creating a model line jba doc

© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply

2

What is a Model Line?

A value stream that achieves complete elimination of waste so that all activities

along the value stream create value.


3

Why Have a Model Line?

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•  A model line focuses the resources for lean improvement work in a defined value stream.

•  A model line serves as a “model” to allow others to see lean principles in action.

•  Allows more rapid improvement in an area of concern.


Line Improvements Line Line

Vertical development

(Link processes to create a cell)

Plane Improvements Plane

(Link cells to produce a product)

50% today beats 90% tomorrow every time

Don’t require perfection - Fail forward quickly

Just do it! - You will learn as you go

Point Point Point

(Eliminate waste at source - Just start

somewhere)

Point Improvements

Height 3rd Dimensional

(Link all elements from concept to

customer)

Spatial Improvements

4

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5

Model Line Development The essential elements for developing a model line are: 1.  Understanding and defining the future state of the business and

the associated goals and metrics

2.  Applying the right resources and the right tools to achieve the three key principles – Takt-time paced, one-piece flow, pull

3.  Implementing the six tactics – Understanding how value flows –  Standardizing work procedures –  Putting visual controls/management in place –  Putting everything at point of use (supply chain) –  Balancing the line (heijunka, takt time, SWIP) – Converting to a moving line (pull production)

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6

Model Line Value Stream

Developing a Lean model line means: Looking at the processes inside and outside the value stream applying the contributions of employees at the strategic points.

Patient care can be seen as a steady stream of interconnecting processes. A value stream describes the entire set of activities necessary to provide patient care from the time service is requested to when services are completed.

Each part of the model line must be Lean. By understanding how all of the processes affect each other, we can apply Lean practices strategically, leveraging improvement opportunities and allowing value to flow freely and rapidly.

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7

Model Line Key Lean Principles

Takt-Time Paced Production

One-Piece Flow Pull Production

Describes the rate of patient flow in the medical center. Lean does not mean doing things faster; it means doing things at the right pace. Essentially, the patient’s rate of demand establishes the pace, or takt time. So, rather than a race, Lean sets the pace in the medical center, ensuring that the patient’s needs are met on time.

The opposite of batch. Instead of serving many patients and then holding them in queue for the next step in the process, patients go through each step in the process one step at a time, without interruption. Processing patients one at a time continuously improves quality and lowers cost.

The opposite of push. It means that patients are processed only when they have requested or “pulled” it, and not before. Doing so prevents providing service that is not needed. Once you have a predictable pace of service, one-piece flow, and reliable processes, you can operate in a pull production environment, which allows you to provide services when the patient needs them.

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8

The Tactics

Tactic 1 – Understand how value flows

Tactic 2 – Balance the line

Tactic 3 – Standardize work procedures

Aligning to the vision and direction set by leadership, employees and managers must define a future state and the associated goals and metrics. Using value stream analysis, employees and managers can understand how best to apply resources and focus Lean tools in the places that will provide the most benefit. Understanding how value is created and flows ensures that changes are made systemically rather than randomly and independently of other organizations.

Balancing the line essentially means evenly distributing both the quantity and variety of work across available work time, avoiding overburden and underuse of resources. Work that is evenly distributed provides predictability and the ability to standardize work processes more easily. This eliminates bottlenecks and down time, which translates into shorter flow time.

Standard work procedures are the foundation of a Lean production system. A standard operation is a known, repeatable process that results in high-quality output. A standard operation ensures that everyone does the same job in the same way, in the best way possible. Standard work procedures also provide the ability to detect abnormalities or defects quickly. This tactic allows easier cross training and provides greater opportunities for all employees as they increase their abilities to perform more than one task.

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9

The Tactics

Tactic 4 – Put visual controls in place

Tactic 5 – Put everything at POU

Tactic 6 – Convert to a moving line

Visual controls can help people quickly and accurately gauge status at a glance. These visual systems fall into two categories: progress indicators and problem indicators. Visual controls allow everyone to instantly see the group’s performance and increase the sense of ownership in the area. Having these types of visual cues can help save time and improve work quality.

Point-of-use is a technique that ensures people have exactly what they need to do their jobs. Using this technique requires close partnerships with the entire supply chain. POU eliminates wasted movement and wasted space, and ensures that time spent on patients and processes adds value.

A moving line moves patients and procedures from one team to the next. The line stops only when a problem is detected. The ability of all employees to stop the line when an error is detected is critical. Equally critical is the ability to get the line moving again once a defect has been detected and corrected. The biggest benefit is the sense of urgency a moving line conveys. Employees can truly see and feel the pace. And a moving line further ensures discipline and commitment to sustaining improvements.

