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GoalThis study explored the use of a Lean daily management system (DMS) for COVID-19 response and recovery in U.S. hospitals and health systems. Originally developed in manufacturing, Lean is an evidence-based approach to quality and process improvement in healthcare. Although Lean has been studied in individual hospital units and outpatient practices, it has not been examined as a whole system response to crisis events.MethodsWe conducted qualitative interviews with 46 executive leaders, clinical leaders, and frontline staff in four hospitals and health systems across the United States. We developed a semistructured interview guide to understand DMS implementation in these care delivery organizations. As interviews took place 6-8 months following the onset of the pandemic, a subset of our interview questions centered on DMS use to meet the demands of COVID-19. Based on a deductive approach to qualitative analysis, we identified clusters of themes that described how DMS facilitated rapid system response to the public health emergency.Principal findingsThere were many important ways in which U.S. hospitals and health systems leveraged their DMS to address COVID-19 challenges. These included the use of tiered huddles to facilitate rapid communication, the creation of standard work for redeployed staff, and structured problem-solving to prioritize new areas for improvement. We also discovered ways that the pandemic itself affected DMS implementation in all organizations. COVID-19 universally created greater DMS visibility by opening lines of communication among leadership, strengthening measurement and accountability, and empowering staff to develop solutions at the front lines. Many lessons learned using DMS for crisis management will carry forward into COVID-19 recovery efforts. Lessons include expanding telehealth, reactivating incident command systems as needed, and efficiently coordinating resources amid potential future shortages.Practical applicationsOverall, the Lean DMS functioned as a robust property that enabled quick organizational response to unpredictable events. Our findings on the use of DMS are consistent with organizational resilience that emphasizes collective sense-making and awareness of incident status, team decision-making, and frequent interaction and coordination. These features of resilience are supported by DMS practices such as tiered huddles for rapid information dissemination and alignment across organizational hierarchies. When used in conjunction with plan-do-study-act methodology, huddles provide teams with enhanced feedback that strengthens their ability to make changes as needed. Moreover, gaps between work-as-imagined (how work should be done) and work-as-done (how work is actually done) may be exacerbated in the initial chaos of emergency events but can be minimized through the development of standard work protocols. As a facilitator of resilience, the Lean DMS may be used in a variety of challenging situations to ensure high standards of care.

EXECUTIVE SUMMARYHospitals with a challenging payer mix (CPM)-high proportions of uninsured and Medicaid patients and a low proportion of commercially insured patients-are an important source of care for low-income, uninsured people. Achieving profitability is difficult for CPM hospitals. From 2005 through 2008, only one-third of 67 CPM hospitals in California reported positive total margins. In-depth group interviews were completed with the management leadership teams of a diverse group of five profitable CPM hospitals to identify the management strategies and practices that the hospitals' leadership teams credited for their financial success. Twelve management policy and practice topics were identified. Four of the policies and practices that managers identified involve organizational actions to increase hospital revenue or operational efficiency. These factors are consistent with those identified in previous research. However, managers also identified eight factors not previously revealed in research on hospital profitability, including management policies and practices that establish the organizational culture, workforce, relationships, monitoring systems, and governance necessary to ensure that hospital employees and affiliated physicians support and successfully implement organizational actions necessary to achieve profitability.INTRODUCTIONFor many years, there has been widespread concern about the financial viability of our nation's safety-net hospitals (Cunningham, Bazzoli, and Katz 2008; Bazzoli et al. 2006; Bazzoli et al. 2005; Cunningham 2007). These public and not-for-profit hospitals are a major source of care for lowincome, uninsured, and underinsured people. Although there is no universally accepted definition of a safety-net hospital, generally such hospitals are characterized by a challenging payer mix (CPM), which we have defined as the combination of (a) a high percentage of Medicaid (Medi-Cal in California) patients; (b) high uncompensated care as a percentage of expenses1; and (c) a low percentage of commercially insured patients in relation to other hospitals (NAPH 2010). Typically, it is difficult for hospitals witfi these three characteristics to achieve financial profitability, because the revenue received from commercially insured patients may be insufficient to make up for the losses incurred from providing services to uninsured patients and patients covered by lower-paying Medicaid and Medicare programs (Felland et al. 2010). Since the beginning of the recession in 2007, rising unemployment and decreasing tax revenues have increased the challenges CPM hospitals face (Holahan and Garrett 2009). The 2009 American Recovery and Reinvestment Act (ARRA) helped maintain the financial viability of safety-net hospitals (Felland et al. 2010). However, even with the support provided by ARRA safety-net providers reported more financial strain in 2008 and 2009 than in previous years (Felland et al. 2010).The literature suggests that many factors that affect hospital profitability are beyond managers' immediate control, including a given hospital's geographic location, extent of health insurance coverage in the primary service area, ownership status, teaching status, amount of competition in the market (Younis, Rice, and Barkoulas 2001; Younis and Forgione 2005; Gapenski, Vogel, and Langland-Orban 1993), and penetration of managed care (Resnick et al. 2005). However, previous studies have also identified a number of factors that hospital management can influence to a greater or lesser extent (in collaboration with others, including nurses and physicians), including factors such as adjusted number of employees, length of stay, bed capacity, occupancy rate, volume of Medicare and Medicaid patients (Younis, Rice, and Barkoulas 2001; Younis and Forgione 2005), surgeon productivity (Resnick et al. 2005), capital structure (Das 2009), supply of physicians in the local market (Kim 2010), amount of nonoperating revenue (net income from sources not directly connected to patient care) (Schuhmann 2010), and market share (McCue 2007). …

