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Implementation of Systems Redesign: Approaches to Spread and Sustain

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Implementation of Systems Redesign:
Approaches to Spread and Sustain Adoption
Heather Woodward Hagg, MS; Jamie Workman-Germann, MS; Mindy Flanagan, PhD;
Deanna Suskovich, BA; Susan Schachitti, MBA; Christine Corum, MS;
Bradley N. Doebbeling, MD, MSc

Abstract
The widespread gap between evidence and practice for clinical and preventive services argues
for a deeper understanding of effective quality improvement (QI) and system change. Using
implementation and system redesign sciences, we have developed and used an effective strategy
to enable robust implementation of QI initiatives, including clinical practice bundles, within a
health care setting. Our program, which applies Lean and systems engineering methodologies, is
specifically designed to exploit the five characteristics of effective innovations, as outlined by
Berwick. This strategy has been applied in over 21 hospitals (six hospital systems) throughout
the State of Indiana and is currently being used as part of the Radically Reducing methicillin-
resistant Staphylococcus aureus (MRSA) initiative funded by the Agency for Healthcare
Research and Quality (AHRQ). The benefits of the process redesign activities are detailed at the
business level through a business case analysis. Additionally, benefits at the personal level are
quantified through workflow analysis (prior to and following the interventions). The intervention
strategy is integrated into the current quality framework for each organization to ensure
compatibility with existing organizational programs. Our staff engagement, training, and
educational programs make systems engineering methodologies and principles readily accessible
to frontline staff. Additionally, each project session requires immediate application of tools and
techniques. This article will discuss our implementation strategy, provide examples of Lean and
systems engineering tool applications, and provide an assessment of spread adoption and
sustainability as a function of this implementation strategy.

Introduction
Quality improvement (QI) initiatives within health care facilities are often designed to improve
the safety and reliability of patient care processes. Unfortunately, as detailed in several studies, 1
health care organizations often cycle through the multiple QI initiatives without sustained
improvement in either process effectiveness or patient outcomes. The result is often increased
staff fatigue, a more stressful work environment, and increased patient care costs.

The challenges of transitioning from the decision to utilize an innovation (adoption) to skilled
and consistent use of an innovation (implementation) 2 are well documented in health care and
non-health care organizations. 3, 4, 5, 6 These challenges or barriers include lack of sustained
leadership support, inadequate resources allocated for implementation, insufficient staff time to
participate, failure to develop robust measurement and data feedback systems, misalignment of

1
incentive structures, and cultural resistance to change. It is estimated that fewer than 40 percent
of health care initiatives successfully transition from adoption to long-term, sustained
implementation. 7

According to Rogers’ “Diffusion of Innovations” model, specific characteristics of innovations

influence the rate of spread. 8 Rogers describes the characteristics of an initiative affecting the
perceptions of an innovation as “predict[ing] between 49 and 87 percent of the variance in the
rate of spread.” Moreover, in adaptating this model specifically to health care, and citing works
by Van de Ven, 9 Berwick notes five characteristics of innovations that are particularly influential
among potential adopters within a health care setting: (1) the “perceived benefit of the change,”
2) “observability” of the innovation, (3) “compatibility” of the change with the current
organizational culture and personal belief systems, (4) level of “simplicity” of the innovation,
and (5) “trialability” of the innovation. 10

In 2003, the Institute of Medicine’s (IOM) report “Crossing the Quality Chasm” 11 recommended
the use of systems and industrial engineering techniques to systematically examine and redesign
clinical processes. A subsequent National Academy of Engineering report made the same
recommendations. 12 Lean is a QI methodology based on systems and industrial engineering
techniques. Lean techniques have been empirically documented as highly effective for systems
redesign within manufacturing environments. Moreover, ample evidence suggests that
appropriately developed and optimized Lean techniques are effective within health care settings.

Since 2004, faculty from the Purdue University College of Technology, Indiana University-
Purdue University Indianapolis (IUPUI)’s School of Engineering and Technology, Purdue
University-Calumet College of Technology, the Regenstrief Center for Healthcare Engineering
(RCHE), and the Indiana University Center for Health Services and Outcomes Research at the
Regenstrief Institute, Inc. have partnered with several Indiana hospitals and hospital systems to
create Lean and Six Sigma® health care programs. As a part of this program, we developed,
implemented, and refined strategies to enable robust QI implementation through application of
Lean and Six Sigma tools, methodologies, and techniques.

