leading a healthcare lean transformation - home | uw … · leading a healthcare lean...

Leading a Healthcare Lean Transformation

Jill Case-Wirth, VP Operations, CNO

Raymond Georgen, MD, FACS

Heather Murphy, ICU Manager

Copyright © 2009. All Rights Reserved3

ThedaCare as a healthcare delivery system

• 4 Hospitals, including a Cancer Center,Heart Institute, Level II Trauma CenterStroke Center, Acute Rehab Unit

• 22 Physician Offices• 6 Behavioral Health locations• 3 Home Care locations• 3 Employer Health locations• 1 Skilled Nursing Facility• 1 Senior Living Facility

Theda Clark Medical Center

Appleton Medical Center

Transforming Healthcare

ThedaCare’s Redesign Equation:

Quality

Cost

Saving Lives and Transforming Healthcare

Copyright © 2010 ThedaCare. All Rights Reserved.

= Value

Lean Technology as a Tool to create better value

“Lean is a set of concepts, principles and tools used to create and deliver the most Value

from the Customers’ perspective while consuming the fewest resources and fully utilizing the skills and knowledge of those

who do the work.”-Lean Enterprise Institute

Copyright © 2010 ThedaCare. All Rights Reserved

The 5 Key Lean Principles

• Value – what the customer buys

• Value Stream – the way the Value is delivered

• Flow – putting value-adding steps in sequence

• Pull – triggering flow from customer needs

• Perfection – continuous improvement foreversource: LEAN THINKING, Womack and Jones, 1996.

Intellectually these principles are easy to understand, making them routine in your organization is never easy

Wha

t is Le

an ?

- OSHA Recordable Injuries- HAT Scores- Employee Engagement Index

- Operating Margin- Productivity

Financial StewardshipPeople

Safety/Quality- Preventable Mortality

- Medication Errors

- Access- Turnaround Time- Quality of Time

CustomerSatisfaction

True North Metrics

Copyright 2010 All rights reserved

Ideal State Information FlowStaff Staff Staff

Lead

CEO

VP

Sr VP

Super-visor

Level 1

StrategyGoalsPurpose•Mentoring•Teaching•Barrier Removal•Strategy•True North

Status of the Business:•Information•Continuous Improvement•Metrics•Escalation

Manager

Level 2

Level 3

Level 4

Level 5

Level 6

Level 7

•Goals•Tactical Management

•Control•Daily assessment

•50-75% Standard Work

•Executive Functions•Strategic

•Innovative•Weekly/Monthly Assessment

•10-25% Standard Work

A3

• As a standard process, it becomes easier for you – To describe key ideas to others, and– to understand others

• It fosters dialogue within the whole organization

• It develops problem-solvers• It encourages front-line initiative• Teaches scientific method

Deploying Level 1 Priorities to Level 2ThedaCare’sStrategic

Plan

Safety(level 2)

People(level 2)Peoplelevel 2 A3

Safety(level 2)Safety

(level 2)Safety(level 2)Safety

(level 2)Safety(level 2)Safetylevel 2 A3

Shared Growth(level 2)Shared Growth

(level 2)Shared Growth(level 2)Shared Growth

(level 2)Shared Growth(level 2)Shared Growthlevel 2 A3

Productivity(level 2)Productivitylevel 2 A3

Safety A3(level 1)

People A3(level 1)

SharedGrowth A3(level 1)

Productivity A3(level 1)

Plan Plan Plan Plan

ThedaCare’s Breakthrough Objectives

“Measurably Better Value”

Cross Function

Team

Cross Functional

Team

Cross Function

Team

Cross Function

Team

Cross Function

Team

Cross Function

Team

Cross Function

Team

Cross Function

Team

Cross Functional

Team

Cross Function

Team

Cross Function

Team

Cross Function

Team

Cross Function

Team

Cross Function

Team

Cross Functional

Team

Cross Function

Team

Cross Functional

Team

Problem statement, background and targets deployed

BackgroundWhy are you talking about it ?

Current SituationWhere do we stand ?

What’s the problem?

Analysis- What is the root cause(s) of the problem?

- What requirements, constraints and alternatives need to be considered?

Goal Where we need to be?

What is the specific change you want to accomplish now?

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

RecommendationsWhat is your proposed countermeasure(s)?

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

A3 or PDSA: What Are We Talking About?

12

What does GOOD look like?

SUPPORT(shared support of the Delivery, Demandand Development value streams)

The Lean Enterprise: 4 Key Value Streams• Businesses typically have four value streams:

Where to start…it depends….

DELIVERY (delivering to customers what the Business sells)

DEMAND (generating demand or orders for what the Business sells)

DEVELOPMENT (developing and improving what the Business sells)

Wha

t is Le

an ?

