Engaging Patients in the Veteran Health Administration’s Lean Enterprise Transformation: A Qualitative Study

Abstract

Background

Lean management is a strategy for improving health care experiences for patients. While best practices for engaging patients in quality improvement have solidified in recent years, few reports specifically address patient engagement in Lean activities. This study examines the benefits and challenges of incorporating patient engagement strategies into the Veterans Health Administration’s (VA) Lean transformation.

Methods

We conducted a multisite, mixed methods evaluation of Lean deployment at 10 VA medical facilities, including 227 semi-structured interviews with stakeholders, including patients.

Results

Interviewees noted that a patient-engaged Lean approach is mutually beneficial to patients and healthcare employees. Benefits included understanding the Veteran’s point of view, uncovering inefficient aspects of care processes, improved employee participation in Lean events, increased transparency, and improved reputation for the organization. Challenges included a need for focused time and resources to optimize Veteran participation, difficulty recruiting a diverse group of Veteran stakeholders, and a lack of specific instructions to encourage meaningful participation of Veterans.

Conclusions/Implications

As the first study to focus on patient engagement in Lean transformation efforts at the VA, this study highlights ways to effectively partner with patients in Lean-based improvement efforts. Lessons learned may also help optimize patient input into quality improvement more generally.

Introduction

Engagement with patients is recognized as a critical component of effective healthcare improvement efforts ^1–3 and has been found to lead to higher quality care, lower costs, and improved healthcare outcomes for patients.⁴ There has been a concurrent surge in popularity of improvement methods that aim to reduce inefficiencies in healthcare delivery systems. One method that has increasingly been adopted is Lean or Lean healthcare. ⁵ Lean methods aim to create value for customers by removing “waste” or non-value from healthcare systems. Lean proponents argue that it reduces costs, increases employee satisfaction, and leads to a better experience for patients.⁶

At first glance, it appears that patient engagement and Lean are quite compatible since both aim to improve health care experiences for patients. However, some have pointed out that Lean execution in healthcare systems is based less on the desires and input of patients but instead managers, and when done well, frontline employees.⁷ In some Lean efforts, patient preferences may be assumed rather than directly ascertained, though critics caution against assuming patient perceptions of benefits align with those of healthcare providers.⁷

Directly engaging patients in Lean-based improvement work may help close the gap between patient satisfaction with care and healthcare improvement efforts. With some noteworthy exceptions,⁸ most efforts have not explicitly involved patients and few studies specifically examine patient engagement in Lean activities. How to optimize the involvement of patients in Lean approaches is necessary and understudied.

In this study, we examine how patient engagement strategies were incorporated into the Veterans Health Administration’s (VA) Lean Enterprise Transformation program. In 2015, the VA adopted Lean management to improve the quality, safety, and experiences of Veterans at several facilities.⁹ Using qualitative interview data, we describe the benefits and challenges of engaging patients in Lean implementation efforts at 10 VA facilities.

Methods

Between 2015–2017, we conducted a multi-site, mixed methods evaluation of Lean deployment at 10 VA medical facilities. A summary of the evaluation’s methods and guiding conceptual framework can be found elsewhere.⁹ The purpose of this larger evaluation was to characterize Lean implementation and sustainment across the VA system. Sites targeted clinical and non-clinical areas where Lean was believed to be most effective and necessary.

The research team conducted three rounds of interviews, one in-person site visit and two follow-up telephone visits with a diverse range of stakeholders. Interviewers conducted a total of 227 semi-structured interviews with 260 individuals between October, 2015 and December, 2017 (Table 1). Participants included medical center directors and other executive leadership. Middle manager participants included service chiefs and frontline supervisors such as nurse managers. Front-line employees interviewed consisted of nurses, physicians, and administrative clerks. Systems redesign staff and Lean coaches contracted to work with each site were also interviewed. Finally, a patient focus group was conducted at one of the 10 sites. Interview guides were based on a conceptual model for evaluating Lean transformation in healthcare settings.⁹ This model includes 10 domains, one of which is patient engagement. Interview questions were designed to elicit stakeholders’ perceptions and knowledge about the Lean deployment efforts at their facility, and interviewees were directly queried about the role of patients in their local Lean efforts.

