Doug Thompson, MD, MMM

Sue Cannon, MSN, RN

Ken Wing, MS, CSSBB

Frontline Led, Data-Based Improvement: Lean Daily Management

The presenters have no

relevant financial relationships

with the manufacturer(s) of

any commercial products

and/or provider(s) of

commercial services

discussed in the CNE activity 2

• Describe the principles and process of LDM

• Utilize LDM tools

• Identify two ways that frontline staff can contribute to improvements in quality and patient safety

• Articulate three benefits of the daily Gemba walks with the use of the tools

Learning Objectives

What is Lean?

• Continuous pursuit of perfection

• Management system based on Toyota

• Body of principles, tools, and

practices that help organizations

be more effective

The Toyota Way

Continuous Improvement – Challenge (We form a long-term vision, meeting challenges with courage

and creativity to realize our dreams.)

– Kaizen (We improve our business operations continuously, always driving

for innovation and evolution.)

– Genchi Genbutsu (Go to the source to find the facts to make correct

decisions.)

Respect for People – Respect (We respect others, make every effort to understand each other,

take responsibility and do our best to build mutual trust.)

– Teamwork (We stimulate personal and professional growth, share the

opportunities of development and maximize individual and team

performance.)

Value added work

what the Customer

is willing to pay for

Value Added Work

• Anything that does not add value for

the patient

Activities that require time, resources,

or space, but do not add value

Daily frustrations

Non-Value-Added

Moving patients for tests and treatments.

Moving things.

Any supplies or materials on hand

Reaching / bending / lifting for a frequently used item.

Task switching. Fetching.

Waiting for a bed, room, person or equipment to be

available

Doing more than the patients needs or wants

e.g., medically unnecessary care, excessive

documentation, excessive approvals needed

Do an extra one just–in-case?

Anything with the prefix „re‟ such as:

re-work, re-test, re-do, re- write, etc.

Any error such as wrong med, patient, test, procedure

Inve

nt

ory

The 7 Wastes

Exercise 1 The

Waste Walk

“Waste walk” in Small Groups

• Identify examples of waste in your work

• Try to think of examples in different waste categories

What is Lean Daily Management (LDM)?

• Staff review their daily frustrations, and focus on a few they believe they can influence

• Staff choose metrics and set goals

• Staff collect data and use simple lean tools to understand root cause and develop and implement solutions

• Senior leadership rounds daily to learn what is going on and provide any needed support

How Staff Contribute to Improvements

• Staff identify problems

• Staff make problems visible to leadership

• Staff collect data to quantify and investigate problems

• Staff help identify root cause and develop and implement solutions

Give staff tools and support they need to solve problems

faced in their daily work

Why LDM?

Increase employee engagement and empowerment

Improve integration and alignment among all disciplines and departments

Ultimate goals

Provide care that is safe, high quality, prompt, courteous, respectful, and efficient

LDM –The GOAL

GOAL sheet Track daily performance along timeline to show progression toward mitigating identified problem

•Write clear goal If goal changes during month, write new goal on post-it and indicate on metric

Simple, dynamic visual aid makes it easy to – See progression of solution development

LDM –The RUN Chart

RUN chart Shows frequency and trends of the problem

Simple visual demonstrating improvement trend

•↓ frequency of negative event over time

Captures data in multiple formats

Upper x-axis: Days of month

Lower x-axis: Total daily events

Only recorded events can be recognized and receive appropriate attention to be resolved

Graph

Total #/day

LDM – The PARETO Chart

PARETO chart Graphic representation of the impact of specific reasons for missing the goal

# occurrences/reason/time period

LDM – The PARETO Chart

PARETO chart Graphic representation of the impact of specific reasons for missing the goal

# occurrences/reason/time period

To document a new occurrence, fill in a box with the date

A spike or trend should trigger a “5 Why” process

List every reason that causes the problem. Some days on the run chart may have multiple reasons for missing the goal.

The stone on the Jefferson Memorial was crumbling.

1. Why was it crumbling? Too frequent washings

2. Why was it washed so often? To remove bird droppings

3. Why were so many birds in the building? Abundant food supply: hundreds of little fat spiders

4. Why are there so many spiders? Spiders were attracted to black flies

5. Why were there so many black flies? Every evening at dusk they emerge in a mating frenzy. At the same time the Park Services turns on its powerful spotlights.

5 Whys Example

LDM –The Action Plan

Action plan List of changes identified by the team to mitigate issues affecting the goal

The action plan is usually developed after the 5 why process has occurred

Start with a verb to indicate the action that needs to be or will be implemented

Identify who and by when an action will be implemented

Give credit where credit is due! Each small success is a step toward better teamwork and patient care.

Use the supplied sample data • Divide group into pairs

• Each pair completes different sheet

• Define a specific goal

– e.g. Zero episodes of … Less than 2…

– Note on the Goal sheet Red vs. Green for each day

• Plot daily data on the run chart

• Complete the Pareto chart

– List reasons along the bottom

– Enter date in a box for each occurrence

Exercise 2 Building the Goal Sheet

and Run and Pareto

Charts

Example LDM Display Board Concept

S Q P C Run Chart Run Chart Run Chart Run Chart Run chart

Pareto Chart Pareto Chart Pareto Chart Pareto Chart Pareto chart

5 Whys/

Action

Plans

5 Whys/

Action Plans

5 Whys/

Action Plans

5 Whys/

Action Plans

5 Whys/

Action Plans

LDM Wins

Script

AREA KPI BOARD

G

MARKERS

Problem

Solving

Folder

Department

Name

Daily

performance

Living Pareto

Chart (built

daily for one

week or more

5 Whys

Action Plans

Up to Five KPI Categories

Miscellaneous

Information

LDM board

Daily “Gemba Walk”

3 Benefits of the Daily Gemba Walks: 1. Bring senior leaders to the Gemba daily

2. Assist in coaching and developing people in problem solving/process improvement

3. Provide resources or other needed support for improvement

where the work is performed,

the source, the scene of the crime

Gemba

Example script

PRE-WALK PLAN: All metrics updated BEFORE the Gemba Walk!

