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An Extended Stay A 64-year-old man with a number of health issues comes to the hospital because he is having trouble breathing. The care team helps resolve the issue, but forgets a standard treatment that causes unnecessary harm to the patient. A subsequent medication error makes the situation worse, leading a stay that is much longer than anticipated.
Mutiny The behavior of a superior starts to put your patients at risk. What would you do? The University of Rochester’s Dr. Paul Griner presents the final installment in a series of case studies for the IHI Open School.
On Being Transparent You are the CEO and a patient in your hospital dies from a medication error. What do you do next? The University of Rochester’s Dr. Paul Griner presents the fourth in a series of case studies.
Locked In A cancer diagnosis leads to tears and heartache. But is it correct? Dr. Paul Griner, Professor Emeritus of Medicine at the University of Rochester, presents the third in a series of case studies for the IHI Open School.
Confidentiality and Air Force One A difficult patient. A difficult decision. The University of Rochester’s Dr. Paul Griner presents the second in a series of case studies.
The Protective Parent During a 50-year career in medicine, Dr. Paul Griner accumulated hundreds of patient stories. Most of his stories – including this case study "The Protective Parent" - are from the 1950s and 1960s, prior to what we now refer to as “modern medicine.”
Advanced Case Study Between Sept. 30th and Oct. 14th, 2010, students and residents all over the world gathered in interprofessional teams and analyzed a complex incident that resulted in patient harm. Selected teams presented their work to IHI faculty during a series of live webinars in October.
A Downward Spiral: A Case Study in Homelessness Thirty-six-year-old John may not fit the stereotype of a homeless person. Not long ago, he was living what many would consider a healthy life with his family. But when he lost his job, he found himself in a downward spiral, and his situation dramatically changed. John’s story is a fictional composite of real patients treated by Health Care for the Homeless. It illustrates the challenges homeless people face in accessing health care and the characteristics of high-quality care that can improve their lives.
What Happened to Alex? Alex James was a runner, like his dad. One day, he collapsed during a run and was hospitalized for five days. He went through lots of tests, but was given a clean bill of health. Then, a month later, he collapsed again, fell into a deep coma, and died. His father wanted to know — what had gone wrong? Dr. John James, a retired toxicologist at NASA, tells the story of how he uncovered the cause of his son’s death and became a patient safety advocate.
Improving Care in Rural Rwanda When Dr. Patrick Lee and his teammates began their quality improvement work in Kirehe, Rwanda, last year, the staff at the local hospital was taking vital signs properly less than half the time. Today, the staff does that task properly 95% of the time. Substantial resource and infrastructure inputs, combined with dedicated Rwandan partners and simple quality improvement tools, have dramatically improved staff morale and the quality of care in Kirehe.

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US Acute Care Solutions and Array Behavioral Care Partner to Deliver Virtual Psychiatric Care in Emergency Departments