Our program was specifically designed to incorporate findings from the implementation science
literature and to exploit the five characteristics of successful innovations as defined by
Berwick.10 As a result of this program, over 40 projects are ongoing or completed across 21
hospitals and 6 hospital systems. These projects have shown remarkable success; more than 78
percent of completed projects exhibit sustained improvement of at least 6 months, with our
longest running projects now in their second year of sustained implementation.

This article discusses our Lean Healthcare program and implementation strategy, provides
specific examples of Lean and systems engineering tool applications, and assesses sustainability
and spread adoption as a function of this implementation strategy.

2
Methods
Lean Healthcare
Lean is derived from methodologies developed in the Japanese automobile industry. It is a
systematic approach to improving the reliability of processes through the identification and
elimination of operational barriers and sources of variability within a process or system.

Within health care processes, the application of Lean tools involves an in-depth examination of
the clinical and operational processes from the perspective of the patient or staff member in order
to identify value added and non-value added steps—i.e., “wasteful” processing steps within the
system. This analysis is limited in scope to the process under investigation and might include
qualitative and quantitative assessments.

Our Lean Healthcare methodology utilizes a project team that is typically composed of frontline
staff (e.g., nurses, clerks) and area supervisors from the project focus area. The project team is
responsible for redesign of current processes or systems to meet the objectives, timeline, and
deliverables set out by an administrative Champion Team. The Champion Team is typically
composed of hospital administrators and department managers for the process under
investigation. Our current strategy calls for a 12-week implementation cycle, composed of eight
3-hour project team sessions, held approximately 1 week apart, with 4 weeks of pilot
implementation. Additionally, we are currently developing and testing a rapid cycle (5-day)
implementation process.

Each project session incorporates approximately 1 hour of instruction in systems redesign and
implementation science principles, methods, and tools, including practical examples based in
health care and case studies. Then, hands-on exercises are used to reinforce principles and
provide a mechanism for more active engagement. Following the instructional portion of each
session, the team members apply these systems engineering and Lean techniques to the
assessment and redesign of current processes associated with implementation of a set of clinical
practice guidelines or operational improvements. Intersession deliverables are assigned to
accomplish project tasks not completed during team sessions.

The objectives for the project team sessions included the following:
1. Define the problem/processes under investigation.
2. Collect baseline data on current systems and processes.
3. Identify operational barriers and failure modes in current processes.
4. Develop the “Future State Process” through application of basic and advanced Lean tools,
systems engineering, and implementation of science principles to redesign current processes
to eliminate or mitigate failure modes; design and perform an implementation pilot to test
process redesign.
5. Implement new processes/systems with a robust control strategy and integrate them into
practice in order to insure long-term sustainability of improvements.

The techniques and methodologies utilized within our Lean Healthcare program are outlined in
Figure 1.

3
Implementation Design
Improving the perceived “benefit” of the change. QI initiatives within health care are, by
definition, developed to benefit the patient through improved quality of care. In spite of the
potential to improve patient outcomes significantly, these initiatives are often perceived in a
negative manner as being just another “flavor of the day” management activity. Both individual
(staff member) and administrative (business) perspectives might not appreciate these initiatives
for their true purpose. These
negative perceptions can develop
prior to or during implementation. Define the Project Charter
Problem
Why does this negative perception Voice of the
exist? The reality is that
Customer
implementation is time- and
resource-intensive both from an
organizational standpoint and an
individual staff member Baseline Process Map
perspective. The enthusiastic Current
fervor that initially accompanies Process Check sheet
the introduction and adoption
Process
phase of an apparent innovation
wanes as the burdens of Identify Observation
implementation and sustainability Operational Worksheet
are realized. Barriers

Furthermore, QI activities often Spaghetti

fail to integrate changes within Diagram
workflow or to adequately assess
and provide feedback on progress
to staff involved in making the
changes. Additionally, health care 5S, Visual
Develop Future Controls, Error
administrators often hesitate to
fully support implementation State Process Proofing
unless these efforts can be directly
linked to a positive financial
impact within their organizations. PDSA cycles

Without strong administrative Process

support, the time and resources Control
required for full implementation Process Control
Strategy
might not be allocated, and the Plan
organizational climate needed to
drive the transition from the
adoption phase into sustainability Figure 1. Techniques and methodologies utilized within the
Lean Healthcare program.
might not be fully realized. The
result is that the sustained system

4
changes needed to establish the innovation into workflow and the organization do not occur, and
the implementation eventually fails. This cycle of failed implementation ultimately jeopardizes
the interest of the organization and individual staff members in investing in future initiatives.

