Nurse managers implementing the lean management system: A qualitative study in Western Canada

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.

Lean Management Systems in Health Care: A Review of the Literature

BACKGROUND AND OBJECTIVES

Many health care organizations now employ Lean tools to improve value in health care, yet reports of their effectiveness vary. This variation may be explained by the context in which Lean is implemented, whether as a tool or as a management system. This article reports on a structured literature review conducted to understand the evidence base for the impact of Lean Management System implementation in health care.

METHODS

A search of PubMed, Scopus, Emerald, EMBASE, CINAHL, and Business Source Complete databases was conducted in November 2017 and repeated in July 2020 to assess the evidence for the impact of Lean Management Systems in health care from 2000 to July 2020. Articles were included if they (1) reported on a Lean Management System or (2) reported on Lean Management System components as described by Mann 1 (ie, leader standard work, visual controls, daily accountability process, and discipline).

RESULTS

A total of 52 articles met the inclusion criteria. Although all articles described some combination of leader standard work, visual management, and daily accountability as part of their Lean Management System, only a handful described use of all 3 components together. Only one explicitly mentioned the fourth component, discipline, required to consistently apply the first 3. The majority reported on single-unit or department implementations and most described daily huddles at the unit level that included review of key performance indicators, identification of improvement opportunities, and problem solving. The role of the leader in a Lean Management System was described a coach and a mentor. Barriers to adoption such as insufficient training and increased workload for nurses were noted along with the importance of relevance to the local context for unit teams to find value in huddle boards and huddles. As yet, evidence of Lean Management System effectiveness in driving health care improvement is absent due to weak study designs and lack of statistical rigor.

CONCLUSION

Well-designed research on Lean Management Systems in health care is lacking. Despite increasing adoption of Lean Management Systems over the past 10 years and anecdotal reports of its effectiveness, very few articles provide quantitative data. Those that do report unit-level implementation only, little use of a comprehensive package of Lean Management Systems elements, and weaker study designs and statistical methods. More rigorous study designs and robust statistical analysis are needed to evaluate effectiveness of Lean Management Systems in health care. This represents a rich area for future health care management research.

Lean Management and Breakthrough Performance Improvement in Health Care

BACKGROUND AND OBJECTIVES

Lean management in health care organizations attempts to empower staff to generate continuous improvement through incremental but regular improvements in work processes. However, because of the increasing pressure on health care organizations to substantially improve quality of care and patient outcomes while containing costs in the relatively short term, many health care leaders are looking for ways to achieve large breakthrough improvements in their organization's performance. The objective of this research is to understand whether and how Lean management can be used to achieve breakthrough improvements in performance.

METHODS

This study used grounded theory and content analysis of in-depth, semistructured interviews with 10 nationally recognized experts in the use of Lean management in health care organizations. The 10 participants constitute a purposive sample of experts with in-depth understanding of the strengths and limitations of Lean management in health care organizations.

RESULTS

Two out of 10 participants defined breakthrough improvement as a major change in a performance metric; 2 participants defined it as a fundamental redesign in a process or service; the remaining 6 participants defined breakthrough improvement as having both these characteristics. The extent to which participants believed Lean was an effective means for achieving breakthrough improvement in performance was related to how they defined breakthrough improvement. The 2 participants who defined breakthrough improvement as a significant change in a performance metric believed Lean methods alone were sufficient. The 2 participants who defined breakthrough improvement to be a fundamental redesign tended not to view Lean alone as an effective approach. Rather, they, and the 6 participants who defined breakthrough improvement as having both change-in-metric and process redesign characteristics, viewed human-centered design thinking as the primary or important complementary approach to achieving breakthrough improvement. Participants identified resources, culture change, and leadership commitment beyond what would be required to achieve incremental improvement as the main facilitators and barriers to achieving breakthrough improvements.

CONCLUSION

This research reveals some differences in experts' definitions of breakthrough improvement, and illuminates the value of human-centered design thinking, alone or as a complement to Lean management, in achieving breakthrough improvement in health care organizations. Most of our expert participants agreed that supplementing Lean management methods with the contributions of innovation design and investing significant resources, strengthening the organizational culture to support the necessary changes, and providing stronger leadership commitment to the effort are important facilitators for achieving breakthroughs in organizational performance.

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.

From self-management to a systemized process: the implementation of lean management in a Chinese hospital's pharmacy intravenous admixture services center

PURPOSE

The purpose of this paper is to explore the importance of lean leadership in an implementation in a Chinese hospital, considering a particular focus on the attitudes of nursing professionals while identifying specific cultural or institutional factors in China that might affect the implementation.

DESIGN/METHODOLOGY/APPROACH

The authors use Harrison et al.'s (2016) framework to explore the outcomes of a nine-month action research project whereby the authors observed the process and outcomes of implementing lean in a pharmacy intravenous admixture service of a Chinese hospital.

FINDINGS

The implementation of lean had positive results, which improved the efficiency of the operation, reduced the work start time and the amount of staff, and improved clinical satisfaction. In the process of implementation, nursing professionals showed a positive attitude toward the implementation and showed no obvious resistance under the positive influence of the head nurse. The combination of Chinese cultural characteristics, nursing culture and strong leadership enabled lean success.

ORIGINALITY/VALUE

The unit moved from self-management to a systemized process of using lean concepts and methods, it is an important change for hospital managers.

Nurse managers implementing the lean management system: A qualitative study in Western Canada

AIM

This study explores the perceptions and experiences of nurse managers involved in implementing the Lean management system in a Western Canadian province.

BACKGROUND

The provincial government of Saskatchewan, Canada, implemented a multimillion-dollar investment in the Lean management system to transform health care delivery by reducing waste and increasing efficiency of processes and outcomes.

METHODS

This qualitative exploratory study employed semi-structured interviews with 14 nurse managers in urban and rural health regions in one Canadian province.

RESULTS

Six themes outline the difficulties nurse managers experienced in juggling role responsibilities alongside a poorly implemented change system with scarce resources.

CONCLUSION

The results showed tensions in the implementation of a Lean model adapted in the context of health care organisations. The expectations for nurse managers to be pivotal players in the implementation of transformative health care practices that promote and sustain strategies to reduce waste, improve coordination and increase patient safety require investment in leadership development.

IMPLICATIONS FOR NURSING MANAGEMENT

Lean management systems significantly impact the roles of nurse managers who require adequate resources and training to successfully adapt. The results of this study may be used for more effective support mechanisms for nurse managers.