Efficient Healthcare

Can you have a culture of excellence and not have a culture of improvement? Don't they go hand in hand? Not necessarily.

Just ask anyone who works in healthcare, where superior clinical outcomes and exceptional patient experiences too often reflect individual efforts to work around the system, not within it.

"The problem with having a culture of excellence is that you have people who are trying very hard, but they don't always organise themselves into effective teams or create efficient processes," says Dr. Lisa Yerian, director of hepatobiliary pathology and medical director of continuous improvement at the Cleveland Clinic.

"People who are committed to excellence can create a lot of workarounds. They will go the extra mile but don't always think about how to go three miles fewer to deliver the same or better quality care."

Imagine if you could create a culture of excellence and improvement in a large healthcare organisation. That's the challenge that pushed the Cleveland Clinic to reinvent its continuous improvement program and push for a true cultural transformation.

Rolling Start

Few organisations, in healthcare or otherwise, can match the Cleveland Clinic's culture of excellence. Located in Cleveland, Ohio, it has been one of the top-ranked healthcare systems in the United States for decades and continues to pioneer new medical breakthroughs every year.

System-wide it employs more than 43,000 "caregivers," including 3,000 salaried physicians and researchers, and 11,000 nurses. They follow a patient-centred model of care organised by departments and institutes, which focus on a single organ system or disease, up-ending the traditional hospital structure based on medical specialties.

The Cleveland Clinic launched a formal continuous improvement department in 2006. The department began by helping different cross-departmental teams with collaborative problem solving and performance metric reviews. Its activity and scope expanded in response to internal demand.

The Cleveland Clinic staff treated 5.5 million patients in 2013 (the most recent year for which data is available), including over 157,000 admissions and more than 200,000 surgical cases. Founded in 1921, the physician-led organisation integrates clinical and hospital care with research and education. Unlike a traditional hospital system divided into clinical departments and divisions, the Clinic is organised into institutes around individual organs or disease systems. The main campus in Cleveland, Ohio, has 1,400 beds. In total the healthcare system has 4,450 beds, which includes facilities in Las Vegas, Florida, Canada and Abu Dhabi. Cleveland Clinic's annual revenues exceed $6.4 billion. It employs over 43,000 people, including 3,000 physicians and scientists, and 11,000 nurses.

Growing slowly over the next six years, the CI department recruited new team members from a variety of industries eager to apply their knowledge of Toyota business practices, lean, six sigma and project management to the healthcare realm.

Embedded in the departments and institutes, they worked with cross-functional groups to apply classic problem-solving methodologies and tools to a list of high priority projects.

These discrete projects had a significant and sustainable impact on quality, the patient experience and costs in a variety of settings within the Cleveland Clinic. Some examples include:

  • Oncology: A cross-functional team reduced outpatient chemotherapy wait times from an average of 60 minutes to 20 minutes.

  • Operating Rooms: Faster setup and turnaround times maximized operating room utilisation.

  • Emergency Department: Split-flow triage paths dramatically reduced average wait times and the number of patients who 'left without being seen.

  • Pathology: 3P and other lean design methods engaged the workforce and improved efficiency during the construction of a new pathology lab.

Continuous Improvement Challenge

Such projects continue today. They're often focused on improving timeliness of care by reducing patient wait times or eliminating waste to make the care they deliver more reliable and affordable.

But as beneficial and important as these focused projects are, they don't necessarily instill a problem-solving mindset, or the skillset to solve everyday problems, among the Cleveland Clinic's thousands of caregivers. In the Autumn of 2012, Dr. Robert Wyllie, the chief medical operations officer, challenged CI department leaders to build a culture of improvement.

"We needed to change the culture so that everyone was thinking about it, teach them some basic tools and a basic approach, and drive responsibility for changes to every caregiver. We had to give everyone the opportunity to look at how they're doing their day-to-day jobs and where they could make improvements, reduce wastes, cut costs and improve the patient experience," says Dr. Wyllie.

But how do you actually go about creating a culture of continuous improvement?

Changing the culture would extend well beyond the CI department. It touched the organisation's management systems, reward systems, and data systems; it would ultimately be reflected in how people talked about and tried to solve problems. Incorporating input from many people and departments, the culture change A3 went through more than a dozen iterations.

"We finally settled on capability as a fundamental contributor to creating a culture of improvement," recalls Dr. Yerian. "You need a certain level of capability to understand how to solve problems effectively and to understand what the most important things to work on are.

Our caregivers need to be capable of identifying and solving problems, with support and coaching, as part of their everyday work. If we could impact capability, we hypothesised, we could impact our culture."

That was the hypothesis for creating a culture of excellence and improvement. Like any hypothesis, it had to be tested. And, for it to spread, people needed somewhere to go to see for themselves what such a culture looked like and how it worked.

The Number One Criterion of a Model Area: It Has to Work…and there was a challenge about to him them hard…

Around this time the impact of the Affordable Care Act (ACA) on the revenue models of healthcare organizations was coming into sharper focus, recalls Chris Donovan, executive director, Enterprise Information Management and Analytics.

"In early 2013 our CFO Steven Glass told me we had to figure out how to take 12 to 14 percent of our costs out. That wasn't something we could do just by asking people to work harder," he explains. The rate of improvement had to accelerate dramatically. There simply weren't enough CI people to support all of the work that had to be done.

"You can do SWAT-team improvement projects, but that doesn't change how people think. We had to change the way we lead. We had to empower people to find efficiencies and solve problems on the fly. We had to change the way we approach our work," Donovan adds.

