527784

research-article2014

AJMXXX10.1177/1062860614527784American Journal of Medical QualityWackerbarth et al

Article

The Human Side of Lean Teams

Sarah B. Wackerbarth, PhD,1 Jamie R. Strawser-Srinath,
DPT, MHA,1 and Joseph C. Conigliaro, MD, MPH2

American Journal of Medical Quality

17
2014 by the American College of
Medical Quality
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DOI: 10.1177/1062860614527784
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Abstract
Organizations use lean principles to increase quality and decrease costs. Lean projects require an understanding of
systems-wide processes and utilize interdisciplinary teams. Most lean tools are straightforward, and the biggest barrier
to successful implementation is often development of the team aspect of the lean approach. The purpose of this article
is to share challenges experienced by a lean team charged with improving a hospital discharge process. Reflection
on the experience provides an opportunity to highlight lessons from The Team Handbook by Peter Scholtes and
colleagues. To improve the likelihood that process improvement initiatives, including lean projects, will be successful,
organizations should consider providing training in organizational change principles and team building. The authors
lean team learned these lessons the hard way. Despite the challenges, the team successfully implemented changes
throughout the organization that have had a positive impact. Training to understand the psychology of change might
have decreased the resistance faced in implementing these changes.
Keywords
lean, teams, group dynamics, quality improvement, change management
Lean organizations focus on eliminating waste. In health
care settings, examples of waste include errors, waiting
time, unnecessary transportation, and excess inventory.1-3
Through the use of lean principles, organizations can
identify strategies to increase quality and decrease costs.
Lean projects require an understanding of systems-wide
processes and utilize interdisciplinary teams. Through
tools such as value stream mapping, teams identify process improvements. The desired end result is a more efficient process designed (and implemented) by the
employees who are engaged in the process on a daily
basis. Although getting people to work together in effective teams is always challenging, lean health care teams
face additional burdens associated with examining complex processes across disciplinary silos. The purpose of
this article is to highlight problems experienced by a lean
health care team. Reflection on the experience provides
an opportunity to highlight lessons from The Team
Handbook by Scholtes et al.4

occurred once a week in 4-hour blocks, and the instruction was provided by an external consulting group. Topics
covered included structured problem solving, 5S (Sort,
Straighten, Shine, Standardize, and Sustain), visual controls, standard work, quality, value stream mapping, pull
systems, and visual scheduling. The participants also
practiced skills during facilitator-led mini projects. These
projects included identifying appropriate modes of transport for patients undergoing echocardiogram testing, 5S
of education materials on a nursing unit, and creating
standard workflows for cleaning patient rooms at discharge. Although the lean training exposed participants to
the tools of the lean approach and provided opportunities
to practice, leadership skills training was lacking.
At the close of the training sessions, an interdisciplinary team, including 6 training participants, was charged
with a project to improve the discharge process. The
scope of the discharge process included the time the
patient entered his or her room until the room was cleaned
and ready for the next patient. To complete the team,

Discharge Process Lean Project

In Fall 2005, a 500+ bed academic medical center
launched a lean process improvement program by providing 96 hours of training to a selected group of 20 employees. The participants had been identified by top
management and broadly represented the organization in
terms of service area and discipline. The training sessions

University of Kentucky, Lexington, KY

North ShoreLIJ Health System, Manhasset, NY

Corresponding Author:
Sarah B. Wackerbarth, PhD, College of Public Health, University
of Kentucky, 111 Washington Avenue, Suite 103C, Lexington, KY
40506-0003.
Email: sbwack0@uky.edu

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American Journal of Medical Quality

Figure 1. Discharge process: current state value stream map.