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© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply

DecOctSepAugJulJunMayAprMarFebJan Nov

Cancer Model Line Integrated Schedule & Timeline Chart

2004


VSMsTactic 1

Standard WorkTactic 3

Quality; PatientEducation &

Best Practices

Phone Access

Staff Education,Training &

Communication

Mistake ProofingTactic 6

Info Flow/IS--CPOE--Website

Visual ControlsTactic 4

PQ Level LoadTactic 2

Lead TimeReduction

PatientIdentification

5S & POUTactics

RPIWsBreast Pt FlowJan 26-30

Ancillary FlowMay 17-21

CPCCSep 27-Oct 1

VADNov 1-5

Check w/processowners for nextsteps by 1/31

Check w/processowners fornext stepsby 1/31

Current & FS VSM: BreastCurrent & FS VSM: Prostate

Analyze opportunities &assign teams for breast VSM

Analyze opportunities & assign teams for prostate VSM

F/U audits

Sort activities Initial 2004audit

F/U 2004audit

Continue sort activities

Adopt/implement "It Takes Two" for all cancer work unitsCreate detailed implementation plan

Implement

-Breast: analyze VSM ID opportunities

Prostate: analyze VSM ID opportunities

Breast pt survey createdPilot Pt Flow Ed Tool/brochure

1/9 Cancer Vis Room ID'd

1.31 Vis Room operational<--------------------------Metrics updated monthly (from Donna Wilker)------------------------------------>

3/1 planning meeting

12/31 Web basedtool in place

Phone metricsreporting




Update dashboards Update dashboards Update dashboardsUpdate dashboards

Final auditJan 2005

Publish 3prostateoutcomes

Do further 3P analysison 30 min pts/OIC

Link to space planning

BCT + on website; reviewedby Kathy Kaye

Current website info given to BCT

Pt support svcs

Publish 3 cancer outcomesStart Greeter program

All breast cancermaterials coordinated

KPO education assessment

Implement lean proposal system

Develop educ plan for staffDevelop educ planfor staff

Discuss Moonshine/pilotopportunities/Kaizen events

Rad Onc MD visitCSR rooming/scheduling

Chemo teach

MD consults

Flow of breast cancer pt

ARNP visit

Mistake-proofing kiosk

Correct VAD

Morning reportin Rad Onc

Pretreatment guidelines

Post treatment guidelines

Pt follow-up calendar

Mistake Proofing:complete chemo orders

Trial Med Onc morningreport (1/05)

Create andonsignals

Trial OIC morning report (1/05)

© 2004, Virginia Mason Medical Center

Establish follow-up guidelines

Post guidelineson V-Net!

Updated 5/16/05

Update BCT website

Appt access goal

Follow-up guidelinesposted on V-Net!

RoomingMoonshine event

Procedural Pausefor right site surgery

GIM CME

Blood draws

Medication order

RN chemo administration

Hem Onc RNcamp checklist

10 V11032012

© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply 11 V11032012


Breast Cancer Integrated Schedule & Timeline Chart

2005


VSMsTactic 1

Standard WorkTactic 3

Quality; PatientEducation &

Best Practices

Phone Access

Staff Education,Training &

Communication

Mistake ProofingTactic 6

Info Flow/IS--CPOE--Website

Visual ControlsTactic 4

PQ Level LoadTactic 2

Lead TimeReduction

PatientIdentification

5S & POUTactics

RPIWsBreast Imaging Center

Check w/processowners for nextsteps by 1/31

Check w/process owners for next steps by 1/31

Current & FS VSM: Breast

Analyze opportunities & assign teams for breast VSM

F/U audits

5S activities Initial 2005audit

F/U 2005audit

Continue 5S activities

"It Takes Two" ongoing for all cancer work units

Breast: analyze VSM ID opportunities

Pt surveys re referrals

<--------------------------Mammography metrics updated monthly (from Shannon Boswell)------------------------------->





Update dashboards* Update dashboards* Update dashboards*Update dashboards*

Final auditJan 2006

Do further analysis ofbreast clinic on the Eastside

Best practice resultreporting (radiologist)

Publish 3 cancer outcomes:ACR accredited BreastImaging Center

Implement Every Day leanproposal system

Path specimen labeling

Add radiology & plastic surgery materials to breast journal

SW screeningmammo scheduling

Core biopsy algorithm -breast center

Clip protocol - whichlessons need follow-up

Needle loc chairMammo result reporting

© 2004, Virginia Mason Medical Center

Establish adherenceto follow-up guidelines staging preop

Remeasure flow of breast cancer patient

Updated 6/6/05

Procedural Pausefor right site surgery

Diagnostic mammo <72°Screening mammo <24°Biopsy <72° quarterly

Pt educ materialson CD rom

*Note: Dashboard to include radiology metrics:1) Biopsies2) Screening mammo volumes3) Diagnostic ultrasound volumes4) Quality

Path consult availableto pts

1) Conservation rates-quality2) Survival rates3) Recurrence

Medication labeling

Mammosite in Breast Imaging Center?

Mammosite planning?

Note: Create Breast Imaging Center business plan.

Conciergeprogram

Update Radiology website

Mammo schedulingdefect tool


Cancer Model Line 2004 Workplan Updated 9/27/04 (Phase I Model Line Implementation)

DELIVERABLE

ACTION NEEDED

RESPONSIBILITY WHEN

NEEDED %

COMPLETE

NOTES

1 VSM: Breast • Define our product: satisfied customer. What do we need to create that the customer has not thought of? Follow-up clinics?

• Post current state VSM in Jacobs’ office; finalize and post future state.

