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    Kathryn E. Naumann
    Kathryn E. Naumann, MS, FACMPE
    Ronald Menaker
    Ronald Menaker, EdD, MBA, FACMPE
    Jeffrey R. Leland
    Jeffrey R. Leland, MA
    Laura C. Tibor
    Laura C. Tibor, MBA

    The American healthcare system faces many challenges such as the uninsured, staff shortages, technology changes, information security, regulatory burdens, quality concerns, legislative uncertainty and lower reimbursement levels. Pressures to control costs are also escalating as the aging population places more strains on organizations providing and coordinating financing for healthcare and healthcare providers.1
     
    These forces are contributing to high levels of burnout for physicians expressed as depersonalization, emotional exhaustion and low sense of personal accomplishment.2,3 Individuals can address burnout by participating in activities that can help them cope with stressors impacting their work such as exercise, nutrition, sleep, stress management, spiritual practices, etc. Leaders can play a vital role by assessing workloads, efficiency, flexibility and autonomy for providers within the work unit and organization.4 These same interventions increase focus on achieving enhanced operational effectiveness and in helping to make physicians and leaders stewards of resources to optimize the patient experience and the financial performance that advances the organization’s mission.
     
    The growing challenges will require understanding principles of well-being5, and integrating those with organizational values and practices6 that lead to effective interactions. The burden of change efforts will be the responsibility of physician leaders, administrators and others in formal and informal roles. One approach to address this challenge is to examine how leaders organize and manage their work interactions with their teams. A potential solution may involve implementing Lean principles and learning from other industries that have utilized this approach to improve organizational effectiveness.

    Lean Principles

    Lean principles and thinking originated in the manufacturing industry more than 100 years ago, and since, healthcare organizations and other industries have been striving to emulate those best practices. “Lean is a cultural transformation that changes how an organization works; no one stays on the sidelines in the quest to discover how to improve the daily work.”7 Leaders play a critical role in improving daily work by leading change within their teams and their own management processes:
     
    The best leaders of Lean operations I have known are also the ones who have recognized that the methods they insist on others using are also ones they themselves adopt. A principal difference between just leading projects, compared with leading Lean operations, is that leaders of ongoing operations have more, and more meaningful, opportunities to take the step of personally adapting themselves to a leaner mode of operating.”8
     
    By utilizing the Shingo guiding principles,9 leaders enable a work culture that values respect and humility, supports and demonstrates continuous improvement, ensures organizational alignment and achieves results that focus on creating value for the customer.
     
    To become Lean, organizations must understand how to define value and waste. Mayo Clinic defines value as quality, measured by outcomes, safety and service, divided by cost. Similarly, the Lean philosophy defines value as what the customer is willing to pay for, while waste (non-value-added activities) is defined as everything else.10 In healthcare, these definitions apply more fluidly to the delivery of patient care, and the translation to leadership or indirect patient care areas can be murky. To aid a leader’s ability to recognize waste in his or her work, it’s helpful to refer to the categories of waste detailed in Table 1. 
     

    Types of waste

    A critical view of waste or muda in systems or process was first identified in the early 1950s by Taiichi Ohno, developer of the Toyota Production System, and includes the first seven categories in Table 1.11 James P. Womack and Daniel T. Jones added another category: misutilization of skills.12 Most workers, hired into a position that the organization has deemed important, believe the work they do is valuable. However, the work may evolve over time to meet perceived needs of internal or external customers which may not be part of a deliberately designed system or value stream for customers.

    Identifying waste

    After studying Lean principles and the eight types of waste, leaders in the Mayo Clinic’s Department of Radiology recognized that they were increasingly feeling the effects of waste in their day-to-day lives and needed to define the waste and find strategies to eliminate it. A brainstorming exercise called a waste walk was conducted. Seven topics emerged for application of Lean principles: email, meetings, re-prioritization, re-work, talent management, unclear expectations and waiting. The group felt strongly that these issues were minimizing their effectiveness as leaders and they looked for strategies to help mitigate these negative influences.

    Strategies to eliminate waste

    The seven topics were framed into strategies to help leaders remove waste from their day simply and effectively. These strategies are a call to action for leaders to be vigilant when attempting to eliminate these types of waste.
     