The 7-Week Cycle of an R.I. Event• 3 weeks before – Value Stream review, Event

Selection, Select Team Leader/Co-Leader and team members estimated financial, quality and staff impact

• 1-2 weeks before – RI Checklist, preparation .. Cell Communication, aim statement, measures

day 1 - current conditions day 2 – create the future day 3 - run the new process day 4 - standard work day 5 - presentation

1st week after - Capture the savings 2nd week after – Update Standard

Work 3rd week after – CFO validation

•Step 1 “Identify” waste

•Step 2 “Eliminate” waste

Continuous Improvement

SW

SW

DP

SA

Team

Time

Performance

DP

SA

VP Mgr

91

6552

37 3745

0

10

20

30

40

50

60

70

80

90

100

2005 2006 2007 2008 2009 2010

Min

utes

Year

AMC Code Stemi Door to Balloon 2005-2010(Goal 60 min)

CODE STEMI

Collaborative CareResults

• Defect–free admission medication reconciliation by the pharmacist at the bedside!

• Screening tools done on admission to improve outcomes and core quality measures: i.e. CMS bundles, DVT, palliative care, smoking cessation, skin breakdown etc.

• Collaboration of patient, core team, and ancillaries built into one plan of care

• Active use of evidence-based Milliman Guidelines to help guide the team in patient care progression

• Use of a “visual” Production Control Board to manage defects in care progression at the bedside

• Improved patient satisfaction

• Improved satisfaction and engagement of nursing staff and physicians


Measure Pre-Collaborative

Care

2007 2008 2009 Desired

Medication Reconciliation –Admission

1.05 defects/chart 0.01 defects/chart 0 defects 0 defects

Pneumonia Bundle

38% 100% 95% 95%

CHF Bundle 92.5% 85% 92%

Patient Satisfaction

68% 87% 90% 99%*

Average Length of Stay

3.7 2.96 3.16 3.09

Cost Per Case $5669/N/A $4467/-21% $4946/-24% $5567/-28%

Collaborative Care – AlphaResults Over Time

* Metric changed in 2009, 99% approximated


Doing Lean versus Becoming LeanSu

mm

ary

Doing LEAN Becoming LEAN

Focus on reducing costs Growing the business by improving processes

Project Business Strategy

Delegated Leadership Top led, constant reinforcement

Tools only used during event weeks Waste ID and elimination part of everyone’s job

Set of “tools” Strategy for improvement

Complex measures Simple, brief, visual, customer focused metrics

Internally focused Customer focused

Pushing to sustain results Organizational inertia, everyone owns the results

Wondering “are we LEAN”? Knowing this is never ending journey, it is not about “getting there”

On the Mend:Revolutionizing Healthcare to Save Lives and Transform

the Industry

1. Focus on the patient in order to determine the real value desired.

2. Identify the value stream providing this value to identify where value is actually created while removing massive amounts of waste

3. Reduce the time required to go from start to finish along every pathway.

4. Pursue principles 1, 2, and 3 endlessly through continuous improvement that engages everyone – doctors, nurses, technicians, managers, suppliers, and patients and their families -- touching the patient pathways.

Jim Womack, Lean Enterprise Institute, Inc; June 2010


Redesign of ICU

Space and Process

Value Stream Mapping

• Value Stream Mapping – the visual representation of the processes (work units and information) required to meet customer demand Includes both value-added and non value-added activities

Allows for “seeing” areas of waste in current state

Future state is roadmap and apt to change

Maps should be the plan for 6 months – 2 years

Project Plan

Process Phase

People Phase

Trials in progress

EMR –build

Implementation

Post Implementation Review


Intense 4 day knowledge building session

Multidisciplinary team of experts brainstorm and share information to kick-off the design process

Gain deeper understanding of cultural, process and spatial needs of project

Builds trust amongst team members

Team takes ownership

Accelerates design schedule

Facilitated by Simpler and ThedaCare Improvement System staff

The 2P (Preparation and Process)

Team Members: Team Role:Beth Malchetske Team LeaderHeather Murphy Team LeaderJill Menzel FacilitatorMike Franz, Architect ParticipantKelly Jung, Trauma Services ParticipantDan Karlin, TC ICU RN ParticipantKatie Klinke, TC ICU Secretary ParticipantChristine Krizenesky, TC ICU RN ParticipantSarah Langjahr, Architect ParticipantAlbert Park, Facilities Planning ParticipantJackie Phillips, Purchasing Participant