The focus of our work in this area has been to fully inform administrators of the organizational
benefits of the initiative. This alliance with administrators is accomplished through
the engagement of a project champion team to align the initiative with organizational strategic
goals and the introduction of economic assessment tools that allow the champion and project
teams to directly link the initiative’s bottom-line cost savings to improved patient outcomes and
staff workflow. This methodology has been termed “building the business case” for QI within
health care. The lack of this “business case” has repeatedly been cited as a limiting factor to
sustainable implementation within health care. 13, 14, 15, 16

The project champion team is typically composed of hospital administrators, department

managers, and key clinicians (or opinion leaders) who are stakeholders for the process under
investigation. During a series of project champion meetings, open discussions are held with
respect to the proposed QI initiative, the evidence supporting the innovation, data on relevant
local processes and procedures (if any), anticipated barriers and challenges with respect to
implementation, and whether an imperative exists within the organization leadership to provide
the necessary support (e.g., resources, time) to ensure a successful implementation.

Project champions are also tasked with building an initial business case for the initiative utilizing
an economic assessment template [or other internal return on investment (ROI) template]. The
business case analysis includes anticipated expenditures resulting from the intervention/
implementation (including training costs), as well a summary of potential economic and strategic
benefits to the organization.

As a result of this process, the champion team occasionally decides not to pursue the initiative or
to delay until another project cycle, and no further action is taken. Once a decision is made to
move forward, the champion team develops the initial project scope, identifies project goals and
objectives, and develops a list of expected project deliverables.

Once the project team is chartered and the project initiated, project leaders and team members
are expected to appropriately quantify potential project ROI prior to project implementation and
validate ROI following implementation. To provide a mechanism for project team members to
confidently link their project implementation to direct and indirect economic impacts, we have
developed a practical, accessible methodology for standardized evaluation of the financial impact
of health care improvement projects. 17 The methodology developed includes Excel®
spreadsheet-based ROI tools, accompanying training materials used to enable project leaders and
team members to suitably quantify potential project ROI prior to project implementation, and to
validate ROI following implementation.

The objective of the ROI tool and exercises includes providing project team members with an in-
depth understanding of the importance of appropriate financial analysis in achieving
management support of operational and patient care improvement efforts. This understanding is
reinforced through a hands-on training exercise that provides practical application in

5
identification and quantification of financial impact, productivity impact and materials,
equipment, and purchased services cost savings.

“Observability” of the initiative. Theories of diffusion of innovation within organizations

categorize the personality characteristics of potential innovation adopters into five clusters:4
1. Innovators.
2. Early adopters.
3. Early majority.
4. Late majority.
5. Laggards.

Within this framework, innovators are estimated to represent about 2.5 percent of the general
population, early adopters about 13.5 percent, early majority about 34 percent, late majority
about 34 percent, and laggards the remaining 16 percent. Rogers8 asserts that the transition
between adoption and implementation develops a self-sustaining momentum, when 15 to
20 percent of individuals have embraced the initiative (i.e., the “tipping point”). Berwick10
describes this phenomenon as being dependent on the interactions that occur among innovators,
early adopters, and the early majority during the adoption phase.
Unfortunately, the typical model for implementing change within health care organizations
provides very little interaction or dialogue between the supervisors planning the initiative and the
health care professionals who must sustain the initiative. For example, meetings to plan clinical
practice implementations or to improve clinical processes are often conducted well outside the
patient care environment without an appropriate team of health care providers who would be
responsible for adopting the processes. Staff input may be obtained, but this often occurs on a
superficial level after key decisions have been finalized. Additionally, staff members who
express concerns about deficiencies in new processes or procedures are often marginalized or
ignored, limiting their capacity or interest in actively engaging in the implementation process and
systematizing the changes to the organization.