Table 1.

Stakeholders Interviewed across 10 VA Medical Centers

Organizational Role	n= 260
Executive Leader	60
Value Stream Process Owner	36
Middle Manager*	54
Frontline Staff*	56
Systems Redesign Staff	35
Sensei	19

^*Conducted in focus group interview format

Six coders independently coded all interview transcripts using a codebook derived deductively from concepts from the conceptual framework as well as inductive codes identified through immersion in transcript data. Patient engagement was one fundamental code applied to sort transcript data. For this study, all quotes tagged with the patient engagement code were extracted and analyzed separately by two coders. In addition, we used the Atlas.ti key word function to search for passages where engagement, patient-centered care, and similar concepts were mentioned. Focus group data was separately analyzed and coded. From these data sources, we used a qualitative descriptive approach¹⁰ and identified overarching themes.

This project was reviewed by our IRB and determined to be non-research as it does not meet the Federal definition of research [DHHS 45 CFR 46.102(d)].

Results

Findings are summarized in Table 2.

Table 2.

Summary of Themes

A Patient-Engaged Lean Approach is Mutually Beneficial to Patients and Healthcare Employees
•  Allows staff to adopt the Veterans’ point of view and uncover taken-for-granted but inefficient aspects of care processes
•  Improves participation of staff in Lean activities by focusing their attention and encouraging more thoughtful engagement
•  Increases transparency and reputation of VHA among Veterans
Veteran Participation in Lean Activities Requires Focused Time and Resources
•  Veterans need specific instructions on how to meaningfully contribute to Lean improvement activities
•  Recruiting a diverse group of Veteran stakeholders is challenging and time-consuming

A Patient-Engaged Lean Approach is Mutually Beneficial to Patients and Employees

Both employees and Veterans described what they considered to be the mutual benefits of having Veterans participate in Lean activities. In addition to some obvious benefits, including insight into taken-for-granted aspects of care delivery, many pointed out less obvious benefits including impacts on employee behavior and VA reputation.

Involving Veterans in Lean Improvement Activities and Incorporating the Veterans’ Point of View

When asked about involving Veterans in Lean-related improvement efforts, the overwhelming sentiment among leaders and employees at all sites was that it was “the right thing to do,” as one leader succinctly put it. For many, the most valuable aspect of Lean participation and training was learning to shift their thinking to focus on the Veteran’s point of view. A systems redesign specialist explained, “I think there’s probably two questions I’ve learned [that] have been the most helpful for us and for me in coaching. And that’s been, so what does the Veteran think of it? …What would they say? What are they seeing?”

Patient participation in Lean events helped facilitate this shift. A majority of sites (seven out of nine) involved Veterans in their Lean efforts in some way. Often, employees involved in improvement efforts needed feedback that could be obtained quickly, which generally involved real-time querying of patients about their preferences in what participants characterized as “voice of the customer” checks.

In addition to seeking out Veteran perspectives as part of voice of the customer activities, some sites also included Veteran participants in their rapid process improvement events (RPIEs). In these instances, patients participated in group discussions and collective brainstorming to identify improvement ideas and potential solutions. Veteran participants were generally regarded as invaluable members of the team alongside leaders and frontline employees. Interviewees noted that Veteran participants provided new ways of thinking about routine processes that many of them take for granted and inefficiencies easy to overlook. One leader reflected on the value of Veteran engagement, stating,

We were in this room and we were all there with our own perception of where the problems were, and then to have… one of our Veteran patients come in [and give input], and [employees] said, ‘We had no idea that’s how the patient was seeing it.’ So, it completely changed the way that they were thinking about what they working on.

