Role reversal: At these hospitals, it's the frontline staff transforming care and saving millions

Turns way of doing business 'completely upside down,' former CEO says

Eschewing the typical top-down approach, some hospitals have empowered frontline workers to change clinical workflows—and have seen startling results, Sabriya Rice reports for Modern Healthcare.

Increasingly, hospitals are employing Lean management techniques, which were pioneered by Toyota more than 30 years ago but have only been used by health care providers in about the past decade, Rice writes.

Want to make the most of Lean? Engage your frontline staff.

The process focuses on achieving efficiencies, often by eliminating waste, developing standardized protocols, and fostering a culture of continuous improvement. And while the areas to focus on are often identified by management, it is the frontline staff who assume the main role of recognizing problems and developing solutions.

For hospital officials, that turns "the way they have done business for their entire career ... completely upside down," says John Toussaint, who brought Lean management to Wisconsin-based ThedaCare when he served as CEO from 2000 to 2008.

Lean in action

Presence Health CEO Sandra Bruce started incorporating Lean management techniques at the 11-hospital system in 2012.

Officials at Presence have since launched seven so-called breakthrough rapid improvement events—targeting perioperative services—in which frontline staff spend one week observing hospital workers and developing solutions to inefficiencies that harm quality and the system's bottom-line.

For the latest rapid improvement event, frontline staff at Presence Saints Mary and Elizabeth Medical Center were tasked with reducing average turnaround times for the surgery floor from 30.55 minutes to 25 minutes—which Kathleen Long, Presence's director of breakthrough improvement, says could add $600,000 of annual revenue.

Armed with notepads, floor maps, and stopwatches, the members of the rapid improvement team observed their colleagues, and later wrote each problem they identified on a Post-it note. They noticed wide variation in the process of turning over surgery rooms, issues with storing surgical supplies, and more. By the end of the week, staff had placed hundreds of Post-it notes on a hospital wall.

The staff vigorously debated the proposed solutions—such as changing supply stockers' work schedules and storing surgical supplies in one place—and then removed changes that were too difficult or that would have a minimal effect from their list of recommendations.

And although they worried about whether their suggestions would face pushback, the surgery manager told them that "whatever this team comes up with, we'll do."

On Friday, the team presented their final report, and the changes will begin to go into effect immediately, with a daily huddle to talk about cases that have a room turnover of more than 25 minutes. And going forward, the hospital will continue to evaluate the changes, including by collecting data and issuing status reports for the next three months.

Successes, challenges

Simply having the rapid improvement team follow the surgical staff around led to a drop in surgery room turnover to 18.4 minutes, suggesting that increased accountability could be a key to achieving the system's goals.

And other examples of Lean techniques in action have achieved longer-term success, Rice notes. For instance, Presence St. Joseph Hospital changed its sepsis early warning system and began tracking performance daily. After four months, the hospital had reduced sepsis mortality from 24% to 9%, and brought down the average cost per case by about $3,000.

One way to engage physicians? Give them ownership.

Bruce says that Lean management has also helped to increase employee engagement and morale, while fostering a culture of continuous improvement where staff feel empowered to make suggestions. The next step for Presence, Long says, will be to share best practices from Lean initiatives across the system.

Despite the success at Presence and several other systems, only "a limited number of health systems are using Lean methods," Rice notes, because of the necessary time and resource commitments, and the culture shock it could pose to some organizations.

But Long says that even with the challenges, using Lean is worth it—because it works. "We can't just keep doing the same things and hope somehow a miracle is going to come from the sky," she says (Rice, Modern Healthcare, 9/26).

Two ways to identify clinical variation


There are many opportunities to reduce care variation in hospitals today—but how should you prioritize those opportunities?

You should start by examining variation in two ways: "horizontal" and "vertical." A horizontal approach focuses on the use of costly resources across multiple conditions, while a vertical approach analyzes performance within a particular condition or patient population to develop a consensus-based standard.

Our infographic gives an example of each approach and explains the challenges of a horizontal approach versus the benefits of a vertical one.


Next in the Daily Briefing

Around the nation: Massachusetts warns providers about fraudulent nursing credentials

Read now