Choosing Wisely®. OHSU has been a proponent of the lean philosophy for several years and I was excited to learn how the organization was applying it to make improvements in quality, safety and professionalism.

Specifically, I was interested in finding out answers to a number of questions, including:

What effects do lean practices have on the development of a culture of high quality and safety, and prudent resource use?

Posters of OHSU’s strategic plan and Pillars of Excellence are displayed in each clinical department area and in all administrative meeting spaces, as part of much larger Key Performance Indicators bulletin board. The Pillars of Excellence poster clearly states that “value is defined by our patients” and focuses on “patients, today and tomorrow.” The bulletin boards are located prominently in areas visited everyday by clinicians and staff.

How did the medical professionals adopt lean and how did it impact their job satisfaction?

Although the lean structure may appear to be implemented from the top down, most of the improvement initiatives are actually defined at the grassroots level. At OSHU, the clinical team identifies “quick hits” each day that can be resolved within 24-48 hours; any clinical issues that can’t be resolved in that timeframe are elevated to “big issue candidates.” This kind of decentralized, local problem-solving has engaged both clinicians and administrative staff. One staff member told me that before the lean implementation, she sometimes felt disenfranchised when orders were coming from upper management. Now, she feels more in control of her working conditions.

The missing element in these efforts is the active engagement of the physicians who work at OHSU. In some areas of the hospital, expectations of the physician’s role need more clarity and potentially a different kind of engagement.

How much of their efforts are focused on patient- and family-centered care?

Patient experience is a key performance indicator for OHSU. Several value streams focus on aspects of patient flow and eliminating unnecessary steps. The major focus on many of the value streams is on flow of blood work, lab work and ED throughput. Patient care is considered in everything the health system does and thinks about, as demonstrated in the “I CARE” button each clinician wears.

Patient experience ratings have put OHSU ahead of its peers, yet I am uncertain how patients are used in the redesign of processes.

How did adopting a lean philosophy help the organization achieve the triple aim?

Central to lean principles is consistency and standardized practice. Hung throughout the buildings are bulletin boards that include charts showing performance indicators on quality, safety, service and affordability. Everyone is trained to understand that they are accountable for their performance.

Two years in, the lean work is incredibly pervasive at OHSU. Whether leadership will be patient about the time needed to achieve consistent results in all four performance areas as best in class is an open question, but improvement is being seen in most areas.

Key learnings from my visit:

• OHSU’s focus on lean facilitated the development of needed standardization and high reliability in clinical operations.
• In complex organizations such as a large health system, implementation of lean strategies requires a massive amount of effort and resources. It’s unknown whether other institutions will invest enough money and time to do the work OHSU has.
• Patient and physician engagement is necessary for lean to succeed as is effective leadership method and to set a clear vision at all managerial levels.
• The quality measurement movement at a national level doesn’t do a good job in capturing the power of data and feedback, and the improvement infrastructure needed to execute this locally focused strategy.

I applaud the courage of OHSU to take such an involved approach to improvement. They are a national leader in advancing the triple aim at a large Academic Medical Center.