In a typical hospital, the sheer numbers of metrics (which can run into the hundreds)and outcomes at the senior team level can be overwhelming, especially for those at the manager or unit level. These measurements are given little or no prioritization, and consequently staff bravely attempt to meet every one, which introduces high stress levels, eats into their working hours and reduces the chance of innovative solutions, with firefighting becoming the norm.
The answer to the question: “which metrics are important” is: “all of them.” However, in a Lean management system, this dilemma is overcome by leadership choosing a small number of key performance indicators, on which all improvement efforts are focused to achieve breakthrough performance (often over a period of 18-24 months). Once a given metric has met the target, it can be monitored and a new one may take its place.
To ensure consistency and a clear direction, these indicators are aligned with the organization’s strategic priorities, such as patient satisfaction, quality of care, staff satisfaction and financial efficiency. Internal or external benchmarking may also be useful in setting targets that compare to peer hospitals, so long as this is not viewed as the ultimate goal, which can lead to complacency.
Metrics must be meaningful to staff at different levels. For example, senior team and board members believe that average length of stay (ALOS) is a critical measure for almost any hospital, yet this lacks meaning for frontline nursing staff, who feel they cannot be responsible for such an outcome as too many factors are out of their control – such as the writing of discharge orders. In a Lean system, nurses would be given more relevant targets such as preparing patient discharges earlier in the day, or measuring the percentage of patients that “felt prepared for my discharge from the hospital”, which would contribute to a shorter ALOS.
The power of visibility
Performance boards are a central feature of Lean, helping management and staff to check progress towards their overall goals, such as hand washing to reduce in-hospital infection rates.
Global Center of Excellence for Healthcare
Director, Healthcare Advisory
KPMG in the UK
There is however a risk that these boards become a one-way communication from managers to staff, or worse still, are ignored completely. Smaller sets of clearly displayed metrics (such as simple run charts) can ensure that staff are more connected to their results, while huddle discussions are not just about reviewing performance but also to generate new improvement ideas, which again raises engagement levels. There is nothing more motivating than to see one’s own ideas – and subsequent successes – on board, which assures people that their input is being taken seriously and leading to positive action.
Sharing of ideas can help spread best practice and improve performance, so staff should be encouraged to communicate with other units in the hospital and take part in job rotation programs.
The ‘quality versus cost’ debate has featured in many Lean discussions, as some healthcare workers (mistakenly) fear that Lean places an excessive emphasis upon cost cutting. Pure cost reduction initiatives tend to produce notable short-term savings of as much as 15 percent, but rarely sustain these successes.
Contrary to traditional thinking, quality and cost are interdependent, as there is a greater potential for long-term savings from improvements in clinical efficiency and quality of patient care, such as shorter length of stay, lower readmission rates or fewer unnecessary diagnostic tests performed on patients. By giving quality the top priority on performance boards, staff will start to change their perceptions and acknowledge the holistic benefits of Lean.