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January 25, 2019
Ann Pekarek in a morning huddle with colleagues

New organizational DNA for Emory Healthcare

Every morning, Ann Pekarek, director of cardiology services at Emory University Hospital, starts her day meeting with colleagues around a white board populated with red and green dots, which identify snags in the system that could disrupt the day. They are on the vanguard of EmPower, Emory Healthcare's version of the Lean management system.

Made famous by Toyota, Lean management embodies a process of continuous improvement by empowering frontline workers to solve problems."Lean flips the traditional organizational pyramid, which puts the CEO at the top and the workers at the bottom," says EVPHA and EHC CEO Jon Lewin. "The Lean system puts workers at the top."

This structure empowers the people who work directly with customers and opens up paths of communications. "Lean is built on a profound respect for the people who do the work," says William Bornstein, chief medical and chief quality officer for Emory Healthcare. Lewin, Bornstein, and the rest of the EHC leadership team believe the Lean approach will accelerate achievement of the "quadruple aim" of better patient health, better patient experience, lower relative costs for patients and families, and greater joy of providing care for staff and physicians.

Bornstein stresses that EmPower is not an initiative, and it's not a multi-year project--it's a way to do business. "Lean is not just a series of quality improvement tools," he says. "Tools are part of it, but the real power of Lean is when it becomes the operating system, the way you do your work. It becomes part of your organization's DNA."

Emory Healthcare first dipped its toe in the Lean pool a decade ago, working with the consulting firm Simpler to learn about Lean and to apply Lean tools to specific projects. Ultimately, leadership decided not to take the dive to adopt the operating system outright.

Then in 2015, the James M. Cox Foundation gave $25 million to improve patient experiences and outcomes. "The Kennedy Initiative gave us a launching point to transform the organization using the Lean system," says Greg Esper, who leads the newly established Lean Promotion office, along with Christina Hummel.

The Kennedy Initiative initially focused on improving processes in urology, radiation oncology, cardiology, and transplantation. Now, EHC leadership is ready to begin rolling out EmPower across the system.

The Lean system has five levels, beginning with laying the foundation and stabilizing it and ending with optimizing outcomes. For optimal results, each level should be mastered before the next level begins, since the lessons build on each other.

Each layer has multiple steps, and the first step in laying the foundation is establishing the daily management system. The daily management system, in turn, has five elements--daily readiness tiered huddles, development of process and outcome metrics, development of standard work, development of how to handle ideas for improvement, and planned work cadence.

The first step in adopting a Lean management system is the tiered daily readiness huddles. EUH cardiology services, which has been having daily tiered huddles for more than a year, offers a glimpse of how it works.

Every day, frontline workers from the five areas in cardiology procedures--heart transplant, cardiac cath lab, echocardiography, electrophysiology, and cardiac observation--meet for 10 to 15 minutes in tier 1 huddles. The cardiac cath lab huddle, for example, is attended by the nursing staff, cardiovascular techs, the charge person, materials coordinator, business manager, lab manager, and physicians when available. This team gathers around a white board that has columns for safety, methods, equipment, staffing, and supplies. Items in each of these columns are marked with either a green dot, meaning there are no concerns, or a red dot, signaling something that needs attention--perhaps a piece of equipment has gone down in one of the cath labs, for example, so fewer cath rooms are available and patient flow needs to be adjusted.

Shortly after their tier 1 huddles, managers from each of the five cardiology areas meet with Pekarek in a tier 2 huddle. Using a similar white board with red and green dots, they present issues identified in their tier 1 huddles that were unable to be resolved. Pekarek then meets with department directors from other areas of the hospital and the EUH senior management team in a tier 3 huddle. There she can raise issues that were not able to be resolved in the tier 2 huddle.

The huddle system means that people who are working directly with patients can have their issues heard by top management within a matter of hours. In one case in the electrophysiology lab, for example, three staff members resigned within a few days of each other, and restaffing needed to occur quickly. Getting a position posted normally takes four to seven days. But thanks to the huddle system, Pekarek was able to have all three positions posted by the end of the day.

Eventually, there will be tier 4 huddles, in which leaders of each hospital and the physician group practice will meet along with other members of the senior EHC leadership team.

"These next two to three years will be about establishing the daily management system," says Esper. "The frontline staff and clinicians are the most important part of the team, because they see the patients and families, know the problems, and have the best ideas about possible solutions. In this process, daily, frequent, and standard communication is paramount, so that problems that can't be solved on the front line are escalated rapidly to achieve timely resolution."

Meanwhile, says Lynda Barrett, EHC vice president for strategic planning, the EHC leadership team also has begun using Lean principles to measure progress on meeting strategic goals. Once a month, Lewin and 16 EHC leaders meet around their own white board, dubbed the EHC Visual Management Board. Using red, green, and yellow dots, the board visually depicts areas where the organization is making progress toward meeting strategic goals, where it may have issues, and where it's having problems. "This is also part of the Lean rollout," she says, "but instead of focusing on daily operations, it focuses on long-term strategy."--Martha McKenzie

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