daily continuous improvement program trey coffey md faap frcpc medical safety officer, sickkids...
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Daily Continuous Improvement Program
Trey Coffey MD FAAP FRCPC
Medical Safety Officer, SickKidsAssociate Director, University of Toronto Centre for
Quality Improvement and Patient Safety
Disclosures
I have no conflicts of interest to disclose
Lean Concepts
• Origins in Toyota Production System c. 1930s
• Term coined and applied to western manufacturing c. 1980s
• Processes analyzed from the point of view of customer value
• Focus on eliminating waste of all kinds in the system
• Deference to expertise – executives on the factory floor (“Gemba”)
Getting to know you
Your prior experience with LEAN is best described as:
A. I am not very familiar with LEAN.
B. My healthcare organization is doing some LEAN things and my reaction is… “meah.”
C. My healthcare organization (or other organizations I am familiar with) did some LEAN and it was an unmitigated disaster.
D. My healthcare organization is completely LEAN
Different Levels of Process Improvement
Adapted from: “The Toyota Way Fieldbook” by Liker and Meier
Very fewLarge issues
FewMedium issues
ManySmall issues
Objective
To tell a genuinely enthusiastic firsthand account
of a unique Lean Management System, which:
• is new to SickKids
• is not yet fully realized nor perfected
• might be revolutionary…
New Job
Paediatric Medicine Quality Committee c. 2005
2011: Emergency Department Performance Improvement Program
We used Lean to improve
Door-to-Floor times!
Reality sets in… Again.
• ThedaCare group of hospitals and clinics in Appleton, Wisconsin.
• Early adopter of Lean methods 8 years ago
• ThedaCare Business Performance System to address sustainability and to develop a culture of daily continuous improvement
Impact
32% improvement in patient
satisfaction
21% reduction in hospital cost per
case
Feb 2012: Learning Partnership with ThedaCare
Awaiting my invitation…
• Rapid process improvement workshop?
• Kaizen event?
Manager Daily Status Sheet
Manager Daily Status Sheet
A few weeks later this appears
Daily Improvement huddle: M,W,F 1:15-1:30
Daily Improvement Board
Just do its
More challenging
problem solving (PDSA3)
Collect Improvement
Cards
Prioritize Issues
Completed
Daily Improvement Huddle Board
Early signs of success: Engagement of frontline nurses on 7B raised hand hygiene compliance
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar0.0
20.0
40.0
60.0
80.0
100.0
57.0
75.0
93.0
78.0
100.07B Moment 1
2011-2012 2012-2013 actual Target
Daily CIP’s Goal:Develop people to solve problems and improve
performance
Different Levels of Process Improvement
Adapted from: “The Toyota Way Fieldbook” by Liker and Meier
Very fewLarge issues
FewMedium issues
ManySmall issues
LargeProjects
LeanEvent
Focus of Daily CIP
Six Sigma
Status Sheet: Manager, Director and VP
DAILY
ManagerStatus Sheet
WEEKLY
DirectorStatus Sheet
EVERY 2 WEEKS
VPStatus Sheet
ManagerCharge Nurse Director VP
Status Sheet: Links Between Levels
DAILY
ManagerStatus Sheet
WEEKLY
DirectorStatus Sheet
ManagerCharge Nurse Director
A wise man once told me: “Behavior drives culture”
24
• Competing priorities for improvement
• Improvement accountability with a few people
• Project teams solve problems periodically
• Ad-hoc use of improvement tools and approaches
Frequent review of improvement priorities
Improvement accountability at all levels
Front line staff solve problems daily
Staff trained in adopting tailored toolkit and approach for problem solving
From: To:
New and Improved Paediatric Medicine Quality Leadership Team
• We still meet monthly to discuss trends in performance and to prioritize which metrics to improve upon
Except now…• I had to get a much bigger room!• I am currently looking for an even bigger room!• Staff come in on their OFF DAYS!• I look forward to it instead of dreading it
Monthly Score Card: Driver and Watch indicatorsThis scorecard dictates the unit focus for the month
Falls, Entrapment, Strangulation, Entanglement documentation scores
7B 7C 7D0%
20%
40%
60%
80%
100%
120%
24%
44%
23%
35%
43%
30%
51%
39%
50%
57%
50%54%
0.670000000000002 0.680000000000001
52%48%
97%100%
72%
83%89%
77%
90%
Aug
Sept
Oct
Nov
Dec
Jan-13
Feb
March
April
Three day Equipment Improvement EventSituation Overview
Finding supplies is difficult
Approach Impact
a place for everything everything in its place
SortSet-in-orderShineStandardizeSustain
5S
RESULTS
Staff-driven problem solving: Over 65 improvement ideas identified and executed since April 2012
Median of 19% Improvement in Engagement Scores
Key ingredients
1. INTRINSIC MOTIVATION
•Provide opportunity for self-leadership •Provide choices •Help members acquire skills and knowledge •Assign tasks but make connections •Coach 2. DISCIPLINE• Simple behaviors repeated over and over
Autonomy
RelatednessCompetence
Self-Determination Theory
Enterprise wide picture
• 12/22 units doing Daily CIP• 20 yellow belts trained• 178 green belts trained
• Larger projects/value streams: Ambulatory, Surgical, Procurement, Pharmacy, Administrative. • ~20 Rapid Improvement Events completed to date
How much does this cost?
• “Lean Promotion Office”
• Office of Process Improvement
• Director, five staff, and an assistant • hired from industry and consulting firms• $1 million/year (approx)
The Hand Hygiene graph continued….
Apr May` Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
20.0%
40.0%
60.0%
80.0%
100.0%
7BCD Moment 1
2012-2013 Target
Linear (Target) 2011-2012
Questions for consideration
1. Are we going to be able to tackle the big stuff?
2. How is this experience going to vary across units?
3. How are we going to substantively engage physicians?
Acknowledgments
SickKids nursing and operational leaders: Kate Langrish, RN, Lynn Mack, RN, Linette Margallo, RN, Dinarte Viveiros, RN
SickKids Office of Process Improvement: Shiraz Bhajwa, MBA, Travis Beamish, MBAAli Shahzada, MBA
Executive sponsor: Jeff Mainland, EVP Strategy, Performance, Quality and Communication