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Leading Change Module 1 Credit CME

Starting Lean Health CareEliminate waste in the workday and equip the team to spend more time on patient care.

Team-Based Learning
Learning Objectives:
At the end of this activity, you will be able to:
1. List ways to identify a high-level process improvement champion and create an interdisciplinary improvement team
2. Explain how to utilize Lean tactics to identify sources of waste in clinic workflows
3. Describe steps to empower front-line staff to identify an improvement project and make improvements
4. Identify Lean methods of improvement

STEPS Forward™ is a practice improvement initiative from the AMA designed to empower teams like yours to identify and attain appropriate goals and tactics well matched to your practice’s specific needs and environment. Wherever you find your team on the practice improvement continuum, the American Medical Association can help you take the next steps – the right steps – to improve your practice. Learn more

How will this module help my practice become Lean?

  1. Descriptions of common Lean methods to help you select the right ones for your practice

  2. Six steps to help implement Lean improvements in your practice

  3. Answers to common questions and concerns about Lean thinking and methods

  4. Case vignettes describing how practices are successfully using Lean techniques to organize workflows and provide better patient care

Introduction
What is Lean?

“Lean” is both a mindset and a method to engage physicians and staff in organizing their practice to run more smoothly. The focus of Lean is to eliminate waste, improve efficiency and add value for the patient.

Six steps to starting Lean:

  1. Identify a high-level champion

  2. Create an interdisciplinary improvement team

  3. Empower front-line workers

  4. Choose a starter project

  5. Celebrate and spread

  6. Sustain

Step 1 Identify a high-level champion

Lean is fundamentally about culture change and therefore requires the buy-in of a high-level person, such as the Chief Operating Officer, Chief Medical Officer or lead physician for the practice. Quiz Ref IDThis high-level person serves as the champion for Lean improvement and should be dedicated to leading the effort. They should have sufficient authority and access to organizational resources to ensure that initiatives are progressing at the desired rate.

Box Section Ref ID

Q&A

  • Why is there an emphasis on waste?

    Waste causes physicians and staff to spend time on activities that do not add value to the patient. Waste also causes physical and emotional fatigue for physicians and staff and contributes to frustration.

  • Can you provide examples of waste that I might encounter in my organization?

    Examples of waste include the time a patient spends waiting throughout their visit, staff time spent waiting on the phone, walking down the hall to a printer and moving in and out of the exam room looking for information, other staff members or supplies.

  • How do we eliminate waste?

    The core concept of Lean is to use meticulous attention to every step in each process to determine which steps add value from the patient’s perspective and which do not. The goal is to maximize value and minimize waste.

How can Lean improve the way my practice operates?

Lean thinking leads to a shift in culture where all team members are empowered to identify sources of inefficiency and innovative solutions to address these problems. Lean works best with the buy-in and involvement of everyone on the team.

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Q&A

Step 2 Create an interdisciplinary improvement team

For each Lean improvement initiative, bring together an interdisciplinary team from all areas of your practice. This may include reception staff, medical assistants, nurses, physicians and representatives from pharmacy, lab, radiology, administration, information technology and/or the business office. It is important that everyone understands from the beginning that the group’s purpose is to work together toward a common organizational goal.

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Q&A

Step 3 Empower front-line workers

Successful Lean projects are usually chosen and designed by the people doing the work. The role of the champion and other leaders is to foster an environment where on-the-ground staff can succeed. Projects are more likely to fail when managers jump in and try to do it all without involving the people on the front lines. Staff can use the following worksheet to submit improvement ideas.

Team improvement idea worksheet
Step 4 Choose a starter project

Although it may seem daunting, the best way to learn Lean methodology is to dive in. Work as an interdisciplinary team to identify an important process to improve. This first project should be small but meaningful.

You may consider a 5S starter project, which focuses on clean and organized workspaces to promote productivity and efficiency and minimize stress. 5S stands for Sort, Straighten, Shine, Standardize and Sustain. Fewer errors are made when tools and supplies are in a reliable location and when less time is spent looking for misplaced supplies or missing information. You might be surprised how much more work gets done when the workspace is uncluttered and reliably organized. Use 5S to reorganize a supply room, team documentation area or workroom.

