How we gradually built our CI model

Published on
May 24, 2023
Roberto Priolo
Roberto Priolo
Roberto Priolo is editor at the Lean Global Network and Planet Lean
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Cleveland Clinic has been at Lean for a few years now. In this interview, their Chief Improvement Officer and Chief Nursing Officer talk about continuous improvement, benchmarks and sustainable outcomes.

Interviewees: Lisa Yerian and Meredith Foxx.

When and how did the Cleveland Clinic's Lean journey begin?

We established the first process improvement team in 2006. They used a variety of tools and approaches, including Lean, Six Sigma and project management, and focused largely on discrete projects and a few tools. In 2012, we decided to build a culture of improvement. I contacted Mark Reich of the Lean Enterprise Institute for advice on how to get started, and he told me, "Sounds like you should make that an A3!" I had never made one before, but I got John Shook's Managing to Learn, studied the A3 examples in it, and got to work on my very first A3 - "How do we change our culture into a culture of improvement?" From the beginning, the way we wanted to build that culture was deeply rooted in lean methods - including A3 Thinking.

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

When did the CCIM come into the picture?

After the initial experiments in our model areas, engagement grew as more and more people became interested in participating in the Lean work. In 2014, we were working with a growing number of teams and realized 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 put our approach on paper. The result was the first version of the Cleveland Clinic Continuous Improvement Model (CCIM).

Our model came from the needs of the caregivers in our organization. We had started with problem solving, using A3 thinking to solve real problems each team faced in their work. When those initial A3 efforts began to yield results, area managers expressed concern that we were starting new A3s for "everything." It became clear that we needed a system to identify which problems to focus on and prioritize. That became our problem-solving system. But then managers started asking how they would know which problems to prioritize. That led to the realization that we had no clear strategy or hoshin to guide our improvement work, and eventually to the introduction of an organizational alignment system. So we gradually built the different parts of the model by listening to the experiences and needs of our teams.

As we went from team to team, we realized that the core questions teams needed to answer to build an improvement culture were pretty consistent: Alignment ("what's most important?"), Visual Management ("how are we doing today?"), Problem solving ("what's getting in the way?") and Standardization ("are we always doing it the best known way?"). We built the CCIM around those questions, and they haven't changed. (Our model, by the way, aligns very well with the Lean Transformation Model).

What was the nursing department's experience with CCIM?

We were definitely early adopters. My current nurse leader started using the improvement model to have all her team members create their own A3s around a problem the department was trying to solve. We focus on using the CCIM and the standard tools to address key issues - this is an ongoing process with our own team and then is passed on to the nursing teams.

To this day, the CCIM is the model that drives our improvement decisions. We hold monthly operational reviews that focus on the OKRs - which is most important - where everyone reports on what they are trying to improve and the key results. People are expected to use the methodology to achieve their results.

Nursing is often one of the first areas to work with Lean . Why is that?

Nurses love to fix! If they can make patient care more efficient and solve problems, they will. They like to see evolution and improvement in the delivery of care.

How did you reach the doctors and other departments of the clinic?

Some of the problems we have focused on recently are interdisciplinary and require a team approach. As you get closer to the cause of a problem, you usually discover that other departments or groups of health care providers (staff) are involved. That is our signal to involve more people in our problem-solving work, to increase the scope and reach of our projects - most of which are still team-based.

How important has it been to establish a clear vision for the organization, and how do you connect it to the work that happens daily at the gemba?

Our goal at Cleveland Clinic is clear. We want to be the best place to receive care and the best to work in health care, and we want to always provide the highest quality and safest care. There are national benchmarks for health care organizations, and we are expected to judge our performance against those benchmarks. Once we uncover the statistics we are struggling with, we immediately know what our next priority is.

Our goals focus on four care priorities: patient care, provider care, community care and organizational care. These four elements define the way we talk about our goals, which is even reflected in the structure of our daily meetings. This approach gives us a way to zoom in on each strategic dimension of our work and identify the issues we need to address next.

How has the system supported organizational improvement? Can you give some examples?

The first thing that comes to mind is our improvement in sepsis. Sepsis is a life-threatening condition that causes high mortality in hospitals. We analyzed the problem thoroughly, looked at the root causes, and came up with a series of countermeasures that ended up significantly changing this quality and safety measure year after year. Another project we are proud of involved readmissions (returning to the hospital for the same reason in a short period of time), especially those related to heart failure. That criterion has also improved significantly each year and now meets or exceeds the national benchmark.

We also determine the financial impact of our improvement work. The combined impact of our improvement work over the past five years was $159 million.

Cleveland Clinic has long been engaged in Lean. What helps you sustain the Lean transformation and the Lean culture of continuous improvement?

We have done well to integrate the Lean culture into our standard daily operations. It is 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 and safe care were not skipped a beat. We now know that we can sustain our way of working even in difficult times, and I think that's because people see the value of lean to their work.

The interviewees

Lisa Yerian
Lisa Yerian is Chief Improvement Officer at the Cleveland Clinic

Meredith Foxx
Meredith Foxx is Executive Chief Nursing Officer at the Cleveland Clinic

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