HHC adopted lean in late 2007 with the aim of spreading to its 23 largest sites and subsidiaries over a three-year period. With the help of external consultants, HHC sought the cultural transformation requisite for achieving radical change and sustainment of operational improvements. To date, we have accomplished some of what we intended, and learned much about the challenges such a lofty goal will encounter. We have modified our plans and clarified our objectives and become acutely aware of just how much we have to learn before we can fully understand what we can achieve.
Our efforts have paid off – 7,000 staff have participated in rapid improvement events and training. We have found more than $300 million in new revenues and cost savings. At individual sites, achievements included:
- developing standard work and process control boards in nursing units helped to reduce the use ns reduced the types of Foley catheters, and education reduced UTIs by 63%
- By adding a swing room for each MD in an outpatient clinic and having the providers come to the patient, patient movement was reduced from 12 steps to 1.
- implemented a patient navigator system in the ED, resulting in median wait time falling by 50%
- creating standard work for pre-surgical assessment and testing resulted in on-time first case starts in the operating suite moving from 6% to a range of 40-50%.
A large system poses some unique challenges and opportunities. We are fortunate to have many sites in which tests of change can be made and compared. At the same time, variation of method is more difficult to see, understand and control when activities are geographically distant and administered by different people and groups. Encouraging local innovation and recognizing differences in population, practices, acuity and history are essential to local ownership and relevance, and doing so while also maintaining replicable, defined standards for the improvement system itself as well as service-specific improvements that build on successive wins requires a high level of awareness and excellent, bi-directional communication that is difficult to create and manage.
We originally intended to implement lean at the 23 largest sites and subsidiaries over three years. However, we ended up spreading this over 5 years and leaving a few sites, including our health maintenance organization, for even later for a number of reasons, including understanding our absorption rate – it took longer to stabilize new sites than anticipated – and the degree of pull coming from these sites.
Breakthrough, the HHC Improvement System, is closely modeled after the Toyota Production System as translated by our sensei and, as we have become more comfortable with lean, our own understanding and tailoring. We have grown to appreciate the value of a standardized approach. Indeed, Breakthrough is a system for setting strategic goals that are aligned with organizational values and guiding principles, and inclusive of tools and tactics for the achievement of continuous improvement in areas of strategic importance. While our first year or two we struggled to understand the wisdom of what felt like rigid adherence to arbitrarily defined improvement processes and structure, we grew to understand that absent a standard, no improvement can be made. Thus despite our work in 19 sites across four boroughs of the city, we deploy the same improvement model at all sites. Holding to this standard is critical to measuring progress between and across sites, spread and building improvement infrastructure.
HHC has faced enormous budget gaps the last several years and is heading into another year of cash flow and deficit issues largely related to changes in reimbursement structures and proposed cuts to traditional sources of revenue.
Initially, sites were encouraged to select the areas for improvement, but over the years, we began to ask sites to focus on areas of strategic priority that could contribute to financial benefits targets. In particular, perioperative services, in which efficiencies drive throughput, and emergency room and inpatient flow, that provided ripe areas for improvements in the revenue cycle, were encouraged.
Our lean ‘system’ has developed over time and we expect more from our efforts as we understand the power and optimal application of various tools and integrate A3 thinking into our planning and improvement efforts. Over the last year we began to cascade hoshin kanri from level 0 through levels 1, 2 and 3; this effort has created significant leadership buy-in to Breakthrough. Our most recent effort has been to develop a daily management system to facilitate both the engagement of staff and managers and to improve our improvement sustainment rate. If it is an accident of timing, the synergy between these strategic initiatives or perhaps the attainment of a tipping point, year 6 is proving to be an important year for us.
This last few months has been spent conducting site assessments against a standardized tool that sets targets for achievement of essential Breakthrough elements. Meeting with site leadership teams has been tremendously helpful. In most cases, these meetings indicate that leaders and core Breakthrough staff are walking the talk and eager to take their learning to deeper levels. Expectations are higher than in the past; results are more aligned with strategic goals, selection of value streams and improvement foci is more strategic.
Over the next year, we will rollout our embryonic daily management system to more locations within existing ‘student’ sites, having learned that we will be most successful if we locate these activities in existing value streams with strong local leadership support and embedded facilitators. We will build on our limited testing of model value streams and spread this learning, and the dedicated sensei resources that accompany it. Hoshin kanri will contribute to our efforts to define our organization more clearly and to set a more clear direction and clarify values and principles.