Improved Participation of Employees in Lean Activities

Some noted that Veteran participation in Lean events held employees accountable and encouraged them to engage with enthusiasm and interest. A leader commented on this, explaining,

[Employees] tend to behave better in front of the Veterans because when the Veterans ask questions sometimes … it makes you stop and say why did you do that? And it makes you stop and say well, why do I do it that way?... is that the only way I can do it?

As this comment suggests, having Veterans present at improvement events appeared to increase employee thoughtfulness and willingness to explore new ways of approaching barriers to care. Veteran presence at RPIEs also appeared to encourage less employee grumbling and grievance airing and instead more productive discussions about ways to improve care processes. Finally, it also appeared to engender greater cooperation among employees. Interviewees attributed this to employees wanting to leave a lasting positive impression on Veteran volunteers. However, some did express concern that while having Veterans present encourages employees to behave professionally, it also has the potential to quell honest discussion about problems VA faces. Specifically, because the VA is a publicly funded healthcare system and therefore subjected to increased public scrutiny, employees worried about presenting a negative image of the VA and its services, which could have larger ramifications.

Greater Transparency and Improved Reputation of VA

Both Veterans and employees noted that Veteran participation in Lean improvement efforts may increase transparency and boost the reputation of the VA. They noted that problems with care at VA locations may make it to the public domain, while more positive experiences of exceptional care may fail to reach the public. This may cause some to overlook the overwhelmingly positive experience most Veterans have with the care that they receive at VA. Veterans who participated in Lean improvement events were given an opportunity to learn about the innerworkings of the VA, a view not generally available to the public. One value stream service chief described this realization as an aha moment for Veteran participants because “they see how much of what we do behind the scenes. The Veteran never sees anything but the [final] product.” Underscoring this point, a Veteran participant said:

So just seeing [employees] who have been involved with the system and who are honest -- I mean these are all wonderful caring people. There’s a reason that they came to work for the VA for less than they could [make]… in the public side.

A value stream service chief similarly noted,

Giving the exposure of this work to the Veterans, then allowing them to bring that back to … other Veterans who can hear about the improvements that are happening throughout the hospital … from a fellow Veteran [is very impactful]. I think when you hear it from a fellow Veteran, it has a much different meaning

Some employees and Veterans concluded that this exposure could ultimately help reduce distrust between the Veteran community and VA.

Veteran Participation in Lean Activities Requires Focused Time and Resources

Although they recognized its value, some VA employees and leaders admitted that they were unsure how to increase and enhance Veteran engagement in Lean events and in healthcare system improvement work more generally, especially for projects that are more internally focused such as human resource improvement projects. Additionally, employees noted several challenges that they faced when trying to foster and implement a more patient-centric Lean strategy.

Instructing Veterans on How to Meaningfully Contribute to Lean Improvement Activities

Simply including Veterans in Lean improvement events was not always sufficient. Interviewees commented that Veterans needed instruction on ways to meaningfully contribute. For example, one leader noted,

[We have had] limited success with [getting Veterans involved in Lean]. But involving a Veteran or a volunteer, same as involving staff, you can’t expect them to know how to be an active participant. You have to work with them… Yes, it’s important but you can’t just stick them in there. You’ve got to give them some support, some training and that sort of thing for them to be successful.

As this comment suggests, the lack of training for Veteran participants was not just a missed opportunity to optimize Veteran feedback, but it could also leave Veteran volunteers feeling overwhelmed and disappointed with their inability to contribute in a meaningful way.

Involving Veterans in projects with smaller, limited scopes appeared to garner the most success. As one value stream service noted, “When we have bigger [over]arching goals from a Value Stream standpoint, we don’t want to bring people who are not adept at what you’re discussing.” In particular, this interview participant went on to say that patient engagement seemed to work best when patient volunteers were asked to provide guidance on topics with which they had some experience and familiarity. For example, Veterans who worked in industries with processes similar to those in healthcare were able to apply insights from those experiences and translate them into a healthcare setting. In addition, some sites gave Veteran volunteers the option of obtaining Lean green belt training, which expanded their knowledge of Lean and enabled greater participation in subsequent improvement events.