• Post pre-treatment guidelines on V-Net! • Label the RPIWs on the VSM. • Breast patient brochure: Why come to VM?

AJ/PM

Dubuque

DD/DW Dubuque

Michelle DeLancy

12/04

3/04

5/04 2/04 12/04

100%

100%

“When needed” based on C Cone availability.

VSM: Prostate • Create future state prostate VSM to include follow-up (tracking, PSAs, etc.)

• Update prostate fishbone.

Susie Creger

Dubuque

3/04

2/04

30%

100%

Dr Corman to work with Susie to create future state VSM

2 RPIW: Breast Patient Flow Dubuque/Sylvester to lead. DD/JS 1/04 100% RPIW: Flow of ancillary svcs Dubuque/Jacobs to lead. DD/AJ 5/04 100% RPIW: Flow of the CPCC clinic Jacobs/Sylvester to lead. JS/AJ 9/04 100% RPIW: Vascular Access Device Dubuque/Jacobs to lead. DD/AJ 11/04 3 5S and POU Tactics: Sorting is

focus in 2004 • Develop and communicate organizational 5S sort

education. • Take pre-sort photos. • Establish department visibility method. • Audits completed prior to July and December. • Final audit January 2005.

JS/DD

Managers Managers

PM/AJ/JS/DD

PM/AJ/JS/DD

3/04

6/04 6/04 6/04 1/05

90%

100% 100% 50%

4 Patient Identification All managers to review “It Takes Two” organizational materials. Each section to implement their program by March: • Med-Onc = check-in process; roomer process;

correct chart; bone marrow aspiration. • Rad Onc = utilization of photos in IMPAC.

o Use of isoloc treatment planning program. o Confirmation via patient stating their name at

time of treatment. • OIC = Confirmation of right patient for chemo

and blood administration: use name, birthdate, MRN (3 checks).

• Perioperative Services. The patient ID process states that each person

Managers

Bagdasarian

Lynch

Wetteland

Creger

2/04

2/04

1/04

1/04

1/04

100%

100%

100%

100%

100%

12

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DELIVERABLE

ACTION NEEDED

RESPONSIBILITY WHEN

NEEDED %

COMPLETE

NOTES

two of the criteria from the ID grid: 1. Full name stated by patient or family member 2. DOB stated by patient or family member 3. Picture ID verifies full name and DOB against new

or existing VM records 4. Armband marked as verified by VM staff 5. Name, DOB and MRN on armband matches order

and/or medical record. 6. Armbands verified and initialed by VM staff. To

meet this criterion, the armband must be blue with initials. This indicates that the person who placed the armband used the "it takes two" process to ID the patient before placing the armband on the patient.

White armband, indicates that two of the five criteria could not be verified. As soon as possible, two of five criteria should be confirmed and the armband changed to a blue one and initialed by the person who has completed that ID process.

Unless contraindicated by patient care needs, place armband on the patient's right arm with label facing away from the patient.

• Pathology owned by Lab; imaging managed by Radiology

5 Phone Access • Install ACD line in Hem Onc. • Install ACD line in Rad Onc. • Each manager to report monthly. • Metrics: Abandonment rates and ASA.

Bagdasarian Lynch RB/LL RB/LL

6/03 4/04

monthly quarterly

100% 100% 100% 100%

6 Lead Time Reduction • Address patient flow with integration of all services on Buck 2.

• Analyze prostate VSM opportunities. • Analyze breast VSM opportunities.

DD/AJ/PM/JS

Creger/Corman

Wechter/DD

10/04

6/04 4/04

75%

50% 100%

Emphasis for Japan trip.

7 PQ/Level Load • Do further analysis of the 30 min. PQ 3P data. • Create a cell for <30 min. OIC patients. • Link to space simulations/space planning.

DD/JS Wetteland/Creger

Sylvester

4/04 3/04 2/04

100% 100% 100%

13

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DELIVERABLE

ACTION NEEDED

RESPONSIBILITY WHEN

NEEDED %

COMPLETE

NOTES

8 Standard Work Create standard processes for: • Chemo teach • ARNP visit • Oncology MD consult • CSR rooming process • Blood draws • Patient check-in flow of the breast cancer patient

(pre treatment) • Rad Onc MD consult • Prescription refills • Pretreatment guidelines, post-therapy guidelines,

follow-up calendar and PCP follow-up tool

Dubuque Dubuque Dubuque

Bagdasarian Wetteland Dubuque

Creger/Taylor

Creger DW/DD/HO

5/04 7/04 12/04 6/04 9/04 8/04

12/04 8/04 8/04

90%

25% 100% 100% 50%

100%

9 Staff Education Training and Communication

• Create breast cancer patient follow-up guidelines for MDs and staff.

• 5S – Sort training for all staff. • Implement lean proposal system (employee

suggestion program) • KPO to assess each employee’s lean education. • Develop an education plan for employees (use

multi-skilled training chart).

