Lean Methodology Helps Drive A Culture of Accountability, Engagement and Transparency: Case study

Mara Nitu1*, Ryan Fier2, Judy Hollingsworth2, Dorota Szczepaniak1 and Brad Burbage1

1Department of Pediatrics, Indiana University, 705 Riley Hospital Drive, RM 5900 Indianapolis, Indiana 46202, United States

2Indiana University Health Physicians, 1302 S Rogers St, Bloomington, IN 47403, United States

*Corresponding Author:
Mara Nitu
Indiana University, 705 Riley Hospital Drive, RM 5900 Indianapolis, Indiana 46202, United States
Tel: 317-944-1387
Fax: 317-944-4471
E-mail: [email protected]

Received Date: November 06, 2020; Accepted Date: November 20, 2020; Published Date: February 01, 2021

Citation: Nitu M, Fier R, Hollingsworth J, Szczepaniak D, Burbage B (2021) Lean Methodology Helps Drive A Culture of Accountability, Engagement and Transparency: Case study. J Health Med Econ. Vol. 7 No. 2: 50.

Visit for more related articles at Journal of Health & Medical Economics


The increased competitiveness in the healthcare leads to higher financial and operational pressures. Continuous process improvements are an essential part of current healthcare environment. According to the Institute of Healthcare Improvement (IHI), the sustainability of process improvement efforts depends on how successful the healthcare organization has been in creating a culture of accountability and transparency with engagement among all members of the clinical team [1]. Thus, the leadership team of the department of pediatrics employed lean methodology to develop a consistent culture of accountability and engagement for each division and team member in the department. Previous isolated lean transformation projects conducted within the departments failed to effectively engage all providers towards consistently embracing value centered mindset. We will discuss how lean methodology facilitated engaging physicians and all other frontline team members towards a value-centered culture.


Accountability; Health Care Quality; Administrative management

Abbreviations: IHI: Institute of Healthcare Improvement; HPMS: High Performance Management System; APP: Advanced Practice Providers


Aligning clinicians and administrators towards attaining the stated goals of the physicians’ organization, (improving access, improving patient satisfaction, timely and accurate documentation and increased focus on establishing and implementing quality metrics) has been accomplished in a top down fashion with little sustainability. Furthermore, engaging providers towards increased transparency and accountability through standard reporting process has been challenging. Lean methodology can lead to successful implementation of standard work.Using this methodology, we aimed to build a culture of accountability and transparency focused on continuous process improvement work in a large academic organization.


Phase 1

The departmental executive leadership team (Vice Chair for Clinical Affairs, Vice Chair of Administration and Associate vice Chair of Operations) secured the support of a Lean transformation leader and begun developing an A3 analysis process.

The reason for action was identified (box 1):

The increased competitiveness in the healthcare industry leads to higher financial and operational pressures for the Department of Pediatrics. Thus, there is a need to develop a consistent culture of accountability and engagement for each division and team member in the department.

Aim: Our goal is to design a standard process of continuous improvement work for the entire department with high provider, leader, and team member engagement and accountability.

Phase 2

We assembled a team of leaders within the department (several division chiefs, division administrators, APP representation and a fellow (fresh eyes) and conducted three meetings to complete the A3 process. Below we outline the process developed after the A3 analysis was completed.

Scope: Pediatric clinical and academic mission.

Trigger: The department of pediatrics and Clinical Administration set yearly metrics goals.

Done: Completion of all Department-Division accountability metrics.

Box 2 to 3 attributes: (current and future state)

Current State Attributeidentified by the working group were: inconsistent engagement and accountability to quality metrics, inconsistent engagement of providers and leaders in establishing targets, insufficient data analytics to support the workand incomplete understanding of the “why” behind various initiatives.

Future State Attributes were also identified:Standard reporting procedure implemented, effective communication occurs between department, division and providers and team members, easily attainable, readily available and automated data flow, data transparency, leadership and provider engagement, accountability, initiative and fast response time, A3 thinking, visual management

Gap Analysis (box 4)

• What is preventing us form attaining this goal? Knowledge in lean methodology? Lack of commitment, division level accountability and engagement (Table 1)?

Short Description of Top 3 – 6 Gaps
Suspected Root Cause
Division accountability meetings vary from division to division (no structure) No standard process for discussing/setting performance metrics
Administrators/Chiefs do not always understand how to effectively countermeasure Not understanding expectations for accountability meetings
Lack of knowledge around A3 thinking
Minimal engagement with Division leaders in setting Division performance targets No standard process for discussing/setting performance metrics.
Sometimes do not understand the ‘why’ behind metrics No standard process for discussing/setting performance metrics
Poor accessibility and transparency of data/metrics Individual “Division” culture and no process/tool for sharing performance of all Divisions.

Table 1 A Gap analysis.

Box 5

Possible solutions to close the gap including action plan and assignment of responsibility and accountability (Table 2).

Root Cause
Top 3-6 Solutions
No Standard process for discussing/setting performance metrics Utilize a Standard Report that is derived from the department report to clinical administration
Not understanding expectations for accountability meetings Utilize a Standard Report that uses A3 Thinking to identify gaps/countermeasures. Use Division Clinical Administrator monthly meetings as training ground for identifying gaps/counter measuring.
Lack of knowledge of A3 Thinking Offer A3 Thinking and Bronze trainings to administrators and chiefs
Individual “Division” culture and no process/tool for sharing performance of all Divisions Create electronic monthly reports to send to Divisions (stepwise approach to transparency). Develop department tracker that is visible next to Mission Control Board.