departments across the medical center were invited to

participate, which resulted in a diverse team of managers
and frontline employees. The team included representatives from departments such as nursing, physical therapy,
pharmacy, internal medicine, social work, environmental
services, and patient transport as well as care facilitators
and unit clerks.
The Discharge Process team was supported by an
executive sponsor, a facilitator from the external consulting group, and a team leader. The team leader was an
industrial engineer trained in health care applications and
employed in the centralized quality and patient safety
department at the academic medical center. The team
developed a current state value stream map (Figure 1),
identified problem areas (Figure 2), and created a future
state map (Figure 3).
The challenges arose as the team began implementing
changes within the organization. Figure 1 highlights the
complexity of the discharge process and the number of
individuals required to care for one patient. The map
made problem areas highly visible, allowing each area to
see how the other areas actions directly affected their
work. Figure 2 includes more than 40 problem areas identified during the process. The team focused efforts primarily on one area: communication between care
providers. The future state map (Figure 3) served as the
ideal state to work toward; from this figure, it is apparent
that the number of steps decreased, and many steps were
planned to occur concurrently.

Challenges and Lessons Learned

The authors detail challenges encountered by this team in
implementing change and suggest lessons from The Team
Handbook by Scholtes et al.4 To facilitate reference to
Scholtes text, page numbers are included in parentheses.

Challenge 1: Large Team

The projects scope was large, especially considering that
this was the first lean project the medical center had pursued. Even though the team involved members from 15
departments, the entire discharge process was not represented. Furthermore, some team members did not receive
training. To develop an overall value stream map, team
members identified their departments processes, and the
facilitator merged the subprocesses. As the team focused
on specific components of the process, several team
members stopped attending meetings when they felt that
the process component under discussion was not relevant
to them. As a result, some areas of the proposed future
state were not examined.
Lesson Learned. Scholtes recommends that teams be kept
to a small size, between 5 and 7 members (pp 2-15). The
larger team could have considered creating the current
and future value stream maps simultaneously to allow for
progress toward a common goal. The larger team then
could have divided into several subteams (pp 2-10). Each

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Wackerbarth et al

Figure 2. Discharge process: problem areas.

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American Journal of Medical Quality

Figure 3. Discharge process: future state value stream map.

subteam would be formed based on how closely the units

interact or based on similar timing of the departments
components in the overall process. Continued meetings
of the larger team would have ensured that improvements
were moving toward the future state and that unforeseen
negative consequences did not arise. This approach
would ensure that the entire process would always progress toward the proposed future state rather than focusing
on one area over another, which caused some team members to lose interest.

Challenge 2: Absent Leader

The team had an executive sponsor who fully supported
the project but was overcommitted. Therefore, he had
limited ongoing involvement in the project. Also, the
team never drafted a written charter for the project. The
lack of a charter became especially challenging when the
team leader went on leave during the point in the project
when the team was implementing the first significant process change. Concurrently, the medical center employed

a lean expert who was transitioning into the role of executive sponsor for the project.
Team members continued the project with executive
support, but this support was not always visible. Team
members had neither a mandate to report on progress to
physicians or middle management to gain acceptance of
the project nor guidelines for parameters within which to
operate. When the team encountered resistance in implementing change, they could not identify a consistent person from whom to seek support. The resulting obstacles
were overcome only when the lean expert intervened to
obtain buy-in from resources controllers after resistance
was encountered.
Lesson Learned. The executive team mandating this project could have assembled a guidance team for this project. Scholtes defines a guidance team as 2 or 3 project
sponsors with diverse skills and resources who assist with
chartering and supporting a complex project (pp 2-7).
The guidance team could have recognized that the scope
of the project was too large and then narrowed the scope

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Wackerbarth et al
or broken the project into smaller components, initiating
the higher priority aspects first (pp 2-10). The guidance
team then could have created a clear mandate defining the
problem, the importance to the organization of solving
the problem, the scope, team membership, and time commitments (pp 2-12). The guidance team approach would
have been beneficial when the team leader went on leave
because it would have allowed project responsibilities to
be divided among the guidance team members.
Scholtes also describes joint review meetings in which
the sponsor (or guidance team) is present to help ensure
the project is on track, demonstrates organizational commitment to the project, and assists in overcoming roadblocks (pp 2-22). The joint review meetings could have
prevented the paralysis of the team faced by the team
leaders because resistance to change from physicians and
middle management could have been overcome with
team members awareness that their work was supported
and respected by the sponsor (pp 2-25).

