Making change last: Using lean methodology to introduce, implement, and sustain successful performance improvement initiatives in an ambulatory care setting

Background: Through a program called Breakthrough, the New York City Health and Hospitals Corporation utilizes Lean methodology to improve performance throughout its health system. Metropolitan Hospital Center (MHC), one of the corporation's subsidiaries has become a Breakthrough early adopter, fully implementing hospital, department, and service-wide efforts to improve processes and eliminate unnecessary waste. Methods: Through a series of Value Stream Analyses that focus on specific areas needing improvement, they identify the potential for activities led by multi-disciplinary teams with the intent of addressing one specific process and/or issue. Rapid Improvement Events last a week and seek to determine the root causes of a problem and assign responsibility for a completion plan that addresses the issue. Other activities include 6S which addresses the organization of space or a “Just Do It” which allows participants to tackle a problem from start to finish without getting caught up in a long process. Among events in the past that addressed continuity of care and clinic flow, they have recently implemented efforts to improve the walk-in process for Adult Medicine patients and the pre-authorization process for managed care services. Results: Through its work with Breakthrough, Metropolitan has seen continuity increase from 44% in August 2010 to 77% in December 2011. Meanwhile, volume has continually increased. Since implementing Breakthrough, over 40 members of their team, coming from all disciplines and levels, have participated in events. A Process Owner (PO), who is typically the manager of the area under review, is responsible for implementing the changes. He/she tracks progress towards goals and addresses any issues that attempt to derail reform. In order to facilitate change, the PO sets up visual management queues that show data trends for the metrics that need improvement. Add to this a Pareto Chart that describes any daily issues that impacted achievement of the target state, and you have what is called a Process Control Board. These boards are located in central areas to enable all staff to monitor the success of the Breakthrough events. In addition to the Process Control Boards, true accountability is achieved through periodic hospital-wide performance improvement reviews where all Breakthrough events are discussed by the hospital's executive leadership. Conclusion: Ambulatory Care Services at MHC continues to strive for improved performance with the introduction of several new value streams and activities that will engage staff throughout the department.