RPIW Team

Managers Creger

Creger

Creger/Mgrs

1/04

3/04 12/04

4/04 12/04

100%

100%

100%

per organizational plan

10 Mistake Proofing • Establish morning report in Med Onc (Hem Onc & OIC on Buck 2).

• Document process in place in Rad Onc. • Rad Onc: decrease lead time/machine scheduling • Mistake proof vascular access device MD orders • Create andon signal to immediately respond to

problems such as: o Hem Onc access o Chemo admin delays o Incomplete scheduling info

• Return calls to patients

Otero/RB/MW

Hsi/Lynch Hsi/Lynch Dubuque

Bagdasarian Charge RN/MW Bagdasarian Bagdasarian

11/04

4/04 6/04 11/04

4/04 4/04 12/04 6/04

100%

50%

75%

Otero presentation 5/04 Work group formed to create SW

11 Quality • Institute greeter program for new breast cancer patients.

• Survey patients re breast services. • Survey patients re biopsy result reporting. • Define process for handling patient complaints.

Goal: prevention. Link to org. process.

DD/JS

DD/JS MA Madsen

AJ/PM

2/04

1/04 9/04 12/04

100%

100%

100%

Use organizational tools created by Sandy Novak.

14

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DELIVERABLE

ACTION NEEDED

RESPONSIBILITY WHEN

NEEDED %

COMPLETE

NOTES Patient Education & Best

Practices • Create a general Cancer Services brochure. • Address outcomes, quality indicators, survival

rates, recurrence rates, conservation rates, number of cases presented at cancer conf.

• Create best practice for: o chemo teach o Med Onc MD consult o Rad Onc MD consult o General Surgery MD consult o ARNP visit

• Create a FAQ document for My Breast Cancer Journey.

• Education kiosks for patients: what to expect during each process: OR – OIC – Rad Onc.

• Mistake Proofing kiosk: o correct path o right site surgery o accurate chemo order o clinical trials?

DD/Wechter Wechter/Schwilke

Med Onc RNs

Creger/Hsi/LL/Taylor

Dubuque/Wechter Dubuque/Jacobs

Sylvester

Dubuque

pending

12/04 12/04

6/04 12/04 12/04 12/04 7/04 12/04

12/04

12/04

100% 25%

My Breast Cancer Journey Will include patient input. Consider for RN PRP project. Link to Medical Center mistake proofing communication with patients.

12 Visual Controls • Create patient flow visual controls for providers. • Create a standard process tool for patients

including patient flow map. • Update signage to reflect services delivered at

each site: Hem Onc, Rad Onc, OIC • Update visibility metrics to include number of

patients coming to OIC, Hem Onc, Rad Onc, today. • Monthly visibility room metrics.

Dubuque Dubuque/Creger

Managers

Managers

Wilker

12/04 12/04

12/04

daily

monthly

13 Info Flow/IS: CPOE • Implement CPOE per organizational workplan • Standard templates created for outpatient meds

Mgrs/Julie King Hem Onc RNs

12/04 7/04

100%

Website • BCT to review current website info. • Update the breast website. • My Breast Cancer Journey on web. • Chemo teach on web. • Links to cancer meds. • Create a model line website – to show the process

and the team (virtual experience). Patient Flow 6/14/2004

• Update the prostate website. • Update Cancer Institute website; feature disease

sites.

Wechter Breast Ca Team

Dubuque Dubuque Dubuque Dubuque

Corman/Tyler Dubuque

2/04 8/04 6/04 7/04 7/04 12/04

9/04 12/04

100% 85% 100%

50%

Responsibility Key: RB=Richelle Bagdasarian LL=Laura Lynch JS=Julie Sylvester DD=Denise Dubuque PM=Pat Maguire DW=Debbie Wechter AJ=Andrew Jacobs HO= Henry Otero MW=Michaelle Wetteland 15


The Cancer Institute at Virginia Mason Cancer Institute Model Line 2005 Workplan Updated 6/06/05

DELIVERABLE

ACTION NEEDED

RESPONSIBILITY WHEN

NEEDED %

COMPLETE

NOTES

1 VSM • Define future state VSM to include the flow of the providers

• All Cancer Directors to complete VSMs

Directors

DD/AJ/Dirs

10/05

2 RPIW: Claims payment for oncology medications

• Self-pay • Off label usage • Denial process • Team leaders: Dubuque, Sylvester

Sylvester/ Dubuque

5/05 100%

RPIW: Hem Onc/OIC paperless system or conversion to one flow; flow of information

Superflow: • Front Desk • Treatment room • Provider schedule • Ancillary services • Short stay infusion • On line nursing documentation • Cerner messaging • Allergy lists • Pain assessments • Cerner documentation • One flow hem onc/OIC

Dubuque/ Jacobs/

Wetteland

11/05

RPIW: EOL Outliers KPO 5/05 100% RPIW: Cancer Hospital Admits:

inpatient à outpatient setting • Deliver current inpt services in outpt setting • Prepare patients for admits to decrease LOS

Jacobs/Purrier 8/05

Kaizen Event OIC scheduling Dubuque 3/05 Rad Onc: IMPAC upgrade Lynch 3rd Qtr Med error prevention Dubuque 2/05 100% 3 5S and POU Tactics • Develop and communicate organizational 5S