CANTON, Ohio, Jan 23, 2023– US Acute Care Solutions (USACS), the largest physician-owned acute care practice in the nation, and Array Behavioral Care, the nation’s leading virtual psychiatry and therapy practice, today announced a strategic partnership to offer comprehensive acute medical and psychiatric care services to health systems. With the newly formed Behavioral Emergency Stabilization and Treatment(BEST) model*, USACS and Array will unite their clinical and technological expertise to combat the growing epidemic of acute mental illness that has impacted the nation for decades. Patients with acute psychiatric issues have significantly higher average emergency department (ED) lengths of stay and are more likely to stay in the ED for longer than 12 hours than those with other medical conditions (Simko 2022)[1]. It is not uncommon for EDs around the nation to have psychiatric patients waitingdaysfor specialist care and transfer to appropriate institutions. The burden on psychiatric patients and their families is paralleled by the challenges posed to the health system, especially during this time of staffing and resource shortages. The downstream result of delays in acute psychiatric care has a domino effect on non-psychiatric patient care and throughput. Array’s sophisticated virtual psychiatric care platform and clinical expertise can improve the speed of evaluation, treatment initiation and patient throughput, which improves the quality of care for all patients in the acute care space. Additionally, by using virtual technology, Array and USACS will be able to facilitate quicker access to care and further address social determinants of health. “By combining our strengths in emergency medicine, hospital medicine and critical care with Array’s expertise in behavioral care, we can meet the physical and mental health needs of our patients and support our health system partners with a comprehensive suite of acute care services,” said Chris Hummer, Chief Executive Officer of USACS. “Our mission at Array is to help address the nation’s mental health needs by using technology to bring licensed behavioral health clinicians to patients everywhere. Together with USACS, we can help provide holistic care to more patients in acute care setting,” said Geoffrey Boyce, Chief Executive Officer of Array. “Health systems see the effects of undertreated mental illness in our communities firsthand. Hospitals are continuing to experience massive influxes of psychiatric patients to their emergency departments because of poor access to outpatient mental health services. This affects not just the psychiatric patients but all patients in the emergency department. If we can manage psychiatric patients through early stabilization and treatment, we can improve the quality of care and clinical operations so that all patients can be seen faster and more comprehensively,” said Dr. Matt Patlovany, President and Chief Clinical Officer of USACS. “At Array, we aim to deliver quality and timely behavioral health, using evidence-based tools that meet patients where they are. We’re excited to see how this strategic partnership can help health systems across the nation meet the physical and mental health care needs of their community,” said Dr. Jim Varrell, Executive Chief Medical Officer of Array. “We at USACS have already demonstrated through our Integrated Acute Care model that emergency medicine, hospital medicine and critical care working together can produce better clinical outcomes for our patients and operational outcomes for our health system partners,” added Dr. Amer Aldeen, Chief Medical Officer of USACS. “Now, we are excited to partner with the national leader in virtual psychiatric care to ensure that high-quality care includes both physicalandmental health.” About USACS Founded by emergency medicine and hospitalist physicians across the country, USACS is solely owned by its physicians and hospital system partners. The group is a national leader in integrated acute care, including emergency medicine, hospitalist and critical care services. USACS provides high-quality care to approximately nine million patients annually across more than 500 programs and is aligned with many of the leading health systems in the country. Visit usacs.com for more. About Array Behavioral Care Array Behavioral Care is the nation’s leading clinician-centric virtual psychiatry and therapy practice with a mission to transform access to quality, timely behavioral health care. Array offers telepsychiatry solutions and services across the continuum of care, from hospital to home, through its OnDemand, Scheduled and AtHome divisions. For more than 20 years, Array has partnered with hundreds of hospitals and health systems, community health care organizations and payers of all sizes to expand access to care and improve outcomes for underserved individuals, facilities and communities. As an industry pioneer and established thought leader, Array has helped shape the field, define the standard of care and advocate for improved telepsychiatry-friendly regulations. To learn more, visitwww.arraybc.com. [1] Simko L, Birgisson N E, Pirrotta E A, et al. (June 02, 2022) Waiting for Care: Length of Stay for ED Mental Health Patients by Disposition, Diagnosis, and Region (2009–2015). Cureus 14(6): e25604. DOI 10.7759/cureus.25604 ###

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Project Background

Lean is an organizational redesign approach that is increasingly being used in health care. The term "Lean Production" was coined by an MIT research team studying leading automotive manufacturers around the world. 1 At its core, Lean focuses on the elimination of waste, with waste defined as any activity that consumes resources (staff, time, money, space) without adding value to those being served by the process. Lean can be implemented in many ways. The world's leading example of Lean production is the Toyota Production System (TPS). Toyota, more than any other company in any industry, has established both the cultural and operational elements required to continuously drive waste out of its production processes. Some argue that Lean's focus on processes makes it especially appropriate for solving complex health care issues. Others argue that Lean's use in manufacturing as opposed to a service industry, and its focus on standardization and defining value from the customer perspective, renders it inappropriate for health care because patients have unique needs, and there are multiple customers (e.g., employers, insurers, patients). 2

Rationale and Purpose

As Lean increases in popularity, the Agency for Healthcare Research and Quality (AHRQ) wanted to better understand if and how Lean works in health care, and, if it does work, what specific mechanisms make the redesign technique successful. To do so, AHRQ awarded a contract to the American Institutes for Research (AIR), a nonprofit research organization headquartered in Washington, DC, to study the application of Lean to health care. As part of this work, AIR conducted five case studies of individual health care organizations that implemented Lean.