Our focus in this area has been to develop implementation strategies that (1) promote positive
engagement and interaction of the project team with staff members, (2) maximize the
“observability” of the project team work, and (3) measure progress and provide feedback
regularly.

Within our Lean Healthcare program, the engagement cycles of project team members with
outside staff members begin immediately through a series of informal staff interviews know as
“Voice of the Customer” Analysis. Within this exercise, “customers” are loosely defined as any
individuals who would be affected by the adoption and implementation of the program. In
addition to staff members (nurses, physicians, pharmacists, clerks, and others) within the patient
care areas, customers might include representatives from environmental services, materials
management, ancillary services, physicians, managers and supervisors, and administrators.
Additionally, project teams often elect to include patients and their families within this process.
Typically, each project team member interviews three to four individuals. The project team
members are instructed to briefly introduce the initiative and then conduct an informal 5- to 10-
minute interview while taking careful notes.

6
Sample questions for “Voice of the Customer” analysis include:
• What do you like about the current processes/procedures/policies related to the specific QI
initiative?
• What do you think needs improvement?
• What would you recommend to improve the current processes/procedures/policies?
• What could potentially threaten the success of this initiative?

The notes from these interview sessions are discussed and summarized during the subsequent
project team session. In addition to providing an opportunity for active engagement with staff
members, the Voice of the Customer interviews are essential for understanding and validating
customer requirements, expectations, and areas of dissatisfaction with the current processes. The
most frequently occurring “needs improvement” and “recommendations for improvement” areas
are prioritized. Plan-do-study-act (PDSA) cycles to develop, test, and implement solutions are
often initiated immediately following this project session. This rapid resolution of “low hanging
fruit” issues within the processes also provides a valuable opportunity to positively affect
perceived benefit of the initiative.

Although several engagement activities, such as Voice of the Customer analysis, are
intentionally built into the implementation, the project team is also challenged in each project
session to develop and test innovative methods of engaging staff members and customers.
Multiple techniques have been found to effectively increase project team and staff member
interaction and to make the work of the project team highly “observable.” These techniques
include encouraging project team members to identify innovators and early adopters outside the
project team and to include these individuals in workflow analyses and Lean tools applications
during the PDSA cycles. Additionally, physical process changes are often developed initially as
prototypes and are displayed in break rooms for staff feedback.

Ensuring “compatibility” of the change and reducing complexity of the innovation. QI

initiatives—such as those for implementing clinical practice guidelines or new health informatics
technologies (e.g., clinical reminders)—are often introduced during the adoption phase, utilizing
a series of policy and procedure modifications and educational inservices, with minimal
consideration for organizational culture, current workflow processes, and the level of
engagement of the frontline staff members. 18 What results is often a set of policies, procedures,
and processes that might be overly complex, impractical, and difficult for frontline staff to
successfully apply and integrate with current patient care practices, regardless of their
commitment to improving patient outcomes.
Additionally, in spite of the success of systems redesign methodologies (e.g., Lean and Six
Sigma) in manufacturing environments, these tools often are not directly applicable within a
health care setting. 19 They also might be difficult for frontline staff members with no formal
systems engineering background to utilize. The absence of the “translation” to the health care
language for Lean and the need for developing relevant case studies and examples into a health
care dialect have been cited as factors limiting the adoption of these practices within health care.

In order to increase the “compatibility” factor of implementation efforts, our work has strongly
focused on the design of systems engineering methodologies and principles that are readily

7
accessible and relevant to health care frontline staff members with little or no prior background
in application of these tools and the use of these “translated” systems-engineering methodologies
to assist frontline staff members in the redesign and optimization of staff workflow practices to
complement components of the quality initiative.

Within our Lean Healthcare program, a technique called Workflow Analysis is used by the
project team to examine the clinical and operational processes from the perspective of the patient
or staff member and to identify opportunities for systems redesign. Workflow analysis is derived
from human factors engineering, where this term describes the study of the human-computer
interaction with software and hardware systems. A workflow analysis study 20 is typically used to
obtain data on baseline existing clinical processes prior to the improvement cycle and to validate
process outputs following system redesign. While conducting an analysis study, direct process
observation techniques are used to physically observe the process under investigation. Lean tools
and techniques, such as process flow diagramming, direct process observation, spaghetti
diagramming, and checksheets, are used by the project team members to collect data to identify
and quantify the impact of operational barriers.

