The Newest Findings from CLEAR on Lean Management and Hospital Performance

Word bubble on performance data, metrics and outputs

“In the United States, the triple aim of improved quality, improved population health, and lower rate of growth in costs remain largely aspirational and elusive. Building on two seminal National Academy of Medicine (formerly the Institute of Medicine) reports, To Err Is Human and Crossing the Quality Chasm, a number of initiatives have been launched over the past 20 years, including quality improvement collaboratives, value-based payment models, the creation of Accountable Care Organizations, and patient- centered medical homes in both the public and private sectors. Although there is evidence of some progress, there remains wide variability in patient safety and quality of care, slow uptake of screening for the underlying social determinants of health, and continuing cost increases higher than the rate of inflation. There is evidence that a large share of hospital spending results in little or no benefit, with an estimated $760 billion to $935 billion of waste in the system, representing approximately 25% of total health care spending.”

Thus begins the latest research article produced by the Center for Lean Engagement and Research in Healthcare (CLEAR), Lean Management and Hospital Performance: Adoption vs. Implementation, published in The Joint Commission Journal on Quality and Patient Safety, Feb. 5, 2021. (Scroll to the end of this post to download the PDF).

Reviewing prior research and studies, including its own research, CLEAR posed the following question:

To what extent might the Lean approach to transformational improvement, if fully and widely implemented, provide a foundation for larger and more sustainable improvements in the quality and cost of care than the United States has achieved to date?

Two Hypotheses

In this latest research, CLEAR evaluated two hypotheses to seek an answer to its question: 

  • The mere adoption of Lean practices in a hospital or health system in 2017 would not be significantly associated with hospital-wide measures of performance in 2018, including independent measures of clinical quality of care, patient experience, and efficiency/financial viability; and,
  • The degree of implementation of Lean by 2017 would be positively associated with various measures of hospital performance in 2018 related to quality and appropriateness of care, patient experience, and efficiency/financial.

CLEAR received input from more than 1,200 hospitals, and concluded that the first hypothesis was confirmed by the data (with the exception of improved HCAHPS patient satisfaction scores), and that the second hypothesis was partly confirmed by the data. In evaluating its findings related to the first hypothesis, CLEAR wrote, “the mere adoption of Lean is, with only one exception (the HCAHPS patient experience measure), not associated with better hospital-wide performance on quality and appropriateness of care, efficiency/financial viability, or patient experience measures.”

Further —

This finding is consistent with the idea that adopting Lean as a targeted intervention or program is insufficient—rather, adopting and implementing Lean as an overall comprehensive sociotechnical management and leadership system requiring widespread and ongoing implementation over time is needed to achieve positive changes in hospital-wide performance.

Discussing its finding related to its second hypothesis, CLEAR noted –

The greater the number of hospital units using Lean, the lower were the risk-adjusted inpatient expenses per discharge, the lower were the risk-adjusted 30-day unplanned readmissions, the lower was the use of imaging for non-recommended conditions, and the higher were the HCAHPS patient experience scores, although some of the effect sizes are small.”

CLEAR posited possible reasons why there was little to no association between Lean implementation and quality measures, noting that these and other possible reasons should be subject to future study.

Degree of Implementation is Key

“The Lean management system based on the underlying Shingo principles is a comprehensive organization-wide sociotechnical system designed to address the complexity of increasingly large-scale health care organizations by removing unwarranted wasteful complexity that does not add value to patients.”

The current findings highlight that the degree of implementation and spread throughout the entire organization determine success.

“Although the findings suggest some encouraging associations between the degree of implementation and performance, hospital care is not yet at the tipping point of sustainable organization-wide improvement.”

There Is Much Work to be Done

CLEAR concluded that, “Given the gaps in care and continued growth in costs, there is a need to move beyond the use of Lean for incremental quality improvement to its use in making break-through improvements…. The lack of association with other performance measures suggests that there is much work to be done.

Inherent in the Lean approach is the development of a continuous improvement culture that empowers the frontline workforce with the problem-solving tools and processes to provide the best value care for patients.

“Creating such a culture on a sustainable basis and spreading it throughout the health care sector is a major challenge likely to influence the success of ongoing health care reform efforts.”

“Show Me the Data”

As Paul O’Neill, Sr. used to say when someone proposed an action plan or declared a project a success – “Show me the data.” This is what CLEAR is working toward, gathering data from those doing the work, objectively assessing the data and reaching data-based conclusions. And this is why CLEAR’s work is so important, and also why Value Capture is proud to help support CLEAR in its work.

One of the most fundamental questions Value Capture asks, in our own work as well as in working with clients is, “how do you know?” What are the data indicating, is the hypothesis for improvement or solution proving to be correct or do the data indicate a course correction? If you want to learn more about Value Capture and how we might help you build hypotheses, “how do you know” measures, and understand the data in PDSA cycles, please either contact Helen Zak at or 617-935-1636, or complete our Contact Form.

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