808383

research-article2018
AJMXXX10.1177/1062860618808383American Journal of Medical QualityFeatherall et al

Article
American Journal of Medical Quality

Creating a Culture of Continuous

1­–9
© The Author(s) 2018
Article reuse guidelines:
Improvement in Outpatient sagepub.com/journals-permissions
DOI: 10.1177/1062860618808383
https://doi.org/10.1177/1062860618808383

Laboratories: Effects on Wait Times, ajmq.sagepub.com

Employee Engagement, and Efficiency

Joseph Featherall, BS1 , Alexander Chaitoff, MPH1,

Anthony Simonetti, MD, MBA2, James Bena, MS3,
Daniel Kubiak, BA3, Michael Rothberg, MD, MPH3,
Kavous Roumina, PhD4, Nathan Hurle, BS3,
Walter Henricks, MD3, and Lisa Yerian, MD3

Abstract
Transforming health care remains a challenge as many continuous improvement (CI) initiatives fail or are not
sustained. Although the literature suggests the importance of culture, few studies provide evidence of cultural change
creating sustained CI. This improvement initiative focused on creating cultural change through goal alignment, visual
management, and empowering frontline employees. Data included 113 133 encounters. Cochran-Armitage tests and
X-bar charting compared wait times during the CI initiative. Odds of waiting <15 minutes increased in both phase 2
(odds ratio = 3.57, 95% confidence interval = [3.43-3.71]) and phase 3 (odds ratio = 5.39, 95% confidence interval
= [5.07, 5.74]). At 3 years follow-up, 95% of wait times were <15 minutes. Productivity increased from 519 to 644
patients/full-time equivalent/month; 33/42 Press Ganey employee engagement components significantly improved. This
study demonstrates the efficacy of a culture of CI approach to sustain wait time improvement in outpatient laboratory
services, and should be considered for application in other areas of health care quality.

Keywords
continuous improvement, culture of continuous improvement, wait times, laboratory medicine

Despite the capability of modern medicine in the United changes are not sustained over the long term.8 In health
States, delivering services to the patient safely and reli- care, many improvement efforts are motivated by exter-
ably remains a challenge.1 Annual national estimates nal regulation, such as Medicare payment penalties for
demonstrate that $910 billion worth of health care spend- readmissions, or risk sharing initiatives such as the
ing is ineffective or causes harm.2 US health care consis- Bundled Payment for Care Improvement.9-11 Such ini-
tently performs poorly in timeliness of care, and these tiatives may underperform targets and often are driven
delays can lead to negative health outcomes.3,4 largely by administrative changes, such as hiring care
Furthermore, medical errors are pervasive, with prevent- coordinators or mandating compliance with discharge
able adverse events causing more than 400 000 deaths per disposition criteria, rather than by frontline staff.
year and up to 20 times more nonlethal errors.5 The regu- Although regulatory initiatives can generate meaningful
latory efforts that have sought to improve quality, such as
the Affordable Care Act, have led to slower than desired
improvements in the quality and cost of care.6 Taken
1
Cleveland Clinic Lerner College of Medicine of Case Western
together, this situation is an imperative for health care Reserve University, Cleveland, OH
2
Tower Health, West Reading, PA
professionals at every level to engage and succeed in con- 3
Cleveland Clinic, Cleveland, OH
tinuous improvement of health care delivery.7 4
Arizona State University, Tempe, AZ
Despite this tremendous need, continuous improve-
Corresponding Author:
ment remains challenging. According to the National Lisa Yerian, MD, Department of Continuous Improvement, Cleveland
Health Service, 33% of improvement projects are not Clinic, Mail Code L25, 9500 Euclid Avenue, Cleveland, OH 44195.
sustained at 1 year, and overall 70% of organizational Email: [email protected]
2 American Journal of Medical Quality 00(0)