Challenge 3: Cumbersome Metric

Aware that metrics were needed to evaluate the project,
the team made attempts to gather data. However, the data
collection forms were cumbersome and unstandardized.
Even with training, discrepancies were found in data
recording. The overwhelming amount of data collected
led to improper analysis of information. Furthermore, the
team had no baseline data, which made it difficult to measure any effects of the project. Lack of baseline data also
made it difficult to spur tension for change.5 Even though
the clinicians were asked to change the current process,
the team was unable to persuade them that the current
state was failing.
Lesson Learned.The value of a scientific approach to
project evaluation must be instilled in team members. For
some team members, this may represent a new approach,
so training in simple ways to gather and analyze data may
be necessary. Scholtes suggests the use of operational
definitions to identify what to measure, how to measure
it, and to ensure that results are valid, regardless of who
collects the information (pp 4-10).
Large projects should focus on initial data collection
efforts and then examine data to determine the value of
the expected information. Collecting data just in case it
is necessary is often overwhelming. Also, baseline data
are essential, and gathering baseline information provides
an opportunity to pilot test the data collection tools for
ease of use, to assess whether data categories are interpreted the same way, and to recognize challenges in analyzing the data. If issues arise at the baseline stage, then
the team may need to refine the data collection tool.
Scholtes recommends running trials of data collection

tools and continuing to run trials until the data received

are consistent and well defined (pp 4-11). The process of
refining the data collection tool could be considered as a
small cycle of change to arrive at the one best way to collect data.
Data need to be used to provide timely feedback to
create tension for change. The data must be presented in
an easy-to-read format. Scholtes describes many graphs
that can be used to facilitate quick interpretation of the
information as well as how to present on a storyboard on
which the goals of the team also are presented (pp 4-35),
allowing those participating in the change to see how the
new process is or is not affecting outcomes. This feedback often will assist in maintaining change efforts and in
gaining support for future change initiatives.

Challenge 4: Lack of Leadership Skills

A backbone of lean principles is to let those who do the
actual work design the improved process; therefore,
many frontline, direct-service employees were involved
in this project. The unique aspect of this project was that
small cycles of change had to occur to ensure that the
solution would have the impact anticipated while not
overwhelming the entire system, which meant that team
members had to implement change in their departments.
Some managers were more supportive than others and
assisted in facilitating these changes. Other team members attempted to implement changes with little support
from their direct managers. Not all team members had
innate leadership skills, which became increasingly
apparent as the implementation stage continued. The
uneven leadership skills of team members led to frustration among other team members because one unsuccessful component of the project could impede the progress of
the entire project.
Lesson Learned. Team members should be selected with
great care. Because lean teams are developed for the
express purpose of instituting changes in procedure, team
members must be respected in their departments, be open
to change, be able to communicate a vision, and help lead
their departments through small cycles of change (pp
2-15). To address this need for leadership skills, teams
should undergo leadership and organizational change
principles training to augment lean tools. Without leadership skills and an understanding of the psychology of
change, change agents will not be successful in disseminating new processes in their home departments.
Team sponsors need to help team members facilitate
the change in their respective areas, which may include
meeting with the department manager to gain support of
the project (pp 2-17) and teaching the team member techniques to help enable change among peers. If a team

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American Journal of Medical Quality

Table 1. Discharge Process: Examples of Process Improvements.

Problem Identified
Lack of communication between care providers

Mode of transport for patients often incorrectly

communicated to patient transport
Patient unaware of discharge date

Improvement Made
Implemented interdisciplinary discharge rounds to
discuss plan of care and determine anticipated
discharge dates
Added mode of transport column to nursing screen
to be updated each shift
Created column with anticipated discharge date that
all providers can see

Savings/Benefit
All providers aware of plan of care: barriers identified
earlier
Decrease rework by patient transport staff because
they are able to have correct equipment for patient
Limited success with bedside nursing communicating
to patient

changes as well as violated a key lean principle because

the team was now creating a process that the members
themselves would not carry out.

member is struggling to gain support from his or her management and peers, then the team leader or sponsor may
need to intervene to ensure that the project continues to
move forward (pp 2-17). Throughout the process, the
team leader or sponsor could provide constructive feedback to help a team member who does not have innate
leadership skills identify strategies to create a tension for
change. This coaching must be handled in a sensitive
manner so as not to devalue the persons participation in
the team (pp 6-24).