  • Quiz Ref IDSort: For each item in the workspace ask, “Does this have a function in this area? If we remove it, will it matter?” One tip is to tag each item with a colored sticker to indicate how often you use it. Green tags identify items that won’t be used in the next 48 hours, but are used at least monthly. These items could be moved to a nearby storage area. Yellow tags are for items used occasionally, but less than once a month. These could be moved to more remote storage. Red tags are for unused, broken or obsolete items that should be discarded.

  • Straighten: Organize materials so that they are easy to find and close to where they will be used. The goal is to not waste time looking for supplies or performing unnecessary steps. For example, it is helpful to have all exam room supplies in the same place in each room. Another possibility is to strategically place printers in exam rooms and nearby hallways to save time spent entering and exiting the exam room to pick up printouts. Small boxes, trays and a label maker are handy tools to assist with organizing the selected area.

  • Shine: Make sure all the materials in the workspace are clean and in good working order.

  • Standardize: Make it easy to keep the workspace organized. Place all supplies in the same labeled location in each office. For example, in one clinic, standardized procedure trays are created daily and brought into the room when needed. Clear instructions are posted where the trays are assembled so the standard set up is simple for anyone to follow.

  • Sustain: Develop routines and share responsibilities to make the 5S activities a habit for all team members.

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Q&A

  • We know we are spinning our wheels in our clinic. What sort of workflow processes might we tackle?

    Ask your staff where they would like to start. Examples of small but meaningful starter projects include: decreasing the number of steps in the patient registration process, decreasing wait times for appointments, reducing faxes between different offices or departments and improving inbox management.

  • Do we need to hire a Lean consultant?

    Many organizations hire a Lean consultant to assist with organizational culture change and large-scale improvements. The consultant makes sure all employees are taught the language and the methodology of Lean, and that they are engaged in change events that impact their work. On the other hand, it is not necessary for every practice to hire a consultant or facilitator to begin to develop a culture of Lean thinking. This module was intentionally created for practices and organizations that want to move to a Lean way of thinking to improve efficiency with their existing resources.

  • How can we find time to do a 5S project?

    Many groups will close their office for a half day or bring their staff in on a Saturday morning to rigorously clean out and organize their workspace. This is often accompanied by some fun team-building activities. Others will conduct Lean improvement during a dedicated morning or evening session on a weekday. Hopefully, the time investment will be worthwhile because your team will be able to work more efficiently.

  • How many changes should be made at a time?

    It is usually best to start small and implement one change at a time. This way you can determine if your change is having the desired effect.

Additional common Lean tools and tactics:

  • An A3 is a one-page visual display of the process improvement project being undertaken. The A3 document provides a snapshot of the activity to keep all stakeholders and supporting leadership informed. A3 can be used to track the progress and success of a Lean project or initiative.

  • Gemba means “the real place” in Japanese. It reminds Lean thinkers and leaders that work is happening in exam rooms, waiting rooms and on the floors, not in offices or conference rooms where many leaders and decision-makers spend their time. Gemba encourages and supports team-oriented and front-line-driven improvements.

  • Go and see is a tactic that starts with observation on the front lines where work is done. Go and see can help you use Gemba principles. Learning from staff who most intimately know the work often yields practical solutions to interdisciplinary challenges. Leaders who go and see observe a process and understand how the outcome is really achieved, rather than simply trusting what the written procedure says.

  • A Kaizen event brings together front-line workers and leaders to map and analyze a process, then work together to redesign or improve the process. Involving all stakeholders helps the new process take hold after the Kaizen event. The purpose of these events is to make proactive, incremental changes, leading to greater sustainability and ongoing improvement.

  • Quiz Ref IDQuick wins can be accomplished locally by a single person or a team that identifies waste and makes a change to reduce or eliminate it without a Kaizen event, in-depth Lean analysis, resources or the support of the Lean champion. Quick wins can energize and involve members of the team. Celebrate even the smallest quick wins that are accomplished by the team.

  • Visually map a process from beginning to end using a process map to help the team identify what work is actually being done and where opportunities for improvement may exist. Process mapping is most frequently used to identify key process steps, sources of waste and changes that could result in creating the ideal workflow.

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Process map toolkit

Use this toolkit to visually map process flows in your own practice. Creating a customized process map will help your team identify what’s working, and where opportunities for improvement may exist.

