Background
Quality improvement
Lean
Understanding lean health care in the context of QI
Aspect | Lean | QI |
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Definition in health care | Continual improvement of processes by increasing value-adding activities and reducing non-value adding activities, variation, and bad work conditions [23]. | Everyone’s continuous effort to create changes, that lead to better patient health, better care, and professional development [8]. |
Origins | Toyota’s production system and approach to quality improvement can be traced back to the company’s development of an automatic stopping device for looms in 1896. Among important contributors to this development have been the quality improvement thinking of Shewhart, Deming, and Juran in the 1950s [22, 30, 42‐44]. | Roots lie in physics, engineering, and manufacturing and the development of statistical methods and scientific approaches to understand and measure variation and thereby identify and eliminate sources of poor quality. By continually monitoring for and improving quality, a distinction was made in 1924 between quality assurance and quality improvement with the help of control charts. Key figures include Shewhart, Deming, and Juran, among others [30]. |
Applications in health care | The first empirical applications of lean in health care began in the mid-1990s, but it was not until 2002 that applications began to spread [20]. | |
Key principles | Jidoka (“automation with a human touch”, i.e. quality is built into the process) and Just-in-time (“only what is needed, when it is needed, and in the amount needed”) [44]. | The “model of improvement” which links the Plan-Do-Study-Act (PDSA) cycle of iterative learning with three questions related to goal, measurement, and what to change [11]. |
Results | Factors related to lean success: comprehensive project organization, employee and safety-staff representation, and top management attendance [35]. | Factors related to QI success: leadership from top management, QI experience, organizational culture, and data infrastructure/information systems [10]. |
Methods
Study design
Study setting
Participants
Data collection
Data analysis
Results
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1. QI and lean share many similaritiesQI and lean were both described as strategies that made use of employees’ desire to create an effective and efficient organization. The majority of participants felt that both QI and lean led to a better working environment and lowered costs.
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Theme 1: Purpose of QI and lean is to focus on patients and become effective and efficientParticipants described that the purpose of QI and lean was to focus on patients—to develop a patient-centered approach with a high degree of patient safety. Another purpose was to become effective and efficient.…that you have the same good quality and the same access to care and maybe even increase your production, your health care production and accessibility, but with the same or fewer resources. (P12)Effectiveness was defined as the ability to identify quality deficiencies and to create value for the patient. Efficiency was related to the importance of avoiding duplication of work, finding and avoiding waste, and cost reduction.
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Theme 2: QI and lean are change strategies to continuously improve care processes by engaging employees through the creation of a culture of improvementParticipants described QI and lean as change strategies that contributed to the creation of a culture of improvement. Both promote continuous incremental change, with the intention of making work easier to perform correctly. Several participants mentioned that both QI and lean focused on care processes. They stressed the importance of minimizing the waiting time patients experience between tasks, and that care processes should make optimal use of resources, both personal and physical.Participants described the importance of engaging and actively involving employees in both QI and lean. Employee involvement was important because it led to commitment and continuity in the improvement process. It was described as a necessity that employees take responsibility for their own part in care delivery and for their contributions to the development of the organization. It was also important for both managers and employees to be self-critical:…this means having to look constantly at oneself and how one works, to be more critical; [this] is part of improvement, as I see it… (P12)Another way to engage employees was through the measurement and feedback of results. Participants described that it was important for employees themselves to measure and understand the reason for the measurements so that they will better understand the results.
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Theme 3: Managers should be present and supportive and front-line staff should take initiativesFor both QI and lean, participants stated that managers should be engaged and present. This included addressing employees by name and spending time on the floor to develop a better understanding of the work situation:…the managers should leave their nice rooms and actually get greater insight into the activities. (P5)Managers should support suggestions from front-line staff. Staff should take the initiative and generate their own proposals. Participants described the importance of authority mandated from above so that both managers and front-line staff could have the power and ability to influence.
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Theme 4: QI and lean will result in a better work environment and lowered costsParticipants described that QI and lean result in a better work environment due to a more structured way of working that was in line with hospital values. The participants also expressed the expectation that QI and lean interventions could lead to cost reductions.If we take the main focus, it is on economics, but employee and work environment values are a part of this too. (P11)
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What is QI?The main difference between QI and lean was that QI was described as a clear and comprehensible strategy to guide organization-wide change. Lean was described as vague, most applicable at the unit level, but generally of dubious relevance for health care.