An example of workflow analysis outputs from a project to implement intensive glycemic

control in a critical care unit is shown in Figures 2a-c.19 These figures are from a published case
study detailing the implementation of several clinical care bundles on a critical care unit. This
particular workflow analysis examined the process of performing a glucose test on that unit.
Note that the process observation worksheet (Figure 2b) indicates that, for this particular
observation, the nurse spent 10 minutes searching for a glucometer to perform the glucose test on
a patient. As published in this case study, the average time to find a glucometer on this unit was
11 minutes. The path the nurse took during the search for equipment and supplies is shown in the
spaghetti diagram (Figure 2c).

Following identification of operational barriers, Lean tools and concepts—such as 5S, visual
controls, and constraint management—are introduced to the project team through the use of
health care-based case studies and hands-on simulation exercises. The latter exercises are
developed specifically to mimic actual health care situations, such as locating equipment and
supplies on a nursing unit and patient flow through an emergency department. Multiple rounds
are conducted to simulate actual process improvement and to build team members’ confidence in
applying Lean tools. These tools are then directly applied to the project team members systems
and processes in order to improve the functionality of clinical processes associated with practice
bundles.

Within our Lean Healthcare program, the faculty facilitator typically allows 1 week between the
training session and a designated “report out” session. Each training group is given a stopwatch,
multiple process observation worksheets, and a digital camera.

8
Figure 2a. Process flow diagram for performing a glucose test on a critical-care patient. Adapted from Woodward-Hagg H, El-
Harit J, Vanni C, et al. Application of Lean Six Sigma techniques to reduce workload impact during implementation of patient
care bundles within critical care – A case study. Proceedings of the 2007 American Society for Engineering Education
Indiana/Illinois Section Conference; 2007 Mar; Indianapolis, IN. Used with permission.

Process Observation Worksheet

Step # Description Distance Clock Time Task Time Wait Time Observations
0 0
1 RN checks patient chart 2:00 2:00
2 Order Obtained?
- If No, call physician to obtain order, scan order
3 RN enters patient room 20 2:30 0:30
4 Glucometer and Supplies available?
- If no, then search for Glucometer and Supplies. 500 12:30 10:00 entered 4 rooms to find glucometer
5 Docking required?
- If Yes, then goto Docking station.
6 QC? If Yes then find QC equipment.
- If Yes, then perform QC.
- RN Returns to patient room 20 13:00 1:30
7 Perform Glucose testing 0 13:30 0:30

Figure 2b. Example of process observation worksheet used during workflow analysis for Glycemic Control Project. Adapted
from Woodward-Hagg H, El-Harit J, Vanni C, et al. Application of Lean Six Sigma techniques to reduce workload impact
during implementation of patient care bundles within critical care – A case study. Proceedings of the 2007 American Society
for Engineering Education Indiana/Illinois Section Conference; 2007 Mar; Indianapolis, IN. Used with permission.

9
The training groups apply
workflow analysis techniques
to baseline their current
processes, identify an area or
instance of “waste” within their
processes, and apply Lean tools
to improve the processes. The
groups are then expected to
collect processing time
information for the improved
process in order to quantify the
improvement.

The results are also translated

into cost impact as part of the
business case analysis,
quantifying the benefit on an
individual and organization
level. The digital camera is
used to record processing
conditions prior to and
following improvements. Figure 2c. Example of “spaghetti diagram” used during workflow analysis for
Team members are encouraged Glycemic Control Project. This diagram depicts the movement of the nurse while
searching for a glucometer. Adapted from Woodward-Hagg H, El-Harit J, Vanni
to summarize their results, C, et al. Application of Lean Six Sigma techniques to reduce workload impact
including photos, into a 5- to during implementation of patient care bundles within critical care – A case study.
10-minute presentation or Proceedings of the 2007 American Society for Engineering Education
Indiana/Illinois Section Conference; 2007 Mar; Indianapolis, IN. Used with
storyboard for the report-out permission.
session.