• Take pre-measurement photos • Establish department visibility method • Audits completed prior to July and December • Final audit January 2006

Managers

4 Patient Identification • Secret shopper every two weeks Managers/MW 5 Phone Access • Ongoing access reports Managers monthly 40% 6 Lead Time Reduction Breast or CPCC clinic at Bellevue clinic location or

travel to outside region: • Address Dauway-Williams Eastside presence • Establish goals, standards, flow • Role of ARNP

Taylor/Hunter/Corman/ Wechter

Taylor/Hunter

6/05

6/05

12/05

50%

50%

16



DELIVERABLE

ACTION NEEDED

RESPONSIBILITY WHEN

NEEDED %

COMPLETE

NOTES

• Breast cancer clinic analysis • Value of breast cancer clinic • Determine what Eastside breast cancer program

should be • How to increase outside referrals • Geographical referral patterns • Quality goal: Determine specialist presence

Taylor/Hunter “” “” “” “”

“” “” “” “” “” “”

4/05

50%

100%

Radiation Oncology • Consult to treatment • Billing – linked to IMPAC upgrade • Linac scheduling

Badiozamani Lynch

Hsi/Lynch

Alex Hsi to determine dates.

7 PQ/Level Load • Do further analysis of Infusion Center demands (Pac Med, Neuro, Rheumatology)

Wetteland/ Dubuque

6/05 30% 3/05: Pac Med sending blood transfusions

8 Standard Work Document standard processes for: • Hem Onc front desk check-in, rooming: beginning

and end of day prep • OIC scheduling • OIC medication delivery • Rad Onc: ARNP weekly visit • Rad Onc: CT/Fluoro/HDR to treatment • Chemotherapy/biological agent administration • Phlebotomy services • Coordinator metric reporting • Self-pay/uninsured patient

Bagdasarian

Wetteland Wetteland

Lynch Lynch

Dubuque

Sylvester/Dub

uque

5/05

12/04

2/05

5/05

100%

90%

100%

To be updated.

To be updated.

9 Lean Staff Education Training and Communication

• Develop/implement lean education plan for employees

• Develop RN residency program • Hem Onc CSR scheduling • Referring MDs CME • Publicize PSA info to staff • All managers through lean mastery • All managers trained in mistake proofing

DD/Mgrs/KPO

Dubuque/Mgrs Bagdasarian Sylvester

RB/LL/MW Dubuque Managers

2/05 3/05

6/05

100% 100%

10 Mistake Proofing • Establish morning report in Med Onc (Hem Onc & OIC on Buck 2) and Rad Onc

• Zero incomplete chemo orders • MD dose calculations • Medication solution and labeling • Bone marrow labeling

Managers

Wetteland Otero

Bagdasarian Bagdasarian

ongoing

ongoing 2/05 4/05 4/05

100%

40% 100% 100% 100%

17



DELIVERABLE

ACTION NEEDED

RESPONSIBILITY WHEN

NEEDED %

COMPLETE

NOTES

• Zero incomplete medication dosage calculations • Vacation coverage • Rad Onc treatment errors • Cerner messaging • Electronic billing – Rad Onc • Eliminate shadow charts in Rad Onc • IMRT: Compare to other organizations • IMPAC upgrade • Charge review/missed charges/coding/

documentation • Order sets for translation to CPOE • OIC RNs 4-hour training in chemo booth

Wetteland RB/Lynch

Song

Lynch Lynch Lynch Lynch

11 Quality (Patient Education & Best Practices)

• ACoS certification requirements • Establish 2005 ongoing list of accomplishments • Colon and liver mets guidelines/pathways • Evaluation of nutrition visit – Rad Onc • Nutrition support group • 12 cancer outcomes • Mistake proofing: defect checklist for new

patient consults • Defect checklist for OIC scheduling errors

RB/LL/Mizuki DD/AJ/JS

Thirlby/Culp Lynch Lively

TM/Whiteside Bagdasarian

Wetteland

8/05 3/05 5/05

3/05

100% 100%

Standard Chemo Certification of RNs through ONS

• Monthly courses offered Wetteland/ Purrier

May/Jul/ Aug/Oct

25%

End of Life • Creation of EOL business plan for role of ARNP • CNE, Grand Rounds presentations • Communication/website • Advance Care notes in Cerner

DD/JS

DD/Headings DD/Malpass

5/05 5/05 6/05 4/05

90% 100% 75% 100%

Darrel Owens

Radiation Therapy • Post consult follow-up calls to patients • Patient survey: radiation oncology • Stereotactic therapy: SHARP, stereotactic lung,

cranial • IMRT – refine technique, expand uses, establish

IMRT program at FROC • HDR – create protocols, establish flow; discuss

mobile unit • Prostate brachytherapy – expand to other sites

Rad Oncologists

Lynch Madsen/Song/

Pham Madsen/Esagui

/Song/Pham Badiozamani

Badiozamani

4/05 biannual

18


The Cancer Institute at Virginia Mason

Cancer Institute Model Line 2005 Workplan Updated 6/06/05

DELIVERABLE

ACTION NEEDED

RESPONSIBILITY

WHEN NEEDED

% COMPLETE

NOTES

12 Visual Controls • Establish morning report Hem Onc front desk • Establish morning report OIC supervisor/charge

RN • Continue Rad Onc morning rounds • Create quarterly cancer dashboards • Create visual control for delays at front desk • Create visual control for status of pt in tx