improvements, they do little to change the attitudes, employees of the organization, defined as “every care-
thinking patterns, and behaviors of frontline workers giver capable, empowered, and expected to drive
such that improvement becomes a daily activity. improvement every day.”19
Broadly, the benefits of continuous improvement can be At the time of this initiative, the health system had an
stifled by overemphasizing tools, techniques, tasks, and established performance measurement infrastructure
compliance, thereby complicating and adding to the including quality, patient experience, access, and finan-
work of managers and frontline staff rather than funda- cial dashboards reviewed by health system executives,
mentally shifting the way health care work is under- institute and department chairpersons, and other leaders
stood, conducted, and improved at every level of the on a periodic basis.20 The health system also had an estab-
organization.12,13 lished internal continuous improvement department.
In response to these and other pitfalls in improvement During executive floor walks and quarterly scorecard
efforts, health care organizations are working to refine reviews, outpatient phlebotomy laboratory wait times
and improve their approaches to continuous improve- were identified by health system and laboratory leaders
ment. A number of reports from researchers, health sys- as a priority for improvement efforts.21,22 The phlebotomy
tem leaders, and health care improvement institutions work areas were not previously involved with continuous
highlight culture in supporting sustained improve- improvement efforts.
ment.14-17 For example, in the Institute for Healthcare In December 2014, the director of phlebotomy, staff
Improvement’s (IHI) 6-Point Sustainability and Spread from the continuous improvement department, and lead-
Model, 3 of the points (supportive management structure, ers and managers from the phlebotomy areas formed a
culture of improvement and deeply engaged staff, and multidisciplinary working group focused on reducing
shared sense of systems to be improved) are cultural in outpatient phlebotomy laboratory wait times. After a
nature.18 Despite the widely discussed theories and mod- brief planning phase, the improvement initiative was
els of a culture of continuous improvement, this concept launched at the beginning of January 2015.
remains somewhat ambiguous and challenging for orga-
nizations to achieve. Interventions
In order to illustrate an initiative targeting the develop-
ment of a culture of continuous improvement, the authors Culture-Based Approach.  Prior to the reenvisioning of the
present a continuous improvement initiative conducted organization’s continuous improvement strategy in 2013,
across 6 outpatient phlebotomy laboratory locations at most continuous improvement work was led by profes-
the main campus of a large health system. The authors sionals from the continuous improvement department
hypothesized that a culture-based continuous improve- rather than local operational managers or teams, relied
ment initiative could: (1) foster a culture of improvement heavily on tools and detailed analysis, subsequently gar-
in each of these working areas, (2) develop each of these nered minimal engagement from those outside the con-
work areas into “model areas” that could function to tinuous improvement department, and often led to
spread the culture of improvement, and (3) reduce patient unsustained change. Although the institution had devel-
wait time for phlebotomy services as aligned with the oped a strong competency within the continuous improve-
institution’s strategic goal of providing timely care. The ment department for application of formal project
focal point of this study is the mechanism by which the management and process improvement methods includ-
thoughts and attitudes of phlebotomy team members (lab- ing Lean and Six Sigma, this skill set remained largely
oratory leaders, managers, and frontline staff) changed as within the continuous improvement department and
they improved their performance and built a culture of evolved to become an “expert-centric model,” wherein
improvement during the initiative. frontline staff and managers remained largely dependent
on continuous improvement experts to apply these meth-
ods. Recognizing this limitation, the continuous improve-
Methods ment team and directors of continuous improvement
partnered with other leaders, managers, and caregiver
Context teams within the organization to collaboratively develop
This study was conducted at a large, not-for-profit aca- a revised model, strategy, and tactics to improve the orga-
demic tertiary care center, at 6 outpatient phlebotomy nization at the cultural and functional levels.17 The lead-
laboratory locations within the main campus, which serve ers of this initiative defined a desired “culture of
~1000 patients per day and employ 47 phlebotomists. improvement” in which every caregiver (including lead-
In 2013, the continuous improvement department, ers and managers) is capable, empowered, and expected
together with executive leadership, initiated a campaign to make improvements every day. Core to the strategy
to create a “culture of improvement” across the 51 000 was the development of continuous improvement
Featherall et al 3

Table 1.  Comparison of Historical and Culture-Based Approach to Continuous Improvement Interventions.

