1. Stephen Shortell, PhD, MPH, MBA
The Center for Lean Engagement and Research
CLEAR
Stephen Shortell, PhD, MPH, MBA
Blue Cross of California Distinguished Professor of Health Policy & Management
Co-Director - Center for Lean Engagement and Research (CLEAR) in Healthcare
School of Public Health
UC, Berkeley
Thomas Rundall, PhD
Henry J. Kaiser Professor Emeritus
Co-Director - Center for Lean Engagement and Research (CLEAR) in Healthcare
School of Public Health
UC, Berkeley
LEAN Design Forum
Berkeley, California
January 26, 2017

2. Today’s Learning Objectives
Understand the current state of research on lean in healthcare organizations
Understand a useful conceptual framework for researching lean implementations in healthcare organizations
Understand the origin, vision, mission and goals of CLEAR
Identify major research questions that CLEAR research projects will address
Discuss CLEAR’s three initial research initiatives
JB: removed question on first item, made text box wider

3. WORKING DEFINITION OF LEAN
The development of a culture that enables an overall management system to create value for customers by eliminating waste and solves problems through the daily application of the scientific method in creating standard work.
JB: I’d prefer to use sentence case for the text of the definition

4. The State of Research Evidence on the
Effects of Lean in Healthcare Organizations
There is some evidence showing positive effects of lean on patient care processes, outcomes, and efficiency.
JB: Adjusted text box formatting

5. Source: Mark Chassin and Jerod Loeb, “High Reliability Health Care: Getting There from Here.” The Milbank Quarterly, 2013, 91,(3):

6. The State of Research Evidence on the
Effects of Lean in Healthcare Organizations
However, systematic reviews of the existing published research indicate that overall the reported effects of lean on organizational and patient metrics are quite mixed, with many studies showing no positive effects and some studies showing negative effects
JB: adjusted text box size and line breaks

7. FROM RECENT SYSTEMATIC REVIEW ¹
FINDINGS
No significant association with patient satisfaction or health outcomes.
Higher costs (taking into account money spent implementing Lean).
Poorer worker satisfaction.
Inconsistent association with process outcomes like patient flow and safety.
CONCLUSION
“The evidence to date does not support the belief that Lean leads to healthcare quality improvements.”
Call for more rigorous, higher quality and better conducted scientific research.
¹ J. Moraros, M. Lemstra, and C. Nwankwo, “Lean interventions in healthcare – Do they actually work? A systematic literature review” International Journal for Quality in Health Care Advance Access, 2015, 28 (2):

8. Problems With the Research Literature on
Lean in Healthcare Organizations
There is little reporting of the external stimulus or context for lean (e.g. market factors), key organizational factors (e.g. how culture affects the lean implementation, and sustainability).
Most reports from peer-reviewed and grey literature are single case studies of limited internal and external validity.
Most reports focus on one organization, department, and project, making it very difficult to determine what external factors or organizational characteristics are important for successful implementation and maintenance of lean.
JB: adjusted text box size and line breaks

9. Problems With the Research Literature on
Lean in Healthcare Organizations
Studies generally fail to use more rigorous quasi-experimental designs or comparative and longitudinal case study designs.
Outcomes measured are primarily efficiency and quality and, less frequently safety and patient satisfaction.
There is a positive publication bias in the lean literature.
Lean studies lack a conceptual framework.

10. Carman, Paez,
Stephens, et al.
Improving Care
Delivery Through
Lean: Implementation
Case Studies. AHRQ
Publication No.
13(15)-0056.
November 2014.

11. “It is important that the research community recognizes healthcare management is every bit as important as clinical medicine for research. In fact, it may be the most important research area from a patient safety standpoint.”
John Toussaint, MD
President and CEO
Catalysis (formerly the ThedaCare Center for Healthcare Value)

12. Lean Enterprise Institute
FOUNDING SPONSORS
Catalysis
Lean Enterprise Institute
Rona & Associates
JB: I couldn’t tell if you left ThedaCare purposely, but I pasted in the Catalysis logo if you want to use that instead.

13. STRATEGIC ADVISORY COUNCIL
Kathryn Correia – HealthEast Care System
James Hereford – Fairview Health Services
Alice Lee - Lean Enterprise Institute
John Toussaint –Catalysis
Craig Vercruysse - Rona & Associates
Peter Ward - Ohio State University
Helen Zak - Catalysis

14. MOVING THE EVIDENCE BASE FORWARD DEVELOPING “ACTIONABLE” KNOWLEDGE
The Center for Lean Engagement and Research (CLEAR) in Healthcare
Vision
The vision of CLEAR is to transform healthcare delivery by providing the knowledge to help organizations eliminate waste and to create greater value resulting in the continuous improvement of patients’ outcomes and experience of care, population health, and reduced growth in the cost of care.
Mission
CLEAR’s mission is to conduct timely, relevant, and actionable research on LEAN whole system transformation initiatives in healthcare.
JB: I’m unsure about the all-caps for “LEAN” here – maybe “Lean” instead?

15. MAJOR TOPICS/QUESTIONS TO BE ADDRESSED
Assess whether lean positively affects key outcomes of interest to healthcare organizations. From a hospital’s perspective, does lean improve quality, efficiency, costs, employee satisfaction, patient satisfaction, and organizational culture?
Identify internal and external factors that are associated with variations in outcomes and processes, so that potential users can understand which experiences are relevant to their own situation.
Identify challenges to implementing lean, potential solutions to challenges, and lessons learned.

16. Initial Research Initiatives
Conduct in-house leading edge research on Lean in healthcare, beginning with the first national survey of Lean in hospitals
Collaborate with specific healthcare organizations and other health services researchers on focused studies of the effects of Lean in particular organizations and departments
Explore forming a Lean Action Research Collaborative with about 10 hospitals/health systems
Facilitate research among other researchers and healthcare delivery organizations through resources and information available on our website (e.g. annotated bibliography of research on Lean in healthcare organizations).
JB: capitalized “Lean” in item 3
Website:

17. WHAT IS NEEDED, WHAT WE PROPOSE
Use of an evidence-based conceptual framework
Examine enterprise-wide, as well as department-specific, lean deployments
More Rigorous Evaluation Designs to Rule Out Alternative Explanation for Study Results - Experimental and Quasi-Experimental
Measures Relevant to the Intervention
Detailed Description of the Intervention
Thorough Examination of Contextual Effects
Assessments of Sustainability – Longitudinal Study Designs
Studies of Spread – Diffusion to Other Units, Other Organizations will Require Effective Partnerships Between Lean Organizations and Researchers
JB: I don’t understand this item. Is it supposed to be two items? “Assessments of Sustainability One Time – Longitudinal Study Designs”. Also, I think it’s nicer to use sentence case here.

18. Isn’t that where the fruit is?
Why not go out on a limb?
Isn’t that where the fruit is?
Frank Scully

19. Stephen Shortell, PhD, MPH, MBA
Thank You
Clear.Berkeley.edu
Stephen Shortell, PhD, MPH, MBA
Thomas Rundall, PhD