With healthcare spending typically the single largest component of any government’s budget, and with demographic changes adding more pressure to an already stressed sector, those responsible for the system are increasingly on the lookout for innovative approaches to ensure its sustainability.
“It is the government’s responsibility to provide taxpayers with the best possible return on investment for their tax dollars,” Scott Andison, executive director of the Health System Strategy Division in Ontario’s Ministry of Health and Long-Term Care, observes. “When government can find ways to save money on operations, it means more dollars are potentially available for direct patient care.”
In 1950, when it appeared Toyota might be forced out of business because of its inability to dent a market dominated by established North American competition, Tajichi Ohno, Toyota’s chief engineer, introduced the Lean concept. The Toyota Production System, a set of principles that simplified complex processes while improving the quality of deliverables and eliminating activities that did not add value, changed assembly lines forever and took Toyota from the brink of closure to the number one car manufacturer in the world in 2007.
Toyota was able to achieve this turnaround because the system Ohno created enabled the company to achieve mass production efficiency by focusing on reducing the three key issues that limit the productivity of any organization: waste, inflexibility and variability.
Lean evolved from this approach as other organizations began to see its value to their own business processes. Its flexibility meant that eventually even the public sector began to introduce Lean concepts, notably the National Health Service (NHS) in the United Kingdom.
As he read about the NHS experience with Lean, Adalsteinn Brown, Assistant Deputy Minister of Ontario’s Health System Strategy Division, was prompted to look at his own organization. He had brought Andison in to be a change agent at a critical juncture for the Ministry, and Lean showed promise as a tool for that change.
“The Ministry was transitioning to a stewardship model for Ontario’s healthcare system that would have several impacts,” Brown explained. “First, the Ministry would be taking on a support and guidance role for the healthcare system, with more autonomy for local healthcare organizations. Second, to accomplish this, several areas of the Ministry would have to be reorganized, leading to the creation of the Health System Strategy Division. If not properly managed, this kind of transition can cause chaos in an organization.”
In Lean, both Brown and Andison recognized the potential to develop a sound approach to day-to-day operations that would help new employees more easily integrate into the evolving organization, while helping existing employees navigate their roles in the face of change. Although government aims for transparency with the public, its internal operations are often anything but and they saw the opportunity to introduce more efficient processes that would clarify roles and eliminate the frustration and re-work that could result from poorly defined project requests.
The NHS had begun its Lean journey in 2007 by undertaking a review of how policy was done. It discovered a number of areas for improvement that were not that different from what Andison suspected was happening in his own division: there was no systematic, department-wide approach to policy-making; policy teams had ambiguous scopes; deliverables were unclear; policy teams had limited transparency of priorities and resource allocation; discussion about priorities or how resources should be allocated was limited; there was no assembled, accessible evidence base; knowledge management was poor; and, team work was limited, with the majority of staff working alone.
Using Lean methodologies, the NHS developed a more rigorous, systematic approach, building health system policy-making capability by defining a department-wide way to develop and deliver consistent, higher-quality policy. This approach was tested in a critical policy area with very positive results: unnecessary steps in the process were eliminated, frustration associated with duplicate/unneeded work was drastically reduced, and the overall time it took to develop policy was reduced.
Though the NHS example seemed like a logical step for Ontario to follow, it was not one Andison thought the division could undertake on its own – a team experienced in Lean implementation was required.
With the support of Brown, Andison brought in a team of external consultants with extensive expertise in helping organizations – including public sector – implement Lean. Recognizing the importance of knowledge transfer and continuity, Andison also hired additional staff with Lean competencies to work with the consultants and eventually take the lead on the division’s Lean implementation.
The project team launched the Lean process with a detailed assessment of the division’s operations to identify key workload drivers and quantify the amount of effort spent on each. The results supported the team’s assumptions: a significant amount of non-value adding, avoidable re-work was taking place.
A workload distribution survey confirmed that Lean improvements should focus heavily on the policy development process, where it was found that approximately 25 percent of staff time was being spent on clarifying and re-working activities. In addition, 77 percent of staff believed that they could benefit from project requests with clearer direction and objectives. Since policy development represented the majority of the division’s work, the Lean team next interviewed managers and staff independently to identify opportunities to simplify the process of policy development.
Understanding that staff buy-in would be critical to the success of the undertaking, and recognizing that staff might be worried that Lean was intended to enable workforce reductions, one of the first things the team did was create a regular newsletter to ensure staff were kept informed of all Lean-related projects. It continually reinforced the message that Lean did not mean doing the same thing with fewer resources; it meant doing more within existing resources. To support that message, the team also introduced a number of “quick win” projects to demonstrate for staff the positive impact Lean would have on them.
“If people don’t believe in what you’re proposing, or if they believe there are ulterior motives for doing it, it doesn’t matter how much time, effort or money you invest in a Lean project, it simply cannot be successful,” said Andison. “Virtually every one of our Lean improvements depends on the participation of staff to some extent, and we found that by communicating openly we encountered very few issues when it came to implementation.”
The team’s implementation roadmap identified a number of opportunities for significant waste reduction including: introducing a policy coordinator function to improve project request clarity; simplifying the approval process; developing a prioritization tool to rank projects in terms of importance, urgency, and resource needs; and developing a flexible staffing model to enable the reallocation of resources from lower priority to higher priority projects and address uneven demand across branches within the division.
Knowing that success in the planning stage of the project was directly attributable to the amount of time spent ensuring a thorough understanding of the division, the team’s roadmap for the next phase included one other very important element – realistic timelines.
“Setting unrealistic expectations about how much can be done and how quickly it can be done is the surest way to set your pro