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Shortly after Don Shilton was named
president of St. Mary’s General Hospital in Kitchener, Ontario, in 2010, the
hospital’s board set a new vision for the organization: to be the safest and
most effective hospital in Canada.
Its success would be measured by a
risk-adjusted mortality ratio that is reported annually for all hospitals in
“Twice in the last five years we
actually have had the lowest mortality ratio in the country,” Shilton (pictured at right) says. The
mortality ratio measures expected deaths versus actual deaths in acute care
hospitals, with a ratio lower than 100 indicating fewer than expected deaths. In
the most recent year, St. Mary’s score was 71—third-best in the country—compared
to a national average of 91.
Along the way, St. Mary’s has cut patient
falls by more than 50 percent and hospital-acquired infections by more than 75 percent,
while also reducing staff injuries and inpatient length-of-stay. Most importantly,
the organization has created a culture in which all staff members are trained
and expected to initiate improvements. That’s why Shilton believes St. Mary’s
has come so far on its Lean-focused safety and quality journey—and is only
“Many organizations fail at a Lean implementation
because it requires a transformation of the culture within your organization,
and that’s a difficult thing to do,” Shilton says. “If you can stay at that,
then five, six, seven years later, you have an organization that is extremely
high-performing with extremely engaged staff who want to make it an even better
Healthcare leaders who wish to
achieve operational excellence must exhibit a special kind of leadership, says
John Toussaint, MD (pictured at right), CEO of Catalysis, a not-for-profit education institute in
Appleton, Wis. His work is inspired by principles developed by former Toyota
engineer Shigeo Shingo, whose ideas are applied to Lean and other
Toussaint headed the ThedaCare
health system in northeastern Wisconsin more than 15 years ago, when Lean
manufacturing principles were just beginning to be used in health care. As a teacher
and student, he has visited more than 200 healthcare organizations in 19
countries, seeing firsthand the many ways that leaders’ aspirations for high
performance get lost in implementation.
“I was at a hospital the other day
that had 245 breakthrough strategic initiatives—that's just ridiculous,” he
says. “That kind of activity creates tremendous overburden on the organization,
so it doesn't focus and it can't get any better at anything.”
The principles in the Shingo Model
require leaders to keep a tight focus on what excellence means for their organizations,
Toussaint says. That means identifying a very small number of strategic
initiatives—maybe just three or four—that set the direction for the
Similarly, leaders need to focus on
a small number of metrics that are directly related to the strategic
initiatives. “What are the things that will let us know that we're either
winning or losing on our organizational performance?” he says.
The leaders’ next job: Articulating
the vision and the metrics to the entire organization. “That’s so everyone who
works there understands, first of all, why they work there, and then whether
the organization is achieving its goals,” Toussaint says.
At Salem Health Hospitals and
Clinics in Oregon, organization-wide strategic initiatives have focused on
improving compliance with hand-hygiene protocols and reducing
healthcare-acquired infections. Meanwhile, individual work units use Lean
principles to address issues specific to their work. For example, the 20-member
finance department at Salem Health used the Lean problem-solving approach to
complete more than 80 projects in the first 10 months of the current fiscal
year. The department’s goal is for each staff member to complete at least four
such projects a year, says Reid Sund (pictured at right), manager of the department and controller
for the system.
“There are problems every day, so we
use the Lean tools to do our work in a methodical way,” Sund says. “Our culture
in finance is that that’s how we solve problems; there's really no other
method. It might not be structured—sitting down and writing it out—every time,
but we use the methodology even in the way we discuss problems.”
Lean leaders at Salem Health learned
from experience that excellence thinking must be embedded in the organization
at all levels, says Debbie Goodwin (pictured at right), RN, BS, MSN, a Kaizen (Lean) learning and
development consultant at the health system.
In its first foray into Lean management,
Salem Health used an event approach, in which a group of employees gathered to
tackle a specific problem using a protocol centered on rapid process improvement.
That required a lot of time and effort and did not generate sustainable
improvement, she says.
In 2012, Salem Health moved to an
“all-in” commitment, with a focus on training Lean leaders in all departments
and embedding Lean fundamentals into the way that frontline staff conduct their
work. “We really needed more of a cultural transformation with our Lean work,”
Goodwin says. “Everyone needs to be involved.”