room

Bagdasarian Wetteland

Lynch

JMS/Ca Coord Bagdasarian

Dubuque

3/05 2/05

1/05

6/05 2/05

30% 100%

100%

100%

13 Info Flow/IS: CPOE • Implement CPOE per organizational workplan? 7/05 Website • Review current website info:

o Cancer Institute o Service lines

• Chemo teach on web • Create a model line website – to show the

process and the team (virtual experience). Patient Flow

• Cancer webmaster • Web training for Mizuki • Virtual tour: Rad Onc, Hem Onc, OIC

Dubuque

JMS/Ca Dirs Dubuque Dubuque

Mizuki

Mizuki/Phillips Dubuque

8/05

12/05

3/05 12/05

100%

14 Other • Address Rad Onc patient parking – dissatisfier • Housing fund for Rad Onc patients

Lynch/Dubuque

Foundation/LL/DD

6/05

15 Growth Radiation Oncology: • Bremerton: Prostate brachytherapy • Alaska: Brachytherapy, HDR, stereotactic

services • Pac Med: Prostate brachytherapy • GHC: IMRT, prostate brachytherapy • Polyclinic: Rad onc services • Peninsula: Prostate brachytherapy, HDR • Valley Medical Center

Hsi Date to be determined by Alex Hsi.

Responsibility Key: RB=Richelle Bagdasarian TM=Trudi McKenzie DD=Denise Dubuque JS=Julie Sylvester AJ=Andrew Jacobs DW=Debbie Wechter LL=Laura Lynch MW=Michaelle Wetteland 19


Breast Cancer Model Line 2005 Workplan Updated 6/06/05 (Phase I Model Line Implementation)

DELIVERABLE

ACTION NEEDED

RESPONSIBILITY WHEN NEEDED

% COMPLETE

NOTES

1 VSM: Breast • Define our product: satisfied customer. What do we need to create that the customer has not thought of? Eastside plan.

• Breast patient brochure: Why come to VM?

Taylor/Hunter

Wechter

12/05

6/05

50%

50%

2 RPIW: Mammography Center Shannon Boswell 6/05 3 5S and POU Tactics: Sorting is

focus in 2004 • Develop and communicate organizational 5S sort

education. • Establish department visibility method. • Audits completed prior to July and December. • Final audit January 2006

Managers

Managers Managers

SP/DD

3/05

6/05 7/05 1/06

77

4 Patient Identification All managers to review “It Takes Two” organizational materials. Each section to implement their program by March: • Med-Onc = check-in process; roomer process;

correct chart; bone marrow aspiration. • Rad Onc = utilization of photos in IMPAC.

o Use of isoloc treatment planning program. o Confirmation via patient stating their name at

time of treatment. • OIC = Confirmation of right patient for chemo

and blood administration: use name, birthdate, MRN (3 checks).

• Perioperative Services. The patient ID process states that each person accepting the patient into a new area, or treating the patient for the 1st time will ID the patient using two of the criteria from the ID grid: 1. Full name stated by patient or family member 2. DOB stated by patient or family member 3. Picture ID verifies full name and DOB against new

or existing VM records 4. Armband marked as verified by VM staff 5. Name, DOB and MRN on armband matches order

and/or medical record. 6. Armbands verified and initialed by VM staff. To

meet this criterion, the armband must be blue with initials. This indicates that the person who

Managers

Bagdasarian

Lynch

Wetteland

Saltzer

1/05

2/05

1/05

1/05

1/05

100%

100%

100%

100%

100%


20



DELIVERABLE

ACTION NEEDED

RESPONSIBILITY

WHEN NEEDED

% COMPLETE

NOTES

placed the armband used the "it takes two" process to ID the patient before placing the armband on the patient. White armband, indicates that two of the five criteria could not be verified. As soon as possible, two of five criteria should be confirmed and the armband changed to a blue one and initialed by the person who has completed that ID process. Unless contraindicated by patient care needs, place armband on the patient's right arm with label facing away from the patient. Pathology owned by Lab; imaging managed by Radiology

5 Phone Access • Each manager to report monthly. • Metrics: Abandonment rates and ASA.

Managers Managers

monthly quarterly

40% 25%

6 Lead Time Reduction • Remeasure lead time gains from 2004. • Measure diagnostic mammo, screening mammo

screening mammo and biopsy metrics • Analyze breast VSM opportunities.

Rita Kelly Boswell

quarterly quarterly

25%

7 PQ/Level Load • Eastside assessment. Hunter/Taylor 6/05 50% 8 Standard Work Create standard processes for:

• Core biopsy algorithm • Clip protocol – which lesions need follow-up? • Patient check-in flow of the breast cancer patient

(pre treatment)

Boswell Boswell

9/05 9/05

9 Staff Education Training and Communication

• Linked remider tool for breast cancer patient follow-up guidelines for MDs.

