Quality Improvement For Institutions | Lean Thinking: Changing Culture. Improving CV Care.

Cardiology Magazine ImageJavier Sala Mercado, MD, PhD, with his dear friend and Lean mentor Marcerlo Zottolo, currently vice president of system analytics at Lee Memorial Health System in Florida.

Since its founding more than 40 years ago, the Instituto Modelo de Cardiología (IMC) Privado S.R.L. has been a leader in innovating cardiovascular care in Argentina. Located in Córdoba, IMC launched its cardiac rehab program in 1974 and performed Argentina's first percutaneous transluminal coronary angioplasty for acute myocardial infarction in 1988.

More recently, IMC, a CathPCI Registry participant and the first hospital in South America to receive Heart Failure Accreditation and Chest Pain Center Accreditation as part of ACC's Accreditation Services, was recognized as part of the ACC International Center of Excellence Program for its commitment to optimizing cardiovascular care and improving patient outcomes.

There's no question that innovation is in the DNA of the IMC. The Institute has been on a continuous journey to drive the advancement of cardiovascular care in Argentina and South America and efforts have accelerated since 2012 with the implementation of Lean thinking.

The Lean management strategy, which aims to maximize the value provided to customers while reducing waste, has strong roots in the manufacturing industry, but is applicable to businesses of any size in all sectors, including health care.

A Journey, Not a Destination

Cardiology Magazine ImageJavier Sala Mercado, MD, PhD, (left) and Professor Isao Yoshino (right) during a Lean learning session in Japan organized by The Ohio State University.

Javier Sala Mercado's, MD, PhD, interest in Lean was sparked 12 years ago when he had an "aha" moment discussing its potential impact on health care transformation with Marcerlo Zottolo, an engineer and consultant who has led Lean implementation in companies and hospitals across Europe and the U.S.

This launched Sala Mercado's Lean journey and he spent the next several years gaining deeper knowledge of the principles by studying cases and learning from mentors at factories, universities and hospitals in the U.S., Japan and Brazil.

In 2012, when Sala Mercado introduced the concept of Lean at IMC, to his knowledge, no other institutions in Argentina were applying Lean and the terminology and philosophy were completely foreign. As such, the proposal for Lean implementation was met with some skepticism amongst IMC leadership.

There was some resistance from board members who thought focusing on clinical innovation would provide the greatest value to patients. Sala Mercado set out to prove how process innovation would support the Institute's True North: advancing patient-centered care.

Small Steps, Big Impact

Lean thinking is now at the heart of the IMC, but it has taken almost a decade to get to this point. And the journey is far from over. Sala Mercado, who is now IMC's vice chief medical officer and chief operating officer, director of the cardiology program at the National University of Cordoba, and IMC Lean leader, started by achieving quick wins to get the support of the board.

Patient registration and appointments, pharmacy, laboratories, administration, IT, purchasing and the maintenance department were identified as areas ripe for immediate process improvement and patient flow optimization. Efforts focused on improving patients' experience by reducing unnecessary steps and waiting time.

Once the results and benefits were proven in the support area, physicians in the institution saw first-hand the benefits of Lean and began to regard it as advantageous both for them and their patients.

With momentum building and internal support growing, the next step was to expand Lean training and establish champions within the organization. In 2016, Sala Mercado led four IMC physician leaders on a trip to the Academy for Excellence in Healthcare, a collaboration between The Ohio State University Fisher College of Business and Cardinal Health, where they were immersed in the Lean principles and how to apply them to achieve institutional transformation. Two years later, the Academy came to Argentina and trained another 20 leaders as Lean leaders.

The Role of Data

Sala Mercado notes that there isn't a finish line when it comes to Lean implementation. Instead, it's a continuous effort of evaluation and process improvement. Real-time data are constantly consulted and analyzed to objectively evaluate how the organization is performing as opposed to making decisions based on how leaders think the organization is doing or the way patients think things are being done.

Sala Mercado is wholeheartedly dedicated to using data to drive decisions. However, he stresses it must be the right data. "It's better to have no data than bad data." His love of data led him to create IMC's Operational Excellence Office that is responsible for overseeing accreditation and metrics/benchmarking (i.e., door-to-balloon times).

Cultural Transformation

Cardiology Magazine ImageParticipants of The Academy of Excellence in Healthcare course on "Creating Lean Leaders to Drive Change in Argentina."

Implementing a Lean process improvement strategy required a cultural paradigm shift at IMC. As part of its long-term vision, the Institute dove headfirst into pursuing accreditation and continuous quality improvement. In order to be successful, it was crucial that IMC's employees were fully aligned with this vision and were willing to change everyday behavior.

While there was some attrition in the early days, and there are different maturity stages throughout the organization, today, Lean thinking is overall at the core of IMC's culture and its employees are continuously looking for ways to improve the patient experience and maximize the use of the Institute's facilities.

How did IMC successfully change its culture? Clear and consistent communication and teamwork played major roles. Physicians were involved at every step and leadership always tied changes back to the value added to patient care, helping to unite stakeholders and mitigate resistance to change.

Expansion Efforts Underway

IMC isn't stopping its Lean efforts anytime soon. In fact, its learning lessons from Brazil and creating the Lean Institute of Argentina that will be incubated by IMC for the first five years before spinning off into an independent organization.

There isn't a secret recipe for success when it comes to Lean implementation, but the work that Sala Mercado and IMC are doing in Argentina has the potential to greatly impact cardiovascular organizations around the world that are working tirelessly to achieve the Quadruple Aim of better outcomes at lower costs and improved patient and clinician experience.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Acute Heart Failure

Keywords: ACC Publications, Cardiology Magazine, Patient-Centered Care, DNA, Heart Failure, Myocardial Infarction, Accreditation, Registries, Academies and Institutes, Pain Clinics, Argentina, Brazil, Leadership, Consultants, Quality Improvement, Angioplasty, Balloon, Coronary, Benchmarking

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