The process map toolkit includes:

  • Two example process flows to get you started

  • A library of common shapes and symbols that can be used to create your own flows

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Step 5 Celebrate and spread

Share how you’ve improved processes with others in your practice. This helps build a team culture and strengthen connectedness. Small celebrations of success will contribute to an atmosphere of camaraderie within the practice.

It’s also important to note that not all solutions will work. It is okay to try an improvement and discover that it doesn’t work or is not a good fit for your practice. This is not a failure. In this case, a team can celebrate the problem-solving and learning process.

Step 6 Sustain

The final step in Lean improvement is to make the improvement stick. Quiz Ref IDYou can encourage lasting change by naming the new process and making it part of standard work for everyone involved. Remind staff of the improvement with visual systems that reinforce the new process, such as a checklist or flow diagram at the point-of-work. For example, if the improvement was creating an expanded rooming process for the nurses or medical assistants in the practice, name the new process “Advanced rooming.” Make sure that every clinical assistant’s computer has a list of the advanced rooming tasks to remind them how to properly perform each step. Team meetings can also be used to reinforce new processes by providing an opportunity for regular check-ins that continue to celebrate success and identify additional improvements.

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Q&A

AMA Pearls
Leaders as facilitators

Lean improvement requires that leaders shift their approach from being managers who design new processes to facilitators who support problem-solving and encourage staff to take action. Successful facilitators ask, listen and support the team. Lean thinking shifts leaders from a stance of “command and control” or “design and deploy” to one of discovering and empowering.

Common vision

Develop a common vision for Lean improvement that rallies leaders and employees around a shared purpose. Examples of unifying statements include, “The needs of the patient come first” at Mayo Clinic and “Our promise to patients: We will know who you are and will be ready for you” at Borgess Health.

To set their common vision, ThedaCare™ in Appleton, WI, developed a guiding narrative around a fictional patient named “Lori.” Lori is a middle-aged woman caring for her aging mother, her husband and her children. Lori’s needs help focus the work of the organization. For example, in designing a new Lean process to pre-register patients by phone the staff considers the impact this process will have on Lori.

Common language

The counterpart to a common vision is a common language. In crafting a common language, some organizations have coined their own terms that suit their Lean improvement activities. For example, “flow-stopper” could be used to describe any activity that impedes patient flow. Many organizations adopt the nomenclature of Lean, including the tools that are outlined in this module, such as 5S, A3, Gemba and Kaizen event.

Flow stations

Several clinics have developed “flow stations” as a result of their Lean analysis of work and waste. In a flow station the physician, nurse and/or medical assistant sit next to each other rather than in individual workspaces in separate rooms or down a hallway. The nurse/MA is the “flow master” responsible for directing non-visit-based work to the physician in manageable batches. Forms, phone calls and emails are broken down into small blocks that can be addressed in the short intervals between patients throughout the course of the day. This “in flow” Lean approach reduces the inherent waste in unused down time and enables the physician to finish work earlier. Some organizations report that their physicians finish their work 30 minutes earlier when using the flow station configuration.

Workload balancing and cross-training: team rather than task orientation

Workload balancing means optimizing task distribution and maximally utilizing the people in a system to improve workflow. Cross-training of roles allows flexibility, so that when the demand varies workers can “flex,” or adapt, to prevent breakdowns in the flow of work. For example, if three nurses on a team can each room patients and do phone work (e.g., triage, advice calls, etc.) they can quickly shift work to meet the needs of the practice. When the need to room patients is high, all three could focus on rooming. If the phones are unusually busy, they can adjust from one nurse to two nurses answering phones.

Work conceptualized as team-oriented rather than task-oriented is easier to flex. In the team-oriented example above, all three nurses see their roles as supporting the work of the entire team. In a task-oriented approach, one of the nurses may see herself as the desk nurse who is only responsible for triage and advice, whereas the other two may see themselves as responsible only for rooming patients. Team-oriented work makes the whole team function more efficiently and with greater cohesion, allowing them to more easily and efficiently meet patient needs.

Stop the line

Front-line staff see hazards in the system that may not be apparent to leadership. For example, in a Lean environment, an assembly worker who sees a defect is empowered to “stop the line,” or to shut down the whole assembly line system. The line does not start again until supervisors come to the scene and the defect is addressed. Practices can encourage clinicians and other staff to report near misses or other safety concerns. While an immediate stop may not be feasible in many health care situations, reporting defects for leaders to respond to is still a critical responsibility of front-line workers.