• 5S – Sort training for all staff. • Implement lean proposal system (employee

suggestion program) • Remeasure flow of breast cancer patient.

Pittinger/Otero

8/05

10 Mistake Proofing • Standard work for screening mammo scheduling. • Needle loc chair: Mammo Center. • Medication labeling. • Procedural pause. • Mammo result reporting. • Mammo scheduling defect tool

Boswell Boswell

Surgeons Boswell Boswell

2/05 2/05

100% 100%

21


DELIVERABLE

ACTION NEEDED

RESPONSIBILITY

WHEN NEEDED

% COMPLETE

NOTES


11 Quality • Institute concierge program for new breast

cancer patients. • Survey patients re breast services. • Define process for handling patient complaints.

Goal: prevention. Link to org. process. • Establish path consults as needed.

Madsen

Kelly Dubuque

T. Jacobs

6/05

8/05 1/05

2/05

100%

100%

Use organizational tools created by Sandy Novak.

Patient Education & Best Practices

• Address outcomes, quality indicators, survival rates, recurrence rates, conservation rates, number of cases presented at cancer conf.

• Create a FAQ document for My Breast Cancer Journey.

• Mistake Proofing kiosk: o correct path o right site surgery o accurate chemo order o clinical trials?

• Add radiology and plastic surgery materials to My Breast Cancer Journey.

• Best practice result reporting. • ACR accredited Breast Imaging Center. • Alternative therapy in Hem Onc.

DD/Wechter/ CDS

Rita Kelly

pending

Boswell/Paige

Boswell Boswell Dubuque

9/05

12/05

12/06 8/05

25%

Waiting for statistician/CRAB Will include patient input.

12 Visual Controls • Update BCT dashboards. • Monthly mammography metrics.

McKenzie Boswell

quarterly monthly

13 Info Flow/IS: CPOE • Implement CPOE per organizational workplan • Standard templates created for outpatient meds

Mgrs/Julie King Hem Onc RNs

12/05 7/05

100%

Website • Create a model line website – to show the process and the team (virtual experience). Patient Flow 6/14/2004

• Update Cancer Institute website; feature disease sites.

Dubuque

Dubuque

12/05

12/05

50%

Responsibility Key: RB=Richelle Bagdasarian SB=Shannon Boswell DD=Denise Dubuque AJ=Andrew Jacobs LL=Laura Lynch

SP=Sarah Patterson JS=Julie Sylvester DW=Debbie Wechter MW=Michaelle Wetteland


22


BREAST IMAGING LINE TACTICS

Tactic 1 – Understand How Value Flows

Tactic 2 – Balance the Line Tactic 3 – Standardize Work Procedures

Ø Goal: All services will be delivered

to the patient. Ø Goal: To meet customer demand for

high quality breast imaging by ensuring all activities in the value stream are value added with 0% defects.

Ø Service: Designed to minimum

delivery time, minimum material consumption and maximum quality.

Ø Result: Cost reduction through the

elimination of waste.

Ø Service Lines

o Screening Mammography o Diagnostic Mammography o Stereotactic Breast Biopsy

Ø Balancing the line

o Mixed model appointments based on demand in alignment with resources

o Autonomation utilize computerized screening programs

o Self explanatory patient instructions

o All hard copies of images produced and stored by the radiology film room

o Level load work between Radiologist, Mammographer, CSR, MA, & Film room

Ø Standardize and document all

processes with clear instructions, illustrations (photos) that are simple and easy to follow.

o Convert to all digital imaging o Standardize all biopsy

supplies & trays o Standard scheduling

protocols o Standard forms o Standard rooming protocols o Standard imaging protocols o Standard radiologist work

flow o Standardize process of JIT

results reporting to patient & PCP

o Standardized reminder system

23


Tactic 4 – Put Visual Controls in

Place Tactic 5 – Put Everything at POU Tactic 6 – Convert To a Moving Line

Ø Develop visual controls that easily

explain service flow and current status.

Ø Progress indicators

o Visual control that indicates production to Takt Time

o Room availability

Ø Problem Indicators (using light and/or sound)

o Abnormal pathology o Calling all Mammographers o Patient call button o Code Button o “Running Late”

Ø Post radiologist specific productivity

and quality outcomes.

Ø Supplies will be at POU in the exact

quantity, right time, and in the right place.

o Biopsy Supplies standardized and in kits

o Kanban driven supply renewal

o Providers on gemba o Previous images readily

available o COW’s or PC’s in room

Ø Pull System that incorporates lights

and sound that signals the downstream process is ready for the next patient

Ø Re-evaluate Takt Time on a

continuous basis throughout the day to ensure demand is being met.

Ø Create Poka-yoke methods and

devices that create O% defect environment.

o Films labeled with correct patient ID.

o Eliminate unread exams.

Ø Arrange equipment in a sequence that facilitates the flow of patients, providers & information

Ø Preventative maintenance schedule

to maximize the uptime of the mammography machines.

Ø Minimize room changeover time

between patients.

