"The Largest Lean Transformation in the World": The Implementation and Evaluation of Lean in Saskatchewan Healthcare

Abstract

The Saskatchewan Ministry of Health has committed to a multi-million dollar investment toward the implementation of Lean methodology across the province's healthcare system. Originating as a production line discipline (the Toyota Production System), Lean has evolved to encompass process improvements including inventory management, waste reduction and quality improvement techniques. With an initial focus on leadership, strategic alignment, training and the creation of a supportive infrastructure (Lean promotion offices), the goal in Saskatchewan is a whole health system transformation that produces "better health, better value, better care, and better teams." Given the scope and scale of the initiative and the commitment of resources, it is vital that a comprehensive, longitudinal evaluation plan be implemented to support ongoing decision-making and program design. The nature of the initiative also offers a unique opportunity to contribute to health quality improvement science by advancing our understanding of the implementation and evaluation of complex, large-scale healthcare interventions. The purpose of this article is to summarize the background to Lean in Saskatchewan and the proposed evaluation methods.

Full text

Healthcare Quarterly Vol.17 No.2 2014 29
Abstract
The Saskatchewan Ministry of Health has committed to a
multi-million dollar investment toward the implementa-
tion of Lean methodology across the province’s healthcare
system. Originating as a production line discipline (the
Toyota Production System), Lean has evolved to encompass
process improvements including inventory management,
waste reduction and quality improvement techniques. With
an initial focus on leadership, strategic alignment, training
and the creation of a supportive infrastructure (Lean promo-
tion offices), the goal in Saskatchewan is a whole health
system transformation that produces “better health, better
value, better care, and better teams.”
Given the scope and scale of the initiative and the
commitment of resources, it is vital that a comprehensive,
longitudinal evaluation plan be implemented to support
ongoing decision-making and program design. The nature of
the initiative also offers a unique opportunity to contribute
to health quality improvement science by advancing our
understanding of the implementation and evaluation of
complex, large-scale healthcare interventions. The purpose
of this article is to summarize the background to Lean in
Saskatchewan and the proposed evaluation methods.
Background
Saskatchewan is a geographically large province (651,036 km2)
in central Canada with a population of just over 1,000,000
people. Across the province, there are 13 defined health
regions overseeing 40,000 employees in a system composed of
hospitals, community health centres, ambulance and emergency
services, supportive care, home care, mental health and rehabili-
tation. With a substantial proportion of the population and
many providers living and working in geographically isolated
settings, with 15% of the population older than 65 years and
15% of the population identified as Aboriginal, the province
faces many complex issues in healthcare delivery (Government
of Saskatchewan 2014). The Saskatchewan government found
through a variety of reviews, reports and patient experience
surveys that its health system was not fully addressing the needs
of the province’s citizens. As a result, the government committed
to a system-wide transformation based on the Lean method-
ology. This transformation has been referred to in the media as
“probably the largest lean transformation in the world” (French
2014, February 5).
Lean was originally derived from the Toyota car company
production line system. This continuous process improve-
ment system is composed of structured quality improvement
techniques, inventory management and waste reduction
(Marchildon 2013). The quality and cost efficiency improve-
ments identified through this system are seen as potentially
transferrable to other industries, including healthcare. For
example, Lean has been implemented in the Virginia Mason
Health System in the United States to improve processes of
patient flow, supply and procurement and payment in hospitals
(Marchildon 2013). The overarching approach used in Lean is
to create a continuous learning cycle that is driven by the “true”
experts in the processes of healthcare (i.e., patients/families, care
providers and support staff), with coaching and sponsorship
“The Largest Lean Transformation in
the World”: The Implementation and
Evaluation of Lean in Saskatchewan
Healthcare
Leigh Kinsman, Thomas Rotter, Katherine Stevenson, Brenna Bath, Donna Goodridge, Liz Harrison, Roy Dobson, Nazmi Sari,
Cathy Jeffery, Carrie Bourassa and Gill Westhorp
SPECIAL FOCUS ON LEAN IN HEALTHCARE

