With growing financial pressures in health care, successful efforts to improve operational efficiency are becoming increasingly important. We present seven critical success factors in the successful implementation of lean in health care, identified through a review of the literature and two case studies. Consideration of these critical success factors may be of value to your organisation if you are considering or already going lean.

Lean is a Quality Improvement technique, which arose from the Toyota Production System. Supporters of lean claim it offers a route to improved efficiency with no compromise on quality or patient safety, though its sceptics need only mention faulty brakes and accelerator pedals to demonstrate the dangers of lean gone wrong.  

However, in the current economic climate the NHS must find cost savings of up to £20 billion by 2014 and lean, which removes ‘waste’ and retains ‘value’ in a process is an attractive option. Indeed, the possibility of finding cost savings through improved efficiency rather than staff cuts or reduced provision of services is an ideal solution. 

Going lean can be a demanding process, with multiple interdependent critical success factors involved. We followed the progress of lean implementation within elective orthopaedic pathways at the Elective Orthopaedic Centre (EOC), Epsom and Charing Cross Hospital, speaking to managers and clinical staff from all levels about what they had learned. We discovered that there are seven critical success factors in the successful implementation of lean, which are outlined below.

Responding to a critical imperative

A critical imperative is a situation which poses an immediate and serious threat to an organisation and its survival. Awareness of a critical imperative and the need to respond to it can provide crucial cohesion and momentum when going lean. The coalition government’s proposal to have GPs commission care on an individual patient basis, with hospitals competing on the quality of care they provide, may represent a critical imperative soon to be felt nationally.

Providing an incentive to participate

Staff are often suspicious of management ‘change initiatives’, perceiving them to be cost-saving exercises which compromise on their ability to deliver care to patients.  Explaining that lean removes inefficiencies from the patient pathway, resulting in an improved experience for both patients and staff is essential. Staff can also be given the incentive of deciding how a proportion of the cost-savings can be re-invested in improving services.   

Communication

Communication is fundamental to lean; all members of staff must understand what is going on, why it is happening and how they are involved in it.  Failure to communicate this can lead to members of staff feeling that their jobs are threatened as their existing roles change. Reassuring staff that they will continue to be valued in the lean organisation is key to engaging them in the change process. With multiple specialities, each with their own loyalties, hierarchies and priorities, this can be a serious challenge; often each group will require a different approach to secure their involvement.

Combating resistance

Resistance almost always stems from a lack of understanding about the changes that are taking place and taking time to provide clarification and reassurance will overcome this.  Some staff may, however, take a more hard-line approach. When faced with this situation, understanding their perspective is essential; the individual may feel that the change threatens their position within the hierarchy of the organisation or has the potential to render them redundant. Understanding their concerns and providing the appropriate response can turn a staff member from being a serious threat to the success of the initiative into a key ally. There may be instances where bringing staff on-side is impossible and it becomes necessary to work around them, in the hope that they will choose to participate in time. 

“Talk to them on a one-to-one basis, ensure they understand the concepts of what you are trying to do.”

Anne Hall, general manager for musculoskeletal services, Charing Cross Hospital

Managing available resources

Lean can be achieved with limited resources however, some investments may be essential. Often staff will perceive that new equipment is necessary to improve efficiency, only to discover that it is no longer required in the lean environment. Encouraging staff to engage with as much of the change as possible prior to making investments will reduce such expenditure. However, when investment in infrastructure is essential, it should be secured rapidly to avoid stalling the entire process.   

Leveraging your organisational culture

Over time, an organisation can develop a culture that is open to change and may even search for it. Often, this occurs when the enthusiasm generated from previously successful initiatives is harnessed to engage staff in new projects. An unsuccessful first attempt at implementing lean shouldn’t necessarily be seen as a failure; it might, in fact, represent the basis from which a second attempt is successful. Be aware though, that previously unsuccessful attempts at lean can generate additional cynicism that will need to be overcome before embarking on a subsequent attempt.

“All staff buy into the fact that we’re constantly reviewing our services and improving them.”

Brian Wells, director, Elective Orthopaedic Centre

Effective leadership

Successfully navigating through the six critical success factors outlined above will require considerable leadership skills, enthusiasm and patience. From initiation, to execution and through to long-term sustainability, lean needs a leader, or leaders, who can deliver all these things whilst generating a momentum that carries the project to fruition. Change isn’t easy and when it goes wrong it can be even more difficult.  Get it right, though, and you will be responsible for having delivered higher quality care for your patients in a more efficient manner, which is an extraordinary prospect.

Based on the report What are the Critical Success Factors in the Successful Implementation of Lean in Healthcare: Two case studies of Lean Implementation in Elective Orthopaedic Pathways

Authors: Field MH, Armstrong L, Hariman KW, Panniker RK, Schorscher N, Heymann TD.

Centre: Imperial College Business School