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This content is taken from the The University of Warwick & Monash University's online course, Leadership for Healthcare Improvement and Innovation. Join the course to learn more.

Skip to 0 minutes and 4 seconds GAYLE SMITH: We had a unique opportunity about 6 and 1/2 years ago because there was a new CEO and a new executive team, and we built the strategy together and I think that we know that we were some way from actually being able to achieve that. So we knew that we had to do things differently and in fact the CEO was leading the organisation to be a different organisation.

Skip to 0 minutes and 39 seconds So that gave us permission and authority to go about setting up a system that was going to focus on getting us to where we wanted to get to, so the re-design leads, the people that are responsible within our health service they’re responsible for providing improvement programme and developing the organisational capability for improvement and determining the improvement methodology that we’re going to use.

Skip to 1 minute and 14 seconds So we’ve taken a very explicit and deliberate approach to improvement and said that if we’ve lined– we’ve actually lined it up with our strategy and said, if we’re going to achieve our organisational strategy and our strategic objectives, then we’re going to need to improve, and we need to align our improvement programme with our strategy and ensure it delivers on those key organisational objectives. So the re-design lead has really taken responsibility for setting up that programme across the organisation, and then delivering that. And that’s required some– first of all, to develop the methodology and all of the tools. Secondly, to train people in their use and then thirdly, to support, coach, monitor, cajole, help people to continue to use the methodology.

Skip to 2 minutes and 9 seconds I think that what we’ve described it as, is leadership at all levels. So we’ve really had to first of all work at getting permission, if you like. So we took a deliberate approach that said we’re going to talk to everybody about what improvement methodology do we want to use. And then we’re going to get them to sign up to it.

Skip to 2 minutes and 33 seconds And so what we did was develop it in consultation with our senior leaders and our front line managers. And then we got approval for it, and we then said what we need is people to consistently use it. If variation is a problem in all of our practise, then variation improvement methodology is also a problem. So we needed to use a strong evidence base for our improvement methodology, and we needed to get compliance with actually using it. We know what works in terms of improvement methodology– and that’s not saying that it’s easy, because it does require rigour and it does require persistence to continue to use that improvement methodology.

Skip to 3 minutes and 18 seconds But we have the results that show if you go about doing improvement in an evidence based way, then it can deliver the organisational results that you’re looking for. What we’ve tried to do is wrap support systems around them, to help make it easier for leaders to use our improvement methodology. We’ve not only provided the training, but we’ve provided regular reporting. We provide assistance for them to provide the reporting. We set up forums for them to be able to report in, and we make them work very visible at all levels of the organisation. And I think that is building a culture of improvement and building a culture where we celebrate achievements in improvement, and progress in undertaking improvement methodology.

Skip to 4 minutes and 11 seconds And that enables us to build an organisation, and networks across the organisation where people not only feel good about the improvement that they want to do, but see other people doing that improvement and see the celebration that happens and actually want to be a part of that.

A strategic approach to lean at Eastern Health

Here we will look at how lean implementation can be made more strategic and systems-focused. We look specifically at a strategic model of lean implementation at Eastern Health, a large ‘health service’ organisation in Melbourne, Australia. Please read the summary text below and then watch the short interview clip with Gayle Smith, Executive Director of Quality, Planning and Innovation.

A common problem with many lean initiatives is their often patchy, fragmented and piecemeal nature. While they may deliver pockets of improvement and best practice, often the impact on the system as a whole is limited or even negative. For this reason, it is frequently argued that the more strategic lean projects become, the more chance they have of success. According to Balle and Regnier, (2007: 35) in lean ‘basic stability is absolutely essential to create the proper learning environment where employees can see clearly the impact of their actions and then learn through the kaizen activities’.

An example of how lean can be made more strategic is Eastern Health (EH): one of the largest public health services in the Australian state of Victoria, serving more than 770,000 residents. EH offers a wide range of health services to this community, ranging across acute care facilities to community health services. In total it has seven hospitals, three of which are equipped with Emergency Departments. As one of 32 health services in Victoria, EH is funded by the state’s Department of Health and Human Services (DHHS) and participates in that state’s Redesigning Hospital Care Programme (RHCP) which we discussed in Week 2.

Responding to government calls for change in 2008, EH established a redesign team, reporting directly to the main board. Over time, this team has grown from one FTE to 4.8 FTEs and now provides training, coaching and support to all staff across the organisation. A major advantage is that this team has had a relatively stable membership contributing to the development of both individual and organisational capability in redesign and improvement.

At the outset, this team consulted external agencies (e.g., local health services and health services elsewhere in the state) and also undertook study tours to the UK, North America and New Zealand to learn more about current best practice. Initial redesign and improvement work in EH then focused on specific areas such as surgery waiting lists or outpatient clinics, in line with DHHS priorities. Over time, however, this work has taken on a more strategic dimension with a specific goal to ‘deliver great care everywhere’. This was labelled the ‘Eastern Health model for redesign improvement’ based on lean thinking principles, including visibility standardisation and continuous improvement. As part of this process, the EH team developed multilevel and local level tools (to guide change management) and invested heavily in face-to-face training, online courses and rapid improvement events to build capabilities. There are currently 25 lean projects ongoing across key service areas including general medicine, emergency department, pharmacy, surgery and medical workforce development. Together these projects aim to deliver improved patient access and flow through the health service and achieve specific targets, including a 4-hour emergency department length of stay.

In future, EH plans to develop a robust return on investment (ROI) model to evaluate progress. However, initial signs are very positive. A notable success story is the ‘every minute matters’ programme (increasing clinical response times). Here, lean principles have been implemented most fully with notable improvements in financial outcomes and patient flow.

Overall, the case illustrates the benefits of adopting a strategic approach towards lean, engaging the wider community of clinicians in the process (to secure legitimacy) rather than just members of the redesign team. It also shows how committing to a single redesign methodology (such as lean thinking) can offer greater clarity and increase the chances of successful implementation.


Balle, M. & A. Regnier (2007) Lean as a Learning System in a Hospital Ward. Leadership in Health Services, 20 (1): 33-41.

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This video is from the free online course:

Leadership for Healthcare Improvement and Innovation

The University of Warwick