Care Redesign
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Limits of Lean — Transformative Care Redesign Must Go Beyond Typical Lean-Based Improvements

Article · February 5, 2017

Many delivery system leaders have looked to Lean improvement methods to guide care redesign. Also known as the Toyota Production System, Lean seeks to empower frontline staff and their managers to analyze work processes, identify sources of waste, and propose redesigns that streamline and standardize workflows. Citing the successes of a few organizations, some health care leaders treat Lean thinking and methods as optimally positioned to drive major leaps in quality, cost savings, engagement of patients and employees, and even population health. Regrettably, limited evidence supports these high expectations. Lean can contribute to improvement, but successful Lean applications typically yield focused, step-by step improvements rather than dramatic jumps in performance or transformational organizational and culture changes that run broad and deep. Attaining even modest improvements through Lean requires leadership vision, commitment, and investment of substantial time and organizational resources.

On its own, Lean lacks capacity to transform culture and generate care that is deeply patient-centered, transcends organizational boundaries, and fosters collaboration for population health among social and medical services. These conclusions come from in-depth Lean implementation studies conducted for the Agency for Healthcare Research and Quality (AHRQ) in 10 diverse delivery systems, as well as over 200 research papers reviewed in 11 literature syntheses.

The Limited Impact of Lean

One of AHRQ’s studies closely examined 12 separate Lean rapid-improvement projects like those reported in the literature. These projects were conducted within five hospital-based delivery systems, three of which had two or more years of Lean experience. Eight of the projects yielded modest efficiency gains, such as reduced costs for hip and knee surgery and improved patient flow in outpatient clinics. A smaller number sought and yielded improvements in care quality and continuity.

Only one project, which streamlined patient flow from admission to discharge, produced results that could have a noticeable impact on overall hospital performance. The cost savings in the hip and knee surgery project were insufficient to close the gap between the hospital’s costs and Medicare’s reimbursement rate. Some reportedly successful projects produced unintended consequences. For example, adding a phone tree at a large outpatient clinic reduced burden on administrative staff so that they could process records more quickly and ensure timely patient arrival at appointments, but the phone tree reduced patient satisfaction.

Three projects were entirely unsuccessful. A rural access hospital failed in its attempt to use Lean to reduce UTI infections. In other systems, two projects stalled indefinitely as they awaited needed IT upgrades. Only a few systems in the study spread process improvements or project learnings beyond the units initially targeted for improvement. Although leaders in four of five systems sought transformation, only one system appeared to be well on the way toward making Lean their main efficiency improvement strategy and establishing a Lean-based quality improvement culture.

Similarly, most Lean applications reported in the research literature yielded incremental improvements in existing care or administrative processes, rather than fundamental organizational breakthroughs. The projects often targeted work processes consisting of linear steps or workflows in a single department or unit. However, in some cases, Lean applications did enhance efficiency in high-cost, high-visibility settings, such as the emergency department. Other reported benefits included reductions in patient waiting time or improvements in care quality.

Preconditions for Lean Success

Successfully improving a targeted process through Lean and spreading gains and learnings from Lean projects within a delivery system does not come quickly or easily. Doing so requires well-planned and carefully orchestrated investments of time and energy by leaders, middle managers, trainers, and frontline staff. Their efforts help ensure conditions contributing to Lean project success, including championing by at least some physicians and limited opposition by others, alignment of Lean activities with other improvement programs, operational and logistical support, contributions by experienced consultants or internal experts, and training managers and frontline staff in Lean. Organizations that have spare resources to devote to Lean and that have had prior quality improvement experience are better positioned to implement and spread Lean improvement activities.

Systems famous for their Lean transformations, such as Virginia Mason, Theda Care, and Denver Health, illustrate the importance of external support and prior experience with quality improvement and system change, as well as highly skilled executive leadership committed to a multi-year, system-wide change strategy that includes substantial logistical and operational support for Lean training and implementation. However, most of the organizations in AHRQ’s investigations have not sufficiently developed these supportive conditions. Nor were these conditions evident in most of the systems described in published research on Lean.

A few organizations that we studied carefully developed their Lean initiatives and achieved impressive results. For example, Palo Alto Medical Foundation Sutter Health used Lean to revamp primary care work teams and flows across 17 clinics. This initiative benefitted from leadership commitment and planning, along with strong logistical and operational support. The Lean-based care redesigns enhanced efficiency, provider satisfaction, and most forms of patient satisfaction, without sacrificing quality.

In contrast, resource-constrained systems, including many safety nets and small and rural systems, often lack the capacity to plan and support an ambitious Lean initiative. They are less able to invest in needed Lean training and other forms of quality improvement, ensure adequate IT infrastructure, and provide coaching and technical support to improvement projects. They may be particularly vulnerable to high levels of turnover and heavy workloads, which pose barriers to staff engagement in Lean.

Beyond the Boundaries of Lean

To address the wide-ranging challenges of health reform, care organizations must undertake three types of transformational change, which are only attainable through broad organizational initiatives extending well beyond typical Lean improvement activities.

  1. Develop patient-centered care. To ensure appropriate care for chronically ill patients, and to promote population health, organizations need to redefine some traditional operating objectives and performance standards and develop new or radically redesigned care processes, such as team-based primary care. As Lean experts and users concentrate on making current processes more efficient, they may devote insufficient attention and energy to developing new goals and care delivery designs.
  2. Span organizational boundaries to coordinate care and promote community health. Except in tightly integrated systems, coordination of medical care requires cooperation across fragmented medical services. Health promotion calls for joint action by medical, social, and educational services. It takes time and concerted effort to build teams that bridge boundaries between care sites and entire organizations. But Lean projects typically rely on teams made up of members of the same organization, who already share objectives and operating assumptions.
  3. Change organizational culture. Radically transforming taken-for-granted assumptions, values, and work procedures goes far beyond targeting selected processes for improvement. To change culture, leaders must articulate an overarching organizational change strategy and align diverse programs and improvement initiatives with that strategy. Strategic and behavior change must be implemented and reinforced through the appropriate use of performance measures, incentives, training, and staffing. Lean thinkers call for culture change, but popular Lean improvement techniques alone do not provide sufficient change levers to promote it.

According to current research, Lean promises more than it has delivered. It is possible that published research studies are lagging practice, where there are some reports of Lean-driven breakthroughs in quality and value and even Lean-based culture change. But a positive publication bias may actually be leading the research literature to overestimate Lean’s potential.

In any case, leaders seeking to deploy Lean or other improvement methodologies to help them confront value-based payment and pursue new care goals would be well advised to start by developing a well-planned and articulated organizational change strategy that fits with the organization’s mission and business plan. Then, leaders can choose improvement approaches to support their change strategy. Heading in this direction will take the organization well beyond the limits of Lean.


Acknowledgments: Thanks for helpful comments from Cindy Brach, Michael Furukawa, Dorothy Hung, David Knutson, Dina Moss, and Brent Sandmeyer.

The views in this blog are solely the author’s and do not represent those of the Agency for Healthcare Research and Quality or any other U.S. government agency.

This article originally appeared in NEJM Catalyst on January 17, 2017.

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