ED PIP

Process Improvement Program Theory & Concepts

References and Links

Topics

To get further reference materials about the important topics that are a key part of implementing successful process improvement initiatives, select one of the links below:

Undertaking an organization-wide improvement project is a big challenge – one that requires a broad set of skills in order to be successful. These may range from communications to understanding Lean, change management, project management, etc. There is a wealth of information out there to help support your improvement journey. Having the baseline knowledge in some of these areas also helps to understand the different skills required to be successful.

The references found on this website are by no means exhaustive; however, they will provide a nice introduction to important topics. The links on the right hand column will take you to the websites of organizations that we believe provide information relevant to the work you are doing or contemplating. On the left hand side, you will find a list of important references. Unfortunately, due to copyrights, we are unable to provide you with the articles directly on this website.

Introduction to Lean

  1. Buescher, B. and Mango, P. Improving service operations: Toyota for Hospitals. McKinsey Health Europe, Number 2, pp. 56 – 67. This article argues that hospitals often have hidden reserves of operational capacity that can be unlocked by examining their process flow. Hospitals that borrow some process-flow techniques from manufacturers can treat more patients at lower cost.
  2. Fine, B., Golden, B., Hannam, R., Morra, D. (2009). Leading lean: A Canadian healthcare leader’s guide. Healthcare Quarterly, 12(3), 32-41.Canadian healthcare organizations are increasingly asked to do more with less, and too often this has resulted in demands on staff to simply work harder and longer. Lean methodologies, originating from Japanese industrial organizations and most notably Toyota, offer an alternative. Lean and its systematic approaches to reducing waste, has found its way to Canadian healthcare organizations with promising results. This article reports on a study of five Canadian healthcare providers that have recently implemented Lean and shares successes, potential obstacles, and ways to surmount these.
  3. Going Lean in Health Care (2005). Institute for Healthcare ImprovementLean management principles have been used effectively in manufacturing companies for decades, particularly in Japan. The Institute for Healthcare Improvement believes that Lean principles can be – indeed already are being – successfully applied to the delivery of health care. Although health care differs in many ways from manufacturing, there are also surprising similarities. Examples in this paper of Lean thinking in health care demonstrate that, when applied rigorously and throughout an organization, Lean principles can have a positive impact on productivity, cost, quality and timely delivery of service.
  4. MacLeod, H., Bell, B., Deane, K., and Baker, C. (2008). Creating sustained improvements in patient access and flow: Experiences from 3 Ontario healthcare institutions. Healthcare Quarterly, 11 (3), 38 – 49.Given that the Emergency Department (ED) is often the “front door” to our healthcare system, developing approaches to improve access and flow in the ED is important – made more challenging by rising patient demand and acuity. Recently, in partnership with the Ministry of Health and Long Term Care, several Ontario hospitals participated in an intensive and sustained effort to improve access and flow with promising results. This article chronicles the efforts of three hospitals to enable other hospitals, physicians, and nurses to learn from these experiences and gain confidence that a similar impact can be achieved in their facilities.
  5. Going Lean in the NHS (2007). NHS Institute for Innovation and Improvement, pp. 1 – 23.Lean thinking, developed from the Toyota Production System, has been applied in many competitive sectors. Such thinking is increasingly being applied to health services in the UK and overseas to: improve the quality of patient care, improve safety, eliminate delays, and reduce length of stay while using no more resources. Some healthcare organizations in the UK are already obtaining real benefits by the adoption of this approach. This guide includes NHS case studies showing the principles and benefits achieved.
  6. Speer, S.J. (2005). Fixing health care from the inside, today. Harvard Business Review, September, 1 – 15.How can health care professionals ensure that the quality of their service matches their knowledge and aspirations? As a number of hospitals and clinics have discovered, learning how to improve the work you do while you actually do it can deliver extraordinary savings in lives and dollars.

Lean Management Systems

  1. Mann, D. The missing link: Lean leadership (2008). Frontiers of Health Service Management, 26:1 (15-26)People often equate “Lean” with the tools that are used to create efficiencies and standardize processes. However, implementing tools represents at most 20 percent of the effort in Lean transformations. The other 80 percent of the effort is expended on changing leaders’ practices and behaviours, and ultimately their mindset. Senior management has an essential role in establishing conditions that enable that 80 percent of the effort to succeed. Their involvement includes establishing governance arrangements that cross divisional boundaries, supporting a thorough, long-term vision of the organization’s value-producing processes, and holding everyone accountable for meeting Lean commitments. This is accomplished through regular, direct involvement. When upper management sets the example, durable Lean success and an increasingly Lean leadership mindset follow..
  2. Speer, S. (2004). Learning to lead at Toyota. Harvard Business Review, MayDecoding the DNA of Toyota doesn’t mean that you can replicate it. This article tries to answer that question by describing how a talented young American, hired for an upper-level position at one of Toyota’s U.S. plants, was initiated into the TPS. His training was hardly what he might have expected given his achievements. With several degrees from top-tier universities, he had already managed large plants for one of Toyota’s North American competitors. But rather than undergo a brief period of cursory walk-throughs, orientations, and introductions that an incoming fast-track executive might expect, he learned TPS the long, hard way—by practicing it, which is how Toyota trains any new employee regardless of rank or function. It would take more than three months before he even arrived at the plant in which he was to be a manager.

