How an Understanding of Lean Can Support Network Objectives

November 2016

By Becky Gourde, MPA, Program Coordinator, Rural Health Innovations

Rural health networks are often formed in response to collective challenges or needs arising out of the communities they serve. As part of health care’s current transition from a focus on volume to a focus on value, networks help drive and facilitate performance improvement efforts that contribute to CMS’s approach of Better Care, Smarter Spending, and Healthier People throughout the delivery of health care. Because Lean efforts usually require little, if any, direct financial investment, the related processes and tools can be a useful option for small organizations working to improve the health outcomes of their rural communities.
What is Lean?
In short, Lean is first and foremost a way of thinking that helps solve problems. Many of the ideas that we now categorize as “Lean” were developed out of the automaking industry. Shortly after World War II, Toyota began developing the Toyota Production System, or TPS, which was influenced by several thought leaders in industrial engineering. Although most people associate Lean with the practice of reducing waste and improving process efficiency, at the heart of the Toyota philosophy are a group of management principles characterized by (1) continuous improvement and (2) respect for people.

Their success with the system inspired other automakers and eventually other industries to adopt similar techniques. (Lean is often associated with a similar methodology called Six Sigma, which was developed in the US in the 1980s and 1990s.) Specialized systems of Lean (Lean Healthcare, Lean Sigma Healthcare, etc.) focus on applications particular to the processes involved with caring for patients.
Applying Lean to rural health networks
For networks with a small number of staff (if any), modest infrastructure, and little influence on the direct provision of patient care, how can network leaders derive benefit from learning about the principles and practices of Lean? Interestingly enough, the Lean way of thinking dovetails with the objectives of rural health networks and provides new approaches for building network capacity. The actions listed below offer ideas for how networks can use Lean practices to their best advantage.

1. Tackle complex problems
One of the notions of Lean is that problems are best solved when groups of people representing diverse roles or perspectives come together to identify issues and implement actions to address those issues. This format of problem solving is a common benefit arising out of rural health networks: networks often serve as ideal settings for candid and strategic discussions regarding the challenges being faced in the community. The network participants around the table have the power to collectively enact solutions that take into account multiple factors and perspectives.

The key to addressing problems using Lean is to work on the underlying root causes under your control, rather than wasting time developing plans to alleviate 20 or 30 symptoms of those root causes. There are several Lean tools that facilitate the process of root cause analysis in ways that offer simple frameworks for dialogue and planning.

  • The fishbone diagram, for instance, provides a structure for organizing and prioritizing a group’s ideas for further consideration. Using a well-defined problem statement, a team can discover relationships among brainstormed factors and use the wisdom of the group to decide which would be best to tackle.
  • The Five Whys method then takes one of those issues and explores it deeper to understand what’s causing the scenario. Just like it sounds, the exercise involves repeatedly asking participants “why” a certain factor has presented itself, often until participants are really annoyed—it’s usually after the annoyance stage that the true root cause emerges!

2. Lead a culture of continuous improvement
Networks function most effectively when they help articulate members’ shared vision for the future of their communities. A shared vision expresses an ambitious and hopeful destination that all members are committed to using as a beacon for developing strategies and activities. The vision and goals are revisited periodically to assess progress and appropriateness, with new goals or elements revised as progress is made and circumstances change.

This iterative process of striving toward better and better outcomes is at the very core of Lean principles. Network leaders are often in the position of facilitating and carrying forward that drive. Understanding Lean’s models for nurturing a mindset of continuous improvement can help guide network leaders through culture reinforcement and change management efforts among members.

In fact, culture is often regarded by Lean experts as the highest priority for organizations wishing to become more effective and efficient: without an open commitment to progress and the empowerment of all participants to take part, performance improvement efforts are doomed to failure.

According to Toyota, this transformation can be accomplished through the “respect for people” principle. Network leaders may recognize the tenets of “respect for people” as their own best practices for network collaboration:

  • Make every effort to understand each other.
  • Take responsibility and build mutual trust.
  • Stimulate personal and professional growth.
  • Maximize individual (i.e., member) and team (i.e., network) performance.

3. Offer education 
As central sources for knowledge sharing, networks often allow member organizations to pool resources to pay for training or education that they otherwise couldn’t afford on their own. Because Lean has shown such positive outcomes throughout health care, coordinating and hosting educational opportunities on performance improvement can be a valuable service provided by a network to participating members and partners. The existing network configuration also provides a natural support system for members to get ongoing input from network leaders and from one another as they implement projects to improve outcomes in their own organizations.

If performance improvement support is something a network is interested in pursuing as a value-added service, it may even be a worthy investment for a network director to become certified in Lean or Lean Six Sigma so that they can serve as trainers and project leads for members, preventing members from having to seek out external consultants on a case-by-case basis. 

​​4. Gather and share outcomes
Part of tracking the outputs and outcomes of a network’s work includes selecting measures and gathering data. The “simple” task of determining which metrics are most appropriate can be an intensive and tiresome process in and of itself, before the data collection even begins. Lean training incorporates an entire emphasis aimed at supporting users in what makes a good metric and which factors to consider.

Many of the recommendations around Lean metrics offer valuable guidance for networks involved in evaluation planning:

  • Understand the ultimate purpose of the measurements
  • Know the difference between process metrics and organizational metrics, and when they’re applicable
  • Confirm that selected metrics are aligned with the network’s (or member organization’s) mission, vision, and goals
  • Determine whether different metrics are required for different audiences
  • Account for the time it takes to actually collect accurate data (circumstances may be unique for each metric)
  • Engage those actually doing the hands-on work
  • Don’t go overboard

It’s also helpful for a network to serve as a repository of member data on selected measures that are relevant to the network’s goals. This process of collecting and sharing member information can encourage benchmarking and sharing of best practices among member organizations working in similar areas.

The information-collector role also allows networks to collect the designs of and results from the various improvement efforts being undertaken by member organizations, providing members with a quick way to see what’s been working well (or not so well) in their regions.

Getting started
You don’t have to become an expert to begin benefitting from an awareness of Lean principles and tools. In fact, performance improvement efforts are often most effective when you start small. If you’ve never been introduced to Lean or a similar methodology before, you may want to look into free or low-cost leaning opportunities (like books or online resources) to see if it would be a valuable investment in your professional development. Or if there’s someone within your network’s member organizations with a background in Lean, you could consider inviting them to a network meeting to review a few ideas that are relevant to a particular network initiative. Selecting one or two new performance management tools to practice with can also help you decide whether to seek out additional training or expertise.

Jamie Martin, Lean Six Sigma Black Belt, SigmaMed Solutions
John Roberts, Lean Healthcare Black Belt, Midwest Health Association Management
Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction by Mark Graban, 2009, Productivity Press
The Six Sigma Book for Healthcare: Improving Outcomes by Reducing Errors by Robert Barry, Amy C. Murcko, and Clifford E. Brubaker, 2002, Health Administration Press
The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer by Jeffrey K. Liker, 2004, McGraw-Hill