Recruiting a Diverse Group of Veteran Stakeholders

Finding Veterans to engage in Lean events proved challenging. Volunteers tended to be older, male Veterans who had ample time to participate. Employees expressed concern that this skewed pool of potential volunteers did not capture the full range of patient experiences. In many instances, because of the challenges of recruiting volunteers, clinics used employees who were also Veterans out of convenience. Some thought recruitment challenges were due to a lack of knowledge among Veterans about such opportunities to participate, with one leader stating, “If people don’t make the Vets aware that they have this opportunity to voice their opinion or to try and help make changes, they can’t volunteer for it.” For interviewees, diversity of stakeholders included differences based on demographic categories, such as age and race, but also diversity of disease and illness experiences.

Discussion

Patient engagement in VA’s national Lean implementation efforts varied from site to site and ranged from no involvement to providing Lean training for Veterans and regularly including them in RPIEs. In general, engaging patients in Lean improvement work was considered aspirational and ethically imperative but not always pursued formally or even informally. In order for patient engagement strategies to flourish, studies suggest patient-centered care must be a fundamental part of the organization’s vision¹¹ or in Lean language, a part of the organization’s “true north.” The VA is a highly mission driven organization, which may account for the overwhelming consensus among interviewees that engaging patients was necessary for Lean efforts to be successful. For healthcare systems that have more provider-driven cultures, the VA’s experience illustrates the value of focusing on changing the organization’s culture to one that embraces patient-centeredness.

VA employees described hearing directly from patients about their experiences as beneficial and eye-opening, a benefit similarly reported in other studies of patient engagement in improvement work.¹² Patient engagement in quality improvement may be one way to capture the “patient voice” and provide clinicians and employees with personal reference points to strategize ways to improve care delivery.¹² Interview participants described how patient feedback exposed routine but inefficient processes in health service delivery, a primary target of Lean-based improvement work. This finding demonstrates how Lean-centered techniques may benefit from using not only outside consultants and Lean experts as change agents, but also patients themselves to help facilitate needed changes.

Interview participants, including both employees and Veterans, believed Veterans themselves benefited from their participation in Lean improvement activities. One of these benefits was greater transparency and an enhanced reputation of the VA. Burns et. al similarly found that participation in quality improvement leads to greater respect for decision makers, and by extension, the healthcare organization more broadly.¹³ In addition, patient participants also noted how they had a deeper understanding of health services processes and the complexities involved, many of which remain hidden to patients. ¹³

Despite the perceived benefits, researchers have found employee skepticism toward involving patients in quality improvement.¹⁴ Critics of existing approaches to patient engagement worry that it may be used as a way to reinforce managerial agendas, particularly when patient involvement is superficial.¹⁵ In these instances, patients may become tokens rather than active participants and their involvement used to signal patient-centeredness without a substantive commitment from the organization ¹⁶ Interview participants in our study appeared aware of this concern, and noted that they wanted to find ways to more fully engage patients in the process. Frameworks have been proposed to address this need and provide specific guidance on facilitating “meaningful engagement” between patients and healthcare professionals, including specific activities such as informing, deliberating, and importantly, collaborating.¹⁷ However, most of these recommendations have not focused specifically on Lean-based quality improvement techniques, and may need to be adapted to fit the Lean approach.

Patients are increasingly becoming active participants in health-related research projects, which may directly or indirectly target quality improvement. Black et al. note that clarifying role expectations and providing patients with clearly defined tasks facilitates more meaningful involvement in research collaborations.¹⁸ This recommendation could be adapted to Lean-based quality improvement partnerships with patients. For example, patients could be actively involved in developing process maps of current workflows, as they may be better positioned to identify redundancies or inefficiencies in these processes than employees.