GEMBA WALK SCRIPT for Presenters: • “Good morning. My name is ___ and I’m ___(role)”

• “Our first goal is _____. Yesterday we were Red (or Green). *point to top letter]

• If Green, move to next metric.

• “We had ______ occurrences [point to run chart]

• “The reasons for yesterday’s fallouts were ____, ____ and ____. *point to Pareto+”

• Our next steps are to _________________ (collect more data with the current Pareto, drill down into the tallest bar, try different Pareto categories, etc.)”

• Address each goal in the same manner.

• When complete, ask “What questions do you have for me or the team?”

Gemba Presenter Script

Video Demonstration

24

Wrap Up

• Learned the principles of LDM

• Practiced the tools to implement LDM

• Learned ways staff contribute to

improvement and benefits of Gemba

Walk

• We are willing to stay afterwards 25

Doug Thompson

eric.thompson@drexelmed.edu

Additional Reference Slides

Integrating LDM into Resident Quality Improvement Curriculum

Continuous Learning

Environment Review (CLER)

ACGME Milestones

• Systems-Based Practice (SBP)

• Practice-Based Learning and

Improvement (PBLI)

ACGME CLER

Patient Safety • Opportunities for residents to report

– Errors

– Unsafe conditions

– Near misses

Participate in inter-professional teams

– promote/enhance safe care

Quality Improvement

• Engage residents

– use of data to improve systems of care

– reduce health care disparities

– improve patient outcomes

ACGME CLER

Pathway 1: QI Education

• Progressive QI education

• Experiential learning

• Clinical site’s systems-based challenges are presented

• Techniques for designing and implementing systems changes

• Clinical site’s priorities for quality improvement

• Education program is developed collaboratively

ACGME CLER

• Actively involved in clinical site QI activities • Clinical site monitors trainee efforts in QI

• Actively involved in clinical site QI activities

– Selection of LDM goals

Trainee Engagement in QI Planning

Pathway 2: Trainee Engagement in QI Activities

ACGME CLER

Question

What organizational structures and

administrative and clinical processes

does the SI have in place to support

GME learning in each focus areas?

Lean Daily Management

ACGME CLER

How comprehensive is the involvement

of residents and fellows in using these

structures and processes to support

their learning in each of the six areas?

Our residents will share

momentarily…

Question ACGME CLER

Framework for Assessment

Knows

Understands

Basic knowledge

Knows How Shows

Demonstrates

Competence

(Workshop/ Simulation)

Does Demonstrates in actual practice

Performance

Applies

Integrated

knowledge

Knowledge Attitudes Skills Miller GE. The assessment of clinical skills/competence/ performance. Academic Medicine, 1990;65:563–567

LDM

Advocate for quality patient care

and optimal patient care systems

System-Based Practice 2 (SBP2)

System-Based Practice 4 (SBP4) Work in inter-professional teams to enhance

patient safety and improve patient care quality

Problem-Based Learning 2 (PBLI2): Systematically analyze practice using quality

improvement methods, and implement changes

with the goal of practice improvement

Residents in LDM A Continuous Learning Process

Hey! I have this

great new idea for a

QI Project that the

residents should

participate in!

Resident and attending leaders conducted needs assessment with PI staff

Educational sub-group formed within resident leaders team to address identified needs

Educational materials developed

All residents receive global training

Residents receive monthly “just-in-time” training on data collection and reporting

Resident Education

Resident and attending leaders conducted needs assessment with PI staff

Implementation sub-group formed to develop plan for integration into one inpatient team

All residents surveyed on goals of LDM interest

Data collected on identified resident goals and addressed on daily “gemba” walks

Periodic monitoring, “5 whys” and action plans performed by core resident leadership team; resident collaborative time utilized

Implementation

Resident Involvement

Implemented October 2014

Participation

Data collection: 44/77 residents

(23/28 PL-1s)

Daily presentations: 14/26 PL-2s

Our Goals

Goals Actions / Successes

Zero occurrences of medication dosage errors

entered by residents

Tamiflu power plan

Albuterol ordering education

Zero instances of residents missing chief rounds

or noon conference

Staggered team sign out

Patient team “soft cap”

Minimal nursing interruptions

Standardized rounding times

Zero instances of residents being unable to

access the patient list

Improved sign out document

Zero instances of residents being unable to

access outside images

New disk drives in patient care areas

Year One

• Integrating resident goals in existing gemba walk sites strengthens interprofessional collaboration

• Maintaining a core team of resident leaders is critical for training and maintaining momentum

• Combining with a longitudinal experience creates continuity and promotes involvement

• Holding frequent trainings improves resident buy-in and data integrity

• Keeping flexibility is critical; goals change over time

• Eliciting resident feedback streamlines the process and promotes buy-in

Lessons Learned

Where do you see yourself?