Lean Management and Hospital Performance: Adoption vs. Implementation

Published:February 04, 2021DOI:https://doi.org/10.1016/j.jcjq.2021.01.010

      Background

      The Lean management system is being adopted and implemented by an increasing number of US hospitals. Yet few studies have considered the impact of Lean on hospitalwide performance.

      Methods

      A multivariate analysis was performed of the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals and 2018 publicly available data from the Agency for Healthcare Research and Quality and the Center for Medicare & Medicaid Services on 10 quality/appropriateness of care, cost, and patient experience measures.

      Results

      Hospital adoption of Lean was associated with higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores (b = 3.35, p < 0.0001) on a scale of 100–300 but none of the other 9 performance measures. The degree of Lean implementation measured by the number of units throughout the hospital using Lean was associated with lower adjusted inpatient expense per admission (b = -38.67; p < 0.001), lower 30-day unplanned readmission rate (b = -0.01, p < 0.007), a score above the national average on appropriate use of imaging—a measure of low-value care (odds ratio = 1.04, p < 0.042), and higher HCAHPS patient experience scores (b = 0.12, p < 0.012). The degree of Lean implementation was not associated with any of the other 6 performance measures.

      Conclusion

      Lean is an organizationwide sociotechnical performance improvement system. As such, the actual degree of implementation throughout the organization as opposed to mere adoption is, based on the present findings, more likely to be associated with positive hospital performance on at least some measures.
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Joint Commission Journal on Quality and Patient Safety
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Institute of Medicine
        To Err Is Human: Building a Safer Health System.
        National Academy Press, Washington, DC2000
        • Institute of Medicine
        Crossing the Quality Chasm: A New Health System for the 21st Century.
        National Academy Press, Washington, DC2001
        • What is value-based healthcare?
        NEJM Catalyst.
        2021 (Epub 2017 Jan 1. Accessed Feb 7)
        • Kaufman BG
        • et al.
        Impact of accountable care organizations on utilization, care, and outcomes: a systematic review.
        Med Care Res Rev. 2019; 76: 255-290
        • Landon BE
        • et al.
        Prospects for rebuilding primary care using the patient-centered medical home.
        Health Aff (Millwood). 2010; 29: 827-834
        • Lewis VA
        • et al.
        Care transformation strategies and approaches of accountable care organizations.
        Med Care Res Rev. 2019; 76: 291-314
        • Wells S
        • et al.
        Are quality improvement collaboratives effective? A systematic review.
        BMJ Qual Saf. 2018; 27: 226-240
        • Agency for Healthcare Research and Quality
        National Healthcare Quality and Disparities Report.
        2018 (Sep 2019. Accessed Feb 7, 2021)
        • D'Avena A
        • Agrawal S
        • Kizer K.
        High-value care every time: recommendations from the National Quality Task Force.
        Health Aff (Millwood) Blog. Jul 33, 2020; (Accessed Feb 7, 2021)
        • McWilliams JM
        • et al.
        Medicare spending after 3 years of the Medicare Shared Savings Program.
        N Engl J Med. 2018 Sep 20; 379: 1139-1149
        • Song Z
        • et al.
        Health care spending, utilization, and quality 8 years into global payment.
        N Engl J Med. 2019 Jul 18; 381: 252-263
        • Rosenberg BL
        • et al.
        Quantifying geographic variation in health care outcomes in the United States before and after risk-adjustment.
        PLoS One. 2016 Dec 14; 11e0166762
        • Fraze TK
        • et al.
        Prevalence of screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence by US physician practices and hospitals.
        JAMA Netw Open. 2019 Sep 4; 2e1911514
        • Jha AK
        • et al.
        Measuring efficiency: the association of hospital costs and quality of care.
        Health Aff (Millwood). 2009; 28: 897-906
        • Shrank WH
        • Rogstad TL
        • Parekh N.
