By Melinda Young


Lean Six Sigma principles and methods can help hospitals improve case management, patient care, and efficiency.

• Lean focuses on eliminating waste and can be used to improve utilization review.

• Hospitals can form Lean teams to focus on specific areas of quality improvement, such as reducing long lengths of stay.

• Brief daily huddles can help a Lean team stay on task and improve results.

One effective way for hospitals to improve patient care and reduce rehospitalizations and longer lengths of stay (LOS) is to take a Lean approach.

Lean and Lean Six Sigma principles, a set of efficiency-focused management practices long used in manufacturing and other industries, can help a healthcare organization eliminate waste and improve quality, and outcomes. (More information is available at:

For example, after employing Lean principles, Mid Coast-Parkview Health in Brunswick, ME, shortened patient stays of 30 or more days by more than 20%, saving $124,000.

“In 2017, we had a total of 26 patients who were here longer than 30 days, totaling 1,528 patient days,” says Cynthia Smith, RN, BSN, CCM, nurse manager, department of case management, Mid Coast-Parkview Health. “Our chief financial officer calculated the cost to the hospital was $764,000 for care that was not reimbursed. We decided to put together a team to talk about how to better manage these patients.”

Following Lean principles also helps reduce readmissions and improve care management and utilization review, says Tami Minnier, RN, MSN, FACHE, chief quality officer at University of Pittsburgh Medical Center (UPMC).

For instance, UPMC’s utilization management process decreased time to initial authorization by 8.27 hours and lowered its cost per case reviewed, saving $834,172 per year, according to internal data.

“Care management is fraught with many process issues, and this principle and approach are key things necessary for care managers to do their jobs well and to achieve what they want,” Minnier says.

The Lean principle is an easy concept to grasp, says Barbara Ragonese, director of quality and patient safety at Italian operations, UPMC, in Rome.

“Lean is based on the avoidance of waste,” Ragonese says. “When staff’s exposed to the definition of waste, including unnecessary movements and waiting times, they can easily identify areas of improvement.”

Case management directors and other managers need to give employees the tools and framework to improve processes, she says. “We’re doing a massive educational program on Lean in Rome,” Ragonese adds. “We’re testing this model.”

Smith, Minnier, and Ragonese offer these suggestions for how hospitals can employ lean principles to guide quality improvement processes:

• Create a Lean team. Hospitals could develop a team that includes case management, the chief nursing officer, a utilization review specialist, quality improvement staff, social workers, a physician advisor, a med-surg advisor, and palliative care.

The team can meet to discuss Lean processes and changes. They can map out barriers to improving patient transitions and cutting out wasted time.

In addition to a Lean team, there can be teams created to fix specific problems. For example, an LOS team could consist of a case manager, a nurse, and a social worker. The team could develop criteria for patients at risk of a long LOS, Smith says. (See story on reducing long LOS cases in this issue.)

“Someone would end up on a long LOS list if they’ve been in the hospital for more than seven days,” Smith says. “Also, any patients who don’t have an acute need to be in the hospital and were issued a [payer] denial letter would be added to the list immediately.”

Teams can provide consistency, Smith adds.

• Train managers, others on Lean. “We share a lot of this training internationally,” Minnier says.

UPMC hosts a learning academy with in-person and online classes. But they are not for new employees, she notes.

“We learned that trying to train people on day one about these principles is overwhelming and not value-added,” Minnier says. “Not everyone needs to be an expert on Lean principles, but every employee needs to know that we value it and appreciate it.”

Lean training can be performed in teams with coaches and hands-on techniques. “We believe it’s best for people to learn in teams — none of us work in a silo,” Minnier says. “None of us can achieve anything on our own in a healthcare environment; we need other members of a team contributing.”

Doctors, nurses, social workers, and others might take Lean training, learning the basics of Lean principles. “Then, we provide them with a coach to guide them through it,” Minnier says. “Working together, over time, brings more values to the student.”

• Start quality improvement projects using Lean principles. Using Lean methodology, UPMC in Rome developed a quality improvement project for hand hygiene compliance, Ragonese says.

“We conducted observation to understand the real level of compliance. We found out we were at 49%, which is in line with data published by The Joint Commission,” Ragonese says.

Using Lean methodology, the organization increased compliance to 80%, she says. “Of course, we’re not satisfied with 80%, and we’ll work more to go to a higher level of compliance,” Ragonese adds. “Our purpose is to reach maximal achievable compliance.”

• Hold daily huddles. Teams can hold daily huddles to discuss efforts to improve quality of care and efficiency. For example, an LOS team might meet daily for five or 10 minutes to talk about patients with long LOS and barriers to discharge. At Mid Coast-Parkview Health, the daily huddles are held in the case management office, using visual props.

“We created a visual whiteboard with a list of patients designated by the long LOS team,” Smith says. “We have had times with no patients listed, but, on average, we have three to five patients on the board.”

The whiteboard includes admission dates, power of attorney status, payer denials, and medical need status. “If we identify that we need the family meeting, we identify who is responsible for it and use the board as an accountability piece,” Smith explains.

If a team member is asked to set up a family meeting, the board serves as a visual reminder that the meeting has to be scheduled. “The board provides a visual cue and accountability for the whole team,” Smith adds.

The daily huddle also includes a quick clinical update and discussion of barriers. “It’s a place where you can quickly troubleshoot any issues you might have and think about what is the task for the day,” Smith says.

• Follow process improvement techniques. Organizations can employ plan, do, see, act (PDSA) methods to implement and test changes.

“We do PDSA, which is a version with plan, do, see if it works, and adapt/adopt it, and keep going,” Minnier says. “We use rapid cycle change. Healthcare in the past would make a change and, in three months, think about changing it again.”

Now, quality improvement changes can be implemented faster and be continuous. The goal is to start a change, stop, redo, redesign, refigure, and keep trying, Minnier says.

In the old way of making changes, a group would take months to plan solutions. Then, they would be emotionally connected to the change and ready to defend it even if it did not work, she says.

“Under PDSA, you create a plan, test it out, and if it works, keep doing it,” Minnier says. “But if it doesn’t work, then revise it and try something new.”

The theory is to not get stuck to the first option and to not be convinced that there is only one answer to the problem, she says.

“It’s about making changes until you get to the change that is right,” Minnier adds.