24


Guiding Vision

Hippocratic Oath First, do no harm

Henry Otero MD

Priority Zero Defects

First priority, zero defects

25


Stop the Line

26


Hepatic Embolization Problems

•  No standard work- “anything goes” §  e.g. pain, symptom management, use of antibiotics,

bowel preps, chemo vs. bland embolization

•  No single owner of patient’s overall experience

•  Critical information not available when needed

•  Poor patient education

•  No physician role definition

27


Hepatic Embolization Our Improvements…

28


Current SAFE Process Hepatic Embolization

Oncologist or Surgeon Radiologist

Hospitalist and Hospital Nurse

Radiology Nurse

Radiologist (Procedure)

Standard order sets

Standard indications for procedure

Hospital plan of care

29


Example #3

Problem:

We need to treat a higher volume of patients with the same resources

30


Radiation Oncology

•  Problem: § Record volumes forced us to focus on

increasing capacity § Hours of operation did not match customer

requested times § We worried about safety with staff working

overtime

31


Theory => Level Loading, Lead Time Reduction, & Standard Work

•  Applied concept of waterfall scheduling §  Staggered start

times

32


Theory => Level Loading, Lead Time Reduction, & Standard Work

•  Created standard work § Radiation

therapist §  Physician §  Patient

Process

33


Radiation Oncology Summary

Improvement Before After % Change

Lead time (arrival to completion

of treatment)

21 minutes

18 minutes -14%

Patients treated per Therapist

8.1 patients

12.75 patients +57%

Idle time of accelerator

140 minutes

32 minutes -77%

Staff walking distance

488 feet

192 feet -61%

•  Increases accomplished with: §  No additional staff, equipment, or space

34


Example #4

Problem:

We need to treat a higher volume of patients with the same resources

35


Oncology Infusion Center

•  Problem: §  Poor utilization of treatment

rooms •  Sometimes over-scheduled •  Sometimes empty •  Cumbersome scheduling

process •  Scheduling errors •  Unnecessary hospital admits

36


Theory => Level Loading

Waterfall scheduling §  30 minute intervals §  Staffed according

to patient demand

37


Theory => Level Loading

•  Schedule adjusted to match expected treatment times •  Ongoing audits to validate actual treatment times

Example Treatments

Before After

Remicade 4 hours 2 hours

Carbo/Taxol 4 hours 3 hours

Carbo/Gem 5 hours 3 hours

38


Oncology Infusion Center Summary

•  Additional capacity created §  With existing treatment space §  No additional staff

•  Allowed new services to be offered

Improvement Gain Remicade 200 min/day

Schedule Updates 1092 min/day Waterfall Schedule 3023 min/day

Total Capacity Gain

4315 min/day (160 minutes per treatment

station per day) 39


What has all this done for us?

• We measure our success… §  Staff satisfaction

§  Patient satisfaction

§  FTE’s

§  Program growth

§  Financial performance

40


Measuring our Success Patient Satisfaction

Overall mean score = 92.0%

0102030405060708090

100

2005Nov

2005Dec

2006Jan

2006Feb

2006Mar

2006Apr

2006May

2006Jun

2006Jul

Satis

fact

ion

Scor

e (%

)

41


Pat. Returns to Function

In Patient Hospital

TBD

Pre-

Op

Prep

arat

ion

Pre-visit L/T

Day of Clinic Visit L/T

Post-Visit L/T

Day of Surgery L/T

Pre-Surgery L/T

Dai

ly M

anag

emen

t Boa

rds

Mat

eria

ls F

low

Use

of N

on-S

urge

on C

linic

ians

Stag

gere

d St

arts

OR

Sch

edul

ing

Proc

ess

Stag

gere

d St

arts

Cas

e C

arts

: Sta

ndar

dize

, Was

te

Stan

dard

ize

Roo

ms

Staf

f Cro

ss T

rain

ing

Visu

al C

ontr

ol

Pull

Sign

als

Primary Care

14.8 days

Total Surgical Services Patient Lead Time

415.5 minutes 15.1 days TBD 43.8 minutes

Acc

urat

e Su

rger

y Ti

mes

Inte

rope

rativ

e St

anda

rd W

ork

for M

Ds

Pre-

Op

Prep

arat

ion

Def

inin

g B

est P

ract

ice

Gui

delin

es

PICIS: Surgery Information System

Implemented Underway Not Started

Inst

rum

ent r

oom

Pre-

Op

Patie

nt P

rep

Load

Lev

el D

urin

g D

ay

Load

leve

l by

DO

W

Turn

over

Tim

e

Red

uced

Sur

g./s

taff

NVA

Tim

e

OR

21

Stan

dard

Roo

min

g

Med

. Rec

.

Nur

se P

ost-o

p C

linic

s

Example Park Nicollet’s Plan for 5 Year Block (Point): Surgical Specialties

42


Next Steps

43 V11032012

1.  Look at your Future State 2.  Choose a model line 3.  Create a communication plan 4.  Develop the Future State Target Sheet 5.  Develop the 6 Tactics document 6.  Develop the Integrated Timeline 7.  Develop the detailed plan with names and dates

•  First do this process for the long-range Future State. •  Follow with yearly target sheets, tactics, timelines, and plans.

creating a model line jba doc

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