To test the A3 hypothesis, Donovan's group, Decision Support Services (DSS), which is part of the finance division, became the first model area for how a culture of improvement might operate on a day-to-day level.

The group is located in an administrative building in a suburb south of the main downtown campus. With the industry-wide push toward value-based care and an increased emphasis on efficiency and costs, it was a fortuitous place to start.

The decision support group generates the monthly patient care and financial reports that managers at all levels use to track performance. Basically, they keep score for the entire Cleveland Clinic organisation.

Kicking off in May 2013, the initial focus in the DSS group was on problem solving. That started with learning how to create and use an A3. An expert from the CI department trained two "lean leads" from each of the group's four teams, who then trained their teams. They rolled out other lean management and problem-solving tools in a similar fashion, always emphasizing the connection with the scientific method through the PDCA (plan-do-check-act) cycle.

Rather than follow a cookie-cutter approach or do comprehensive across-the-board training, the CI department tried to introduce methods and tools to the DSS teams only when they were needed.

That way they weren't introducing solutions to problems that hadn't arisen yet. The approach was less didactic and more purposeful than many introductions to lean principles because it focused on providing solutions to real problems that the team was facing.

For example, when the DSS group implemented a kaizen suggestion process, it generated a flood of ideas. To prioritise those ideas managers realized that they needed a better understanding of the strategic priorities of their department and the Cleveland Clinic organisation as a whole.

They could then align improvement activity accordingly.

To do this they utilised a strategy deployment tool first developed in the 1950s known as OGSM (objectives, goals, strategies and measures).

"Building these capabilities is highly engaging; it's fun and really connects with people," says Dr. Yerian. "But in order to provide value the work has to be connected to the priorities of the organisation. The organisation's leaders need to see that the problems the teams are solving are those that are most important to them."

This strategy deployment work was one example of the lean leadership capabilities that the Cleveland Clinic had to develop in parallel with the core problem-solving approaches and tools.

During the weekly CI reflections, in addition to practicing and modeling coaching behaviors themselves, Dr. Yerian and Chris Donovan—who separately attended LEI lean coaching and leadership workshops—would give managers and executive directors feedback on how they posed questions to their teams, and how they discussed and recognised results.

"If we had just taught the frontline how to solve problems, without changing the way we lead, it wouldn't have gone anywhere," says Dr. Yerian.

Utilising the problem-solving tools, implementing countermeasures and continuing to follow the PDCA process, the decision support group started to find permanent solutions to intransient problems and began to make dramatic performance improvements. During the first three months, they documented 130 kaizens (approximately one per person per month), saving over 1,600 hours. When the initiative began, they were rarely hitting the monthly target date for releasing the monthly financial reports. Today, they always hit the target, and expect to get the reports out a day earlier this year.

Today Finance, Tomorrow the World

As the first model area the decision support group made a commitment to welcome visitors from other parts of the Cleveland Clinic organisation to come and see what they were doing, to talk candidly about what worked well, and to share what some of the challenges had been. The lean leads are also helping to spread the problem-solving capabilities to other departments.

This took some of the burden off of the CI staff, which is currently made up of only 32 people in an organisation of more than 40,000 total employees.

"We wanted to create a ripple effect," says Dr. Yerian. "Building lean capabilities and then teaching others is an excellent development opportunity for our caregivers."

Hundreds of caregivers from across the organisation and beyond have visited decision support services, reinforcing the message that the lean work they were doing was important to future of the organisation.

The visitors included the Cleveland Clinic's executive officers, who were all briefed in advance on lean leadership methods, such as productive questions to ask that would support the group's efforts.

They included CEO and President Toby Cosgrove, CFO Steven Glass, and Executive Chief Nursing Officer Kelly Hancock, who returned the following week with her leadership team with the purpose of establishing a similar lean model area in nursing.

Today the lean model area in the in-patient nursing unit has achieved dramatic improvements in patient call light responsiveness and nurse communication.

Internal demand ultimately led to the creation of six additional model areas representing a cross section of the organisation in both clinical and administrative areas, on the main campus and in regional hospitals. These included: surgical supply, nursing, pharmacy, business intelligence, revenue cycle management (another finance group) and outpatient phlebotomy.

After starting with problem-solving tools, each area pulled in capabilities and CI department support as needed. Because they were all following their own path, progress was sometimes painfully slow.

"Just as we ask others to reflect on their work, and where their problems and opportunities are, the CI department had to be doing the same thing," says Dr. Yerian.

Reflecting on the pace of progress, in the spring of 2014 the CI team began to develop a model for creating a culture of improvement.


The Cleveland Clinic improvement model articulates core elements of their approach and loosely defines leadership and caregiver behaviour for different levels.

Does everyone know what matters most to the Cleveland Clinic and what they need to deliver? Does everyone know how they are doing, and if they are winning or losing today?

By starting with those questions, communicating the expectations, and tracking hour-by-hour performance, they made some dramatic improvements in a very short period of time.

Specifically, in the six outpatient phlebotomy locations on the main campus, they improved the percentage of patients being seen within 15 minutes from 51% to 96% within two months.

"You need to build the capabilities that will help solve the problems that you face in delivering on your purpose," explains Dr. Yerian. "In the earlier implementations we were teaching our caregivers some things that weren't relevant to the immediate problems that they needed to solve. It's no wonder that this team achieved results three times faster – we eliminated all that waste!"

Healthcare Continuous Improvement as in other tremendously complex organisations is mightily difficult. But as can be seen at the Cleveland Clinic and many like it, far from impossible.

Value Stream Experts prides itself on delivering in the toughest environments and is delighted to be considered a pioneer in Lean Transformation into the Global Healthcare sector.

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