Prior to the case studies, the AIR research team conducted a review of the literature to determine whether an evidence base exists for using Lean in health care. We found that the majority of studies about Lean lack data on key areas and domains important for understanding quality improvement, organizational behavior, and organizational change. In addition, the literature is largely anecdotal and devoid of theoretical frameworks, not comparative, authored by the individuals who have implemented the projects rather than independent investigators, and limited to those projects that were successful. a

Four major findings stemmed from the literature review:

In short, considerable gaps remain in the existing literature about Lean. These gaps make it very difficult, if not impossible, to discern which organizational characteristics and/or environmental conditions are critical for successful implementation and sustainability of Lean and its impacts on efficiency, quality/safety, and other important outcomes (e.g., patient satisfaction). This lack of research warrants additional investigation of the implementation of and outcomes related to Lean.

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Conceptual Framework

AIR developed a conceptual framework to guide the case study research, drawing on the results of the systematic literature review and, specifically, on the literature about health care quality improvement (including such related topics as implementation and diffusions of innovations) and on the literature about organizational learning, innovation, and change ( Exhibit 1 ). This framework builds on and integrates theoretical/conceptual literature on organizational learning, innovation, and change and related work in health care, such as quality improvement. At the most basic level, hospitals, medical groups, and other health care organizations that attempt to use Lean are seeking to improve or fundamentally reconceptualize core administrative and/or clinical processes.

As shown in Exhibit 1 , our theoretical/conceptual framework comprises five major elements, as follows:

Some schools of organizational theory point out that all organizations are dependent on their environment, because no organization possesses or can produce all the resources (e.g., inputs, distribution channels) required to fulfill their aims (refer to Scott and Davis, 2006, 3 for an overview of resource dependency theory). In the case of Lean, one key resource is Lean knowledge and skills. Currently, most health care organizations lack this expertise in-house, so typically they are in the position of looking for this expertise from external individuals or groups that have experience in other industries. In addition, health care organizations often seek out this expertise locally, via linkages to university departments (e.g., engineering programs that use the technique with manufacturing firms) or local manufacturing firms or consultants. Therefore, the availability and capability of these entities with expertise in Lean, and the nature of the relationships they establish (e.g., frequent, positive interaction, "ownership" of the project taken by the organization versus remaining with the outside organization), may influence the ability of health care organizations to successfully implement, sustain, and disseminate Lean.

Several aspects of structure are likely to have an impact on the ability of health care organizations to successfully implement, disseminate, and sustain quality improvement initiatives such as Lean. At the most basic level, there are a variety of structural characteristics that have been shown to influence both positively and negatively a hospitals' desire to undertake and sustain initiatives like Lean (e.g., size, medical staff organization, such as employed or private practice physicians, profit and teaching status).

In addition to general structural characteristics noted above, four other aspects of structure have been found to be important for learning, innovation, and change and quality improvement. These include: culture, b existing knowledge and skills, information infrastructure, and slack resources. With respect to culture, Schein 6 defines organizational culture as "a set of basic tacit assumptions about how the world is and ought to be that is shared by a set of people and determines their perceptions, thoughts, and feelings and, to some degree, their behavior." It involves the norms, values, beliefs, and behaviors of an organization reflecting how things are done within the organization. A culture conducive to quality improvement will encourage questioning and risk-taking at all levels, if not require double-loop learning and "meta-learning" in which an organization evaluates its basic operating assumptions, how it learns best, and makes efforts to improve its learning practices. 7,8 Conversely, a very hierarchical culture emphasizing rules, regulations, and reporting relationships is negatively associated with implementation of quality improvement and related practices.

As noted, existing knowledge and skills about quality improvement more generally and the use of Lean by the Toyota Production System (TPS) more specifically, are also important factors influencing implementation. Health care organizations have varying degrees of knowledge and skills, as well as experience, in quality improvement more broadly. Those with greater expertise and experience with quality improvement can build upon them when beginning to use process redesign techniques like Lean. When it comes to expertise in Lean more specifically, many health care organizations have to seek out knowledge and skills from outside organizations, since the technique has historically been used in manufacturing. Therefore, an important concept related to existing knowledge and skills is an organization's absorptive capacity, which Greenhalgh and colleagues 9 define as the ability to identify, capture, interpret, share, reframe, and re-codify new knowledge; to link it with its own knowledge base; and to put it to appropriate use. Precursors of absorptive capacity include the knowledge and skills of key staff and the organization overall, as well as some of the structures and processes described in this section.