Theda Clark ICU Room 2PTeam Members: Team KC Schuler, Chaplin ParticipantDan Storzer, APAP ParticipantDavid Yeazle, RT ParticipantJaime Ross, TC INU RN Fresh EyesRandy Schoenrock, AMC ICU RN Fresh EyesShirley McGlin CustomerDr. Burkett, Surgical Associates AdhocDr. Georgen, Surgical Associates AdhocDr. Greene, NeuroSpine AdhocDr. Price, Neuro Science AdhocDr. Sekhar, Surgical Associates AdhocDr. Whiteside, FV Pulmonary Adhoc

Reason for Action The ThedaClark ICU will be relocating to a newly designed unit on the 2nd Floor as a

part of Hospital of the Future Initiative. In order to optimize an improved room layout, the following areas need to be addressed:

• It is challenging in the current physical space to perform key patient processes

• Provider frustration due to intermediate bed capacity issues

• Lack of effective space for families to be involved in the patient progression of care

• Hunting and gathering of supplies and equipment takes care team away from patient care

Scope: Intensive Care Unit and Intermediate Care Unit Patient Rooms

Initial State The current ICU process flows are a result of the 1st Floor location which has limited space

and is not adjacent to intermediate level of care

Currently the ICU and INU are on separate floors which results in:

• A failure to optimize staff with similar skill sets

• An increase in patient transfers, handoffs, and care team changes.

• No association between units even though they provide similar services The current ICU Room Layout results in waste and defects:

• Nurses spend an average of 4.2% of their time outside the patient room looking for supplies, equipment, etc.

• The average nurse travels 197 feet per hour when treating patients

• The average respiratory therapist travels 474 feet per hour when treating patients

• Rooms are crowded when families are visiting making it difficult to provide care

• In room procedures are inefficient due to lack of supplies and equipment accessible to staff.

Initial State The current ICU process flows are a result of the 1st Floor location which has limited space

and is not adjacent to intermediate level of care

Currently the ICU and INU are on separate floors which results in:

• A failure to optimize staff with similar skill sets

• An increase in patient handoffs

• No association between units even though they provide similar services The current ICU Floor Layout results in waste and defects:

Broke into 3 groups to develop “paper doll” layoutsRated floor plans on criteria:

Safety/ErgonomicsWarm/Friendly Family Environment Common Footprint/EfficiencySecurityLine of SightPrivacyFlexibilityCost

Rapid Experiments

Target State Space that allows family to feel welcome and present for their loved one.

Intermediate Level space that have the ability to go to ICU acuity during surges

Measure Initial Target

Quality % of Patients Satisfied with ICU Family Areas 0% 90%

% of ICU Patient Rooms that are in the care team’s line of sight

38% > 90%

# Interruptions when charting in Nurses Station 5.5 times per hour 2.8 times per hour

Business # of Interruptions to Patient Care per day to search for supplies and equipment

360 times per day on the unit

120 times per day on the unit

Employee Engagement

TC ICU physical space supports a private consultation process

No Yes

Time for workforce response to team need 0-5 minutes 0-3 minutes

Patient Rooms

Old ICU Patient Room New ICU Patient Room

AA/Monitor Watch Station

New Monitor Watcher StationOld Monitor Watcher Station

Nursing Station

Old ICU RN Central Location New ICU RN Station - Outside the Patient Room

Confirmed StateQuality

Customer

BusinessEmployeeEngagement Meeting target

Not meeting target

Measure Initial Target Achieved

Quality % of Patients Satisfied with ICU Family Areas

0% 90% “Big Time Improvement”

% of ICU Patient Rooms that are in the care team’s line of sight

38% > 90% 100%

# Interruptions when charting in Nurses Station

5.5/hour 2.8/ hour 2.5/hour

Business # of Interruptions to Patient Care per day to search for supplies and equipment

360 times per day 120 times per day 63 times per day

Employee Engagement

TC ICU physical space supports a private consultation process

No Yes Yes

Time for workforce response to team need

0-5 minutes 0-3 minutes 0-3 minutes

Copyright 2010 All rights reserved

LeaderStandard

Work

Daily Stat Sheet

Daily Defect Huddle

Leadership Team

Monthly Scorecard

Monthly Performance

ReviewMeeting

PDSA and

Countermeasures

Visual Management

Leader Standard

Work

The Business Performance System

Business Performance System

• Daily Stat Sheet- Learning & Understanding the business

• Daily Performance Review Huddle – Daily Problem Solving in the work

• Leadership Team – The support to see performance, understand problems & implement responses

• Monthly Scorecard- knowing our numbers

• Process observation-monitoring method for standard work processes

Insert stat sheet

Level: Manager Score Card Owner: Heather Murphy Mgr Monthly Scorecard -(Page 2 )

Hospital Division Drivers: The Performance we must respond to and focus daily improvements on to move the System True North Metrics. Key: TN/True North, SD/Strategy Deployment HD/Hospital Driver HI/Hospital Initiative HW/Hospital Watch True North Metrics: System measures we aim to improve through our drivers.

