Ann M. Dohn, M.A.

Stanford DIO

Nancy A. Piro, Ph.D.

Program Manager/ Education Specialist

Changing the Culture: GME-Streamlining and Standardizing for Cost

Savings and Efficiencies

Disclaimer

No Conflicts of Interest to Report

Session Core Competency Focus

This presentation addresses the GME Leader Core Competencies of:– Developing and Supporting

Residency Program Directors & Coordinators

– Managing the Institution’s GME Operations.

Three Key Session Objectives

1. Provide a foundation for the understanding and application of lean philosophies and practices to GME.

2. Describe specific process improvement measures that can result in increased efficiency and cost savings in a graduate medical education (GME) setting.

3. Provide a Toolkit Forms Templates Examples to streamline and standardize

GME processes at their respective institutions.

Thinking Out of the Box?

Thinking Outside the Box – Looking to Industry and Corporations

What does industry have that we can use?– Conveyor belt to move patients in

and out of OR’s?

No….

But they do use a “Lean Philosophy”– Respect for People– Total Elimination of Waste

And they use “Lean Tools” such as – Kaizen– 5S’s– 3 M’s

Lean – Toyota Production System (TPS)

TPS system managed to get by with “half of everything”!– Physical space– Personnel– Capital Investment– Inventory

Resulted in far fewer than half the defects and safety incidents

NUMMI

Lean Culture Shift

Make problems visible – not hide them or “not talk about mistakes/problems”

Fix problems permanently – get to the “root cause” and eliminate it.

Focus on the value and respect for people.

Lean Tools --- A Sample

Kaizen Elimination of WASTE - 3Ms Problem Solving

– 5 Whys– Fishbone Diagrams (Ishikawa

Charts) 4 Ms– 4 Ps

Lean Tools: Kaizen

What is ‘Kaizen’?Gradual, unending continuous improvement of processesProcesses must be improved to get improved resultsBy improving and standardizing activities and processes, Kaizen aims to eliminate waste

Kaizen Basics

Focus is on small, incremental change (not necessarily huge leaps, innovation)

Quality Control = quality of people– “A company that is able to build

quality into its people is halfway to building quality outcomes”

Respect for People– “Only people produce

improvements”

Lean Tools: 3M’s

All about Waste- Identifying it and Removing it– MUDA = Waste of using resources

without creating added value– MURI = Waste of overburdening

people or equipment/resources– MURA = Waste of unevenness,

variability in processes

Five Why’s Problem Solving Method

Keep asking ‘Why’ until you discover the root cause of the problem

– No magic in 5 – might be 3, or 7, or 10 Why do we? (conduct orientation in

person, fill out multiple forms, take on line training for non MDs)

Lean Tools: – Fishbone Charts using the 4Ms – 4 Ps

Manpower/Personnel Materials Method(s) Machines / Equipment

People Process Policy Principles

Ishikawa Diagram of ER Prolonged Wait Times

Materials Methods/Process

Manpower/People Machine\Equipment

WHY? WHY?

WHY? WHY?

xxx hr wait time in ER

5Ss - Mnemonics Retained

Sorting Simplifying Sweeping Standardizing Self Discipline

= Seiri

= Seiton

= Seiso

= Seiketsu

= Shitsuke

QUICK EXERCISE

5Ss in Action

19

AFTERBEFORE

ER Rooms

Now ---How Can this be Applied to GME?

Have read the books Know the materials Understand the tools Have stolen former Toyota

Manager …– So what do we do

Putting Philosophy into Practice

Flowchart the processes– Ask- “Why are we doing this?”

Fishbone the problem Huddle to discuss with the team Look for the 3Ms Apply the 5Ss

Start with the Current State

CURRENT CULTURE– Paper driven registration (forms,

forms, and more forms)

CURRENT CULTURE

– 87 programs (87 fiefdoms all doing their own thing….but having common requirements)

Current Culture

Lack of standardization/inconsistencies (MURA)

Overburden (MURI) Waste (MUDA) of both materials

and time– Lots of files– Time to file personnel folders or

ACGME letters

Time-consuming institutional oversight of programs (MUDA, MURI)

Streamlining a GME Process Example

What GME Processes would be the best targets to streamline and improve eliminating waste and redundancies?

Where to start?

Low hanging fruit vs. most impact on residents/faculty/GME staff

Actually you can do both!!!

Drivers: Where to start?

Areas of largest number of ACGME citations?

Questionnaire data?– Program Directors’ Needs Analysis– Incoming House Staff survey data– Annual GME resident survey data– Program Coordinator requests

Where to start?

Huddle-need team involvement– Respect for people– Respect can lead to elimination of

unnecessary work

Real Time Examples of What We Standardizing We Have Done

Project One: Program evaluation standardization

Project Two: Orientation standardization/streamlining

Project Three: Policy standardization

Project Four: Summative evaluation standardization

Project Five: Paperless Office/Registration

Project One: Standardize Program Evaluations

Factors driving decision to standardize:– Largest number of program citations

from ACGME– Lack of consistent data on program

evaluation for APRs (MURA)– Huge amount of paper generated to

produce suboptimal evaluations (MUDA)

– Burden of work on the coordinators (MURI)

Standardized Program Evaluations

What did we do?Developed standardized comprehensive core competency-based Program Evaluations – by Faculty and Trainees Presented the draft templates to the Program Directors who edited and approved them.