Health care organizations also may vary considerably in terms of their information capability, including information technology (such as electronic health records) and the information they routinely have available or can readily produce. Without timely information that is not overly burdensome to collect, it is difficult to assess problems or assess what works to overcome them.

Finally, related to other general structural characteristics (e.g., profit status), health care organizations that have more slack resources (e.g., better profit margins, higher staffing levels) often are more likely to succeed in quality improvement. Individuals and teams need the time and other resources (such as education and training, ongoing assistance, information) to fundamentally re-examine and redesign processes, rather than creating temporary fixes. All of this requires at least an initial investment of resources before a return can be realized.

At the organizational level, this includes the vision for and goals of Lean. Different organizations have different visions of and goals for Lean . c For example, one key difference appears to be whether the health care organization views Lean as a specific "tool" and set of techniques to "refine" or improve existing processes in smaller, discrete organizational areas, or whether it views Lean as a mechanism for fundamentally transforming care delivery processes and the entire organization, including potentially its culture.

Other aspects of the Lean initiatives of importance at the organizational level are: scope and pace of Lean activity, locus of lean activity, and coordination of Lean activities and resources. A major decision that organizations must make is in how many areas and how quickly to try to implement Lean. Regardless of whether multiple areas of the inpatient or outpatient setting are being addressed or a single area and related value stream—that is, whether the locus of lean activity is broad or narrow—coordination of Lean activities is required.

At both the organizational and Lean project levels, a variety of other factors are important. These include: leadership, education/training, communication about Lean, Lean team composition, resources, and routinization. For example, the composition and size of the Lean team itself may be shaped by several organization wide sub-domains (vision of and goals for Lean, locus of Lean activity, resources); team size and resources also reflect the content of the specific Lean project. These team features, in turn, have a significant impact on the teams' overall effectiveness. A team is a type of formal group or collection of individuals who see themselves, and are seen by others, as a socially intact entity; share responsibility for tasks and outcomes; and operate within a broader organizational context, interacting with the larger organization or specific organizational subunits. 14

A health care organization's ability to successfully implement, disseminate, and integrate Lean may also be affected by the content or nature of Lean, particularly the "fit" or "match" between the characteristics of the organization's social structure and the nature of Lean. Work on the diffusion and dissemination of innovations, including organizational innovations like Lean, suggest that some innovations are a better "fit" or "match" with existing organizational structures and networks, and that successful dissemination and integration is more likely when the degree of "fit" or "match" is greater. Aspects of Lean that are important for "fit" or "match" include: the perceived advantages relative to current practice (e.g., Lean results in superior efficiency and/or quality); compatibility with values, beliefs, and mission/vision; complexity (e.g., whether Lean is relatively easy to understand and use); trialability (i.e., the ability to experiment with Lean, on a limited basis, as opposed to an all-or-nothing approach); and observability (i.e., the extent to which the results are observable to key groups and stakeholders). 15 For example, alignment between Lean and the organizational culture is likely to be poor when there is limited experience with or trust of multidisciplinary teamwork. Similarly, in organizations where physicians are used to high levels of autonomy, there may be resistance to Lean's stress on standardization of care processes.

Outcomes, both intermediate and ultimate. The next element of our conceptual framework is the outcomes associated with Lean implementation. The intermediate outcomes include employee satisfaction, culture change, increased knowledge of Lean, and routinization and diffusions of Lean methods and skills. For example, in the near or intermediate term, Lean can positively or negatively impact satisfaction among physicians and other clinicians and staff. The final outcomes include aspects of efficiency, quality, safety, and satisfaction. Further, in order for organizations to sustain Lean, there has to be a business and/or strategic case resulting from the initiative.

Integration of Lean into organizational routines. The final element of our conceptual framework is a feedback loop from the intermediate and ultimate outcomes to the internal context or organization. If organizations perceive and experience positive outcomes from their Lean efforts, they will be more willing and able to sustain their Lean efforts. In addition, as the organizations gain more experience with Lean, they will continue to learn about when and how to use it and how best to integrate it into their organizational structures and processes generally and, more specifically, with respect to quality improvement and Lean.