        Waste in the US health care system: estimated costs and potential for savings.
        JAMA. 2019 Oct 15; 322: 1501-1509
        • Schneider EC
        • Squires D.
        From last to first—could the US health care system become the best in the world?.
        N Engl J Med. 2017 Sep 7; 377: 901-903
        • Nembhard IM
        • et al.
        Why does the quality of health care continue to lag? Insights from management research.
        Acad Manag Perspect. 2009; 23: 24-42
        • Griffith JR.
        An organizational model for excellence in healthcare delivery: evidence from winners of the Baldrige Quality Award.
        J Healthc Manag. 2017; 62: 328-341
        • Toussaint JS
        • Griffith JR
        • Shortell SM.
        Lean, Shingo, and the Baldrige framework: a comprehensive method to achieve a continuous-improvement management system.
        NEJM Catalyst. 2020; 1
        • Toussaint J.
        Management on the Mend: The Healthcare Executive Guide to System Transformation.
        ThedaCare Center for Healthcare Value, Appleton, WI2015
        • Salah S
        • Rahim A
        • Carretero JA.
        The integration of Six Sigma and Lean management.
        International Journal of Lean Six Sigma. 2010; 1: 249-274
        • Chassin MR
        • Loeb JM.
        High-reliability health care: getting there from here.
        Milbank Q. 2013; 91: 459-490
        • Liker JK.
        The Toyota Way: 14 Management Principles from the World's Greatest Manufacturer.
        McGraw-Hill, New York2004
        • Lukas CV
        • et al.
        Transformational change in health care systems: an organizational model.
        Health Care Manage Rev. 2007; 32: 309-320
        • Ohno T.
        Toyota Production System: Beyond Large-Scale Production.
        Productivity Press, Portland, OR1988
        • Shingo S.
        A Study of the Toyota Production System: From an Industrial Engineering Viewpoin. Dillon AP, translator.
        Productivity Press, New York1989
        • Womack JP
        • Jones DT.
        Lean Thinking: Banish Waste and Create Wealth in Your Corporation.
        Free Press, New York2003
        • D'Andreamatteo A
        • et al.
        Lean in healthcare: A comprehensive review.
        Health Policy. 2015; 119: 1197-1209
        • Graban M.
        Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement.
        3rd ed. CRC Press, Boca Raton, FL2016
        • Isfahani HM
        • Tourani S
        • Seyedin H.
        Lean management approach in hospitals: a systematic review.
        International Journal of Lean Six Sigma. 2019; 10: 161-188
        • Moraros J
        • Lemstra M
        • Nwankwo C.
        Lean interventions in healthcare: do they actually work? A systematic literature review.
        Int J Qual Health Care. 2016; 28: 150-165
        • Barnas K.
        Beyond Heroes: A Lean Management System for Healthcare.
        ThedaCare Center for Healthcare Value, Appleton, WI2014
        • Toussaint J
        • Gerard R.
        On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry.
        Lean Enterprise Institute, Cambridge, MA2010
        • Kaplan GS.
        Transforming culture, transforming care: Virginia Mason's ground breaking journey to healthcare reform. Interview by Mark Hagland.
        Healthc Inform. 2011; 28: 44-46
        • Harrison MI
        • et al.
        Effects of organizational context on Lean implementation in five hospital systems.
        Health Care Manage Rev. 2016; 41: 127-144
        • Udod SA
        • et al.
        Nurse managers implementing the Lean management system: a qualitative study in Western Canada.
        J Nurs Manag. 2020; 28: 221-228
        • Mazzocato P
        • et al.
        Complexity complicates Lean: lessons from seven emergency services.
        J Health Organ Manag. 2014; 28: 266-288
        • Radnor ZJ
        • Holweg M
        • Waring J.
        Lean in healthcare: the unfilled promise?.
        Soc Sci Med. 2012; 74: 364-371
        • Shortell SM
        • et al.
        Use of Lean and related transformational performance improvement systems in hospitals in the United States: results from a national survey.
        Jt Comm J Qual Patient Saf. 2018; 44: 574-582
        • Po J
        • et al.
        Lean management and US public hospital performance: results from a national survey.
        J Healthc Manag. 2019; 64: 363-379