Historical Approach to CI Culture-Based Approach to CI

Minimal time dedicated to communicating project Issues and goals communicated extensively to all stakeholders, including
goals up and down leadership structure front line, managers, and senior/executive leadership, facilitating alignment
Manager/CI staff inform frontline staff of deficits Managers/CI staff respectfully inquire about performance and
understanding of goals and challenges
Managers/CI staff develop and present solutions Managers/CI staff communicate goals and emphasize frontline staff
responsibility for outcomes
Managers/CI staff conduct analysis Open-ended questions used to develop understanding of frontline staff
perspective
Frontline staff are seldom recognized Deliberate recognition and information campaign regarding successful
model areas
Stagnant CI leadership/training structure Recruitment of work area leaders from model areas as trainers/CI
ambassadors

Abbreviation: CI, continuous improvement.

capability in caregivers at all levels of the organization. A Phase II: Visual Management and Rapid Cycle Improve-
comparison of the culture-based approach with the his- ment—Weeks 5 to 24.  During the week of February 1,
torical approach is displayed in Table 1. The details of 2015 (week 5), a continuous improvement department
this model are shown in Supplemental Table 1 (available staff member, in collaboration with the phlebotomists,
with the article online). rapidly created a paper reporting chart that was updated
by the phlebotomy coordinator every half hour. The
Phase I: Measurement and Establishing Goals—Weeks 1 to binary outcome of whether or not 95% of patients had
4. A barcode-based patient wait time tracking system been served within the 15-minute target wait time was
was implemented in the phlebotomy areas (Altosoft, tracked with red or green dots.23 The laboratory supervi-
Newtown Square, Pennsylvania). After data collection sor and phlebotomy coordinator also were tasked with
was established, continuous improvement department tracking failure modes using a magnetic Pareto-type
staff conducted site visits to the 2 highest volume phle- chart (online Supplemental Figure 1).24 The following
botomy work areas. During these site visits, a continuous week (week 6), the phlebotomy area established leader
improvement staff member observed phlebotomy work- standard work to ensure that the visual management sys-
flows and spoke informally with frontline staff with the tem was maintained, performance was discussed with
goal of understanding their perspectives and challenges. the team, and the system used to evaluate the impact of
Conversations were conducted in a manner respectful to process changes was implemented by the team (online
the work and the worker, largely using open-ended ques- Supplemental Figure 2).25
tions. Examples include the following: “How is your With visual management in place, frontline staff began
work area doing today?” “Is the lab performing well to conduct a series of improvement efforts in their work
today?” “Can you show me?” areas.17 The continuous improvement staff coached front-
During this time period, continuous improvement line staff to implement rapid-cycle Plan-Do-Check-Act
department staff explained that senior executives and root cause analysis.26,27 Rapid-cycle improvements
reviewed phlebotomy patient wait times quarterly, and included the following: (1) establishing a “float” phlebot-
also shared the newly collected wait time data with the omist who greeted patients and walked them to a phle-
phlebotomy team. They also discussed the intentions of botomy booth, instead of each technician doing this
the initiative, including wait time improvement, model individually; (2) establishing standard supplies in each
area creation, and area leadership and skill development. booth, which were refilled each night; (3) creating a “start-
Additionally, it was clearly communicated that frontline up procedure” for a technician to prepare equipment for
staff were responsible for improving their work area, the day, prior to opening the phlebotomy area; (4) posting
learning required skill sets, and maintaining performance a magnetic team assignment board, which used name tags
after project completion. Continuous improvement and a schematic of the phlebotomy area floor plan to
department staff also communicated clearly with phle- assign roles for the day; (5) relocating patient check-in
botomy leaders and managers that they were responsible barcode scanners to shorten walking paths; (6) automating
for ensuring that frontline staff were capable, empow- repetitive data entry steps; and (7) establishing a desig-
ered, and expected to improve. nated “overflow” phlebotomist, who would help check in
4 American Journal of Medical Quality 00(0)