30 Healthcare Quarterly Vol.17 No.2 2014
“The Largest Lean Transformation in the World”: The Implementation and Evaluation of Lean in Saskatchewan Healthcare Leigh Kinsman et al.
from their managers and leaders (de Souza 2009). It provides
a multi-faceted, patient-centred approach to managing and
improving healthcare.
Lean is being introduced into the Saskatchewan healthcare
system in stages. The initial phase centred on a project called
“The Productive Ward: Releasing Time to Care,” a nurse-led
quality improvement approach for hospital wards that was devel-
oped by the National Health Service in the United Kingdom
(National Health Service 2014). This process improvement
initiative was implemented in all medical and surgical wards
across the province and used Lean principles to increase the
engagement of front-line nurses in improving quality of care
and reducing waste.
More recently, the Ministry of Health has established Lean
offices (also known as Continuous Improvement or Kaizen
Promotion Offices [KPOs]) in five health regions and provin-
cial health system organizations (e.g., the Saskatchewan Cancer
Agency and Saskatchewan Health Quality Council) and aims to
train and certify over 800 Lean leaders by 2016 to lead quality
improvement work (Saskatchewan Ministry of Health 2012).
The exact cost of the implementation of Lean is unknown, but
it is clear that this is an unprecedented investment in health
system improvement in Saskatchewan. The Saskatchewan
Health Quality Council has the overarching provincial roles of
standardization and coordination of Lean training, events and
planning across the province. As part of the Lean reform, all
large initiatives (e.g., major construction works) are required to
use the highly structured Lean design principles.
The Saskatchewan government has made publicly available
a range of ambitious targets to be achieved as a result of system
transformation using Lean methods. The following state-
ments reflect three of these targets (Saskatchewan Ministry of
Health 2013):
• “By2017,therewillbea50%improvementinthenumber
of people who say, ‘I can access my Primary Health Care
team for care on my day of choice; page 7.’”
• “ByMarch31,2017,nopatientwillwaitforemergency
room care (patients seeking non-emergency care in the
emergency room will have access to a more appropriate
care setting); page 10.”
• “ByMarch31,2017,establishacultureofsafetyresulting
in zero defects to patients and staff; page 6.”
Evaluation
The public investment and magnitude of this immense health
system transformation make comprehensive evaluation essen-
tial; the situation also provides an unprecedented opportunity
to add substantial knowledge to the evidence base regarding
large-scale health system transformation. Primarily, the purpose
of the evaluation of Saskatchewan’s Lean implementation is to
generate knowledge that will inform ongoing decision-making
regarding Lean in Saskatchewan. Just as importantly, the evalua-
tion creates a unique opportunity to understand how the princi-
ples from the Lean Management System, originally designed
as an industrial model, can be used to reduce healthcare costs,
maximize efficiency, improve the patient experience, decrease
wait times, improve care and enhance teamwork. The evalua-
tion will move beyond an understanding whether Lean “works”
to provide a more nuanced picture of when, how and for
whom the Lean implementation in Saskatchewan is successful.
The underlying processes of change and how differences in
contexts influence system change and patient outcomes will be
essential to understanding the transferability of Lean to other
healthcare settings.
Systematic Review
We have undertaken a systematic review of the evidence
regarding the use and impact of Lean in healthcare. Previous
Lean investigations have reflected the challenges researchers
confronted in the evaluation of complex, real-world, large-scale
health services interventions. We have identified a lack of appro-
priate theoretical concepts, problems with the methodological
quality and limitations in outcome measures and analysis
that inhibit the generalizability of study findings, despite the
majority of studies reporting successful outcomes with Lean
(Holden 2011; Mazzocato et al. 2012). It is therefore impera-
tive to synthesize review findings to inform our research design
and optimize our contribution to the body of knowledge
regarding large-scale, complex health services interventions. We
have registered the systematic review on Lean in PROSPERO
(CRD42014008853) and submitted a review protocol to BMC
Systematic Reviews.
Methodological Development and Baseline Data
Collection
The evaluation framework and methodology for a multi-year
longitudinal evaluation was developed following these steps:
• Extensivestakeholderengagement(workshopsand
meetings)
• KeyinformantinterviewswithregionalKPOleaders
• Asystematicliteraturereview
• Leanimplementationmapping(i.e.,theextentofthe
implementation of Lean across four selected health regions)
• In-depthinterviewswith29healthservicesmanagers,clini-
cians, administrative staff and patients who have partici-
pated in Lean initiatives
• Explorationofexistingpatientoutcomedatabases
• Consultationwithinternationalmethodologicalexperts

Healthcare Quarterly Vol.17 No.2 2014 31
Leigh Kinsman et al. “The Largest Lean Transformation in the World”: The Implementation and Evaluation of Lean in Saskatchewan Healthcare
To guide and link processes and results, an interim Logic
Model has been developed (Figure 1). The Logic Model incor-
porates contexts, inputs (i.e., funding, infrastructure, human
resources etc.), activities (Lean activities, including strategies),
outputs relating to health system processes and behaviour
change, and outcomes that align with the provincial Lean goals
(“better health, better value, better care, and better teams”).
The Logic Model is supported by a series of more detailed
“theory diagrams” that map out how processes of change are
expected to work. Selected theories will be tested and refined
over the course of the evaluation.
Using the Logic Model and theory diagrams as a founda-
tion, we will incorporate a variety of approaches and methods
to undertake our evaluation, including realistic evaluation
(RE), quantitative methods, economic analysis and qualitative
methods.
Realist Evaluation
As the overall approach, RE is particularly helpful for large-scale
evaluations as it moves beyond evaluating whether something
works to understanding what works for whom in what circum-
stances and why, and provides valuable contextual evidence for
translation of a policy or program into other settings (Pawson
and Tilley 1997). There are four concepts explored through
RE: context, mechanism, outcome (or outcome pattern)
and context-mechanism-outcome configuration, or CMOC.
Mechanism refers to underlying processes of change that
generate particular outcomes. Context refers to features of the
organization, staffing, geography and culture that affect whether
and how interventions work, and describe for whom and in
what circumstances they will work. For the evaluation of Lean
in Saskatchewan, this approach will be used to elucidate what
Lean achieves in different contexts and to understand how and
why this is the case.
Quantitative Methods
We will use an interrupted times series design examining indica-
tors of patient outcomes, quality of care and costs in the form
of a multiple-baseline approach. This research design represents
a robust method of measuring the effect of an intervention as
FIGURE 1.
Interim Lean evaluation Logic Model*
3P = production, preparation, process; 5S = sort, streamline, shine, standardize, sustain; KPO = Kaizen Promotion Office; RPIW = Rapid Process Improvement Workshop.
*As of November 2013.
Context: Saskatchewan Health System and Population
Lean implementation
Measures
Lean impact
Kaizen basics workshops, protocols, policies
Resources, costs, time etc.
Number workshops, including 3P, 5S, RPIWs. Proportion of staff attending,
workshop evaluations, practice changes
Teamwork, professional practice, measurements of patient safety and
quality of care, staff and patient satisfaction, work loss reduction
Efficiency, cost, time, access, hospitalisation rates, length of stay
Chronic disease rates, population “wellness”, risk factors
Intervention activities
Outputs
Description of province, regions and health system
Outcomes
Immediate Better teams
Better care
Intermediate Better value
Long term Better health
Inputs Policy, KPOs, infrastructure,
human resources
Implementation and
maintenance of Lean
System and behaviour changes

