By Melinda Young


A hospital’s process improvement (PI) could begin with a focus on reducing gaps in quality service. The Cleveland Clinic started such a process, focusing on engaging all employees in process improvement — rather than leaving the work to one PI team.

When using a traditional approach to process improvement, the health system could improve some processes, but had not changed the culture across the system.

A systemwide cultural change was needed. The health system drove this change, following a belief that the organization could not improve fast enough or in a sustained way without engaging all caregivers in the problem-solving process.

There were three possibilities why the systemwide culture of process improvement did not already exist: a desire gap, a capacity and team gap, or a capability gap. The Cleveland Clinic worked to reduce the capability gap.

The Cleveland Clinic started process improvement with a classic problem-solving approach of understanding its gaps in quality service.

The choice was between closing the quality improvement gap through continuous improvement, led by a small team of professionals (which was the traditional approach), vs. establishing a culture of continuous improvement that involves everyone. The Cleveland Clinic chose the more challenging approach, which eventually will involve all employees.

“We had been using a fairly traditional process improvement approach for about six years,” says Lisa Yerian, MD, director of enterprise continuous improvement. “Then, we realized that although we could accomplish specific projects and deliver results, we had not fundamentally changed the culture. We were around 40,000 caregivers, and had a small process improvement [PI] team.”

If the health system — which has since grown to more than 60,000 employees — relied solely on the PI team, the results were limited.

“We were unable to think in a large way about the care we delivered, and how to improve on that,” Yerian says. “We embarked on a culture of improvement.”

The driving force of this systemwide cultural change was the belief that the organization could not improve fast enough, or in a sustained way, if caregivers were not engaged in solving problems and delivering better care to their patients, she adds.

Changing the Capability Gap

The first step to creating this systemwide cultural change was to understand why the PI culture did not exist. They found three main possibilities:

• A desire gap. One possibility is that a health system’s staff does not want to change.

“We dismissed this reason because we could tell in the culture we experience here that people very much care about the patient,” Yerian says. “Our mantra is ‘patient first,’ and people are very centered on patients.”

For example, when leaders walk through the halls and talk with employees, they can see that people are working hard to improve service and processes, she adds.

“A component of our culture is to feel that you are responsible for a patient’s care, and you want it to go well,” Yerian says.

• Capacity and team gap. This issue involves a hospital not having the time to address process improvement.

“People are very busy, see a lot of patients, and they don’t have the time to spend on improvement,” Yerian says. “That is a real factor, but it’s just not a factor we could countermeasure.”

A time and capacity gap cannot be resolved easily. Plus, just giving people more time might not solve the problem, she adds.

“If we gave people more time, I wasn’t confident that it would result in measurable improvements,” Yerian says. “As we were working through this, we got lots of information from other stakeholders across the organization. We were partnering with executives, managers, and bedside care managers from multiple teams to find out what occurs, how they felt about it, and what they thought.”

• Capability gap. “This is the gap we spent our efforts working on,” Yerian says.

The theory is that the health system could make process improvements if employers were oriented toward patients first. If they wanted to improve, they were given the capability to improve.

The system would need to teach staff how to identify problems in their work, and perform complex problem-solving. The key is to engage employees in the improvement process, as part of their day-to-day workflow. This solution has far greater potential impact than the traditional PI committee approach, she notes.

“If you think about more than 40,000 employees and now 66,000 caregivers, and they each have the ability to improve quality across all domains, vs. the prior state of 30 people on the continuous improvement team, this can have a dramatic impact for our patients,” Yerian explains.

Once the Cleveland Clinic settled on addressing the capability gap, the question was to figure out how to engage staff.

“When we started out, we found through conversations an understanding that we couldn’t grow our capability across 40,000 people all at once,” Yerian says. “We started with one team, learned from this experience, and then went to the next team, using what we had learned.”

The first team was in the finance division. Yerian trained the team, along with a couple of people from the existing quality improvement (QI) team.

“They talked about the problems they faced in their work,” she says. “We realized the first capability to build was around problem-solving. We used a common, complex problem-solving methodology.”

The methodology, called A3, involves Lean processes. “This was used by Toyota to represent the methodology to work through problems in a systematic way,” Yerian says. “You define a problem, understand the current problem, do an analysis around the cause, and test various solutions — plan, do, check, and adjust.”

It is a commonly used QI tool, where people use cycles of experience and learn to use data to drive improvement, she adds.

One way to teach A3 is through directing teams to use it to solve their own problems: “They were learning by doing, which is different from learning by listening or reading,” Yerian says. “What happens when people learn by doing is they build the skills to do it again, and they own the results. Our team started to solve these problems, and could see they were solving their problems and improving. They were very excited about it because they had never done anything like this before.”

Once the team showed progress, they invited other leaders to observe. This helped spread enthusiasm for the improvement process.

“My impression was that what engaged the other leaders was more the excitement of the team around what they were capable of doing,” Yerian says. “There was a process they did in their team that took three hours, and they got it down to under 30 minutes. They used the same solution to apply to other processes.” But it was the team’s excitement that helped with buy-in, she adds.

Over time, the team approach spread to include more than 300 teams and 18,000 caregivers/staff members, she says.

The Cleveland Clinic placed videos on YouTube, showing teams’ process improvement success stories, including reducing patient wait time. (The videos can be viewed at:

“It’s very organic,” Yerian says. “We’ve been pleasantly impressed by the level of improvement.”