Sustaining Improvement

  1. Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings, Institute for Healthcare Improvement, 2003.Because waits, delays, and cancellations are so common in health care, patients and providers assume that waiting is simply part of the care process. But recent work on assessing the reasons for delays suggests otherwise.
    IHI believes that the key to improving flow lies in reducing process variation that impacts flow. While some variability is normal, other variation is not and should be eliminated. Hospitals working with IHI have tested a range of changes to reduce process variation and improve flow. These changes are described in this paper.
  2. Alikhan, L.M., Howard, R. J., Bowry, R., (2010). From a project to transformation: How “going against the flow” led to improved access and patient flow in an academic hospital. Healthcare Management Forum. Fall/Autumn, 20-26.A results-driven approach to optimizing patient flow, grounded on quality improvement, change management and organizational learning principles, is described. Tactics included collaborative governance, performance management, rapid process improvements and implementation toolkits. Results included an 83.1% decrease in emergent volumes waiting for greater than 24 hours and a 49.1% improvement in emergency department length of stay for admitted patients. There were no adverse outcomes on other key indicators. Sustainability remains the challenge but early results are encouraging.

Change Management

  1. Deutschman, A. (2005). Change or die. Fast Company, May, 54 – 62.In this article, the author poses the question: Why is so darn hard to change? Citing research conducted at John Hopkins University, he notes that 90% of heart bypass patients can’t change their lifestyles – even at the risk of dying. No wonder that changing people’s behavior is the toughest challenge in business. However, there’s compelling science behind the psychology of change – it draws on discoveries from emerging fields such as cognitive science, linguistics and neuroscience and offers some surprising answers and ways to improve the odds
  2. Dickson, D., Anguelov, Z., Vetterick, D., Eller, A.. Singh, S. (2009). Use of Lean in the Emergency Department: A case series of four hospitals, Annals of Emergency Medicine. In pressA description of the effects of Lean on quality of care in four American emergency departments (EDs). One year post-Lean, length of stay was reduced in three of the EDs despite an increase in patient volume in all four. Each observed an increase of patient satisfaction lagging behind by at least a year. The narratives indicate that the closer Lean implementation was to the original Toyota principles, the better the initial outcomes. The immediate results were also greater in the EDs in which the frontline workers were actively participating in the Lean-driven process changes. A factor that considerably affected the outcomes in the second and third year post implementation was the level of continuous leadership commitment to Lean.
    Conclusion: Lean principles adapted to the local culture of care delivery can lead to behavioural changes and sustainable improvements in quality of care metrics in the ED. These improvements are not universal and are affected by leadership and frontline workforce engagement.
  3. Kotter, J.P. (1995). Leading change: Why Transformation efforts fail. Harvard Business Review, March-April, 59 – 65.Why do so many transformation efforts produce only middling results? One overarching reason is that leaders typically fail to acknowledge that large scale change can take years. Moreover, a successful change project goes through a series of eight distinct stages. These stages should be worked through in sequence. Skipping steps to try and accelerate the process invariably causes problems. And, since the success of a given stage depends on the work done in prior stages, a critical mistake in any stage can have a devastating impact.
  4. Lucy, J. (2005). Why major Lean transitions have not been sustained, Management Services, Summer.In an effort to get a balanced view, research involving three groups of professionals who deal almost exclusively with change was undertaken. The objective was to compare and contrast the three groups and see if there were any common views. Ten common pitfalls to successful Lean transitions arose.

Physician Engagement

  1. Heenan, M., Higgins, D. (2009). Engaging physician leaders in performance measurement and quality. Healthcare Quarterly, 12 (2), 66 – 69.Following the release of its strategic plan to 2012, in which it highlighted patient safety and quality as key directions, St. Joseph’s Healthcare Hamilton recognized the importance of engaging its medical staff to achieve these goals. To facilitate engagement, a medical quality scorecard was developed in collaboration with medical leaders with a view to enabling physicians to easily identify their program goals, measure their progress, and transfer knowledge across the organization.
  2. Engaging physicians in a shared quality agenda (2007). Institute for Healthcare ImprovementAs part of its 2007 Innovation Series, the Institute for Healthcare Improvement released this white paper in which it described the importance of medical staff leadership and the participation of these leaders in achieving a patient safety and quality culture.
  3. Lee, T.H. (2010). Turning doctors into leaders. Harvard Business Review, April, 2 – 10.Health care delivery is fragmented and chaotic, principally because of an explosion of knowledge and technological advances. Taming this chaos requires a new breed of leaders at every level. Health care’s new leaders must organize doctors into teams; measure their performance, not by how much they do but by how their patients fare; deftly apply financial and behavioural incentives; improve processes; and, dismantle dysfunctional cultures. By organizing care delivery around patients’ needs, the leaders of cutting edge health care organizations are raising the quality, efficiency and value of the services they provide.