MHA: Strategic Quality What’s Up Wednesday|Lunch and LearnYour clinical quality, process improvement resource

Jessica Rowden, MHA, BSN, R.N., CPHQ

Director of Clinical Quality

http://web.mhanet.com/quality-and-health-improvement.aspx

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June Topics

Virginia Mason Institute: 5S

Listeners will learn to identify 5S as a foundational principle of lean and demonstrate the ability to apply 5S with an emphasis on sort and simplify

Second of a three part webinar series of Waste, 5S and Time Observation

Transparency

NHSN

Immersion project

HEN 2.0

Upcoming events

© 2015 Virginia Mason Institute

Concepts of 5S

Missouri Hospital Association

Objectives

5© 2015 Virginia Mason Institute

• Identify 5S as a foundationalprinciple of lean

• Understand how to apply 5S to agenba with an emphasis on sortand simplify

5S is a strategy that helps keep our

workplace safe and organized.

The 5Ss are:

• Sort

• Simplify

• Sweep

• Standardize

• Self-Discipline

5S

6© 2015 Virginia Mason Institute

5S

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Rocks in Our Shoes

5© 2015 Virginia Mason Institute

5S

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Clinic Before 5S

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After 5S

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Sort

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Sort – Red Tag

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Sort – Is this 5S?

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5S

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Simplify

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Simplify – Gynecology Drawer

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o 5S of the ENT Carto Reduced large metal

ENT cart to a handy

tackle box.

ED Flow of Equipment – 5s

© 2015 Virginia Mason Institute

Flow of Supplies

• 2Bin System

• 5S

• Visual Control

PCT searching

for one supply

© 2015 Virginia Mason Institute

5S

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Sweep18

© 2015 Virginia Mason Institute

Sweep – Rosemary’s Office Map

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Sweep – Rachel’s Office Checklist

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Sweep Implementation

Sweep Duty Checklist

(for ensuring tasks are completed)

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5S

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Standardize

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Standardize

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5S

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Self-Discipline

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Measuring 5S Progress

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Sorting Simplifying Sweeping Standardizing Self-Discipline

Level V Continuously

Improve

Cleanliness problem

areas are identified and

mess-prevention actions

are in place

Map created for each

item in storage room

showing general location

and layout of materials

and can be retrieved

quickly with minimal effort

Potential problems are

identified and

countermeasures are

documented

Reliable methods and

standards are shared

throughout similar work

areas

Root causes are

eliminated and

improvement actions

focus on developing

preventive methods

Level IV Focus on

Reliability

Work areas has

documented

housekeeping

responsibilities and

schedules, and the

assignments are

consistently followed

Items move from storage

to use; create visual

control to identify point of

use

Inspection of area occurs

daily and work areas and

equipment are restocked

and organized

Reliable methods and

standards are adhered to

by all members of the

work group

Sources and frequency of

problems are

documented as part of

routine work, root causes

of noncompliance are

identified and corrective

action plans are

developed

Level IIIMake it Visual

Initial cleaning has been

completed; items

disposed of according to

auction disposition

Needed items are

outlined, dedicated

locations are properly

labeled and required

quantities are determined

Visual controls and

indicators are established

and marked for the work

area equipment, files and

supplies

Documentation for all

visual controls exists

Work group routinely

checks area to maintain

5S agreements

Level IIFocus on

Basics

Needed and not-needed

items are identified and

those not needed are

removed from work area

Needed items are stored

and organized according

to frequency of use

Work group has agreed

on items to be checked

and acceptable

performance levels

documented

Work group has

documented agreements

for needed items,

organization and work

area controls

Documentation of

completed 5S is posted in

work area; 5S is

incorporated into new

staff orientation

Level IJust Beginning

Necessary and

unnecessary items are

mixed together

throughout the work area

Items needed are located

in various places

throughout the work area

Key work items are

missing and current

location is not known

Standards for work area

organization are not

followed or documented

Work area checks are not

done regularly and there

is no visual measurement

of 5S performance

Example5S improvement

• What further improvements couldbe made?

• Are there other applications of 5S besides physical spaces?

31© 2015 Virginia Mason Institute

Supply Room before 5SNeat, but not efficient

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Supply Room after 5SUsing Supply Replenishment System

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The Benefits of 5S

5S is a visual control that:

Promotes

Safety

• Hazards removed

• Walkways are

cleared

• Bending, twisting

and lifting are

minimized

• Outdated items are

removed

Promotes

Teamwork

• Shared agreement

and implementation

• Clearer

understanding

of one another ’s

roles

• Team innovates and

creates together

Cuts

Costs

• Common, standard

supplies identified

• Each work area has

only the needed

supplies and

equipment

• Extra resources are

shared

• Custodial time saved

Improves

Productivity

• People work better

in organized areas

• Easy access to

supplies and tools

• Less time searching

and walking

• Anyone can easily

find what they need

to serve the

customer

34© 2015 Virginia Mason Institute

How do you approach the genba for 5S?

35© 2015 Virginia Mason Institute

A lean journey is a learning journey.TM

© 2015 Virginia Mason Institute

Transparency

Transparency Questions?

Dana Downing, MBA-H, CPHQ

Vice President of Quality Program Development

ddowning@mhanet.com

573/893-3700, ext. 1314

NHSN

Confer your NHSN Data to HIDI

Why?

To provide you the most robust data portfolio

To better assist you with more improvement opportunities

See the Instructional Guide

Immersion Pilot Project Update

Immersion Project Webinars

Quarter Three Wrap-Up

July 18, 1-2 – Falls Immersion Project webinar

July 19, 10-11 – Sepsis Immersion Project webinar

July 19, 1-2 – Readmission Immersion Project webinar

July 25, 1-2 – CAUTI Immersion Project webinar

July 26, 1-2 – OB Immersion Project webinar

Future Projects

HAI/ASP

Leadership?