In recent years, spurred by developments in evidence-informed medicine, a movement to strengthen evidence-informed managerial decision making in healthcare organizations has emerged in the United States and in other countries. The drivers of this movement include demands by payers and consumer groups for improved quality of care, increased operational efficiency, and greater accountability from healthcare organizations. But numerous barriers to managers' use of evidence in decision making exist, including time pressures, perceived threats to autonomy, preference for colloquial knowledge based on individual experiences, difficulty accessing the relevant evidence base, reliance on external consultants (and others) to determine the quality of the information, and lack of resources. To help managers overcome these barriers, we developed the Informed Decisions Toolbox. It provides tools to help managers efficiently perform the six key steps in the evidence-informed approach to decision making: (1) framing the management question, (2) finding sources of information, (3) assessing the accuracy of the information, (4) assessing the applicability of the information, (5) assessing the actionability of the evidence, and (6) determining if the information is adequate. To build an organizational environment conducive to evidence-informed decision making, we suggest four leadership-driven strategies: (1) recognize and respond to the growing demand for accountability as a strategic issue, (2) establish organizational structures and processes for knowledge transfer, (3) build a questioning organizational culture, and (4) build organizational research capabilities. With organizational support, managers who use the tools presented in the Informed Decisions Toolbox will be able to take control of the decision-making process, will be less reliant on colloquial evidence and consultants, and will be better able to improve the performance of their organizations.

In many developed countries, including the United States and the United Kingdom, the relationships between doctors and hospital managers are strained. The purposes of this article are to examine survey data from the United States and the United Kingdom on doctor-manager relationships and to identify the sources of strain common to both countries as well as those particular to each country's health system. The two countries exhibited many similarities. A very high proportion of respondents from both countries identified external factors-such as governmental budget cuts, pressure from third parties to increase physicians' workload, and the turbulence of the policy environment-as important barriers to improving doctor-manager relationships. Other common sources of strain were concerns over resource availability and the relative power of doctors and managers. Sources of relationship tension particular to each country were also found. Substantial divergence of opinion was expressed with respect to internal factors that affect doctor-manager relationships. Respondents from the United States were more negative than those from the United Kingdom in their ratings of teamwork and communication between doctors and managers, and they were also less likely to have confidence in the medical staff. Respondents from the United Kingdom were more likely to believe that hospital management is driven more by financial than clinical priorities. Managers can implement several strategies to improve doctor-manager relationships, including greater organizational transparency in decision making; more frequent communication between managers and doctors; and more physician involvement in decision making, especially with regard to important resource-related decisions, and in organizational governance.