Group recognition

Recognition and reward in a Lean culture is often at the group level, rather than at the individual level. With Lean improvements, the focus changes from producing volume (e.g., the number of patients seen) to producing value (e.g., the number of patients who have all of their needs met).

Situational awareness

Pilots need to see all of the essential data on their control panel at a glance. Health care workers can also benefit from being able to quickly view all crucial information. Line-of-sight and visual cues are ways for staff to access this crucial information to help a clinic’s efficiency. For example, when the nurse can see the status of each of his exam rooms from his station he will know when a room is free and act on this information to room another patient.

Visual management system

A visual management system (VMS) is a tool to promote situational awareness. A visual management system uses symbols, colors and pictures instead of text to more quickly and reliably create situational awareness. With this type of system, staff have unmistakable visual cues in their work environment so standards and activities are obvious and a high level of performance is maintained.

Example 1: A clinic call center

A visual management system at a call center might include a yellow screen if an incoming call hasn’t been answered in 30 seconds and a red screen if the call hasn’t been answered in 60 seconds, alerting all, including managers, to the need to pick up the call.

Example 2: A clinic

In a clinic, a visual management system might be a whiteboard listing physician schedules, staff schedules and roles on a daily basis, how many patients are on each physician’s schedule and any indications that a physician is falling behind on patient visits and may need assistance. Similarly, a patient’s status during their visit and which team member or service they are waiting for can be communicated to the entire care team with flags outside an exam room door or colored dots in the electronic health record (EHR).

Example 3: An office setting

In a clinic administration office, a visual management system might be a list of key problems and the status of work on each item. In a storage room, a visual management system would include labeling what supplies belong where and when applicable the label will have a corresponding picture of the item. Some clinics and organizations line their halls with data about every aspect of their work, including financial, quality and satisfaction metrics. These data are regularly reviewed and used to drive further improvements. For example, leaders and their direct reports make weekly data rounds in these hallways to talk to front-line workers and strategize how to make processes better.

Box Section Ref ID
Conclusion

Lean approaches can bring about cultural change. Becoming a Lean organization has several advantages, including: reducing or eliminating waste of time and/or resources, improving overall efficiency and fostering team cohesion. The information in this module will help you identify opportunities for Lean improvements and learn how to enact them in your practice.

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Where CME credit is designated, the activity is part of the American Medical Association's accredited CME program. The AMA is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Article Information

Target Audience: This activity is designed to meet the educational needs of practicing physicians.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork, and quality improvement.

Planning Committee:

  • Rita LePard – CME Program Committee, AMA

  • Ellie Rajcevich, MPA – Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA

  • Sustainability – AMA

  • Sam Reynolds, MBA – Director, Professional Satisfaction and Practice Sustainability, AMA

  • Christine Sinsky, MD – Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

  • Krystal White, MBA – Program Administrator, Professional Satisfaction and Practice Sustainability, AMA

Author Affiliations:

  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

Faculty:

  • Sharon Fine, MD, FAAFP, Medical Director, Physician Danville Health Center and Northern Counties Health Care, Danville, VT; Deborah J. Guglielmo, MSN, Corporate Director, Michigan Quality System; Randall Huss, MD, Rolla Division President, Mercy Clinic, Rolla, MO; Carlos Roberto Jaén, MD, PhD, Professor and Chair of Family and Community Medicine, University of Texas Health Science Center, San Antonio; Jeffrey Panzer, MD, Family Practice Physician & Medical Director of QI, Oak Street Health; Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA; Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA; Sundance L. Rogers, MD, ABIM, FACP, Internist, Virginia Mason Medical Center, Bainbridge Island, WA; Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA; Whitney M–B Walters, MSEM, Director, University of Michigan Health System Lean for Clinical Redesign BCBSM CQI; Rachel Willard Grace, MPH, Research Manager, Center for Excellence in Primary Care, Department of Family & Community Medicine, University of California, San Francisco

About the Professional Satisfaction, Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy, and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure statement: The content of this activity does not relate to any product of a commercial interest as defined by the ACGME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

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