Purpose of Case Studies

The purpose of the individual case studies, as part of the larger project, was to examine the ways in which each organization has implemented Lean and identify the factors that influenced progress within individual Lean projects and on the ultimate outcomes. At a practical level, these individual case study reports are designed to provide potential Lean users with information that will enable them to make informed decisions about implementing Lean, based on experiences that are relevant to their own situation.

The individual case studies contributed to goals of the project overall by providing evidence to answer study questions corresponding to each of the aims described here.

Aim 1. Assess whether Lean positively affects primary outcomes of interest to the participating hospitals. From the organization's perspective, does Lean improve quality, efficiency, costs, employee satisfaction, and organizational culture?

Aim 2. Identify internal and external factors that are associated with variations in outcomes and processes, so that potential users can understand which experiences are relevant to their own situation.

Aim 3. Identify challenges to implementing Lean, potential solutions to the challenges, and lessons learned.

To meet these aims, AHRQ and AIR conducted five case studies. The next section describes the methods of the case study approach.

Definition of the Sample

To address the gaps in the Lean literature and examine the domains included in the conceptual framework, it was critical for our purposive sample of organizations to be diverse in nature and that it would expand the evidence base regarding the Lean method. These organizations—from single hospitals to entire systems composed of multiple hospitals and clinics—were considered to be the "cases" for this study. To qualify as a case, the organization must have implemented Lean in two or more projects (e.g., kaizens, d rapid cycle improvements, gembas, e and rapid improvement events).

Five diverse health care organizations were selected for the study:

Exhibit 2 presents factors considered in the selection of case study organizations.

Using the criteria described above, five diverse organizations were purposively selected for inclusion in our project. Exhibit 3 describes each organization, based on the selection factors for organizational selection, and indicates a pseudonym for each organization.

After determining the participating organizations, projects from each organization were selected for specific examination. "Projects" are defined by the organization but usually refer to specific Lean events in a department, unit, or segment of the value stream. The focus on specific projects allowed us to better understand how Lean works practically speaking at each organization, and how variation in the project target area may affect Lean success. This information allowed for a second level of detailed analysis to examine these factors and their influence on Lean implementation, sustainability, and success.

In sum, 13 distinct projects were studied across the five case study organizations. Nine of the projects were studied from a prospective analytic perspective, and data were collected at the beginning and during the course of the project. Four projects were studied from a retrospective analytic perspective, and data were collected after the conclusion of the project. Further, 10 projects focused on Lean implementation for a single department or operating unit within a health care organization. Three projects focused more broadly on the entire hospital's operations, including the construction of an entire hospital using Lean principles. The breakdown of projects based on the additional selection criteria are presented in Exhibit 4 .

Exhibit 5 depicts the research design of the overall project.

Data Collection Activities

Data collection activities included site visits with in-person interviews, digital diaries, collection of documentation, and telephone interviews. Data collection methods varied by analytic perspective (i.e., prospective and retrospective) and the stage of implementation of the Lean project (i.e., pre-implementation, implementation, post-implementation). Exhibit 6 shows the breakdown of data collection activities by both analytic perspective and stage of implementation.

Pre- and Post-implementation Data Collection Activities

Data collection methods during pre- and post-implementation were included in site visits with in-person interviews and collection of documentation. f

Site visits with in-person interviews. AIR collected qualitative data via site visits by conducting in-person interviews. The purpose of these interviews was to:

AIR visited each site twice. The first visit was to gain baseline information for prospective projects and to collect all of the information on retrospective projects. The second visit was to follow-up on the status and outcomes of all prospective case projects. The first visits occurred between November 2009 and May 2010, while the second visits occurred between September and December 2010. g

Each site visit lasted between 2 and 4our days and consisted of a series of individual and small group interviews. Each interview took 30-60 minutes. Interviews were conducted with the administrative and clinical personnel from each of the participating health care facilities as described in Exhibits 7 and 8 .

Collection of documentation. The purpose of this activity was to solicit materials and data directly collected by the sites on the implementation and impact of Lean including:

Documentation from the organization also included quantitative data (e.g., Lean project metrics, patient satisfaction scores, cost savings, etc.) for review relevant to:

Organizations provided data on indicators of quality, patient safety, customer service, efficiency (including costs), workforce development, and/or changes in the physical environment based on the type of Lean project(s) they implemented and the information they collected. The type of indicators and amount of data provided varied by organization. The most common indicators provided include quality/patient safety, customer service, efficiency, workforce development (including physician development), and architecture/physical environment.

