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Laguna Honda
Lean Transformation
Laguna Honda
Strategic Performance Management
November 2017
Background
2
SEE IT
Remove wastes
Create
standard work
Respect people
SAY IT
MAKE IT
BETTER
FIX IT
1.
Identify problem and
value
2.
Map out allsteps in the
process
3.
Create bestwork flow
4.
Do the work and make it
happen
Perfo
rmance Im
pro
vem
ent
Quality
Assura
nce
2017 Staff Satisfaction Survey Responses
3
“Offer more opportunities for
professional development.”
“Create a culture to value the input of line
staff for problem solving by increasing participation.”
“Improve communication between depts…
continuous improvement by way of lean methodology.”
“Involve frontline staff in improvement
projects/work.”
“Balance the changes from lean culture.
Everybody is talking about it but we don’t
know what it is.”
“Better communication between lean staff
(Administration) and frontline staff. Get more
input.”
“Continue w/ lean transformation.”
“Continue with lean transformation as this
gives structure and organization to enhance
good working environment.”
“Spreading lean continuous improvement
principles.”
Objectives
4
Improve
Enable
Align
Support strategic goals by
aligning initiatives, projects and
metrics at all levels
Facilitate Lean initiatives that
focus on improving flow,
quality, safety, resident
experience & setting standards
Provide training, coaching,
and support for Lean systems
& tools. Develop lean leaders
around data driven performance
As an organization, we need to move from a culture of
compliance, to a culture of improvement.
Challenges
5
Developing a Lean culture is a slow process
Exposure of Lean initiatives
Teaching Lean methods and tools to all departments and shifts
Engagement at all levels
Sustaining improvement efforts
Our Tools
6
Value Stream Mapping(VSM)
• A technique used to illustrate, analyze and improve the steps required to deliver a product or service
Kaizen Workshops
• Workshop attended by owners & operators with intent of improving a specific process
Gemba Walks
• Personal observation of the work
A3 Thinking
• Root cause analysis; a systematic approach to problem solving
5S Workplace Management
• Standardize workspaces to eliminate unnecessary items and improve organization
Our Lean Journey
7
Training & Coaching
VSM’s & Hoshin Kanri
Kaizen Workshops
5S
Jul 2016 Oct 2017
Oct 2016 Jan 2017 Apr 2017 Jul 2017
Jul-16
Intro to Lean Rollout
Feb-17
VSM #1-Kaizen 1: Pre-Admission
Mar-17
Pharmacy 5SApr-17
Nursing 5S- Phase 1
Apr-17
VSM #1- Kaizen 2: Clinical Assessments
Jun-17
VSM #1- Kaizen 3: Room Readiness
Jul-17
Nursing 5S- Phase 2
Jul-17
VSM #2: Discharge
Aug-17
Nursing 5S- Hospital Wide Rollout
Sep-17
Lean EHR Prep Workshop- Cohort 1
Aug-16
LHH Leadership & Rona Plan Lean Transformation
Sep-17
VSM #2- Kaizen 1: Care Planning
Jun-17
Monthly DMS Training
Nov-16
VSM #1- New Admissions
Sep-16
3-Day Executive Education
Nov-16
Intro to A3 Thinking Jan-17
Start of A3Workshops
The Start of Our Lean Journey
8
Jul 2016 Oct 2017Oct 2016 Jan 2017 Apr 2017 Jul 2017
June 2016
• Strategic Performance Management Team developed a plan to introduce lean methodologies to all departments at Laguna Honda
July 2016
• Laguna Honda leadership received formal introductory training on the basic principles of lean
August 2016
• LHH Executive Team met with Rona Consulting to discuss approach for the organization’s lean transformation
• Projects were selected based on the needs of the San Francisco Health Network
September 2016
• 3-Day Executive Education
Value Stream Map (VSM) #1:
New Admissions
9
Jul 2016 Oct 2017Oct 2016 Jan 2017 Apr 2017 Jul 2017
Problem
• The existing admission process was flawed causing many delays and creating a long waitlist for approved patients.
Actions
• Improved Resident Care Team notification & communication
• Mapped new PASRR workflow to eliminate waste
• Set standards for timely completion of H&P documentation for coding
Results
• 3 Kaizen/Rapid Improvements: (1) Preadmission, (2) Clinical Assessments and, (3) Room Readiness
VSM #1 – Kaizen Workshop 1:
Pre-Admission
10
Jul 2016 Oct 2017Oct 2016 Jan 2017 Apr 2017 Jul 2017
Problem
• The pre-admission and screening process was very inefficient and community partners had expressed their concerns to our organization.
Actions
• Developed guidelines for SNF requirements in the new standard Laguna Honda admission application
• Developed standard work for screening, reviewing and responding to applications.
Results
# of Incomplete
Applications Received
per month
Time for Clinical
Decision of New Apps.
# of Apps. reviewed by
Screening Committee
per Month
71% to 3.3% 5.5 days to 2.6 days 134 to 27
VSM #1 – Kaizen Workshop 2:
Clinical Assessments
11
Jul 2016 Oct 2017Oct 2016 Jan 2017 Apr 2017 Jul 2017
Problem
• The length of time for all Resident Care Team members to complete their initial clinical assessments could take 7 to 14 days.
