Hoshin and Kata in the Lean transformation of a hospital
April 25, 2023
Roberto Priolo is editor at the Lean Global Network and Planet Lean
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The Hospital de Bellvitge in Barcelona relies heavily on hoshin and Kata to create a work environment based on cooperation and joint problem solving.
The Hospital de Bellvitge in Barcelona serves an area of 250,000 people - nearly 2 million for specialized care or high-tech treatments. Each year, the hospital performs about 20,000 operations and receives 120,000 emergency room visits. About six years ago, the organization decided to apply Lean Thinking as a way to meet its needs. The hospital needed to increase the number of surgeries, but always struggled to find beds for recovering patients.
Faced with long waiting lists, they wanted to increase their efficiency. I already had experience with Lean from my time at Terrassa University Hospital, and when I suggested that Lean would be the way forward for the hospital, I was asked to lead the Lean transformation myself. In the second half of 2017, we started in the surgery department. The following year, Antonio Olmos, a process engineer, joined me and we started implementing some improvement projects together. Since then, the "Lean team" has continued to grow, with some people leaving and others joining. Today I work with two process engineers, a nurse and a doctor who comes to work with us part of his time.
Kata as Lean tool to secure results
As we became more and more experienced with Lean Thinking and implemented more and more projects, we realized that we were struggling to maintain the results of our improvements. That's when we decided to start working with Kata. To this day, it is one of the Lean tools we rely on the most. For the vast majority of our projects, when we "close" the A3, we install a Kata board for our follow-up on a weekly, bi-weekly or monthly basis (depending on the project).
For major projects, such as the project on afternoon discharges, we have placed a Kata board in the various departments - neurology, pneumology, thorax, trauma, nephrology, etc. A few of these departments are already using Kata independently, and we as a Lean team only come by occasionally to offer support (a testament to the culture change that has taken place), while other departments still need more help regularly, as they are still changing their way of thinking and doing things.
Digital visual management to support Kata
Kata has played an important role in ensuring the sustainability of results and continuing to improve KPIs. To manage our digestive system endoscopy rooms (a procedure with very high demand and a long waiting list), for example, we used our experience with Kata and visual management to design a productivity board that tells the team what has been done each day, by comparing the procedures actually performed with those they expected to perform. Today, this board is digitized and automated. We also use Leader Standard Work to structure our weekly planning meetings and to visually manage the department, in an effort to give the team visibility into the comings and goings of patients and facilitate their quick discharges. The system is designed so that the team knows when it is time to let the family know, for example, that the patient is ready to go home. All of this was a direct result of our Kata work, supported by our visual management.
Of course, introducing Kata in our hospital was not always easy, especially in the departments that were not in the habit of meeting regularly to discuss work. We went to great lengths to make them understand the importance not only of using Kata, but also of having a morning meeting to review the current situation day by day (there is no point having a board, or even filling it with data, if there is no regular meeting around it - that is the essence of Leader Standard Work). But eventually everyone joined in because they saw improvements in daily work and realized they could play an active role in it. Over time, of course, the way different teams use Kata has evolved: some teams are no longer as structured as they were in the beginning (they use the five Kata questions, for example), but the ethos of continuous improvement and the focus on KPIs, peculiar to Kata, are still at the heart of every action.
The results were great: the number of discharges before noon could be significantly increased. This obviously had a positive effect on patients waiting for a bed to become available.
Hoshin Kanri as Lean tool to connect goals with daily work
Kata is not the only Lean practice that various departments have decided to adopt. There is also Hoshin Kanri (also called strategy deployment), which we introduced before the pandemic. Today, a number of departments are using this powerful tool to connect their goals to daily work, using A3 thinking as the preferred way to solve problems. We have even begun an interesting experiment with Hoshin within our transplant team. In reality, four teams are working together, and with Hoshin, they are looking for synergies that can make the transplant process - from donor identification and accessibility of waiting list candidates to surgery and follow-up - more agile for our patients.
We then have a "macro-hoshin" for the entire Hospital de Bellvitge, which we developed with the help of Oriol and Nestor from Instituto Lean Management and implemented at the end of 2021 based on our previous experience with all local Hoshin processes. The idea was to align the strategy of the different departments with the overall strategy of the hospital. Our Neurology department - an early adopter of many of our lean practices - was a particularly good example of how department leadership needs to spend time with people on the front lines, explain the importance of the KPIs (especially "why" they are so important) and set clear expectations.
Engagement in that area is a model for the rest of the organization. When people understand the contribution their work makes to the overall goals of the hospital (and its impact on quality of care), we see a shift in their thinking. They realize "what's in it for them": if you're working to free up beds in your area, it's more likely that your patients will all end up in the same place (rather than having to stay in the emergency room, for example, until a place becomes available).
Integrating strategic objectives into SQDCP
Something very unique that we did at Bellvitge with our Hoshin was to build our key strategic objectives into the traditional SQDCP structure for KPIs. The reason for this was that some departments had a very clear set of indicators, while others struggled to identify their own, resulting in a strategic plan for the hospital that was created with everyone's input, but which ultimately did not represent every department. Moreover, to define our strategy, we had traditionally created a huge document - which we used as a basis but eventually wanted to replace with something more user-friendly. The new hoshin was therefore based on three strategic objectives - patient experience, people development and leading collaboration across the field - and on two levers for change, namely innovation and a data-driven organization.
We needed a few sessions to identify the KPIs and reduce the long list we had created to a few lagging indicators (results). Once we finished the alignment, we invited the entire Board of Directors, with the intention of making the process their own and making a clear connection to the work already being done at the departmental level. Since then, we have added two strategic objectives: sustainability and a set of KPIs that the Catalan Health Service asks us to pursue.
Over time, leadership has become more and more accustomed to the Hoshin meetings, and we have seen great engagement and a much greater focus on data. The KPIs we track are tied more to outcomes than to processes, and we are probably as close to a perfect set of indicators as we will ever be. We adjust occasionally, but the combination of hospital-wide Hoshin and local Hoshin boards works very well for us. It especially helps to ensure that people participate and that things happen. It creates accountability and expectations.
Thanks to this system, the Hospital de Bellvitge can now think strategically about its positioning as an organization in the Catalan healthcare landscape.