How we gradually built our Continuous Improvement model

Interviewees: Lisa Yerian and Meredith Foxx

Roberto Priolo: When and how did Cleveland Clinic's lean journey begin?

Lisa Yerian: In 2006, we created our first process improvement team. They used a variety of tools and approaches, including Lean, Six Sigma and project management, and focused mainly on specific projects and on a few tools. In 2012, we made a commitment to build a culture of improvement. I reached out to Mark Reich of the Lean Enterprise Institute for advice on how to get started, and he told me: “Sounds like you're going to have to do an A3 for that!” I had never done one before, but I picked up John Shook's book Managing to Learn, studied the A3 examples in it and started on my first A3 - “How can we change our culture into a culture of improvement?”. The way we aspired to build that culture was deeply rooted in lean methods – including A3 Thinking – from the very beginning.

In 2013, we built our first model area in Finance and then expanded to Nursing, Pharmacy and other areas. From there, lean continued to spread throughout the organization.

RP: When did the Cleveland Clinic Improvement Model (CCIM) come into the picture?

LY: After the first experiments in our model areas, engagement grew as more and more people became interested in taking part in the lean work. By 2014, we were working with a growing number of teams and realized that we needed to be a little clearer and more concrete about what we were actually doing to build a lean culture. So I asked the team to start putting our approach down on paper. What they created was the first version of the Cleveland Clinic Improvement Model (CCIM).

Our model really grew out of the needs expressed by the caregivers in our organization. We started with problem solving, using A3 thinking to solve real problems that each team faced in its work. As the initial A3 efforts began to produce results, area managers expressed concern that we would start new A3s “on everything”. It became clear that we needed a system to identify and prioritize the problems we should focus on. That became our problem-solving system. But then managers started asking how they would know which problems should be prioritized. This led to the realization that we did not have a clear strategy or hoshin to guide our improvement work and, eventually, to the introduction of an organizational alignment system. So, basically, we gradually built the different pieces of the model by listening to the experiences and needs of our teams.

Our model really grew out of the needs expressed by the caregivers in our organization. We had started with problem solving, using A3 thinking to solve the real problems each team faced in its work. As those initial A3 efforts began to generate results, area managers expressed concern that we would start new A3s "for everything". It became clear that we needed a system to identify and prioritize which problems we should focus on. That became our problem-solving system. But then managers began to ask how they would know which problems should be prioritized. This led us to realize that we did not have a clear strategy or hoshin to guide our improvement work and, eventually, to the introduction of an organizational alignment system. So, basically, we gradually built the different pieces of the model by listening to the experiences and needs of our teams.

As we moved from team to team, we realized that the core questions they needed to answer to build a culture of improvement were quite consistent: Alignment ("what matters most?"), Visual Management ("how are we doing today?"), Problem Solving ("what is getting in the way?") and Standardization ("do we always do it the best known way?"). It was around these questions that we built the CCIM, and they have not changed. (Incidentally, our model aligns very well with the Lean Transformation Model.)

RP: What has the Nursing Department's experience with the CCIM been?

Meredith Foxx: We were definitely early adopters. My current nursing leader began using the improvement model to have each of her team members develop their own A3s around a problem the department was trying to solve. Our focus is on using the CCIM and the standard tools to address what matters most – this is an ongoing process within our own team that then spreads across the nursing teams.

To this day, the CCIM is the model that informs our improvement decisions. We hold monthly operational reviews focusing on OKRs – what matters most – during which everyone reports on what they are trying to improve and their key results. People are expected to use the methodology to achieve their results.

RP: Nursing is often one of the first areas to start working with Lean. Why is that?

MF: Nurses like to solve problems! If they can deliver care to patients more efficiently and solve problems, they will. They like to see evolution and improvement in the delivery of care.

RP: How did you reach physicians and other areas of the clinic?

MF: Some of the problems we have focused on recently are interdisciplinary and require a team approach. When you start to get closer to the root cause of a problem, you usually find that other departments or groups of caregivers (employees) are involved. That is our signal to bring more people into our problem-solving work, to expand the scope and reach of our projects – most of which are still team-based.

RP: In terms of metrics, how important was it to establish a clear vision for the organization, and how do you connect it to the work that happens in the gemba every day?

MF: Our goal at Cleveland Clinic is clear. We want to be the best place to receive care and the best place to work in health care, and to always deliver the highest-quality and safest care. There are national benchmarks for health care organizations, and we are expected to assess our performance against these metrics. Once we identify the metrics we are struggling with, we immediately know what our next priority is.

LY: Our goals are centered on four priorities of care: caring for patients, caring for caregivers, caring for the community and caring for the organization. These four elements illustrate the way we talk about our goals, which is also reflected in the structure of our daily meetings at different levels. This approach gives us a way to focus on each strategic dimension of our work and to identify the problems we need to address next.

RP: How has the system supported the improvement of the organization? Can you share some examples?

MF: The first example that comes to mind is our improvement in sepsis treatment. Sepsis is a life-threatening condition that causes high mortality in hospitals. We analyzed the problem in depth, looking at its root causes and creating a set of countermeasures that ended up significantly changing this quality and safety metric year after year. Another project we are proud of concerns readmissions (returning to the hospital for the same reason within a short period of time), particularly those linked to heart failure. This metric has also improved dramatically year after year and now meets or exceeds the national benchmark.

LY: We have also determined the financial impact of our improvement work. The combined one-year impact of our improvement work over the past five years has totaled 159 million dollars.

RP: Cleveland Clinic has been on a Lean journey for a long time. What helps you sustain the transformation and the culture of continuous improvement?

MF: We have done a good job of integrating the lean culture into our daily leader standard work. It was interesting to see how, even during the pandemic, in the areas where lean is deeply rooted, the daily practices we rely on to ensure high-quality, safe care were not interrupted. We now know that we can sustain our way of working even in challenging times, and I believe this is because people see the value that lean adds to their work.