A nine-step roadmap for implementing Lean in rural hospitals

Rural hospitals and health systems looking to innovate, collaborate and grow can learn from Toyota’s decades-old discipline of Lean manufacturing oriented toward quality improvement. Today, many health care organizations have embraced the Lean model to accomplish big things. Large hospitals spend hundreds of thousands of dollars on Lean consultants, but small hospitals without big budgets can also benefit from Lean without the exorbitant expense. 

At AHA’s 2019 Rural Health Care Leadership Conference, Dan Grigg, CEO of Harney County Health District in Burns, Ore., shared his best advice for how smaller, rural hospitals can get creative in improving affordability, bolstering the patient experience and reducing costs by implementing Lean concepts.

Grigg asserted that rural hospitals have an uphill battle to gain the confidence and trust of their communities. “Throughout the country there is a belief that bigger is better.” He cited a recent conversation with his sister in Wyoming who said she would never use her local rural hospital and would instead drive two hours to a bigger hospital — even though she had no personal experiences with the local hospital and could not give a good reason for not trusting it. “We will never provide all the services of a big hospital,” said Grigg. “But we can be as good as or better than the big hospitals at the services we provide, and it requires a culture of continuous improvement.”

Grigg received in-depth training in Lean while working at Salem (Ore.) Hospital, where executives brought on consultant John Black, a global leader in Lean methodology who works with health care organizations to improve quality, streamline processes, save time and reduce costs. Grigg became convinced that the culture, structure and tools offered by Lean are effective at improving health care quality. “This really expanded my view of how we can make hospitals better,” said Grigg. However, as he moved into rural health care, he realized how challenging it is for an independent rural hospital to implement Lean — due to the high costs of using outside consultants, and to having fewer internal resources.

Grigg has taken his experience with Lean and developed a nine-step roadmap for success that rural hospitals can follow to implement Lean in their organizations without having to budget a lot of money for expensive consultants. Below is a condensed list of key takeaways: 

1. Shared learning: executive team, board chair, and chief of staff. Grigg said that it starts with buy-in from the executive team, the board, the chief of staff, physicians and other top leaders working together to build a culture of improvement and engage employees. Upon moving to Harney District Hospital, where he now serves as CEO, Grigg used a “book club style” approach to help the leaders learn about Lean and to begin to understand the value it can bring to the organization. This helped ensure they were all on the same page and had a common vision and approach. 
2. Identify an internal champion. It takes a person on the inside who knows employees and the organization’s strengths and weaknesses to help lead, organize and guide the group toward change, Grigg said. Rather than hiring an outside consultant, Grigg recommends changing a current staff member’s role to focus on value improvement. He also suggests choosing a trusted, respected person who is willing to receive training and education to develop the necessary skills to facilitate change. 
3. Explore training resources. Grigg recommends talking openly with nearby hospitals and health systems about their efforts to implement Lean. Oftentimes, other organizations in nearby communities may be working on projects with similar values or end goals and be open to sharing resources. In fact, after some initial research, Grigg discovered that a nearby health system, St. Charles in Bend, Ore., was also in the process of implementing Lean. “They opened their doors to us, and didn’t charge us to sit in on their training and events,” Grigg said. In addition, he partnered with three other small hospitals in the region to jointly write a grant through the Office of Rural Health — every state has one — to receive $20,000 each, which they put toward hiring a Lean trainer from Purdue University to come train the staffs. “It was wonderful because that didn’t come out of our regular budget, but completely from grant funds.” 
4. Design Lean 101 — basic education for all staff. Once your key champion is trained, there should be basic training for the rest of the staff, Grigg said. “It’s one thing for a few leaders to understand Lean; it’s another for the rest of the staff to buy into it,” Grigg said. “The only way they are going to do that is if they understand the principles.” Together, leaders at Harney District Hospital sat down to design Lean 101, which they shared with staff, providers and their board. Grigg cautioned not to expect everyone to be open to the changes right away; long-term commitment is a big undertaking but is worthwhile for achieving the growth in the end. 
5. Develop a no-layoff policy. When staff hear about proposed systemwide changes that come with Lean, employees are often fearful of what it may mean for their jobs, Grigg noted. That’s why leaders at Harney District Hospital implemented a no-layoff policy that meant that, although there may be some change in roles and priorities, no employee would be laid off as a result of Lean. The policy did a lot to alleviate concerns. 
6. Transformational plan of care. Once the staff and board have been briefed, Grigg suggests holding a daylong leadership meeting to develop a plan to transform care. This includes agreeing on key metrics and on improvement priorities for the year. This meeting is then held annually. “We spend time in our annual meeting making a plan for the year, agreeing on metrics by which to judge our success going forward, what areas we needed to improve upon, and how we want to spend our resources for the following year,” Grigg said. The team maps out the next 12 months and largely sticks to it, he reported.
7. Set up a data tracking, alignment and sharing system. Harney District Hospital leaders created a data tracking system to hold themselves accountable and to increase transparency. It also fostered even more employee engagement, requiring department managers to check in with each other to determine what they should be tracking to align with the goals of the overall organization. They post their results on a big white board in the hallway, where there is a good amount of public traffic, so others can see the data. They update the board on a regular basis. 
8. Begin Lean events. Lean provides a wide variety of tools and approaches that can be used to improve care. Projects that involve multiple departments are often undertaken as multiday events. An example of a Lean event is “Value Stream Mapping,” where staff map out a common process and identify problems and opportunities for improvement. Rapid improvement events can then be held to troubleshoot and brainstorm together in making improvements. Anyone from medical assistants to doctors to those making referrals can weigh in with ideas on how to improve the value stream. Grigg advises taking as much time as your hospital can devote to such events — whether it is a one-day event or an event lasting several days. “In a small hospital, it’s hard to free up staff for those Lean events,” Grigg acknowledged. “We modify the concepts to fit our size.”
9. Implement tiered daily huddles. Lastly, Grigg advocates for regular check-ins that he calls “tiered huddles,” in which every department in the hospital can chat briefly to get on the same page and share information. With three tiers, staff are coming together at the department level, in a multidepartment group, and at the executive level. These gatherings occur daily and have improved communication tremendously, he said.

Over the past three-and-a-half years, Harney District Hospital has increased transitional care bed days from 57.8 per month to 71.7 days per month, decreased its onboarding time for employees by 31 percent, decreased its clinic accounts receivable by 27.4 percent, and even seen its noise level unexpectedly decrease.