Rapid Improvement Events (RIEs), A3 Problem Solving, and Voice of the CustomerJudy Krempin, MS, CPHQManagerQuality, Safety, Performance Improvement

2

RAPID IMPROVEMENT EVENTS (RIES)

3

Objectives

State when a Rapid Improvement Event (RIE) should be used

Name the people (roles) who should be involved in an RIE

process

Describe the timeline for an RIE cycle

4

Why use an RIE?

Rapid improvement events enable you to:

Learn and implement continuous improvement practices (i.e.,

Lean Tools)

Work as representative team

Focus on a targeted process/ area and patient population

Improvement work is completed within a specific time

period

Reduce variation, improve flow, improve value for the patient

5

Who is involved?

The hospital-wide Quality Improvement Committee, a high level steering committee commissions the team

RIE team (project team) will be responsible for planning and implementing the Lean tools

Note: All employees should do their own Kaizen (continuous improvement) daily – they do not have to wait for a rapid improvement event to think about reducing waste.

6

Wednesday-Friday:

Implement changes

Three-week preparation

period

Monday:Discuss current

process flow

Tuesday:Redesign flow and remove

waste

Three-week post-event sustainment

3 weeks 1 week3 weeks

Create Team

Team Charter

Approval of Charter/ A3

Communicate To Staff

Voice of the Customer

Observation & Data Collection Current State Flow Chart/ Value Stream Map Identify Barriers Spaghetti Diagram COPQ 5S Brainstorm Improvements Future State Flow Chart/ Value Stream Map Benchmarks and Measures Mistake Proofing Leveling Standard Work Specific Task List & Timeline

Report Results

Teach Standard Protocols

Update Policies

Monitor Results

Targeted Gemba Walks

Huddle at the PI Board

Source: Advisory Board interview, December 2006.

Rapid Improvement Event

7

RIE Supports the Mission, Vision, Strategy of the Organization

8

Rapid Improvement Events

Will accomplish the following:

Quickly implement Lean tools to eliminate waste and non-value added work

Train staff in Lean tools and application

Improve work flow

Improve productivity

Reduce stress

9

Summary of Key Points for RIEs Must have all three phases - The planning

phase and follow-up phase are just as important as the workshop (“hot week”) phase.

These events can be focused on one area or process, or on multiple areas.

Only successful if management (champion) is in support and there is cooperation from the staff.

Keep events manageable with focused projects. Expand as you experience success.

Always keep 5S as the initial part of any event.

10

A3 & PROBLEM SOLVING

11

Objectives

State the principles of A3 thinking

Describe the benefits of the A3 process

Articulate how to use tools to document the A3 process

12

A3 Thinking

A3 is structured problem solving

Helps us to truly grasp the root of the problem before we determine a solution

Transparency of thought and analysis

Develop A3 for all RIEs hospital-wide and all department specific

13

Three Pillars of A3 Thinking

14

A3 Elements

Project Title Executive Sponsor Background Current State

(Compelling Reason for Action)

Goals/Measures Analysis/Root Causes

Interventions / Future State Map

Observations Results / Conclusions Follow up(Has this change resulted in improvement?)

Plan to Sustain

PlanDo

StudyAct

15

Title: What you are talking about?

Background

Current Situation

Goal

Analysis

Recommendations

Actions

Follow Up

Why are you talking about it?Cost of poor quality?

Where do we stand today?

What’s the problem?

Where do we need to be?

What is the specific change you want to accomplish now?

What are the root causes of the problem?

What are your proposed interventions/ countermeasures?

What activities will be required for implementation and who will be responsible for what and when?

How we will know if the actions have the impact needed? What remaining issues can be anticipated?

Authors: John Shook and David Verble. Lean Enterprise Institute. www.lean.org

A3

16

A3 Background & Scope

Why are we forming this team?

How does the work of this group support the overall goals of the organization?

Which patients?

Which settings of care?