HEN 2.0

HEN 2.0 Update HEN 2.0 Status Report updates will be sent out early next week

Site visits to be completed July – September

Case Example template to be completed and returned prior to visit

OB harm prevention workshop July 28, Hilton Garden Inn, Columbia

End of HEN Launch of HIIN August 24, Courtyard by Marriott, Columbia

Survey Monkey of PFE and Operational metrics – please respond by next Wednesday July 13

Data needed for OB measures (harm with and without instruments, preeclampsia, EED, hemorrhage)

Sepsis measure transitioning from post-op to overall rate and sepsis mortality…pulling from claims

Educational reimbursed for state and/or national conferences

Up to $5,000/hospital

Expenses must be invoiced by August 15

Hospitals that still have opportunity to get $5,000

Black River Medical Center

Bothwell Regional Health Center

Carroll County Memorial Hospital

Cass Regional Medical Center

Cedar County Memorial Hospital

Citizens Memorial Hospital

Des Peres Hospital

Ellett Memorial Hospital

Excelsior Springs Hospital

Freeman Health System

Freeman Neosho Hospital

Golden Valley Memorial Healthcare

Harrison County Community Hospital

I-70 Community Hospital

Lake Regional Health System

Lee's Summit Medical Center

Liberty Hospital

Madison Medical Center

Mercy Hospital Carthage

Mercy Hospital Joplin

Mosaic Life Care at St. Joseph

Nevada Regional Medical Center

North Kansas City Hospital

Northeast Regional Medical Center

Ozarks Community Hospital

Ozarks Medical Center

Phelps County Regional Medical Center

Pike County Memorial Hospital

Poplar Bluff Regional Medical Center

Putnam County Memorial Hospital

Ray County Memorial Hospital

Salem Memorial District Hospital

Samaritan Hospital

Scotland County Hospital

Southeast Health Center of Stoddard County

Southeast Hospital

SSM Health Saint Louis University Hospital

St. Alexius Hospital, Broadway Campus

St. Anthony's Medical Center

St. Mary's Medical Center

Ste. Genevieve County Memorial Hospital

Sullivan County Memorial Hospital

Texas County Memorial Hospital

Twin Rivers Regional Medical Center

Western Missouri Medical Center

HIIN or HEN 3.0

The contract is a fixed price contract

The project is slated to begin September 30, 2016 – 2 year base project, one year option

Proposals due June 27th at 2 p.m. ET

Questions on RFP due to CMS by June 2nd. Refer to page 99 of RFP for details

Baseline data: 2014

Goals: 20 percent reduction in harm, 12 percent reduction in readmissions

Measure changes: OB and EED measures removed and Sepsis and C Diff now required

Will require QIO/QIN 11th scope of work alignment

CMS wants alignment with AHRQ antibiotic stewardship

Member Resources and Support

Resources

MHA

HEN 2.0 resource library

Regulatory Web page

QAPI guide

MHA Survey Manual

Quality Regulatory Orientation Guide

Quality Initiatives Resources page

HRET Based Resources

Eliminating Harm Checklists – for all preventable harm topics

Readmissions

Falls

Sepsis

CDI

Pru

CLABSI

Airway safety

Failure to Rescue Change Package

Iatrogenic Delirium Change Package

Surgical Site Infections Change Package

Undue Exposure to Radiation Change Package

HRET Based Resources

Fact sheets

ADE

– Data Collection and improvement fact sheet

– Excessive Anticoagulation with Warfarin – Inpatients

– Hypoglycemia in Inpatients Receiving Insulin

– Adverse Drug Events due to Opioids

Sepsis

– Data collection and improvement fact sheet

– Outcome measure

Trajectory

Monthly Newsletter

Upcoming Events

Put us on your calendar! MO HEN OB Harm Reduction Workshop

July 28

Hilton Garden Inn – Columbia

Registration

END of HEN Convening

August 24

Courtyard by Marriott – Columbia

Registration

Monthly HEN webinars

Third Wednesday of the month, Noon to 1 p.m.

Register for all webinars using this link.

MHA - Monthly What’s Up Wednesday

First Wednesday of the month at noon

Register for 2016 WUW

Other MHA events here

MHA Collaboration with Children’s Mercy Hospital

Thursday, Aug. 18, Noon - 1 p.m.Patient Advocate-Policy Design StrategiesRegister

Thursday, Nov. 17, Noon - 1 p.m.Family-Centered RoundsRegister

HRET Sponsored Webinars – July

HEN 2.0 Falls

July 7 11-12 pm

HEN 2.0 CAUTI Webinar

July 12 11-12:00 pm

HEN 2.0 SSI

July 21 11-12 pm

HEN 2.0 Sepsis

July 26 11-12 pm

HEN 2.0 VAE

August 2 11-12

MHA Seminar

Facilitation Skills for LeadersPart I — Thursday, July 14, 2016Part II* — Friday, July 15, 2016

*Must attend Part I to attend Part II

Program information

Thank You for Joining Us

See you August 3 at noon!

Virginia Mason Institute Series– Time Observation

• Listeners will learn to identify time observation as a foundation principle of lean and demonstrate the ability to understand key components of proper time observation

Contact Information

Jessica Rowden, MHA, BSN, R.N., CPHQ

Director of Clinical Quality

Missouri Hospital Association

jrowden@mhanet.com

573/893-3700, ext. 1391