Standardized Program Evaluations – Process Implementation

Annually the GME office:– Delivers --via our Residency

Management System (RMS)--176+ evaluations

– Aggregates each program’s data after the evals have been completed

– ‘Prints’ (electronically to pdfs) their aggregate Program evaluation reports

– Posts the Program Eval Reports (pdfs) on their APR site (in the RMS)

Program Evaluation Standardization “Toolkit” Example

Standardization of Program Evaluations

Benefits– Fewer citations– Can be input to our Institutional

Report Card– Easy oversight by DIO/GMEC– Early warning system

Results of Project One

Less paper wasted (none used) Program evaluations sent out

centrally by GME using standard evaluation forms

Compliance with program evaluation can be easily monitored by GME

Reduction in ACGME citations Less concern about

confidentiality from house staff

Project Two: OrientationStandardization/Streamlining

360+ incoming residents/fellows attending one day orientation sessions– Completion of various

mandated training– Issuance of computer codes,

pagers, ID badges, parking permits, etc.

How do we cope with residents unable to attend orientation?

CURRENT CULTURE

– Face to face orientation great to know what we look like but big

differential in quality of some presentations

inability to really control content of each presentation and test knowledge of materials

Wasted both incoming trainee time and staff time - MUDA– 20+ speakersLong lines waiting for such stations

as photo ID - MURI Lack of standardization of

presentations - MURA Loss of the one auditorium large

enough to hold groupDifficulty in keeping the attention of

the trainees (material overload vs. shopping at Nordstrom's) - MURI

Project Two: OrientationStandardization/Streamlining

Project Two: Web-based Orientation

Based on the input from resident orientation questionnaires:– All mandatory modules became Web-

based Offered in advance of orientation Many have post tests Can verify completion of training Can be done from home/Starbucks

Unintended Outcome

Have we gone too far?

Project Three: Standardization of Policies

Design a policy template for common program requirement policies to reduce redundancies (MURA, MURI, and MUDA)– Supervision– Moonlighting– PLAs– Recruiting– Duty Hours– Work Environment– Beyond Duty Hours– etc.

Policy Development

Teaching the Use of Policy Templates

Program director noon conferences

Policy writing workshop

Monitoring Implementation of the Policies

Verify in our residency management database (system which cannot be named)

Easy Online Policy Verification for each program - Example

Project Four: Summative Evaluations – The Drivers

ACGME Citations– Incoming and Outgoing!!

Multiple / variable forms (MURA) Redundant wasted paper (MUDA) Overburden PCs and PDs (MURI)

How Do We Do This Efficiently and Effectively?

Fill in the blank?

Multiple Choice??

Can my coordinator help me out here?

Fill in the blank?

Multiple Choice??

Can my coordinator help me out here?

Project Four: Summative Evaluations – What did we do?

Developed Standard Evaluation Template for Summative Evaluations

Comprehensive over program training years

Core-competency based

User friendly word document

Held Program Director and Program Coordinator Teaching Sessions / Workshops

Taught the use of the template and how to pair it with aggregated

evaluation data from our RMS

Use of Resident Evaluations from RMS:

Programs could select the evaluations to use –– We recommended:

Evaluations Competencies by Resident Resident/Faculty Ranking Report

(aggregate) Aggregate Comments Report Evaluation Competencies Report

Coordinate with Aggregated Evaluation Data

Summative Evaluation Template

Macro-enabled Word Doc

Additional Considerations

Special Cases– At the end of a preliminary year

(internship) Need to list Rotations

Final Points

Review report with trainee Place a copy of the summative

evaluation in the Trainee’s permanent file and upload to our residency management system

Project Five: The Paperless GME Department

Files Program reviews Registration PIF reviews

Project Five: The Paperless GME Department

Load all forms into the residency management system (RMS)– Scan– Upload– Direct enter

Project Five: The Paperless GME Department

Program reviews– Review on line

Duty hours Policies Annual program review documentation Evaluations

– % complete– Ranking status– 360’s– Surveys– Board pass rates – etc…

Project Five: The Paperless GME Department

PIF Reviews– shared document review on line

Project Five: The Paperless GME Department

Incoming House Staff– Learning modules web-based

Standardized content Post tests Tracking that all modules complete Annual review of module content

– Registration Summative Evaluation Acquisition Access to RMS system to enter data Upload forms/documents

Project Five: The Paperless GME Department - Results

500 fewer pages of paper per Internal Review x times 2 drafts and an average of 20 Internal Reviews per year = – Savings of 40 reams of paper =

Two entire trees saved (17 reams of paper = one tree)

Time Saved (walking, waiting, mailing eliminated)

Questions?

Contact Information:

Ann Dohn, DIO– adohn@stanford.edu

Nancy Piro, Program Manager– npiro@stanford.edu