Which process?

What are the start and end points of the process?

17

A3 Background &Cost of Poor Quality (COPQ)

What are the dollars at risk?

Quantify the value of wasted staff time for non-value added activities

What are the additional days in length of stay when patient harm events occur or care coordination activities fail?

What are the risks to the organization if publicly reported data reflect poor performance?

18

A3 Current Condition (and Compelling Reason for Action)

Problem Statement: One sentence stating the compelling reason for action

Problem Description: Patterns, frequency, nature of problem

Facts: Show graph or process map that describes problem

19

A3 Goals

High level statement describing what we will improve? How? By When?

Aim Statement

How will we know a change is an improvement?

Process Goal?Outcome Goal?Note Benchmarks

Measures

20

A3 Analysis/ Root Causes

5 Whys: Ask “why” multiple times to identify the root cause

1 Why did the problem happen?

2 Why did that happen?

3 Why did that happen?

4 Why did that happen?

5 Why did that happen?

21

A3 Analysis/ Root Causes

Process

Effect

People

Place Policies

22

A3 Interventions / Future State Map

Identify the most effective solution that can be implemented, considering time and cost

Obtain approval from project sponsor

If steps in a process will change, show flow diagram

Consider standard work and visual controls

23

A3 Observations

Assign tasks to specific people and set target date:

Communicate plan to people affected by change

Implement interventions (pilot)

Collect data

24

A3 Results/ Conclusions

Team meets to discuss results of the trial/ implementation

Discuss unintended consequences

Decide what input, sequence, or step needs adjustment

25

A3 Follow Up

Tasks Target 

Date

Responsible 

Person(s)

Decide if new PDSA is needed

26

Why?

‘A3 Thinking’ The A3 Report

Background of the problemContext required for full

understanding Importance of the problem

Diagram of current situation (or process)Highlight problem(s) with storm burstsWhat about the system is not IDEALExtent of the problem(s), i.e.,

measures

List problem(s)Most likely direct (or root) cause:

Why?Why?

Why? Why?

Diagram of proposed new processCountermeasures noted as fluffy

cloudsMeasureable targets (quantity, time)

What? Who?

Cost:

When? Where?

Actions to be taken

Responsible person

Times, Dates

How will you check the effects?When will you

check them?

In red ink/pencilDate check doneResults, compare

to predicted

Background

Current Condition

THEME: “WHAT ARE WE TRYING TO DO?”

Root Cause Analysis

Target Condition

Implementation Plan

Follow-Up

Plan Actual Results

To:By:Date:

27

First Step: Hand Drawn A3

28

Electronic A3 (eVSM)

www.evsm.com

29

A3 with Photos

Source: http://www.shmula.com/wordpress/wp-content/images/shmula-5s-fishbone.png

30

A3 Templates 

31

Format A3 for Easy Uptake of Information

Goal is to tell a story

Strive to make the story visual

Address all A3 elements

32

A3 Plan to Sustain

How will these improvements be sustained?

Monthly A3 Reports with Data

Real Time Feedback/ Huddles

Visual Management

Go See

Standard Work

Leadership Rounds

33

Summary of Key Points The goal of an A3 is to tell a visual story

and communicate our problem solving approach.

The left side of the A3 represents the “Plan” of the Plan-Do-Study-Act methodology.

The value of spending time planning is that we understand the root causes of the problem before selecting an intervention or solution.

34

VOICE OF THE CUSTOMER (VOC)

35

Objectives

Define the Voice of the Customer (VOC)

Identify who the customer IS for a process

Describe how the needs of the customer are defined

36

What is a Customer?

A customer is:

Anyone who interacts with a product or service, from its design, development, transformation, and every step along the way to the end-user

Anyone whose perception of the value offered can affect whether or how an organization continues to deliver those offerings (American Society for Quality)

37

Primary Customer

38

What is VOC?