    Email strategies

    1. To whom do you send email?

    1. Only utilize email when necessary; identify when it’s appropriate and when it’s not
    2. Critically assess recipients; reply only to those who need to receive the reply/message

    2. What should you include in an email?               

    1. Mindful reflection on why you are sending the email and clearly defining the purpose and scope
    2. Be clear, concise and specific
    • Utilize bullets, not paragraphs
    • Specify a call to action for recipients or be clear when no action is needed
    • Identify what you expect from the email recipients
    • Assign a due date for action items           

    3. How do you organize emails?

    1. Organize email files around topics so that past emails can be archived for actionable retrieval
    • Simplify email file system (only have a few archive folders)
    • Delete unnecessary emails to remove clutter

    Meeting management strategies

    1. Before a meeting

    1. Establish a clear purpose for the meeting and deliverables
    • Only schedule the meeting once assured all information and attendees are available
    • Shorten meetings to 30 minutes or less when possible
    • Reduce frequency of regularly scheduled/recurring meetings to what is absolutely necessary
    1. Create an agenda around important and actionable topics
    • Send the agenda and necessary attachments to all attendees at least 48 hours in advance
    • Specify the decisions and pre-work needed for attendees

    2. During a meeting

    1. Manage the meeting      
    • Start on time, follow the agenda, facilitate decisions/actions and end on time
    • Delegate someone to take notes during the meeting so the leader can focus on the content being discussed
    • Document action items (who, what, by when) and other critical informatio

    3. After a meeting

    1. Leave meetings with accountabilities affirmed and timelines
    • Each attendee follows up as defined, with the appropriate information/actions taken
    • The meeting leader should hold others accountable for action item completion and communicate back to attendees

    Re-prioritization strategies

    1. Process for prioritizing

    1. Set clear expectations for what the process is expected to achieve
    • Define an intake process with prioritization tool
    • Prioritize initiatives collectively
    • Create standard work for how to stay on task

    2. Prioritization

    1. Setting priorities
    • Focus on the critical few (limit the total number of priorities so high priorities receive the appropriate resources)
    • Clearly identify the resources required and establish timelines
    • Finish high priorities before starting new ones

    3. Delivery of priorities

    1. Block the noise
    • Place a “do not disturb” sign on office door and clearly define available time when others can visit
    • Block calendar time to work on/complete projects
    • Track unnecessary interruptions and strive to eliminate them
    1. Clearly define deliverables
    • Define what success looks like and an objective method to evaluate that success
    • Respond appropriately to needs when they arise
    • Identify when initiatives should end
    • Establish a frequent review of project portfolio and progress

    Strategies to prevent re-work

    1. Identification 

    1. Achieve consensus on the problem and/or where the re-work exists
    2. Ensure you have the correct individuals helping with situation/problem
    3. Clearly outline what is in/out of scope for the initiative
    4. Find the root cause of the problem
    • Identify defects/errors causing the re-work
    1. Develop and/or utilize a robust frontline problem-solving/improvement process to decrease/eliminate daily re-work

    2. Improvement

    1. Develop tactical interventions and tests of change to address the root cause
    2. Set clear expectations and processes via standard work by task and role
    • Utilize templates to organize standard work so all stakeholders are familiar with expectations
    • Ensure those expected to follow the standard work are included in the development

    3. Closure

    1. Ensure deliverable was met, re-work has been eliminated/reduced and improvement will be sustained
    • Consensus was achieved
    • Ensure the re-work/problem will not resurface in the near future 

    Talent management strategies

    1. What needs to be done?

    1. Clearly define job requirements and align those to the recruitment strategy and candidate selection criteria to assure that the right person has clear guidance
    2. Develop a robust hiring system
    • Communicate an accurate job description
    • Specify minimum and preferred requirements
    • Utilize behavioral interview questions and an interview rating system
    • Review prior job appraisals and contact references

    2. Who is the right person?

    1. Meet with individuals to understand their talents, interests and desires; channel work that meets these criteria
    2. Identify individuals who can do the work and will develop their leadership capabilities by doing the work
    3. Ask and respond to the question, “Are you the correct person to do the work?”