Interviewees also described the challenges of recruiting a diverse group of patient volunteers to participate in Lean-based improvement efforts, a challenge reported elsewhere.¹⁹ In addition to logistical challenges, they noted the challenge of finding patients who can think expansively about issues. Similarly, Burns and colleagues described the challenges of finding patient volunteers “without an axe to grind” and who represented the so-called “ordinary patient.” ¹³ Many reports of engaging patients in healthcare improvement predominantly involve collecting data about patient experience and satisfaction (commonly through surveys, focus groups, or in-depth interviews) with less focus on partnering with patients to improve services.²⁰ Though interview participants in our study were unable to provide concrete suggestions for increasing the diversity of patient participants, this issue will likely remain a challenge for organizations who engage patients with quality improvement. For this reason, healthcare organizations may wish to collect data about patient experience and satisfaction in tandem with direct patient engagement. This may minimize the pitfalls of focusing too narrowly on the concerns of a select and small group of patient volunteers.

Limitations

Our study has several limitations. While the sample size was relatively large for a qualitative study, findings may have limited applicability outside the VA, a highly integrated health care system. Some sites were also early in their Lean journeys, and interview participants from more established Lean programs may have greater insights into barriers to and solutions for engaging patients. Finally, though some patients were interviewed as part of this study, their involvement in our evaluation was limited. This study and others like it would benefit from more robust incorporation of the patient perspective.

Conclusions

As one of only a handful of studies to focus specifically on patient engagement in Lean-based improvement efforts, and the first paper to focus on patient engagement in a multisite Lean transformation effort at VA, this paper adds to the growing literature on patient engagement with quality and process improvement efforts. Employees and Veterans reported benefits from involving Veterans in Lean activities, namely, revealing taken-for-granted inefficiencies, increased transparency, and improved reputation for the organization. However, engaging Veterans proved challenging. Challenges included a need for focused time and resources to optimize Veteran participation, specific instructions for Veterans to encourage meaningful participation, and methods to enhance recruiting a diverse group of stakeholders. Future work should identify developing engagement strategies tailored to Lean management techniques.

Biography

Caroline Gray, PhD is a sociologist and an investigator at the Center for Innovation to Implementation (Ci2i) at the VA Palo Alto Health Care System, where she is also the lead qualitative methodologist. She is interested in applying qualitative methods to understand healthcare transformation and its impact on healthcare professionals.

Anita Vashi, MD, MPH, MHS is a physician investigator at the Center for Innovation to Implementation at the VA Palo Alto Healthcare System, and an Assistant Professor in the Department of Emergency Medicine at UCSF and Stanford University (Affiliated). Dr. Vashi received her MD and MPH from the University of Michigan and completed a health policy and research fellowship as a Robert Wood Johnson Clinical Scholar at Yale University.

Martin Charns, MBA, DBA is director emeritus and investigator at the VA Center for Healthcare Organization and Implementation Research in Boston, MA and Professor of Health Policy and Management at the Boston University School of Public Health. His research has focused on organizational factors and organizational transformation to improve quality of care. He is co-principal investigator with Anita Vashi on the Evaluation of the VA Lean Enterprise Transformation.

Kathryn J. Azevedo (Mendoza), Ph.D., M.A. manages behavioral health interventions as a medical anthropologist at the VA Palo Alto Health Care System and the National Center for PTSD in Menlo Park, CA. Recent work leverages open science to increase access to evidence-based care and better mobilize resources within a health care system. She completed her graduate training at the University of California, Irvine and a postdoctoral fellowship at Stanford University School of Medicine

Tracy Urech, MPH, is a Research Health Science Specialist at the VA HSR&D Center for Innovation to Implementation (Ci2i) at the VA Palo Alto Health Care System. She has a Master in Public Health in Health Services Organization. She has extensive project management experience, especially with multi-site studies.

Barbara Lerner, PhD, MS, CGC, is an investigator in the Center for Healthcare Organization and Implementation Research at the VA Boston Healthcare System. She has a doctorate in Healthcare Research with a focus on quality outcomes and has studied the implementation and dissemination of quality improvement programs in a variety of healthcare organizational settings.