The “voice of the customer” is a process used to capture the requirements/feedback from the customer (internal or external) to provide the customers with the best in class service/product quality

This process is all about being proactive and constantly innovative to capture the changing requirements of the customers with time

39

How do we obtain VOC?

The stated and unstated needs of the customer can be captured in a variety of ways:

o direct discussion or interviews

o surveys

o focus groups

o customer specifications

o observation

o warranty data

o field reports

o complaint logs

40

Who are the Customers?

External customers Those not employed by the organization who interact with a product or

service

Often the person who pays for the service

Person who receives the output of the process

End user

Patient (sometimes called the “primary customer” in healthcare)

Internal customers Those in the organization who participate in the development/ delivery of the

product/ service People who need the output of the previous “step” to do their job Employees

Organization/ Stakeholders The stakeholders or leaders of the organization who want the

process to operate efficiently

41

Defining Customer Requirements

To adequately determine customer requirements, practitioners need to conduct discussions with the customer

Through these conversations, practitioners typically gather generic customer needs

Practitioners must go on to translate these generic needs into specific items called critical-to-quality requirements (CTQs)

42

Transitioning from VOC to Critical to Quality

To begin the translation to specific CTQs, consider the typical generic needs of the customer:

Cost: How efficient is the process operating from the perspective of the business? What costs are involved for the patient?

Timeliness: Delivery to customers when they want it

Quality: Did the customers get the what they wanted? (e.g. well-explained, helpful, done right the first time)

43

Obtain Voice of the Customer (VOC)

Identify the stakeholders in the process List all customers/receivers throughout this process

Talk to people! This is the beginning of our communication strategy.

Answer these questions: What are your customers saying?

What needs to be improved and why?

What does the process look like?

What is happening in the environment?

o National, regional, local, internal

Can we validate the perceived need for improvement using data?

44

VOC

1) Who is the customer of this process 2) What do they say about this process, what do they need? 3) What is the key issue for improvement?

Customer Voice of Customer Key Issue

45

VOC for Patients/ Family – Timely Care 

1) Who is the customer of this process 2) What do they say about this process, what do they need? 3) What is the key issue for improvement?

Customer Voice of Customer Key Issue

Patient I was stressed upon arrival but relieved when the doctor showed me pictures

Patient uncertainty about process/ outcome

Patient Would help to have more explanation if surgery is delayed for ½ hour or more

OR case delays/ Explain delays

Patient/ Family My mom didn’t know why it took so long. OR case delays/ Explain delays

Patient There seemed to be a lot of duplication in the questions they asked me

Cumbersome Pre-op process/ Duplication

Patient The nurses made sure I was comfortable Patient comfort

Family More information about what is going on after a few hours. I thought my wife would be done by 3pm.

OR case delays/ Explain delays

46

Example “Critical to Quality”: OR Cases Start On Time

Driver 1

Driver 3

Driver 4

Requirement 1

Requirement 4

Requirement 5Requirement 6

Customer Need (CTQ)

Driver 2Requirement 3Requirement 2

47

Example “Critical to Quality”: OR Cases Start On Time

Doctor has adequate information to select procedure(s)

Level load schedule

Separate emergent and elective case flow

Patient is on timeDoctor and staff are on timeEveryone involved knows the plan for the day

Standardized room set up

Supplies replenished on pull system (kanban)

Separate internal and external set up

Standard work

Contingency plan for increased patient demand (staff, rooms, communication)

Performance management – goal, visual management, threshold for action

Case Starts on Time

Consistently

Duration of surgery is appropriate for case

Schedule is blocked when surgeons are unavailable

Correct Surgery Scheduled

Schedule Reflects Demand for Services

On Time Staff

Supplies in Reach When Needed

Consistent Process to Clean and Set Up

Flow Management

Surgery Scheduling Guidelines

48

Summary of Key Points

Voice of the customer requires communication and current data.

Customer needs must be translated into specific items called critical-to-quality (CTQ) requirements.