Implementation Phase Data Collection Activities

Data collection activities during the implementation phase were mainly qualitative, including recording of digital diaries, telephone interviews, and collection of documentation.

Digital diary. For prospective projects, the participating establishment assigned an onsite quality specialist or coordinator who worked closely with each department and Lean project. This onsite person kept a "digital diary," using a diary entry guide and a hand-held digital voice recorder to describe key aspects of the implementation process. The onsite coordinator dictated his or her answers to these questions into the digital recorder and sent the MP3 files to AIR researchers via email. The onsite coordinator made diary entries one to two times each month. In some situations, the individuals completing the digital diaries were uncomfortable completing these entries into the recorder. In these cases, we substituted short telephone interviews once or twice each month, in addition to those scheduled for all sites. This alternate method yielded similar information to the traditional digital diaries.

Telephone interviews. For each prospective project, we conducted telephone interviews with 1-3 individuals per department. The types of interviewees depended on the specific department and projects but largely included Lean champions, team leaders, or Lean process owners. The telephone interviews lasted approximately 30 minutes and were completed two to three times during the project implementation.

Collection of documentation. AIR collected qualitative documentation from each participating facility as described previously. The purpose of this collection of documentation was to assemble ongoing documents as they were being developed, used, and distributed. As available, quantitative data related to the cases in terms of process and outcome variables being collected by each organization for their Lean project were collected during this process.

Institutional Review Board (IRB) and Office of Management and Budget (OMB) Approvals

AIR received OMB approval to conduct the research presented in this document. AIR's IRB approved all protocols, recruitment, and interview procedures before any contacts were made or any data were collected.

Data Analysis

All qualitative data from site visit in-person interviews, telephone interviews, and digital diaries were managed and analyzed using NVivo, a qualitative data analysis software program. NVivo can accommodate diverse types of qualitative data including text, audio, and video. All interviews and digital diaries were transcribed before uploading to NVivo. Print documents were also scanned and uploaded into NVivo.

We developed a coding system for the interviews and digital diaries based on an earlier but very similar version of the conceptual framework shown in Exhibit 1 . To ensure a consistent application of the coding system across three coders, inter-coder reliability was tested after every 20 interviews. The average reliability for all coding was 92.8 percent.

After coding was complete, we analyzed the data for each individual case. We employed a variety of qualitative techniques to draw conclusions from the data (e.g., noting patterns and themes, plausibility, relationships between variables, and finding intervening variables). Other data provided by each organization were summarized as appropriate, for example, using descriptive statistics for quantitative indicators and integrating qualitative information from materials into the cases as needed.

Limitations

The use of primarily qualitative data collection techniques presents some limitations. The freedom to tailor questions and probes to each respondent is the hallmark of the qualitative interviewing methodology. Because the interviewer does not adhere inflexibly to the written questions—by asking every question, using the exact written language, in the exact sequence—the study findings are limited by two potential sources of bias. First, if the language and sequence of the questions are associated with the responses, our conclusions might also vary in an unknown way. Second, because there are no rigid categories, aggregating responses requires interpretation by the analyst, and it is possible that one analyst's interpretation may differ from another's. However, the reliability of the coding noted above suggests that this was not a serious source of bias.

a. An executive summary of the literature review is available separately at http://www.ahrq.gov/research/findings/final-reports/leanprocess.html .

b. Culture is often considered a process, instead of a structure, as it must continually be reinforced, and it can change. However, culture is relatively stable and changes slowly. In addition, some see Lean as a way of altering culture. So, we included culture in this model as part of the organizations' structure.

c. Some may also consider the vision for, and goals of, Lean as part of the organizational process rather than a structural feature of the organization. However, in more rational organizational theories, visions of and goals for something like Lean are viewed as occurring first and shaping the organization of the Lean work. So, we include this sub-domain here and also consider how the vision for and goals of Lean may be reinforced, refined, or changed through the implementation process.

d. A kaizen is a rapid improvement process that focuses on eliminating waste, improving productivity, and achieving sustained continual improvement in targeted activitiesand processes of an organization.

