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An Approach to Sustaining

Lean in Primary Care Clinics

An Analysis Using the

LEI Lean Transformation Model

Katrina Appell, Ph.D.

Lean Coach, Lean for Clinical Redesign CQI

University of Michigan Health System

3BCBSM Value Partnerships & Physician

Group Incentive Program

• Value Partnerships (2005)

– Collection of patient safety, clinical quality, and care process efforts that

makes health care work better in Michigan

• Collaboration between Michigan physicians, hospitals and Blue Cross Blue

Shield of Michigan

• Physician Group Incentive Program (2005)

– Encourage and incentivize physicians to more effectively manage

populations of patients and build an infrastructure to more robustly

measure and monitor care quality

– 40+ physician organizations

• 19,000+ primary care and specialist physicians

• Collaborate on initiatives to improve care

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1. Clinics need support to become Patient Centered Medical

Homes (2009)

2. Improvement efforts were not spreading and had

inconsistent sustainment within Physician Organizations

(2013)

What problem(s) are we trying to solve?

Hypothesis - For sustainment we need to:

• Develop problem solving skills within physician organization

• Develop clinic managers to coach their teams to solve

problems

• Develop physician organization coaches to support the work

in additional clinics

What is the underlying philosophy or thinking

that enables the transformation effort?

Future / Target

Facts

Current

Vision

Learning grounded inContinuous Improvement and Respect

What is the underlying philosophy or thinking

that enables the transformation effort?

Change = D * V * F > R1

DESIRE FOR

CHANGE

• Dissatisfaction with the current state

• Willingness to learn a better way

VISION• What we want to create or achieve together

FIRST STEPS• What we are going to do to learn and

improve towards our vision

RESISTANCE• Resistance is a sign that you have touched

on something valuable2

• Surface, understand, and respect resistance

1 Developed by Kathleen Dannemiller2 Adapted from Flawless Consulting by Peter Block

What is the underlying philosophy or thinking

that enables the transformation effort?

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Characteristics of Readiness

Ready

Yes No

Stability:

● Business

● Staff

● Leadership

Commitment and willingness to learn & change:

● Leadership

● Lean Coaches

● Clinic Team

Lean coaches capable of success:

Foundational characteristics:

● Temperament (patience & humility)

● Emotional intelligence

● Understanding of role

● Core beliefs (continuous change vs. control)

What role is leadership taking?

Supporting the clinics to be successful (Evidence-based Readiness)

9What role is leadership taking?

Developing Leaders as Coaches:

PDSA Coaching Sessions

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Foundational Learning

What capability development is taking place?

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What capability development is taking place?

And team (learners too!)

Learner (Practice Manager)/Practice Coach

(always learning)

Learner /Physician Organization Coach

(always learning)

Lean for Clinical Redesign Coach

(always learning)

Cycle 1 2 3PO Coach Observe Partner Lead

12What actual, operational improvements were

implemented to engage the entire clinic?

Socialize/Validate:

• Value Stream Map

• Understand the Situation

• Problem Definition

• PDSA Cycles

Daily at Huddles:

Share Problem Solving

13What actual, operational improvements were

implemented to create habits and routines to

support the culture?

Weekly:

• PDSA Session at Lean Daily Management Board

– Dedicated problem solving time

Monthly:

• Learning Collaborative

– Learning across

clinics

What actual, operational improvements were

implemented?Problems and Improvements from Bronson Medical Group

Mammogram Completion Rate – Bronson Internal Medicine Oshtemo

Implemented Chart Prep &

Mini Huddle Standard Work

Accurate Demographics – Bronson Rambling Road Pediatrics

Appointments Created Bronson Rambling Road Pediatrics

73% 85%

Standard Work for verifying

demographics at every point of contact50% 93%

Implemented Standard Agenda

Mini-Huddle745 in 2014

Tota

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Lea

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Starting out Maturing

Maturity in Integrating Lean and Business Strategy

I. Apply Tools II. Management Led Lean

III. Aligned

Continuous Improvement

Without Philosophy

With Philosophy

Used with Permission: The Toyota Way to Continuous Improvement (2011 Liker and Franz)

Results as Lean Evolves to Aligned

Continuous Improvement