Health care organizations began implementing Lean management and high reliability organization (HRO) principles in the 1990s to improve quality and efficiency by aligning leaders and staff to a shared vision, fostering a culture of continuous improvement, identifying the root causes of complex problems, and engaging frontline staff as drivers of improvement efforts.1 There are 4 components for establishing a Lean management system: (1) leader standard work; (2) visual management; (3) daily accountability; and (4) discipline to institute the first 3 components.2 Leader standard work promotes continuous improvement by setting a standard routine of behaviors, actions, and tools consistently performed by leadership. These include routine and frequent frontline check-ins (ie, Gemba walks) as well as standardization of employee onboarding, training, and evaluations. Visual management refers to the process of making problems and abnormal conditions readily apparent to staff and leadership.3
The US Department of Veterans Affairs (VA) is committed to implementing similar principles of HROs, which focus on error analysis and process improvement to foster a culture of safety, leadership commitment, and staff engagement.4,5 Visual management is an important tool for HROs; it reflects the mindset of promoting transparency, teamwork, and openness.6,7
Visual management boards (VMBs), such as huddle boards, Gemba boards, or visibility walls, are critical tools that can promote daily accountability and the core principles of Lean thinking and HROs.1,6,8,9 Accountability is enhanced through frequent real-time, data-driven feedback between staff and leadership. This is often facilitated with a huddle, a structured and disciplined team meeting that provides bidirectional information.1 Frequently, a VMB is incorporated into the structure and flow of the huddle.
In a literature review of 20 years of implementation of Lean management systems in health care, Winner and colleagues report that while the frequency and duration of huddles vary, they are often united by several characteristics, including the involvement of the unit team, focus on feedback, problem identification and solutions, and central location around a visual board.1 VMBs most often take the form of a magnetic, dry-erase board located in a hall or conference room central to the work area.1 In addition to identifying and tracking problems in the place of work, VMBs can also provide a representation of key performance indicators and metrics, disseminate essential unit information, and acknowledge the work and successes of staff and leaders.6,8-12
This article outlines the commitment of the Lieutenant Colonel Charles S. Kettles VA Medical Center (VAMC) within the VA Ann Arbor Healthcare System (VAAAHS) to the HRO principle of visual management. We describe the incorporation of VMBs throughout VAAAHS and provide a detailed report of the development and use at a large outpatient subspecialty clinic.