patients during times of increased patient volume, when instrument were calculated. Based on instructions from
signaled with a light by front desk personnel. Also, during Press Ganey Associates, Inc., a standard of a 0.15 unit
the first week of April (week 13), it was recognized that change was considered a meaningful change. Analyses
limited and poorly located computer workstations caused were performed using SAS Software version 9.4 (SAS
delays. The continuous improvement department staff Institute Inc., Cary, North Carolina) and R Statistical
member coached the phlebotomy team through the steps Software version 3.4.2 (R Foundation for Statistical
of creating a process map and calculating future state time Computing, Vienna, Austria).
savings. The team used this analysis to present the busi- This study was reviewed by the Cleveland Clinic insti-
ness case for computer workstation changes to manage- tutional review board and was determined to be a quality
ment on the same day.21,28-30 Baseline and post-improvement improvement initiative. Therefore, no institutional review
workflows are shown in online Supplemental Figures 3 board oversight was required.
and 4.
Results
Phase III: Additional Workstations and Post Improvement—
Weeks 25 to 30. Workstations, ordered after conducting Patient Wait Times
the process map analysis, were installed in the blood draw
During the 30-week study period, 113 133 patients uti-
rooms to reduce unnecessary phlebotomist steps for data
lized outpatient phlebotomy laboratory services at the
entry (online Supplemental Figures 3 and 4). Additionally,
project sites. Overall, the aforementioned set of interven-
the visual management board enabled the team, visitors,
tions caused a dramatic increase in the percent of patients
and patients to quickly see the positive effects of their con-
being served within 15 minutes. Specifically, at the end of
tinuous improvement efforts on their patient wait time per-
the study period, more than 99% of patients were seen
formance. The phlebotomy team’s continuous improvement
within the target wait time (Figure 1).
work was highlighted and used to communicate the model
Mean wait time and standard deviation in minutes
area’s success story to other work areas through a variety
decreased steadily across phase 1 (12.7, 13.10), phase 2
of venues, including the organization’s website and social
(7.13, 7.30), and phase 3 (5.87, 5.87). Phase 2, after the
media channels. Internal and external visitors visited the
implementation of visual management, demonstrated
“model area” to observe and learn from the team’s prob-
prolonged bias toward the lower control limit (LCL;
lem-solving efforts and continuous improvement culture.
Figure 2). Furthermore, during the period of rapid-cycle
The chief executive officer visited the area after improve-
improvements, shorter periods of increased bias toward
ments were achieved, and a short video was created to
the LCL and reduced variation were observed. Last, dur-
highlight, share, and celebrate the work.31
ing phase 3, corresponding to the workflow restructuring,
an additional trend toward the LCL with an increased
Study of the Interventions number of wait time sample means falling below the LCL
was observed.
Measures.  Wait times were tracked using bar-coded cards
During Phase 1, 74% of patients waited less than 15
administered at check in and collected at time of service.
minutes. This increased to 91% during Phase 2, and in
Data were tracked using Altosoft (Newtown Square,
Phase 3 it was nearly 94%. Specifically, there were sig-
Pennsylvania).
nificant increases in the odds of a <15-minute wait time
Employee satisfaction and engagement were tracked
in Phase 2 (<0.001) and Phase 3 (<0.001) relative to
using Press Ganey surveys administered in October
Phase 1 (Table 2).
of the year prior to and in November directly after the
initiative.32 These surveys asked participants to rate
agreement with 43 respective statements using a stan- Employee Satisfaction and Engagement
dard 5-point Likert-type scale. From 2014 to 2015, multiple aspects of employee satisfac-
tion increased. The 10 questions with the largest positive
Analysis.  To determine trends in the percent of outpatient changes and 10 questions with the smallest or most nega-
phlebotomy laboratory visits requiring a wait time of less tive changes from 2014 to 2015 are reported in Table 3.
than 15 minutes, Cochran-Armitage trend tests were cal- The entire set of employee engagement component scores
culated overall and by project phase. Odds ratios with are displayed in online Supplemental Table 2.
95% confidence intervals also were calculated overall
and by phase using logistic regression models. To assess
changes in employee satisfaction and engagement, the Follow-up and Durability
difference in Likert-type scale means for each of the Three years after initiation of this work, phlebotomy wait
items on the Press Ganey employee engagement survey time remains <15 minutes for 95% of patients (online
Featherall et al 5

Figure 1.  Patient wait times throughout quality improvement effort.