32 Healthcare Quarterly Vol.17 No.2 2014
a trend over time. It is a useful design when recruitment of
a control cohort is impractical, for example, due to changes
in hospital policy or, as in this case, where an intervention is
staggered, resulting in different stages of implementation across
the province. It is also amenable to Saskatchewan’s approach of
collecting and displaying indicators over time using run charts
or statistical process control methods. The final list of outcomes
includes the number and focus (service lines) of the different
interventions used to implement Lean; adverse events; health
services utilization (e.g., readmissions, lengths of stay); measures
of workplace efficiency (e.g., amount of waste); staff time
(e.g., sick leave); and wait times (e.g., wait times in the
emergency department, wait times to surgery).
Economic Analysis
We will track the total incremental cost of Saskatchewan’s Lean
healthcare implementation in two stages. The costing in stage 1
will include all costs and resources across all settings associated
with the implementation, including the total training cost of the
health professionals and administrators. The costing for stage 2
will assess the incremental cost of the operation of the imple-
mentation. A cost-benefit analysis will incorporate measures
such as the utilization of healthcare services (i.e., lengths of
stay in hospitals, readmission rate, emergency care visit, physi-
cian services and prescription drug use), waste reduction
(i.e., materials and inventories) and patterns in work loss (i.e.,
sick leaves).
Qualitative Methods
Qualitative methods guided by realist principles will consist of
interviews and focus groups. The emphasis in qualitative data
collection will be on collecting detailed information about
contexts and about decision-making processes that generate
specific outcomes in particular places.
Conclusion
The Saskatchewan health system transformation using Lean
methodologies is an ambitious and resource-intensive under-
taking that has the potential to substantially redesign the
Saskatchewan health system. It is imperative that such a huge
public investment be rigorously evaluated to inform ongoing
policy development. The comprehensive research design
described in this article (including Realist methods) will provide
invaluable evidence regarding the impact of Lean and the
contexts that influence its impact.
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About the Authors
Leigh Kinsman, RN, BHSc, MHSc, PhD is a member of the
School of Rural Health, Monash University, in Victoria, Australia.
Thomas Rotter, Dipl. Kfm., BA health economics, MPH, PhD,
PhD is a member of the College of Pharmacy and Nutrition,
University of Saskatchewan, in Saskatoon, Saskatchewan. He can
be contacted by e-mail at thomas.rotter@usask.ca.
Katherine Stevenson, BA , BScPT, MSc, is a member of the
School of Physical Therapy, College of Medicine, University of
Saskatchewan.
Brenna Bath, BScPT, MSc, PhD is a member of the School
of Physical Therapy, College of Medicine, University of
Saskatchewan.
Donna Goodridge, RN, PhD is a member of the College of
Nursing, University of Saskatchewan.
Liz Harrison, DipPT, BPT, MSc, PhD is a member of the
School of Physical Therapy, College of Medicine, University of
Saskatchewan.
Roy Dobson, BScPharm, MBA, PhD is a member of the College
of Pharmacy and Nutrition, University of Saskatchewan.
Nazmi Sari, PhD, is a member of the Department of Economics,
University of Saskatchewan.
Cathy Jeffery, BA, MN, PhD candidate, is a member of the
College of Nursing, University of Saskatchewan.
Carrie Bourassa, PhD, is a member of the Department of
Indigenous Education, Health and Social Work, First Nations
University of Canada, in Regina, Saskatchewan.
Gill Westhorp, PhD, is a member of Community Matters, in
Unley, South Australia.
“The Largest Lean Transformation in the World”: The Implementation and Evaluation of Lean in Saskatchewan Healthcare Leigh Kinsman et al.