e. Gemba is a Japanese word that literally means "the place where the real action takes place."

f. This activity solicited materials and data collected by the sites on Lean implementation and impact: internal reports/memos, materials promoting Lean adoption, tools used in Lean implementation (see Lean Healthcare Exchange at http://www.leanhealthcareexchange.com/?page_id=300 ), press releases, and data on process evaluation.

g. Note, as of January 27, 2011, one of the prospective projects had not begun data collection, and the second site visits had not occurred for two other prospective projects. The Lean hospital (LHC Horizon) is an ongoing prospective project on a different project schedule. Data for the Lean hospital are collected at every visit; an additional visit will occur after the hospital is opened.

h. Door-to-balloon (D2B) is a cardiac care time measurement for treatment of myocardial infarctions, specifically defined as the time from patient arrival at the hospital to the time of percutaneous coronary intervention. 16

Publication: 13(15)-0056

Internet Citation: Introduction to the Case Studies. Content last reviewed November 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-intro.html

Book Detail Thumbnail

Case Studies in Population and Community Health Management

Connie j. evashwick, scd, lfache jason s. turner, phd.

Book Description

Photo of Managerial Epidemiology: Cases and Concepts, Fourth Edition

Managerial Epidemiology: Cases and Concepts, Fourth Edition

Photo of Hospitals and Community Benefit: New Demands, New Approaches

Hospitals and Community Benefit: New Demands, New Approaches

Photo of Population Health, Epidemiology, and Public Health: Management Skills for Creating Healthy Communities, Second Edition

Population Health, Epidemiology, and Public Health: Management Skills for Creating Healthy Communities, Second Edition

Explore our case studies to gain insight into the latest healthcare technology trends, guidance, and perspectives from prominent industry experts.

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Clinical Research as a Care Option with Clinical Trials Access Network

case study in healthcare management

Learn how a provider community primary care group was able to offer the latest treatment options and diagnostics by using Clinical Trials Access Network.

Explore All Case Studies

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Cardiology IT Solutions Solve Workflow Issues

Learn how Change Healthcare Cardiology’s IT solutions helped one medical center develop faster workflows, turnaround time, and more.

Businesswoman explaining something to female colleague over computer at desk in office

Helping an Emergency Services Practice Streamline Accounting

Learn more about Change Healthcare’s physician management services.

collaborating team members

Helping a Medicare Payer That Had Failed CMS Audits

Change Healthcare Consulting helped a midsize payer modernize and automate its care management system and pass CMS audits.

Smiling businessman and businesswoman discussing project at office workstation

A Midsized Plan Achieved HEDIS Certification and NCQA Accreditation with Help From Change Healthcare Consulting

Change Healthcare Consulting helped a fast-growing plan build its HEDIS program. It completed its HEDIS audit on time and helped the plan with NCQA accreditation.

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Anesthesiology Group Improves Thanks to RCM for Physician Practices

Learn how an anesthesiology group increased profitability, efficiency, and stability thanks to Change Healthcare RCM for physician practices.

Doctors standing at hospital entrance

Replacing a Core Administrative Processing Solution (CAPS)

Learn how Change Healthcare Consulting helped a regional health plan implement an enterprise architecture to reduce complexity and improve user productivity.

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Grand View Health Leans on Change Healthcare During Pandemic

Change Healthcare quickly stood up a dedicated registered nurse triage team to handle more than 4,000 hotline calls per month.

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EHR Selection and Procurement Case Study

Discover how a medical provider engaged Change Healthcare consultants to oversee the selection and procurement process for a new electronic health record (EHR) system.

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Coordination of Benefits Services Help Health Plan

Discover how a regional carrier generated 250%+ ROI and increased yearly collections by $500,000 with comprehensive coordination of benefits (COB) solutions.

Einstein Health Network

"Optimize Calls, Scheduling with Patient Access"

Discover how a health system streamlined its provider patient scheduling and strengthened customer service to manage more than 65,000 patient calls monthly.

Elderly 70s man seated on sofa make distant video call, senior patient look at laptop screen communicating with doctor therapist online, older generation and modern tech application easy usage concept

Bluegrass Orthopedics COVID-19 Crisis Response

Bluegrass Orthopedics needed a Covid-safe solutions that could maximize resources and keep patient care thriving from a distance.

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