Actions
• Implemented Pharmacy chart preparation process
• Improved Resident Care Team communication
• Created standard work with expectations to complete initial clinical assessments w/in 48hrs of admission
• Created Admission Kits for clinical assessments and ADLs kits for residents
Results
Social Services
Assessments, n=82
Rx Chart Prep
Process
82% compliance
rate
process time & did not
decrease med rec errors
Clinical Nutrition
Assessments, n=82
72% compliance
rate
Activity Therapy
Assessments, n=82
4% compliance
rate
VSM #1 – Kaizen Workshop 3:
Room Readiness
12
Jul 2016 Oct 2017Oct 2016 Jan 2017 Apr 2017 Jul 2017
Problem
• Vacant rooms are scheduled for a new admission within 24 hours of discharge. However, the process of cleaning & repairing a room can take several days.
Actions
• Facilities, Nursing, and EVS collaborated to create a “Room Readiness Checklist”
• Implemented new method to send notifications when discharges are confirmed
• Created standard work & mapped new workflow with sequencing and time requirements
Results
July 2017 – Aug 2017
Vacant Rooms Prepared
w/in 24hrs, n = 24
50% Compliance
Rate
Sep 2017 – Oct 2017
Vacant Rooms Prepared
w/in 24hrs, n = 30
77% Compliance
Rate
Return on Kaizen for VSM #1
13
Category Kaizen Measure Data % Change
Motion
Pre Admission
# of steps taken to transfer the
Admission Application to the clinical
screener
Baseline: 500 steps by
Admission Cord.↓ 100%
Result: 0 steps by
Admission Cord.
Clinical
Assessments
# of steps taken during Nsg
Assessment
Baseline: 308 steps by Nsg↓ 100%
Result: 0 steps by Nsg
Cost
SavingsPre Admission
Salary spent per month on non-value
added time for unnecessary
screenings & incomplete application
follow up
Baseline: $3,515↓ 100%
Result: $0
Time
Savings
Pre AdmissionTurn around time from receiving
application to admission decision
Baseline: 5.5 days↓ 44%
Result: 2.9 days
Room
Readiness
Turn around time to prepare a
room after discharge
Baseline: 48 hrs↓ 75%
Result: 12 hrs
Defects
Pre AdmissionAdmission Application missing
clinical information
Baseline: 71% (n = 52)↓ 68%
Result: 3% (n = 30)
Clinical
Assessments
Initial clinical assessments
completed w/in 48 hrs
Baseline: 100% (n = 22)↓ 52%
Result: 48% (n = 82)
Room
Readiness
Rooms prepared w/in 24 hrs of
discharge
Baseline: 100% (n= 70)↓ 77%
Result: 23% (n = 54)
Pharmacy 5S – Workplace Management
14
Jul 2016 Oct 2017Oct 2016 Jan 2017 Apr 2017 Jul 2017
14 San Francisco Health Network
1. Sort 3. Shine
5. Sustain
2. Set in Order 4. Standardize
Nursing 5S – Workplace Management
15
Jul 2016 Oct 2017Oct 2016 Jan 2017 Apr 2017 Jul 2017
Nursing 5S- Phase 1 Nursing 5S- Phase 2
Before After
Value Stream Map #2:
Discharge
16
Problem
• Some short stay residents who have housing remain at Laguna Honda beyond their skilled nursing need, which contributes to a waitlist and backup in the network.
Actions
• Created a script for A&E and each discipline to acknowledge short stay
• Documented reason resident not present in RCC note
• Discussion with referring sources re: start discharge plan.
Results
• 3 Kaizen/Rapid Improvements: (1) care planning, (2) discharge preparation and, (3) discharge day
Jul 2016 Oct 2017Oct 2016 Jan 2017 Apr 2017 Jul 2017
VSM #2 – Kaizen Workshop 1
Care Planning
17
Jul 2016 Oct 2017Oct 2016 Jan 2017 Apr 2017 Jul 2017
Problem
• There are no estimated discharge dates for Short Stay residents due to unclear ownership in care planning
Actions
• Revised the Resident Care Team meeting notes form
• Standardized physician work flow for Short Stay referrals to LHH’s specialty clinics
• Created an educational program for staff on short stay goals
Results
• Process Owners will evaluate the outcomes at 30, 60 and 90 days
Moving Forward
18
Training & Coaching
VSM’s & Hoshin Kanri
Kaizen Workshops 5S
Lean Certification
Oct 2017 Jun 2018
Jan 2018 Apr 2018
Oct-17
Lean EHR Prep Workshop- Cohort 2
Oct-17
Monthly DMS Training
Nov-17
VSM #2-Kaizen 2:Discharge Prep
Oct-17
Lean Certification Training
Jan-18
VSM #2-Kaizen 3:Day of Discharge
Nov-17
Lean EHR Prep Workshop- Cohort 3
Nov-17
Nursing 5S- Hospital Wide Rollout
Dec-17
Lean CertificationTraining
Jan-18
Lean CertificationTraining
Jan-18
Hoshin Kanri Mar-18
VSM #3: TBDMay-18
VSM #3- Kaizen 1: TBD
Nov-17
Lean CertificationTraining
Strategic Performance Management Team/
Kaizen Promotion Office
19
• Health Program Planner
Elizabeth Schindler
• Administrative Analyst
Vincent Lee
• Jr Administrative Analyst
Olivia Thanh