In Sund’s finance department, that
means all supervisors complete Lean leader orientation, a 12-week program in
which participants learn Lean concepts—team huddles, visual management boards, and
four-step problem solving, among others—and demonstrate mastery of them.
That training is reinforced by a
coaching matrix. “I’m constantly being coached not only by my supervisor, but
we also have a Lean sensei who rounds on me,” Sund says. “She is very helpful
in providing feedback on various things we are working on.”
Meanwhile, Sund uses a “coach,
coach, tell” approach to managing his staff. That means he first coaches them
to use Lean fundamentals to solve problems and only instructs them on what to
do if the coaching is not effective.
Exhibit: Guiding Principles of Operational Excellence
St. Mary’s General also takes the
“all-in” approach to cultural transformation through Lean principles. Three
years ago, Shilton challenged the 1,300-member staff to implement one
improvement per employee during the year. The staff exceeded that goal—and the
next year’s goal of two per employee. “Then last year, we hit three
improvements per employee,” he says.
Such a performance shows that the
hospital’s employees want St. Mary’s to strive to improve, while other
statistics show they like working at a place that is focused on improvement. In
the most recent employee engagement survey, 91 percent of staff said St. Mary’s
is a good place to work at—compared to a Canada-wide healthcare average of 58
percent. Similarly, St. Mary’s staff, on average, said they look forward to
going to work 91 percent of the time, compared with 74 percent for their
colleagues around the country.
“Engagement is through the roof,”
Shilton says. “So, we have people regularly coming up with ideas and
implementing improvements to the organization.”
That engagement translates to improvements
not only in quality and safety but also in financial performance. As St. Mary’s
General has increased market share, Shilton says, the number of inpatient days
has increased by 7.3 percent in the past three years, and total salaries have
increased by 7.1 percent. But the overall cost per inpatient day has decreased
by 0.9 percent.
Likewise, emergency department (ED)
visits increased by 8.1 percent during that period, but the hospital’s cost per
ED visit fell by 4.9 percent. “A whole systemic culture change has really led
us to become a high-performing organization,” Shilton says.
That culture change has been
supported by structural changes in the way St. Mary’s General operates. For
example, the manager of every unit meets daily with the charge nurse or unit
lead to go through a standardized set of questions to prepare for predictable
“If we have a sick call this
afternoon, how are we going to handle that? Or where are we going to put the
next two admissions that come from the emergency department?” Shilton says.
Likewise, each manager meets with
his or her department director every week; each director meets with a vice
president once every two weeks; and each vice president meets with Shilton once
a month. At each of the meetings, the conversation is driven by a set of
questions that are designed to proactively address predictable problems.
As with any cultural transformation,
creating enterprise excellence through Lean fundamentals will happen only if
the organization’s top leaders embrace it for themselves. That means not only
learning Lean concepts but using them consistently, Goodwin says.
“This is challenging for people who
have previously been recognized and rewarded for a different leadership style
because this is very much a coaching style that says leaders don’t have all the
answers,” Goodwin says. “If senior leaders tell the mid-level folks in the Lean
office to do Lean but don’t do it themselves, those [implementations] don’t
work so well.”
Change requires adequate support. Training department heads and
supervisors in Lean methodology is not sufficient to achieve significant and
lasting improvement, Goodwin says. Salem Health, with a staff of about 4,800,
employs about 10 staff members who are dedicated to coaching leaders and
supporting initiatives throughout the organization or to managing the health
system’s Lean strategy. “Building an infrastructure of resources was definitely
needed to implement the Lean system here,” she says.
Focus on quality and safety. Although Lean principles, by
definition, seek to improve efficiency by eliminating waste, healthcare
organizations that focus primarily on financial performance will not succeed in
a Lean transformation, Shilton says.
“Make it all about improving quality
and safety; do not make it about saving money,” he says. “The only way you are
going to be successful with this is by engaging the frontline staff in the
journey and in wanting to make your organization better—and people don’t become
nurses or doctors or social workers because they want to save money.”
Butcher writes about healthcare business and policy topics for several HFMA
Interviewed for this article:
Goodwin, RN, MSN, kaizen (lean) learning and development consultant, Salem
Health, Salem, Ore.; Don Shilton, president, St. Mary’s General Hospital,
Kitchener, Ontario; Reid Sund, controller, Salem Health, Salem, Ore.; John Toussaint, MD, CEO, Catalysis, Appleton Wis.
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