“Trialability” of the Initiative

Throughout our experiences in facilitating health care teams in systems redesign, our faculty
facilitators have consistently noted that when project team members were encouraged to
immediately apply Lean tools introduced during the project sessions to “test” improvements
within their own work environments, these teams were more successful with respect to long-term
retention and application of these tools, compared to those who might have delayed
implementation. The facilitators also noted that these applications were more likely to be
sustained over the duration of the implementation if the team went through several test cycles
prior to final implementation. Additionally, solutions following these multiple tests of change
were often highly customized in comparison to solutions generated by other project teams
implementing similar QI initiatives.20, 21

The need for adaptation and customization to sustain change in health care is well documented
and is believed to be the one of the fundamental requirements for spread of innovations. 22
However, Lean and systems engineering techniques, as applied within manufacturing, rely
heavily on a foundation of standardization of processes and systems. As engineering and
technology faculty with backgrounds in manufacturing applications of systems redesign, we

10
initially struggled to reconcile the level of customization necessary to provide sustainability and
the level of standardization that is often a characteristic of successful Lean process design in a
manufacturing environment.

However, the more we investigated this phenomenon, the greater our understanding that the
complex and dynamic nature of health care systems and processes often precludes
standardization at a level that is typically required within manufacturing applications of systems
redesign. As a result, within our program, we have opted to include both customized and
standardized components. The general guideline we have developed is that standardization of
processes, policies, and procedures must occur where evidence-based literature exists, linking
specific clinical practice to patient outcomes.

All other clinical workflow processes related to implementation (and for which no evidence
linking to patient outcomes exists) can be customized to best fit the needs of a particular project
team or organization. For example, within a recently AHRQ-funded MRSA (methicillin-resistant
Staphylococcus aureus) collaborative, the requirements for when a patient should be placed in
isolation were standardized among participating hospitals because there was evidence to suggest
that contact isolation reduced the likelihood of transmission. However, the processes and
procedures that have been developed associated with placing colonized and infected patients in
contact isolation vary greatly across participating health care facilities and even within facilities.
Therefore, customization of these processes and procedures is necessary to compensate for
systematic, cultural, and organizational differences.

For aspects of the implementation not requiring standardization, project teams are encouraged to
optimize workflow practices through application of Lean and systems engineering principles by
utilizing small, incremental tests of change, also known as PDSA cycles. An added benefit of
this technique is that allowing project team members to optimize their own workflow processes
through the PDSA cycles ensures that the resulting process and system changes fall within the
project team members’ capacity for technical complexity and within their confidence level to
implement the changes successfully.

Additionally, as the complexity of the interventions increases, project pilots are often utilized to
provide a test bed for parallel implementation of multiple PDSA cycles. A pilot implementation
plan is generated to test the solutions through a 4- to 6-week timeframe. Often, during the pilot,
the scope of the implementation can be reduced to a specific patient population or unit. A pilot
implementation plan is created to detail actions that must occur prior to implementation of a
specific aspect of the process redesign. Project team members are assigned as owners for
individual action items, and dates for completion are determined.

The project team also develops a process control plan prior to implementation. This plan
includes components of data feedback from the processes and creation of an administrative
infrastructure to encourage sustainability of process improvements.

The control plan is developed to ensure regular feedback of process performance data during and
following implementation. Typically, daily data collection and feedback are used throughout the
pilot implementation, with the frequency of feedback decreasing as improvements are sustained
and the implementation “tipping point” is reached as the project is adopted and integrated.

11
To continue project
Table 1. Assessment scales used in this study
observability following
implementation, results from Sustainability assessment scale
daily data collections are
Initiative sustained to goal for majority of primary
often displayed prominently Excellent
control metrics for >9 months following implementation
within the process areas to
encourage staff discussion Initiative sustained to goal for majority of primary
Good
control metrics for >6 months following implementation
of progress and to foster
awareness among staff Initiative sustained to goal for majority of primary
Fair
members, including those control metrics for >3 months following implementation
not on the process team. Initiative did not sustain to goal for majority of primary
Poor control metrics for ≤3 months following implementation;
other significant implementation issues existed
Results and None No implementation occurred
Discussion Spread assessment scale
To date, the implementation Systems engineering principles spread to other unit or
strategies outlined above Excellent
project focus with no faculty assistance
have been used in over 40
Systems engineering principles spread to other unit or
QI projects, 21 hospitals, Good
project focus with limited faculty assistance
and 6 hospital systems
within the State of Indiana. Some evidence of application of systems engineering
Fair
principles beyond initial project area
To evaluate the No evidence of application of systems engineering
Poor
effectiveness of our principles beyond initial project area
implementation strategy,
each of the 36 completed
projects was retrospectively evaluated to assess the sustainability of improvements over time and
the extent of spread of Lean and systems engineering techniques beyond the initial project focus
area. Table 1 outlines the evaluation criteria used in this assessment, and Table 2 presents a list
and count of projects by topic.