Measure of

Source SD,

HD, HW Department Drivers

YTD Status(Fill in Red/Green Only No

Numbers)

Sponsor/Owner Measure Of True North Metrics

Safety/Quality Reduce the number of unplanned extubations Rachel Janzen Safety /Quality Reduce the Number of Preventatble Mortalities to (# of mortalities/month)

Financial Stewardship Decrease productive hours/UOS Heather Murphy Safety /Quality Reduce the Number of Medication Errors to (# of med errors/month)

Financial Stewardship Decrease managed expenses/UOS Heather Murphy People Reduce the number of OSHA Recordables to (# of OSHA Rcrdbls/month)

People Reduce turnover to (# of terms/month)

People Increase Employee Health Assessment Tool Scores

Customer Satisfaction Patient Results Turnaround to (# hours? Turnaround time)

Customer Satisfaction Increase % of Same Day access (% of pts granted same day/month)

Customer Satisfaction Qualtiy of Time

Financial Stewardship Increase Operating Margin to x%

Financial Stewardship ProductivityAutomatic feed

Watch Indicators: The Performance we are watching and may only respond to if the metric is changed to a DRIVER. COLOR BOTH THE MONTH AND YEAR To Date RED OR GREEN

Measure of

Source TN, SD, HD, HI

HW Watch Indicators OwnerTarget or Trigger (only

if there is one) Previous Year or

Baseline Estimated

Completion Date Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec YTD Avg YTD % Change vs Baseline)

Safety/Quality

% Completed NIHSS assessments to order written Kristin 90.0% 80.0% Plan > 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%

Actual > 93.0% 93.0% 90.0% 92.0% -15%

Safety/Quality

%Clinical triggers called appropriate to UW-OPO standards Sue 1.0 Plan > 100.0 100.0

Actual > 0.6 0.6 #DIV/0!

People

low rate for forceover hours per 24 hour period Heather 0.4 0.4 Plan > 0.4

Actual > 0.0 0.0 0.5 100%

Safety/Quality

Emergent Airway situations Jenny 0.0 4.0 Plan > rm 246/ICU

Actual > 1.0 0.0 0.0 100%

People TN

Number of unmet competencies by due date Allyson 0.0 2.0 Plan > 0.00 0.00 0.00

Actual > 2.00 4.00 8.00 100%

People

OSHA recordable incident rate for Strains/Sprains Heather 0.0 0.1 Plan > 0.00 0.00 0.00

Actual > 0.00 0.00 0.00 100%

Customer Satisfaction

Patients readmitted to the unit after transfer Heather 2.2 2.2 Plan > 2.20% 2.20% 2.20% 40%

Actual > 5.70% 5.90% 1.70% 100%

Plan >

Actual > #DIV/0!

Safety/Quality

Number of Improvements HeatherPlan >

Actual > 9.0 20.0 15.0 #DIV/0!

Safety/Quality

%compliance to standard work transfer checklist to floor to ICU transfers Rachel 90.00 90.00 Plan > 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0

Actual > 90.0 82.0 96.0 100%

Manager Score Card

Process Observation Calendaring

Sun Mon Tue Wed Thu Fri Sat

Process Observation Pareto

Processes Nov

em

ber

Dec

e

Janu

a ryFe

bru

ary

Mar

c h

Apr

il

May

June July

Aug

ust

Sept

em

ber

Oct

obe

rN

ove

mbe

rD

ece

mbe

r

Example ProcessWhite Board

PCB Problem Solving Tool (tollgates/delays)I&O

Pain Management

Environmental Safety

Safe Patient HandlingCare Plan Notes

Purposeful RoundingFall Bundle

Process: #1 Standard Work Observation Card

Role:

Process: #1

SW location:

Process: #1

Observation of standard work will require coaching when the standard isn’t followed

Coaching is a leadership competency

Managers – DO NOT delegate this responsibility until you KNOW the person you are delegating to is able to coach effectively!

Recipe for Success

Respect for People Continuous Improvement

Excitement from ProgressPassion

Joy of Achievement

Candor with Respect

Tell the inspiring stories Speak to the value of

teams and the results they can achieve

Appeal to what’s right for patients Remove barriers/

headaches

Hold each other accountable

Speak with accurate data that supports the results

Provide continued coaching and mentoring

Value staff and provider input and act on it Turn negative energy into

positive activity If the experiments

aren’t working, seek to understand why

and have courage to change


Thank You,Questions?

leading a healthcare lean transformation - home | uw … · leading a healthcare lean...

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