A Critical Access Hospital’s Lean Journey

Kelly Rinehart, RN and Kathy Haberly, RN

Download PDF


Critical access hospitals are not immune to the healthcare crisis as funding and reimbursement are shrinking for them as well, leading to hospital closures or purchases from large hospital systems.

As hospitals face doing more with less, they are looking at Lean methods to improve their bottom line, and many are finding that the benefits go beyond saving dollars. Improvements in teamwork, staff engagement in process improvement activities, patient safety and satisfaction, and staff and physician retention have positively impacted the organization by creating a culture of daily improvement.

PeaceHealth Peace Harbor Hospital is a critical access hospital located in the coastal town of Florence, Oregon. Leadership recognized the need for doing more with less and incorporated Lean into their strategic plan. In September 2011 and January 2012, they embarked on their Lean journey training 40 managers and frontline staff from areas of hospital administration, central supply, home health/hospice, medical clinics, finance, ICU, surgery, emergency department, central processing, radiology, medical/surgery unit and quality improvement.


The Lean training consisted of six full days of training broken into three modules of two days each. Each module was spaced 10 days apart to allow for Lean homework to be completed before beginning the next module.

Participants learned about the significance of waste in their work and how to identify it when conducting observations. Collecting data prior to making improvements was imperative and was emphasized throughout the training process.

Using Lean methods such as: A3 Problem Solving, Standardization, Value Stream Mapping, Time and Motion studies, 5S, Level-Loading, Just-In Time inventory, and Plan-Do-Check-Act (PDCA), the staff improved processes in their individual work areas during the training period. 

Keys to Success for PeaceHealth Peace Harbor Hospital

Sustainment and spread is the most difficult part of Lean training and improvement implementations. PeaceHealth Peace Harbor Hospital staff used their creative skills to educate, implement, and spread Lean throughout the organization with the following implementations:

  1. A quarterly Lean newsletter highlights Lean successes in departments throughout the hospital.
  2. One resourceful clinic manager used the Lean training to develop a Lean mini course for her staff. She created a training manual with two, one-hour sections designed to be taught during lunch hours.  The first session explains the Lean philosophy and terminology.  The next session covers the Lean tools and how to apply them to Lean projects. Even though these training sessions are brief, frontline staff has learned Lean quickly and come up with numerous project ideas and successful Lean implementations. To date, 72 of 100 staff members have been trained. An additional key to success is keeping Lean work on the forefront. To keep Lean work a high priority, the clinic manager also formed a Lean Leadership Team consisting of all the clinic managers and the hospital Lean facilitator. They meet every six weeks to discuss the status of all Lean projects, assign, and prioritize work.
  3. A Lean Transformation website allows staff access to Lean tools, Lean methodology information, and an electronic Lean project request form they can complete and submit.  The request is routed to the quality team and the staff member’s manager for approval.
  4. Critical to success at driving Lean through an organization is a dedicated Lean Facilitator or two or three. Organizations set themselves up for failure by conducting the training then allowing enthusiasm and momentum to die after the trainer has left because there’s no one driving the work. The Lean facilitator at Peace Harbor tracks projects and project requests, conducts Lean education, performs gemba walks with leadership and maintains the metrics and cost/benefit database.
  5. Incorporating a 15 minute “Introduction to Lean Thinking” as part of the new hire orientation has elicited fresh ideas for projects from these new staff members and demonstrates leadership’s commitment to frontline staff designing and improving their own work.
  6. Regularly scheduled gemba walks with hospital leadership are critical for sustainment and spread of Lean through the organization. Rick Yecny, CEO and Chief Mission Officer for PeaceHealth Peace Harbor Medical Center, demonstrates his enthusiasm and commitment to Lean every time he visits a patient care unit. The staff and Rick benefit from these gemba walks; the staff understand the importance of their Lean work and strive for timely progress with projects to provide a meaningful report and Rick enjoys the opportunity to see his organization at work improving processes and the patient’s experience. In Rick’s own words: “I really love the gemba walks. In Japanese, gemba means ‘the real place.’ I love the gemba walks because I get to see the who and where of value creation from our frontline caregivers and to experience their excitement as they explain each of the many projects occurring across our Medical Center.  Gemba walks are a wonderful way for me to connect with our caregivers and for the caregivers to express the excitement and value attached to each of their projects.”

All of these implementations have been essential to PeaceHealth Peace Harbor Hospital’s success and sustainment of their Lean training and implementations.

Lean Struggles

One of the basic premises of Lean is that frontline staff design and improve their own work. Where Lean often fails is when managers drive the Lean work with no, or little, input from staff. This is a common problem when first initiating Lean improvements. Lean is a culture change for managers and requires stepping back and serving as a guide and coach rather than as the initiator of projects that don’t have meaning to the frontline staff and their work. Managers should assist staff with prioritization of work based on the organization’s strategic plan and after doing a thorough cost/benefit analysis. Of course there are times when a process is so dysfunctional that it is causing actual or potential patient harm. These processes move to the top of the improvement priority list.

PeaceHealth Peace Harbor Hospital experienced difficulty in one department where the manager has been the driver for most of the projects.  Without staff buy-in, there has been limited success in implementing Lean in this department.   This experience reinforced the fact that it’s critical for frontline staff to take ownership of their work.

Collecting data is an area that needs to be addressed in Lean training since frontline staff is not familiar with collecting and presenting measurement data. Staff will frequently jump into process improvement activities before collecting any baseline data. Without the baseline data they have no idea whether the target really is a problem and how much they’ve improved once they complete the work.

Time to work on Lean projects is always a problem. Departments often work with minimal staff and Lean must support the Lean work by releasing the time necessary to work on projects. This may mean keeping staff in their departments on low patient census days to do Lean work. Keeping staff in the unit for even a few hours, rather than sending them home, has helped keep projects on schedule and moving towards completion.


As a result of the training and improved Lean skills amongst staff, the Lean Facilitator is receiving three to five Lean project requests per week.

Since the first training session nine months ago, 12 departments have successfully completed over 50 projects with over 40 projects still in progress.

Within the first Lean training session, a total of six weeks, the 20 participants saved the organization $17,486.00 and eliminated nearly 1,000 hours of waste.


An often overlooked benefit of Lean work is the way it enhances teamwork, communication and collaboration skills in staff.  These skills directly improve patient care and satisfaction, job satisfaction and cohesiveness of the organization. PeaceHealth Peace Harbor Hospital has observed greater teamwork amongst staff since their implementation of Lean. All assigned projects require a team of individuals to do the work and provide communication to other staff members. People are no longer allowed to work in silos. These behavioral changes are what drive a culture change within an organization and PeaceHealth Peace Harbor Hospital is well on its way to developing a culture of daily process improvement.


Kelly Rinehart, RN
Lean Consultant, Medical Risk Consulting, LLC

Kathy Haberly, RN
Lean Facilitator PeaceHealth, Peace Harbor Hospital


version 09.19.2012