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Lean management and hospital performance: adoption versus implementationStephen M. Shortell, PhD, MBA, MPHBlue Cross of California Distinguished Professor Emeritus of Health Policy and ManagementCo-director, CLEAR, UC Berkeley School of Public HealthCo-authors: Janet C. Blodgett, MSc; Thomas G. Rundall, PhD; Rachel Mosher Henke, PhD; Elina Reponen, MD, PhD

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Outline• Central question• Prior research• Current study and results• Conclusion and discussion

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Central question• To what extent might lean, if fully and widely implemented, provide a

foundation for larger and more sustainable improvement in the quality and cost of care than what we have achieved to date?

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Lean working definition• An overall management/ operating system that uses a continuous

improvement culture that empowers front line workers (nurses, physicians, support staff) to solve problems and eliminate waste by standardizing work to improve the value of care delivered to patients.

• A socio-technical system approach emphasizing culture, leadership, work design, tools.

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Prior research• Consistent evidence of positive results when used in individual projects/

units/ departments• Less evidence and mixed evidence of its use organization wide

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Key results from the national survey of lean - 2017• 61 percent (adjusted for non response) of hospitals report using Lean• Only 12 percent (102 hospitals) report being “mature” in its use – having it

implemented throughout the hospital• Extent of use positively associated with self reported performance• Adoption of Lean by 2014 positively associated with lower adjusted Medicare

spending per beneficiary in 2015– Associated with no other independent objective performance measures

• For a subset of public hospitals it was positively associated with EBITDA margin and fewer patients leaving the ED without being seen. No other relationships.

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Current, updated study• 2017 adoption and implementation measures linked to 2018 objective

independent publicly reported performance measures

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Adoption and implementation measures• Adoption of any Lean• Number of operating units throughout the hospital using lean (0-29)• Number of years using lean• Leadership Commitment Index• Daily Management System Index• Education and Training Index

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Performance measures• 30-day risk adjusted mortality index• 30-day unplanned readmission rate• Adjusted inpatient expense per discharge• Composite: appropriate/efficient use of medical imaging• Composite: patient safety• Composite: timeliness of care• Death rate among surgical inpatients with serious treatable conditions• EBITDA margin• HCAHPS score• Medicare spending per beneficiary

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Control variables• Ownership• Member of a system or network• Core-based statistical area type• Member of Council of Teaching Hospitals• Bed size• Market concentration• Percent Medicaid discharges• Primary care/Specialist provider ratio

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Results• Lower adjusted inpatient expense per discharge• Lower 30-day unplanned readmission rate• Above national average in appropriate use of imaging• Higher HCAHPS patient experience scores• Top quartile of hospitals implementing lean (20-29 units using it) versus

the bottom quartile of hospital units using lean (0-9 units) had adjusted inpatient expense per discharge approximately $1,000 lower

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Linear regressions summary across dependent variables

(β and 95% CI for relationship with number of units doing Lean)

Control variables include number of years using lean, ownership, system or network membership, core-based

statistical area type, bed size, teaching status, percent Medicaid discharges, market concentration, primary

care/specialist provider ratio.

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Logistic regressions summary across dependent variablesOdds ratio and 95% CI for relationship with number of units doing Lean

Control variables include number of years using lean, ownership, system or network membership, core-based statistical area type, bed size, teaching status, percent Medicaid discharges, market concentration, primary care/specialist provider ratio.

Odds ratio >1 indicates that using Lean in more units is associated with greater odds of being above the national average on that composite performance measure

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Conclusion• It is the degree of implementation and spread that really matters, not

mere piecemeal adoption• The results are encouraging, but we are far from the tipping point of

achieving sustainable everyday quality improvement

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For discussion• Have hospitals using Lean done a better job of responding to Covid-19?• What role can Lean play in making breakthrough improvements in quality

and financial performance?• What might payers and policymakers do to accelerate hospitals and

other healthcare organizations use of lean and related transformational performance improvement approaches?

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Relevant publications• Rundall, T.G., Shortell, S.M., Blodgett, J.C., Henke, R.M. and Foster, D., 2020. Adoption of Lean management and

hospital performance: Results from a national survey. Health Care Management Review. DOI: 10.1097/HMR.0000000000000287

• Toussaint, J.S., Griffith, J.R. and Shortell, S.M., 2020. Lean, Shingo, and the Baldrige Framework: A Comprehensive Method to Achieve a Continuous-Improvement Management System. NEJM Catalyst Innovations in Care Delivery, 1(3).

• Toussaint, J. and Barnas, K., 2020. Becoming the Change: Leadership Behavior Strategies for Continuous Improvement in Healthcare. McGraw Hill Professional.

• Shortell, S.M., Rundall, T.G. and Blodgett, J.C., 2019. Assessing the relationship of the human resource, finance, and information technology functions on reported performance in hospitals using the Lean management system. Health Care Management Review. doi: 10.1097/HMR.0000000000000253

• Shortell, S.M., Blodgett, J.C., Rundall, T.G. and Kralovec, P., 2018. Use of lean and related transformational performance improvement systems in hospitals in the United States: Results from a national survey. The Joint Commission Journal on Quality and Patient Safety, 44(10), pp.574-582.

• Po, J., Rundall, T.G., Shortell, S.M. and Blodgett, J.C., 2019. Lean Management and US Public Hospital Performance: Results From a National Survey. Journal of Healthcare Management, 64(6), pp.363-379.

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Acknowledgements• IBM Watson Health• American Hospital Association Survey Data Center• Catalysis• Lean Enterprise Institute• Rona Consulting Group – Moss Adams• Value Capture• The Jewish Healthcare Foundation of Western Pennsylvania

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Thank you

For more information see: clear.berkeley.edu

Contact: shortell@berkeley.edu