETTING, AND PARTICIPANTS

In this case-control study, mergers at community nonrehabilitation hospitals in Federal Office of Rural Health Policy-eligible zip codes during 2009 to 2016 in 32 states were identified from Irving Levin Associates and the American Hospital Association Annual Survey. Outcomes for inpatient stays for select conditions and elective procedures were derived from the Healthcare Cost and Utilization Project State Inpatient Databases. Difference-in-differences linear probability models were used to assess premerger to postmerger changes in outcomes for patients discharged from merged vs comparison hospitals that remained independent. Data were analyzed from February to December 2020.

EXPOSURES

Hospital mergers.

MAIN OUTCOMES AND MEASURES

The main outcome was in-hospital mortality among patients admitted for acute myocardial infarction (AMI), heart failure, stroke, gastrointestinal hemorrhage, hip fracture, or pneumonia, as well as complications during stays for elective surgeries.

RESULTS

A total of 172 merged hospitals and 266 comparison hospitals were analyzed. After matching, baseline patient characteristics were similar for 303 747 medical stays and 175 970 surgical stays at merged hospitals and 461 092 medical stays and 278 070 surgical stays at comparison hospitals. In-hospital mortality among AMI stays decreased from premerger to postmerger at merged hospitals (9.4% to 5.0%) and comparison hospitals (7.9% to 6.3%). Adjusting for patient, hospital, and community characteristics, the decrease in in-hospital mortality among AMI stays 1 year postmerger was 1.755 (95% CI, -2.825 to -0.685) percentage points greater at merged hospitals than at comparison hospitals (P < .001). This finding held up to 4 years postmerger (DID, -2.039 [95% CI, -3.388 to -0.691] percentage points; P = .003). Greater premerger to postmerger decreases in mortality at merged vs comparison hospitals were also observed at 5 years postmerger among stays for heart failure (DID, -0.756 [95% CI, -1.448 to -0.064] percentage points; P = .03), stroke (DID, -1.667 [95% CI, -3.050 to -0.283] percentage points; P = .02), and pneumonia (DID, -0.862 [95% CI, -1.681 to -0.042] percentage points; P = .04).

CONCLUSIONS AND RELEVANCE

These findings suggest that rural hospital mergers were associated with better mortality outcomes for AMI and several other conditions. This finding is important to enhancing rural health care and reducing urban-rural disparities in quality of care.

The cross-national applicability of lean implementation measures and hospital performance measures: a case study of Finland and the USA

Background

Health-care organizations around the world are striving to achieve transformational performance improvement, often through adopting process improvement methodologies such as lean management. Indeed, lean management has been implemented in hospitals in many countries. But despite a shared methodology and the potential benefit of benchmarking lean implementation and its effects on hospital performance, cross-national lean benchmarking is rare. Health-care organizations in different countries operate in very different contexts, including different health-care system models, and these differences may be perceived as limiting the ability of improvers to benchmark lean implementation and related organizational performance. However, no empirical research is available on the international relevance and applicability of lean implementation and hospital performance measures. To begin understanding the opportunities and limitations related to cross-national benchmarking of lean in hospitals, we conducted a cross-national case study of the relevance and applicability of measures of lean implementation in hospitals and hospital performance.

Methods

We report an exploratory case study of the relevance of lean implementation measures and the applicability of hospital performance measures using quantitative comparisons of data from Hospital District of Helsinki and Uusimaa (HUS) Helsinki University Hospital in Finland and a sample of 75 large academic hospitals in the USA.

Results

The relevance of lean-related measures was high across the two countries: almost 90% of the items developed for a US survey were relevant and available from HUS. A majority of the US-based measures for financial performance (66.7%), service provision/utilization (100.0%) and service provision/care processes (60.0%) were available from HUS. Differences in patient satisfaction measures prevented comparisons between HUS and the USA. Of 18 clinical outcome measures, only four (22%) were not comparable. Clinical outcome measures were less affected by the differences in health-care system models than measures related to service provision and financial performance.

Conclusions

Lean implementation measures are highly relevant in health-care organizations operating in the USA and Finland, as is the applicability of a variety of performance improvement measures. Cross-national benchmarking in lean healthcare is feasible, but a careful assessment of contextual factors, including the health-care system model, and their impact on the applicability and relevance of chosen benchmarking measures is necessary. The differences between the US and Finnish health-care system models is most clearly reflected in financial performance measures and care process measures.

Lean Management and Hospital Performance: Adoption vs. Implementation

BACKGROUND

The Lean management system is being adopted and implemented by an increasing number of US hospitals. Yet few studies have considered the impact of Lean on hospitalwide performance.

METHODS

A multivariate analysis was performed of the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals and 2018 publicly available data from the Agency for Healthcare Research and Quality and the Center for Medicare & Medicaid Services on 10 quality/appropriateness of care, cost, and patient experience measures.

RESULTS

Hospital adoption of Lean was associated with higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores (b = 3.35, p < 0.0001) on a scale of 100-300 but none of the other 9 performance measures. The degree of Lean implementation measured by the number of units throughout the hospital using Lean was associated with lower adjusted inpatient expense per admission (b = -38.67; p < 0.001), lower 30-day unplanned readmission rate (b = -0.01, p < 0.007), a score above the national average on appropriate use of imaging-a measure of low-value care (odds ratio = 1.04, p < 0.042), and higher HCAHPS patient experience scores (b = 0.12, p < 0.012). The degree of Lean implementation was not associated with any of the other 6 performance measures.

CONCLUSION

Lean is an organizationwide sociotechnical performance improvement system. As such, the actual degree of implementation throughout the organization as opposed to mere adoption is, based on the present findings, more likely to be associated with positive hospital performance on at least some 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.