        • Shortell SM
        • Rundall TG
        • Blodgett JC.
        Assessing the relationship of the human resource, finance, and information technology functions on reported performance in hospitals using the Lean management system.
        Health Care Manage Rev. Epub. 2019 Jun 6;
        • Lee JY
        • McFadden KL
        • Gowen CR 3rd
        An exploratory analysis for Lean and Six Sigma implementation in hospitals: together is better?.
        Health Care Manage Rev. 2018; 43: 182-192
        • Rundall TG
        • et al.
        Adoption of Lean management and hospital performance: results from a national survey.
        Health Care Manage Rev. 2021; 46: E10-E19
        • Damschroder LJ
        • et al.
        Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.
        Implement Sci. 2009 Aug 7; 4: 50
        • Shortell SM
        • et al.
        Assessing the impact of continuous quality improvement/total quality management: concept versus implementation.
        Health Serv Res. 1995; 30: 377-401
        • Bradley EH
        • et al.
        Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems.
        Circulation. 2006 Feb 28; 113: 1079-1085
        • Bradley EH
        • et al.
        A qualitative study of increasing β-blocker use after myocardial infarction: why do some hospitals succeed?.
        JAMA. 2001; 285: 2604-2611
        • Curry LA
        • et al.
        Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study.
        BMJ Qual Saf. 2018; 27: 207-217
        • Curry LA
        • et al.
        What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study.
        Ann Intern Med. 2011 Mar 15; 154: 384-390
        • Hill JE
        • et al.
        The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review.
        Implement Sci. 2020 Apr 19; 15: 23
        • Goldman LE
        • Vittinghoff E
        • Dudley RA.
        Quality of care in hospitals with a high percent of Medicaid patients.
        Med Care. 2007; 45: 579-583
        • Joynt KE
        • Jha AK.
        Abstract P319: Which types of hospitals have higher readmission rates for heart failure.
        Circ Cardiovasc Qual Outcomes. 2011; 4: AP319
        • Ly DP
        • Cutler DM.
        Factors of US hospitals associated with improved profit margins: an observational study.
        J Gen Intern Med. 2018; 33: 1020-1027
        • Sloan FA
        • et al.
        Hospital ownership and cost and quality of care: is there a dime's worth of difference?.
        J Health Econ. 2001; 20: 1-21
        • Taylor Jr, DH
        • Whellan DJ
        • Sloan FA.
        Effects of admission to a teaching hospital on the cost and quality of care for Medicare beneficiaries.
        N Engl J Med. 1999 Jan 28; 340: 293-299
        • Tjur T.
        Coefficients of determination in logistic regression models—a new proposal: the coefficient of discrimination.
        Am Stat. 2009; 63: 366-372
        • Bate P
        • Mendel P
        • Robert G.
        Organizing for Quality: the Improvement Journeys of Leading Hospitals in Europe and the United States.
        CRC Press, Boca Raton, FL2007
        • Menachemi N
        • et al.
        Implementation of Lean in a health system: lessons learned from a meta-analysis of rapid improvement events, 2013–2017.
        J Healthc Manag. 2020; 65: 407-417
        • Center of Excellence
        Dartmouth College, University of California, Berkeley, Harvard University, High Value Healthcare Collaborative.
        National Survey of Healthcare Organizations and Systems, Jun 2017 (Aug 2018)
        • Ahn C
        • et al.
        Lean management and breakthrough performance improvement in health care.
        Qual Manag Health Care. 2021; 30: 6-12
        • Baker DW
        • Chassin MR.
        Holding providers accountable for health care outcomes.
        Ann Intern Med. 2017 Sep 19; 167: 418-423
        • Chassin MR.
        Getting better at measuring hospital mortality.
        JAMA Intern Med. 2020 Mar 1; 180: 355-356
        • Chassin MR
        • et al.
        Accountability measures—using measurement to promote quality improvement.
        N Engl J Med. 2010 Aug 12; 363: 683-688
        • Austin JM
        • et al.
        Assessing the agreement of hospital performance on 3 national mortality ratings for 2 common inpatient conditions.
        JAMA Intern Med. 2020 Jun 1; 180: 904-905