Figure 2.  Patient wait time X-bar chart.

99% confidence interval; daily sample (n = 9).

Table 2.  Trends by Wait Time Improvement Initiative Phase.

Versus Phase I Versus Phase II

Phase Mean Wait <15 Minutes (95% CI) Odds Ratio (95% CI) P Odds Ratio (95% CI) P
Phase I 0.739 (0.733, 0.745) — — — —
Phase II 0.910 (0.908, 0.912) 3.57 (3.43, 3.71) <.001 — —
Phase III 0.939 (0.935, 0.942) 5.39 (5.07, 5.74) <.001 1.51 (1.42, 1.61) <.001

Abbreviation: CI, confidence interval.

6 American Journal of Medical Quality 00(0)

Table 3.  Outpatient Phlebotomy Laboratory Services Employee Satisfaction Scores With the Largest and Smallest Magnitude of
Change Pre and Post Continuous Improvement Intervention.

Survey Question Mean (2014), N = 29 Mean (2015), N = 22 Change

Adequate department staffing 2.04 3.09 1.05a
Willingness to work at organization in 3 years 3.66 4.23 0.57a
Willingness to recommend workplace 3.52 4.09 0.57a
Respect abilities of my manager 3.76 4.32 0.56a
Overall satisfaction 3.38 3.91 0.53a
Efforts toward safe care delivery 3.89 4.41 0.52a
Productive discussion of errors 3.61 4.10 0.49a
Communication between departments 2.93 3.41 0.48a
Communication between all medical personnel 2.68 3.14 0.46a
Report mistakes without fear 3.46 3.91 0.45a
Decision involvement 3.00 3.18 0.18a
Proud of organization 3.86 4.00 0.14
Effective teamwork among nurses and doctors 3.29 3.43 0.14
Manager respect 4.00 4.14 0.14
Department works well together 3.83 3.91 0.08
Career development opportunities 3.41 3.45 0.04
Recognition 3.28 3.27 −0.01
Freedom to question decisions 2.83 2.82 −0.01
Departments work well together 3.38 3.33 −0.05
Fair compensation 2.41 2.14 −0.27a
a
Considered practically significant for guiding future continuous improvement work.

Supplemental Table 3). Furthermore, the measurement Based on temporal correlation, the greatest improve-
system, visual management system, and supporting ments were driven by alignment of the priorities of senior
behaviors used in this initiative were spread to more than leaders, frontline managers, and staff through respectful
80 additional outpatient phlebotomy laboratory sites conversation and a visible, real-time performance mea-
across northeastern Ohio and are now standard for the surement system (Phase 1). The second most notable
study institution outpatient phlebotomy laboratory areas. improvement in wait time and provider efficiency was
This expansion was driven entirely by phlebotomy lead- during the workflow redesign implementation (Phase 3),
ership and achieved without continuous improvement during which the goal of 95% of patients waiting ⩽15
staff involvement. Additionally, phlebotomy staff from minutes was met.
the model area were recruited to coach frontline staff in Regarding the culture-based approach, the methodolo-
other work areas on building continuous improvement gies presented here focus on the subtler aspects of con-
culture and capability. tinuous improvement, including alignment throughout
the leadership structure, respectful communication and
inquiry, delegating responsibility and providing capabil-
Discussion ity for improvement and maintenance to the local team,
A culture of improvement approach to continuous rewarding and publicizing achievement, and creating
improvement reduced patient wait times and improved clear pathways for leadership and growth. Such an
employee satisfaction in outpatient phlebotomy labora- approach was designed to address the deficits of more
tory services. The effort was conducted over a 30-week centralized, specialist skill set–based approaches applied
improvement cycle (113 133 patients) at a large, inte- previously in the study organization. Instead, the model
grated academic medical center. Following the effort, presented here adapts and simplifies traditional process
99% of patients were seen within the prespecified 15-min- improvement methods such as Lean and Six Sigma, mak-
ute target, variation in wait time was greatly reduced, and ing them accessible to all levels of the organization, with
improvements have largely been sustained for years. In the aim of pervasive rather than special project-focused
addition to benefit to patients, phlebotomy laboratory per- improvement.19 Serving leadership, change management,
sonnel reported significantly higher satisfaction and and other approaches also were applied where needed to
engagement following the improvement cycle. support the desired culture. These interventions led to
Featherall et al 7