As shown in Table 2, 89 percent of projects (32/36) have been implemented and improvements
sustained for at least an initial 4-week pilot period. A summary of the sustainability and spread
assessment results is presented in Table 3. Of those projects that were implemented, 78 percent
(25/32) were found to have sustained the majority of project goals for more than 6 months.
Additionally, 75 percent of projects (24/32) resulted in the spread of Lean, systems engineering,
and implementation science principles beyond the initial project focus area with limited faculty
assistance.

Of the four projects that failed to make the transition from adoption to implementation, one
failed due to the complexity of the proposed redesign; the other three failed due to lack of
administrative support during the pilot phase, which likely reflected a failure of perceived benefit
to the organization.

12
Conclusion
Our program for successful implementation and sustainability of QI initiatives in health care
emphasizes principles of Lean manufacturing, systems engineering, and implementation science.
This approach specifically emphasizes+ working to incorporate staff engagement and ownership,
including training programs that make these methodologies and principles readily accessible to
frontline staff with little or no prior experience. Furthermore, each project session requires
immediate application of tools and techniques to the processes under investigation with ongoing
measurement and feedback of the impact. The benefits of the process redesign activities are
detailed through a business case analysis and through quantifying the impact of process redesign
utilizing workflow analysis. Through a consistent application of these principles, we have found
that interventions are integrated into workflow, adopted, and sustained over time.

Table 2. Completed projects by category

Project
implemented? (N)

Project categories Y N

ED patient flow 1 2
Surgical flow 3
Outpatient scheduling/registration 2
ICU admission process redesign 1
Hospital lab process redesign 4
Discharge process redesign 2
IT process redesign 2
Medication delivery process redesign 2
Equipment/supply area redesign 2
ICU LOS reduction (incl VAP /
5
glycemic control bundles)
Implement central line bundle 1
Implement MRSA bundle 6
Patient fall reduction 1
Radiology capacity optimization 2

Totals 32 4
Percent projects implemented (%) 88.89

13
Table 3. Summary of project sustainability and spread assessment
Sustainabilitya Spreada
Project categories Excellent Good Fair Poor Excellent Good Fair Poor
Number of projects 14 11 7 0 12 12 5 3
Total projects (%) 44 34 22 0 37.5 37.5 16 9

% projects sustained >6 months 78

% projects exhibiting spread with

75
limited or no faculty assistance

A Sustainability and spread assessment performed only on projects that were implemented.

Author Affiliations
VA Health Services Research & Development Center on Implementing Evidence-based Practice,
Roudebush Veterans Affairs Medical Center, Indianapolis, IN (Ms. Hagg, Dr. Flanagan, Dr.
Doebbeling); Indiana University Center for Implementing Evidence-based Practice, Regenstrief
Institute, Inc., Indianapolis, IN (Dr. Flanagan, Dr. Doebbeling); Department of Medicine,
Indiana University School of Medicine (Dr. Flanagan, Dr. Doebbeling); Department of
Mechanical Engineering Technology, College of Engineering and Technology, Indianapolis
University – Purdue University, Indianapolis, IN (Ms. Hagg, Ms. Workman-Germann, Ms.
Suskovich); Department of Mechanical Engineering Technology, College of Technology, Purdue
University – Calumet, Hammond, IN (Ms. Schachitti); Department of Mechanical Engineering
Technology, Purdue College of Technology, West Lafayette, IN (Ms. Corum).

This work was supported in part by AHRQ ACTION contract HHSA2902006000131, TaskOrder
No. 1, and also supported in part by HSRD Center grant #HFP 04-148.

Address correspondence to: Heather Woodward Hagg, MS; telephone: 317-514-5219; e-mail:
[email protected].

3. Weiner BJ, Alexander JA, Baker LC, et al. Quality

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