Table 2 Root cause and possible solutions.

Box 6 and 7

Rapid experiments and implementation plan of the possible solution (Figure 1).


Figure 1 Accountability process.

This includes a diagram representing the Accountability Process that has been established.It outlines the Phase 1 vs Phase 2.I also included some detailed boxes at each step to represent the tool that was being used during discussion, who, frequency, etc.

Box 8

Evaluating implementations (Metrics and Results).

Metrics: A standard reporting process outlining all metrics was established (Table 3).

Department of Pediatrics
Metrics – All Divisions
Median Lag
(Rolling 3 months)
(60th %ile benchmark)
WhiteSpace target
Clinical Operating Margin
Academic Operating Margin (dollars) target
Net Promoter Score target
Non-Compliant Notes target
Cerner Minutes Per Patient target

Table 3 Department of Pediatrics metric reporting board.

The metrics are tracked monthly at all reoccurring meetings by the department and divisions (Table 4).

Frequency Attendees
Division Chief Meetings Monthly Division Chiefs, Vice Chairs, and Chairman
Administrator Meetings Monthly Division Administrators, Associate Vice Chair of Operations
Faculty Meetings Quarterly All Faculty, Providers, Vice Chairs, Chairman

Table 4 Structured reoccurring meeting.

• % of leadership meetings where standard reporting is usedIncludes the following standard reoccurring meetings: Internal Division Reviews (36 = 18 divisions at 2/year), Division Chief Meetings (10 from Marthru Dec), and Clinical Division Administrator Meetings (10 from Mar thru Dec). If meetings don't occur, they will not count in the denominator.

• Success rate in using A3 thinking during the semi-annual Division reviews

Each internal division review will be graded on their success of using A3 thinking in the preparation of the agenda and the presentation of their metrics and countermeasures

They will score:

2 (YES) if they have demonstrated and successfully used A3 thinking

0 (PARTIAL) if they have partially demonstrated and used A3 thinking

0 (NO) if they have not demonstrated or used A3 thinking

• Number of Division Administrators who have been Bronze trained

• Number of Division Chiefs and Administrators who have received A3 Thinking training

• To facilitate better two ways communication with all members of all divisions, and insure that increased

understanding exists among team members in respect to department measures and countermeasures, minimum two representatives of the executive team will perform yearly visits to each division meeting.

We will measure the % of Divisions where Chair's office leaders come to at least one division faculty meeting during year.

Box 9

Insights and next steps (See the Discussion Section).


The standard reporting procedure has been implemented for all 18 divisions with a 92% success rate during the first semiannual review (Table 5). Most notable, the standard reporting procedure was followed with 100% success at the second semiannual meeting. A mechanism was created to insure readily available and automated data flow. Each division review was graded on their success of using A3 thinking in the presentation of their metrics and countermeasures (0- does not meet, 1-partially meets and 2-fully demonstrates). During the first semiannual review, the average A3 thinking score for the 18 divisions was 1.81 (target: 1.50). Effective communication has begun between department, division, providers and team members with increasing frequency. Visual management strategies have been used to increase transparency. As division leaders became more familiar with the A3 thinking process, we have observed an increased engagement in discussing current measures, gaps and in developing countermeasures. All department’s metrics were successfully attained. At the division level, each leadership team was prepared to identify gaps and offer countermeasure. Most notable, the overall median lag improved from 26.8 days (Jan 1st 2019) to 16.8 days (August 31st 2019) without adding new providers.


Table 5 Results.


“Culture” has been defined by Edgar Schein as a “shared way of thinking and feeling about problems within an organization” [2]. Changing the culture of an organization might seem a daunting task as it seems difficult to find appropriate metrics to measure the impact of the intervention.

According to a study conducted by IHI, the management practices identified that might result in sustained culture change focused on high performance include standardization, accountability, visual management, problem-solving and escalation [3]. In a High- Performance Management System (HPMS) (a set of management practices will result in behavioral shifts that will untimely be linked to cultural transformation towards transparency, proactive problem-solving and team collaboration) has been proven to be effective by a series of experiments conducted by IHI in multiple healthcare settings in the US and Europe. These management practices are systematic applications of quality improvement and Lean principles. IHI studied several reputable healthcare organizations who have been successful in implementing a HPMS and demonstrated sustained improvement. In a recently published report [4], similar tactics were demonstrated to result in sustained improvements in fifteen inpatient respiratory wards in Scotland and two ambulatory surgery centers in the US. We are reporting how similar management tactics with a specific focus on Lean methodology resulted in culture change in a large academic department of pediatrics with 300 providers spread across 18 divisions, ranging from primary care providers to various pediatric specialties with clinical presence both in the inpatient and outpatient space. Furthermore, these management tactics have been successful in facilitating the management of the rapid changes in patient volume observed during the COVID-19 pandemic (Table 6). Specifically, the transition towards standard volume while promoting virtual visits was managed by setting targets and tracking weekly progress.

Virtual Visits target# n/a >0.25 total >0.25 total
  actual %(of total visits)      
In- Person Visits target# n/a 0.5* preCOVID 0.75* preCovid
  actual %(of total visits)      
Total Visits target# n/a    

Table 6 Reverse Surge during COVID-19.


Team members’ engagement in a matrix organization is the key element in the journey to build a high reliable organization. Executive leadership involvement is key. Various process improvement methodologies (Lean in our case study) will offer a rigorous and structured framework to lead the change to transparency and accountability.


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