Saskatchewan, like other provinces, spends almost half its budget on healthcare. Historically, growth in spending has been around eight percent each year. Despite this injection of funding, disparities in the quality of care and access to care persist.

The Saskatchewan Ministry of Health is using the lean organizational improvement methodology to create the transformational shift in culture that is needed in the both the ministry and the health system. Lean is a customer-focused approach that puts the needs of the patient first and improves the safety, timeliness, efficiency and quality of care. Lean helps us respond to the needs of our customers as voiced by patients, families, providers and health care administrators. Lean supports the ministry's top priority of achieving a patient- and family-centered health system and of making effective use of its resources to ensure the system is sustainable.

In 2008, the ministry began its lean journey under the leadership of a new Deputy Minister and lean champion, Dan Florizone. The ministry launched four teams focused on different areas: provincial vaccine management; preparation and management of information technology contracts; processing of medical billing claims; and provincial laboratory services.

The ministry's efforts have focused on implementing improvement rather than planning it, and early successes have created buy-in and a demand for future projects. After two years, the ministry now has 20 teams engaged in lean improvements, six of which are tackling issues of a province-wide nature such as the flow of surgical patients between regions.

Why choose lean?

Research has shown that monetary rewards are effective motivators only for rudimentary or routine tasks while purpose, mastery and autonomy are the motivators of innovation. Everyone needs to feel connected to a greater purpose, be able to get better at what they do and have control over their work. Lean is an approach that can motivate public servants in these three ways and, in our experience with its implementation, finding new ways for employees to reconnect with this common purpose has been a powerful motivator for change.

Another intrinsic motivator is mastery. Lean provides a common set of principles and tools to foster collaborative efforts to improve the system. Lean requires us to create a learning organization and foster learning and growth of our employees. Lean breeds a workforce that is committed to a common purpose and has the knowledge and skills to identify and solve problems at the source with innovative thinking.

Lean also fosters autonomy. It is often referred to as an approach that is implemented both top-down and bottom-up. Teams of cross-functional employees must be allowed to identify and define the problems they face and develop innovative solutions.

To foster and encourage autonomy and innovation in a lean enterprise, the formal leader must frequently and consistently communicate the purpose. The leader's role is to help employees link lean to other key strategic priorities in the organization. The leader can remove barriers to implementing improvements, particularly those that impede horizontal flow of value across vertically organized departments or organizations. The leader must be courageous and transparent about systemic problems and not bury the issues employees raise. The leader must abandon authoritarian styles of leadership and empower staff to lead and implement change while maintaining oversight responsibility for the effectiveness of the processes. This is a cultural shift for leaders in traditionally hierarchical organizations, public or private.

Value stream thinking is a core lean principle that teaches that we must focus our improvement efforts on the end-to-end process required to bring a product from raw material into the hands of the customer, to deliver a service, to meet a customer requirement from order to delivery, or to develop a design from concept to launch.

A few short months after the launch of lean within the ministry, it gave $5 million financial support and a strategic roadmap to all regional health authorities and the Saskatchewan Cancer Agency to deploy lean. The 2010-11 Strategic and Operational Directions for the health system, which establishes performance targets for the health sector, requires every region and the cancer agency to deploy lean improvement efforts in at least two areas, including one that directly supports a major provincial strategy to improve the patient's experience with, and access to, surgical services.

To date, regions have launched more than 90 lean initiatives focused on improving a wide array of programs and services including patient flow, linen supply management, laboratory services, medication administration and patient safety.

The ministry's efforts have also created an interest in lean government-wide. In June 2010, the government, as part of its Public Sector Renewal plan, committed to implementing at least two lean improvement efforts in each of 17 provincial government agencies, and intends to have implementation plans for each effort in place by October 31, 2010.

Saskatchewan will be the first provincial government in Canada to incorporate the lean approach throughout its public service. Goals set by some of the first initiatives include a 40 percent reduction in the time to acquire a new hire, a 50 percent reduction in the time for employees and timekeepers to enter timecard data, and establishing and meeting the target deadlines for Cabinet Decision Items 80 percent of the time.

The ministry has learned that lean is not a project, but a journey in which it can transform its services by linking daily efforts with the greater purpose of providing the highest quality services to our ultimate customer - the patients and families we serve.

Trish Livingstone is the director of Health System Quality and Efficiency Management with the Saskatchewan Ministry of Health.

Sidebar

Value stream thinking

A ministry team focused its efforts on vaccine management and distribution related to costs associated with waste from expired products and exposure to unsafe temperatures which totalled $931,000 in 2008-09. By looking at the value stream - the end-to-end process from the customer's point of view - they recognized that the process did not end at the ministry's door but extended into the health region and beyond.

They invited a regional representative to join their team and implemented a pilot project to test their improvement initiatives in this region. They reduced the number of "touch points" for the vaccines as they travelled to the clinics. Additionally, by better matching demand to supply, the team reduced their inventory by 45% and reduced the time to do inventory counts from two days to two hours. Waste caused by exposure to unsafe temperatures was reduced by 65% ministry-wide. Waste due to expired products was reduced by 73%. Overall, the team saved $1.28 million and expects further savings as the improvements are now being spread to other regions.