improvements, not only in work area performance but from initiation through completion and beyond, reside
also in the attitudes and beliefs of work area employees with the local team, and this strategy is communicated
as demonstrated by engagement surveys. Such changes in clearly from the beginning of the initiative. Simple prob-
attitudes included increases in trust within the department lem-solving tools are learned and applied by managers
(0.25 unit increase), perceptions that mistakes lead to and frontline staff under the guidance of a continuous
positive change (0.43 unit increase), efforts toward safe improvement coach, rather than complex “expert-based”
care (0.40 unit increase), and department working analyses and solutions performed and developed by the
together (0.57 unit increase) (online Supplemental Table continuous improvement department. Respectful and
2). Although improved performance is achievable with- open communication and inquiry are used to allow all
out such mental states through coercion, compliance, cor- caregivers, from front line to executive leaders, to realize
rective actions, and incentives, among others, true the importance of the initiative goals and generate align-
sustained continuous improvement that spreads to other ment. Professionals in the continuous improvement
areas is not possible without such cultural components. department act as coaches and facilitators rather than
The initiative and data reported here demonstrate the fea- implementers of analysis techniques and projects; their
sibility and efficacy of a continuous improvement initia- goal is to spread a philosophy of respect for the work, cel-
tive, focused on work area culture, which leads to ebrate the worker, and build capability among staff at all
short-term performance improvement, changes in work levels, who will in turn coach and develop others to con-
area beliefs and attitudes, and sustained performance and tinue to build this culture (online Supplemental Table 1).19
spread of improvements.
Continuous improvement methods are reported from
settings ranging from outpatient laboratory services and
Limitations
primary care offices to operating rooms.33,34 Although This report has several notable limitations. First, this
many studies describe in detail the techniques, tools, and study was not a randomized experiment and thus direct
outcomes from continuous improvement projects, there is causality cannot be drawn. Second, this study did not
uniformly little acknowledgement of the cultural aspects investigate whether reduction in phlebotomy wait times
of continuous improvement in these reports. As a result, influenced other variables, such as safety or overall
improved workflows are largely imposed on a work area facility throughput, as patients are seen for a number of
and become static or regress after implementation.12,13 In services during the same day. Third, this study was con-
these cases, project leaders are focused on solving the ducted at a single center. Fourth, additional hiring did
apparent problem, often seeking rapid operational impact, occur to reduce overtime in the time period following
rather than developing the mind-sets, attitudes, and skills the intervention and prior to the employee engagement
of the frontline workforce to achieve durable change and survey. This is likely to have affected the “adequate
ongoing improvement. Hence, reports of subsequent suc- department staffing” question. However, all improve-
cessful improvement efforts led by the local team rather ment data presented here were achieved without the
than by continuous improvement professionals are largely addition of staff. Future continuous improvement proj-
lacking. Although continuous improvement entered the ects that focus on culture change at other institutions
mainstream medical literature as early as the 1980s,35 and are warranted, and should use rigorous methods to
was bolstered in the early 2000s by the Institute of assess their impact.
Medicine’s To Err Is Human report,36 the deeper cultural Despite these limitations, the present study begins to
aspects of improvement work have been brought into investigate the important link between improving work-
focus only more recently and remain poorly under- place operations and the attitudes, perceptions, beliefs,
stood.8,14,37,38 Because of subtlety, many continuous and behaviors that both characterize and create a work-
improvement initiatives may fail to address the issue of place culture. In order to most deeply understand the util-
culture and instead become entrapped in formal method- ity of continuous improvement initiatives and their ability
ology or simply enact performance improvement without to lead to durable change, continuous improvement mea-
the ownership of frontline staff. Unfortunately, such sures should be expanded to include variables that oper-
failed initiatives waste precious resources and can lead to ate at a deeper level and may be considered more proximal
reluctance to participate in future improvement work. causes of improvements, such as workplace capability,
In this study, the authors present an approach to con- employee capability and development, employee engage-
tinuous improvement that minimizes focus on tools and ment, compensation methodologies, advancement oppor-
techniques, but focuses on organizational communication, tunities, staff recognition mechanisms, and management
problem-solving efforts of frontline staff, and continuous and leadership engagement, among others. Additionally,
improvement coaching. In this model, ownership of and more rigorous methods can be applied to more strongly
responsibility for the continuous improvement effort, establish causality.39
8 American Journal of Medical Quality 00(0)