Lessons Learned.During the initial planning stages, the

guidance team could have defined the time commitment
required of each team member (pp 2-12). Throughout the
project, the guidance team could have continued to work
with supervisors to ensure sustained middle-management
support of the project (pp 2-17).

Challenge 5: Latecomers

Discharge Process Project Results

Because the project was large, the team initially failed to

recognize some key participants. For example, information technology representatives were not part of the original team. The team quickly realized that their input was
crucial because many of the processes in the future state
required automation. Without a clear mandate, the team
found it difficult to educate new members about the overall goal and vision of the project, which created challenges when the long-term team members could not
understand why the new members were not getting it.

The discharge process team was charged with improving

the discharge process at a 500+ bed academic medical
center. Despite the 6 challenges highlighted, the team
successfully implemented changes throughout the organization that have had a positive impact.
The team primarily focused efforts on communication
between care providers. The team designed, developed,
and implemented a discharge rounding process that
involved a brief meeting attended by representatives from
all services to determine a patients anticipated discharge
date and to identify barriers to discharge. The meetings
have become a standard aspect of patient care, and the
team has focused recent efforts on developing a means of
informing the patient of his or her anticipated discharge
date. Table 1 presents 3 specific problem-focused changes
that were implemented to improve the discharge process
as well as the associated benefit resulting from these
changes.

Lesson Learned.As with any large project that covers a

broad time frame, members leave and join the team late
because of specialized needs encountered by the team or
staffing changes within the organization. Regardless of
the reason for the addition, it is crucial to integrate a new
member quickly. Scholtes advocates providing new team
members with an overview of the charter, a progress
report, and training and encouragement to take on a team
role (p 6).

Challenge 6: No Time
As the project continued, managers began to pull staff
away from the project because they felt that too much
clinical time was lost, especially among team members
from nursing because so much acute patient care revolves
around the bedside nurse. Although physicians drive the
plan of care, the bedside nurse determines how that plan
of care is carried out. This attrition limited many of the
decisions and increased the time required to implement

Conclusion
Based on the authors experience, application of lean
tools is often the easiest part of a process improvement project. The larger challenge was to establish
and maintain a productive team dynamic. By recognizing and reflecting on the causes and consequences
of these challenges, the team has been able to overcome these obstacles, and these efforts are continually
rewarded.
Lessons learned during the experience of the discharge
process team influenced the launch of new project teams.

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Wackerbarth et al
Specific policies include the following requirements for
team-based projects:
all teams must begin with a planning meeting with
the executive sponsor, the team leader, or both;
the general purpose, measures, team members,
scope, and anticipated time resources must be outlined prior to initiating any project; and
teams must participate in a revamped education
process to focus on just-in-time training to provide familiarity with tools applicable to cases at
hand.
Subsequent teams have avoided some of the challenges the authors team faced. The Pneumonia Core
Measures Group has experienced tremendous success in
their work to concurrently audit charts for core measure
reporting to Centers for Medicare & Medicaid Services
(CMS) and the Joint Commission. With strong executive
leadership, a clear aim, and strong metrics, this group was
able to meet 5 out of 6 standards set by CMS. Teams
focusing on central-line infections and ventilator-associated pneumonia have had similar success.
With its focus on the reduction of waste, the lean philosophy can have immediate appeal to those working in
hectic health care environments. Although the science of
lean principles is sound and the team approach provides
the systems perspective necessary to improve
complex health care environments, lean initiatives require

resources, training, and organizational commitment.

Remediating the frustration that teams can experience is
a critical means to ensure that the benefits of change
efforts offset the organizational costs.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.

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