    3. How do we best support our talent?

    1. Empower your talent to get work done
    2. Set clear role expectations and hold them accountable
    • Address problems/issues as they arise
    • Coach/educate all levels of management to be comfortable with giving routine feedback and follow through to ensure action is completed when needed 

    Strategies to avoid unclear expectations

    1. Priorities

    1. Avoid too many competing expectations and priorities

    2. Role

    1. Create a clear list of responsibilities within a team
    • Provide role clarity via standard work for staff and leaders
    • Train new and current employees on standard work

    3. Process

    1. Create a process for how work should be done
    • Observe and audit standard work to reinforce expectations
    1. Outline deliverables with timelines
    • Be specific: what, by whom, by when
    • Clearly outline: vision, success definition, deliverables, timeline, team members and project priority
    • Receive acknowledgment that what is being asked for can and will be done; avoid passive resistance

    Waiting reduction strategies

    1. Process

    1. Establish systems that will allow for decisions to be made in a timely manner
    • Value stream the process to see what can be improved and what non-value-added steps can be eliminated
    • Clearly identify the appropriate amount of time needed to make the decision
    • Coordinate time to work on other problems/issues while waiting for decisions
    • Identify individuals, for specific situations, who can provide preliminary approval followed by full committee endorsement

    2. Action

    1. Escalate decisions that can and need to be made quickly
    2. Coordinate the availability of physicians to expedite decisions
    3. Ask the committee chair for expedited presentation and/or approval pathway

    3. Reflection

    1. Identify what could be done better the next time to reduce waiting

    Conclusion

    As organizations strive to maintain or increase effectiveness and decrease burnout, it is critical to define clear ideal behaviors that align with the organization’s guiding principles and values. Utilization of these Lean strategies may enhance the effectiveness, efficiency and well-being of leaders, while optimizing the value for patients and providers trying to address the challenges of the U.S. healthcare system. Although the strategies may seem straightforward, vigilance is needed to ensure that leaders can focus on high-value activities. 
     
    Acknowledgments: The authors acknowledge the assistance of Sonia Watson, PhD, in editing the manuscript.
     

    Notes:

    1. Rice T, Unruh LY, Rosenau P, Barnes AJ, Saltman RB, van Ginneken E. “Challenges facing the United States of America in implementing universal coverage.” Bull World Health Organ. 2014;92(12):894-902. doi: 10.2471/BLT.14.141762.
    2. Shanafelt TD and Noseworthy JH. “Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout.” Mayo Clin Proc. 2017;92(1):129-146. doi: 10.1016/j.mayocp.2016.10.004.
    3. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. “Burnout and satisfaction with work-life balance among US physicians relative to the general US population.” Arch Intern Med. 2012;172(18):1377-1385. doi: 10.1001/archinternmed.2012.3199.
    4. Shanafelt and Noseworthy.
    5. Ibid.
    6. Berry LL and Seltman KD. “The enduring culture of Mayo Clinic.” Mayo Clin Proc. 2014;89(2):144-147. doi: 10.1016/j.mayocp.2013.10.025.
    7. Toussaint JS and Berry LL. “The promise of Lean in health care.” Mayo Clin Proc. 2013;88(1):74-82. doi: 10.1016/j.mayocp.2012.07.025.
    8. Mann D. Creating a Lean Culture: Tools to Sustain Lean Conversions. 3rd ed. Boca Raton, FL: CRC Press, 2015.
    9. Shingo Institute. “The Shingo Model is not just another initiative; it is a new way of thinking.” Utah State University, 2017. Available from: shingoprize.org/model.
    10. Womack J and Jones D. Lean Thinking: Banish Waste and Create Wealth in Your Corporation. New York: Simon & Schuster, 1996.
    11. Ohno T. Toyota Production System: Beyond Large-Scale Production. Portland, OR: Productivity Press, 1988.
    12. Womack and Jones.
    13. Jimmerson C. Value Stream Mapping for Healthcare Made Easy. Boca Raton, FL: CRC Press, 2010.
    14. Graban M. Lean Hospitals. 3rd ed. Boca Raton, FL: CRC Press, 2016.
    15. Imai M. Gemba Kaizen. 2nd ed. New York: McGraw-Hill, 2012.
    16. Grabow PA and Goodman PL. The Lean Prescription. Boca Raton, FL: CRC Press, 2015.

    Ronald Menaker

    Written By

    Ronald Menaker, EdD, MBA, FACMPE

    Ronald Menaker can be reached at menaker.ronald@mayo.edu.

    Jeffrey R. Leland

    Written By

    Jeffrey R. Leland, MA

    Jeffrey R. Leland, MA, is a former operations manager, Mayo Clinic, Rochester, Minn.

    Laura C. Tibor

    Written By

    Laura C. Tibor, MBA

    Laura C. Tibor, MBA, operations manager, Mayo Clinic, can be reached at tibor.laura@mayo.edu.


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