Conclusion 11. Dundon JM, Bosco J, Slover J, Yu S, Sayeed Y, Iorio

R. Improvement in total joint replacement quality met-
This study of a continuous improvement initiative dem- rics: year one versus year three of the bundled payments
onstrates the ability of a culture of improvement for care improvement initiative. J Bone Joint Surg Am.
approach to drive sustained, durable change in a health 2016;98:1949-1953.
care setting. In this case, patient wait times for a vital 12. Hartzband P, Groopman J. Medical taylorism. N Engl J
outpatient service were reduced significantly. Med. 2016;374:106-108.
Simultaneously, the satisfaction of the employees ser- 13. Moraros J, Lemstra M, Nwankwo C. Lean interventions in
vicing those patients was improved significantly. These healthcare: do they actually work? A systematic literature
review. Int J Qual Health Care. 2016;28:150-165.
principles may be applied to other areas of process
14. Zarbo RJ. Creating and sustaining a lean culture of

improvement in health care settings. continuous process improvement. Am J Clin Pathol.
2012;138:321-326.
Acknowledgments 15. Brandrud AS, Schreiner A, Hjortdahl P, Helljesen GS,
The authors wish to thank Joseph Knapp for his careful manage- Nyen B, Nelson EC. Three success factors for con-
ment, implementation, and spread of this project. tinual improvement in healthcare: an analysis of the
reports of improvement team members. BMJ Qual Saf.
Declaration of Conflicting Interests 2011;20:251-259.
The authors declared no potential conflicts of interest with respect 16. Institute for Healthcare Improvement. A Culture of

to the research, authorship, and/or publication of this article. Change at ThedaCare. http://www.ihi.org/resources/
Pages/ImprovementStories/ThedaCareFeatureStory.aspx.
Funding Accessed November 11, 2017.
17. Drickhamer D. Transforming healthcare: what matters

The authors received no financial support for the research, most? How the Cleveland Clinic is cultivating a problem-
authorship, and/or publication of this article. solving mind-set and building a culture of improvement.
https://www.lean.org/common/display/?o=2982. Published
ORCID iD May 28, 2015. Accessed March 1, 2018.
Joseph Featherall https://orcid.org/0000-0002-2634-9484 18. Griffin F. How-to guide: sustainability and spread.

http://www.ihi.org/resources/Pages/Tools/HowtoGuide
Supplemental Material SustainabilitySpread.aspx. Accessed March 1, 2018.
19. Yerian L, Hurle N. No More Projects: Kickstarting a

Supplemental material for this article is available online. Continuous-Improvement Culture in Healthcare. https://
createvalue.org/wp-content/uploads/No-More-Projects.
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