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Lean management and hospitalperformance: adoption versusimplementationStephen M. Shortell, PhD, MBA, MPHBlue Cross of California Distinguished Professor Emeritus of Health Policyand ManagementCo-director, CLEAR, UC Berkeley School of Public HealthCo-authors: Janet C. Blodgett, MSc; Thomas G. Rundall, PhD; Rachel Mosher Henke,PhD; Elina Reponen, MD, PhDOutline Central questionPrior researchCurrent study and resultsConclusion and discussion21
Central question To what extent might lean, if fully and widely implemented, provide afoundation for larger and more sustainable improvement in the qualityand cost of care than what we have achieved to date?3Lean working definition An overall management/ operating system that uses a continuousimprovement culture that empowers front line workers (nurses,physicians, support staff) to solve problems and eliminate waste bystandardizing work to improve the value of care delivered to patients. A socio-technical system approach emphasizing culture, leadership, workdesign, tools.42
Prior research Consistent evidence of positive results when used in individual projects/units/ departments Less evidence and mixed evidence of its use organization wide5Key results from the national survey of lean - 2017 61 percent (adjusted for non response) of hospitals report using Lean Only 12 percent (102 hospitals) report being “mature” in its use – having itimplemented throughout the hospital Extent of use positively associated with self reported performance Adoption of Lean by 2014 positively associated with lower adjusted Medicarespending per beneficiary in 2015– Associated with no other independent objective performance measures For a subset of public hospitals it was positively associated with EBITDA marginand fewer patients leaving the ED without being seen. No other relationships.63
Current, updated study 2017 adoption and implementation measures linked to 2018 objectiveindependent publicly reported performance measures7Adoption and implementation measures Adoption of any LeanNumber of operating units throughout the hospital using lean (0-29)Number of years using leanLeadership Commitment Index Daily Management System Index Education and Training Index84
Performance measures 30-day risk adjusted mortality index30-day unplanned readmission rateAdjusted inpatient expense per dischargeComposite: appropriate/efficient use of medical imagingComposite: patient safetyComposite: timeliness of careDeath rate among surgical inpatients with serious treatable conditionsEBITDA marginHCAHPS scoreMedicare spending per beneficiary9Control variables OwnershipMember of a system or networkCore-based statistical area typeMember of Council of Teaching HospitalsBed sizeMarket concentrationPercent Medicaid dischargesPrimary care/Specialist provider ratio105
Results Lower adjusted inpatient expense per dischargeLower 30-day unplanned readmission rateAbove national average in appropriate use of imagingHigher HCAHPS patient experience scores Top quartile of hospitals implementing lean (20-29 units using it) versusthe bottom quartile of hospital units using lean (0-9 units) had adjustedinpatient expense per discharge approximately 1,000 lower11Linear regressions summary across dependent variables(β and 95% CI for relationship with number of units doing Lean)Control variables include number of years using lean, ownership, system or network membership, core-basedstatistical area type, bed size, teaching status, percent Medicaid discharges, market concentration, primarycare/specialist provider ratio.126
Logistic regressions summary across dependent variablesOdds ratio and 95% CI for relationship with number of units doing LeanOdds ratio 1 indicates that using Lean in more units is associated with greater odds of being above thenational average on that composite performance measureControl variables include number of years using lean, ownership, system or network membership, core-basedstatistical area type, bed size, teaching status, percent Medicaid discharges, market concentration, primarycare/specialist provider ratio.13Conclusion It is the degree of implementation and spread that really matters, notmere piecemeal adoption The results are encouraging, but we are far from the tipping point ofachieving sustainable everyday quality improvement147
For discussion Have hospitals using Lean done a better job of responding to Covid-19? What role can Lean play in making breakthrough improvements in qualityand financial performance? What might payers and policymakers do to accelerate hospitals andother healthcare organizations use of lean and related transformationalperformance improvement approaches?15Relevant publications Rundall, T.G., Shortell, S.M., Blodgett, J.C., Henke, R.M. and Foster, D., 2020. Adoption of Lean management andhospital performance: Results from a national survey. Health Care Management Review. DOI:10.1097/HMR.0000000000000287Toussaint, J.S., Griffith, J.R. and Shortell, S.M., 2020. Lean, Shingo, and the Baldrige Framework: A ComprehensiveMethod to Achieve a Continuous-Improvement Management System. NEJM Catalyst Innovations in Care Delivery,1(3).Toussaint, J. and Barnas, K., 2020. Becoming the Change: Leadership Behavior Strategies for ContinuousImprovement in Healthcare. McGraw Hill Professional.Shortell, S.M., Rundall, T.G. and Blodgett, J.C., 2019. Assessing the relationship of the human resource, finance,and information technology functions on reported performance in hospitals using the Lean management system.Health Care Management Review. doi: 10.1097/HMR.0000000000000253Shortell, S.M., Blodgett, J.C., Rundall, T.G. and Kralovec, P., 2018. Use of lean and related transformationalperformance improvement systems in hospitals in the United States: Results from a national survey. The JointCommission Journal on Quality and Patient Safety, 44(10), pp.574-582.Po, J., Rundall, T.G., Shortell, S.M. and Blodgett, J.C., 2019. Lean Management and US Public Hospital Performance:Results From a National Survey. Journal of Healthcare Management, 64(6), pp.363-379.168
Acknowledgements IBM Watson HealthAmerican Hospital Association Survey Data CenterCatalysisLean Enterprise Institute Rona Consulting Group – Moss Adams Value Capture The Jewish Healthcare Foundation of Western Pennsylvania17Thank youFor more information u189
To what extent might lean, if fully and widely implemented, provide a foundation for larger and more sustainable improvement in the quality and cost of care than what we have achieved to date? 4 Lean working definition An overall management/ operating system that uses a continuous impr
