Advancing Equity: Lean Leader Practices and a Path Forward.

Abstract

Policy Points This study highlights health care leaders' use of lean management practices to advance equity and scale initiatives supporting the delivery of high-quality care for all patients. As a next step in this work, there is a need to develop new measurement systems with clearly defined performance metrics that ensure accountability to equity standards. Standards can be reinforced by government agencies, professional associations, and accrediting bodies. Examples include building equity-specific metrics into Centers for Medicare and Medicaid Services' Medicare Advantage STAR ratings, American Medical Group Association and America's Physician Groups recognition programs, National Committee for Quality Assurance certification criteria for health plans, and Joint Commission accreditation for hospitals.

Context: Lean management is a sociotechnical approach to quality improvement that aims for consistency in work processes and outcomes. This can be leveraged to reduce inequities by ensuring delivery of high-quality care to meet the needs of patients with diverse backgrounds. Despite recent efforts in the field, there is limited study on how managers implement health equity and workforce diversity goals as strategies to improve patient care. Given the important role of leadership in fostering workplace culture, we examined leader activities and specifically their use of lean management practices to support equity initiatives in health care.

Methods: We conducted in-depth interviews with 67 leaders ranging from C-suite executives to frontline managers in five US hospital-health systems. Interview transcripts were analyzed and validated via parallel coding, yielding an interrater agreement of 92.6%. We identified cross-cutting themes on how leaders use lean methods to promote equity in care settings, and elicited insights regarding barriers, facilitators, and recommendations for continuous improvement.

Findings: Leaders highlighted the lean daily management system (DMS) as a robust platform to introduce and scale systemwide equity initiatives. The DMS consists of standardized practices including tiered huddles, leader rounding, and problem-solving that enable employees to accomplish daily tasks in alignment with organizational priorities. Humble inquiry was also cited as an effective way to address patient safety issues while fostering cultural humility and learning. Leaders strongly recommend integrating equity into other strategic goals (quality, affordability, patient/employee experience) and stratifying data to inform key performance indicators. Recommendations to strengthen accountability include setting equity goals and building them into performance evaluations, clearly communicating cultural norms and expectations, and creating equity-focused data reporting systems as the next step or evolution in this work.

Conclusions: Health care leaders can use lean management to advance equity by reducing variation in care processes and improving measurement of outcomes across diverse populations.