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Theme 5: QI is a natural fit for health care and an effective organizational strategyAll participants described that QI was a natural fit for health care. Considerable doubt regarding the relevance of lean was expressed. Several mentioned the hospital’s effort to capture its values. The values described in the policy document were described as an important management tool. Participants explained that QI had emerged as a core value and this realization created a common foundation across units and among employees for continued engagement in QI.Participants described that QI led to changes in organizational structure, while lean was seen as specific to improvement in everyday work.…lean may be a way of working… to make both small and the large things more effective, but it is not a way with which to work with structural changes (P12)
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Theme 6: QI enables staff and managers to question and improve work practicesQI helped staff and managers to question how work was carried out. QI was associated with a positive “dissatisfaction” with current routine; to constantly be curious and interested in developing new ways of working. Participants described QI as daring to be self-critical and not worrying about prestige:To dare – dare to vet oneself, to be without prestige, and to see that there are always opportunities to do things in a different way, and to, somehow, dare to have that attitude… (P12)Participants described QI as a way to improve how things were done, develop smarter ways of working, discover smarter ways by setting SMART goals, and learn through PDSA cycles. QI helps the organization face the challenges associated with a constantly changing external environment:…the world is changing all the time, so what I mean is that it [QI] is not just about always developing new ways of working or new techniques, that is not even possible, but it is about being in step with [the environment] and maintaining a takt in the organization so that it adapts itself in the right way. That, well, that is the challenge. (P10)Participants stressed the importance of developing seamless care chains and providing better services. Participants also described that distance to patient care determines the focus of QI: Managers should focus on structural or organizational improvement and staff, who are closer to patients, should utilize their unique and practical knowledge and apply QI on operational improvements. It is important that the managers recognize and utilize the knowledge of staff on the floor. It is also vital that managers help each other to move beyond silo thinking. They need to develop an understanding of the bigger picture, a “helicopter perspective”:…that managers actually really help each other, that in our complex organization they leave their silos and see that, okay, the red numbers here probably depend on this, or maybe also that; that we must help each other and have a helicopter perspective and actually look horizontally… (P5)Participants recognized the existence of economic aspects in QI. They saw economic thinking as a base to build upon, which they contrasted with lean where they saw cost reduction as the ultimate goal.
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What is lean?
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Theme 7: Lean is an operational strategy to improve care processes at the unit levelParticipants described lean as an operational strategy and QI as an organizational strategy. They felt that basic organizational principles such as how the hospital is structured can not be changed with lean. They thought these major structural changes were too difficult for lean because these were issues where it was difficult to achieve consensus, and they saw consensus as part of lean.Participants mentioned a number of operational sub-strategies connected to lean. These included working at the unit level and the importance of having structure and clear governance. Together, these lead to the development of organized work processes with clear task divisions for staff. To this end, it was important that the small lean improvement groups had the mandate to make their own decisions:…we have systematic improvement going on all around us, in small groups, each with its own mandate to make decisions. (P9)
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Theme 8: Exercise caution with terminologySeveral of the participants mentioned that lean, in contrast to QI, had acquired a negative connotation throughout the organization. The concept had sometimes been used in an arrogant manner. They described that staff and managers did not always understand what to do with lean, nor what it amounted to. Some participants felt that lean had become something abstract, something people talked about without understanding it, and that staff were influenced by these negative opinions. Lean was often associated with Toyota and participants described that this had increased the skepticism of staff and managers towards the concept. This skepticism was compounded by what managers felt was a hidden economic agenda. A skepticism they felt staff shared.Yeah, they say that there are no economic agendas, but many do make that connection. And, many say that it is hidden, that when one talks about lean, what it really is about is to make things cheaper, and so forth… (P4)Participants described that some had written off lean as another fad that would soon disappear. All of this led some participants to avoid the term and instead discuss “flow”, “value-adding time”, or “value-creation”.
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Theme 9: Lean is a philosophySome participants differentiated QI and lean by describing lean as a philosophy. This philosophy manifested itself in a toolbox of methods and a number of sub-strategies, such as continuous improvement, the development of long-term goals, employee participation, the importance of leadership, and the development of a sustainable improvement culture. Lean was also described as an ideology based on common sense with sound principles.Lean – it is both a deep philosophical reasoning around continual improvement, it is somehow this entire culture… a long-term perspective, linked to an entire toolbox. (P9)
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Discussion
Aspect | Lean | QI |
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Purpose | To focus on patients and become effective and efficient (Theme 1) | |
Definition | Change strategies to continuously improve care processes by engaging employees through the creation of a culture of improvement (Theme 2) | |
Roles | Managers should be present and supportive; front-line staff should take initiatives (Theme 3) | |
Expected effect | A better work environment and lowered costs (Theme 4) | |
In practice | Lean is an operational strategy to improve care processes at the unit level (Theme 7) Lean is a philosophy incorporating strategies and a methods toolbox (Theme 9) | QI is a natural fit for health care and an effective organizational strategy (Theme 5) |
Lessons learned | Exercise caution with terminology which staff might find foreign to health care (Theme 8) | QI enables staff and managers to question and improve work practices (Theme 6) |