Transcript Establishing a Lean Thinking Capability: Early Experience

Establishing a Lean Thinking
Capability: Early Experience
Mark S. Kirschbaum, RN, PhD
Chief Quality, Pt. Safety, & Clinical Information Officer
Adam G. Spieker, MBA
Quality Management Specialist
As a result of this workshop, you will
be able to:
• Identify the contributions of embedding a lean approach into
performance improvement efforts
• Understand what it takes to begin establishing an infrastructure to
support the application of Lean
• Discuss practical pointers to establishing the infrastructure,
including lessons about how to avoid or overcome hurdles
Workshop Overview
Forces Driving Reform
Introduction to Lean
UTMB Early Experience
Our Horizon
Improvement Structure & Deployment
Idea-driven Organization
Forces Driving Reform – Quality
No link between higher costs and quality or safety
• 98,000 to 195,000 people killed per year by medical
mistakes
• 57,000+ deaths from inadequate care
• 2M hospital-acquired infections with 90,000 deaths per year
• 55% overall adherence to recommended care
• Health care costs rising 1.5 to 2 times the rate of inflation
• Uninsured now total 45.5 million
• Up to 2-fold variation in per capita spending across
communities
• Ranked 37th in overall health system performance by WHO;
22nd in life expectancy, 28th in infant mortality
• US spends 52% more per person than next most costly
nation, Norway
Comparative Reliability
Between Industries
PPM
1,000,000
Difficulty with Referral
100,000
10,000
1000
Mammography Screening
• ••
••
•
Low
Back TX
Post Heart
Attack
Medications
100
IRS - Tax Advice
(phone-in) (140,000 PPM)
•
Inpatient
Airline Baggage Handling
Medication
safety
10
•
1
DEFECTS
SIGMA
U.S. ANESTHESIA DEATHS
50%
1
31%
2
7%
3
1%
4
0.02%
5
•
Domestic
Airline Flight
Fatality Rate
(0.43 PPM)
0.0003%
6
Sigma Scale of Measure
Taken from David C Classen, M.D.,M.S. , Assoc Prof of Med U of Utah, VP First Consulting Group
5
Un-reliability in health care
10-1
Beth McGlynn, NEJM: Beta blockers for acute
myocardial infarction
>3 Hemoglobin A1c tests per two years
10-2
Polypharmacy in the elderly
Medication injuries
Deaths in risky surgery
10-3
Neonatal mortality
General surgery deaths
Deaths in routine anesthesia
Deaths from major radiotherapy machine failures
Deaths from seismic non-compliance
10-4
10-5
10-6
6
Progress is Slow
1999/2001: IOM Wake-up Calls
• “To Err is Human”
• “Crossing the Quality Chasm”
2007 AHRQ National Healthcare Quality Report,
measures of patient safety, showed an
average annual improvement of just 1 percent
Janet M. Corrigan, PhD, National Quality Forum, The National Quality Agenda:
Leveraging Our Collective Efforts, 2008
Delivery System Inertia
Absurdly fragmented delivery system
Obsession with the services, not the outcomes
Predilection for autonomy over “systemness”
Lack of accountability for critical aspects of care
And so much more…
Janet M. Corrigan, PhD, National Quality Forum, The National Quality Agenda:
Leveraging Our Collective Efforts, 2008
Common Themes
Outcomes-focused reimbursement will
increase risks to revenue growth
Operating efficiency will be the driver
of future inpatient profitability
Bundled payments will make specialty
care more rare and less profitable.
Source: The Advisory Board
Top 10 implications of reform – 7.01.2009
The burning platform of healthcare
Pockets of excellence coexist with
enormously variable performance across
the delivery system.
Chassin and Loeb. Health Affairs, 30, no.4 (2011):559-568
Pockets of excellence and enormously
variable performance at UTMB
Not unlike other health care centers nationally,
UTMB is indistinguishably mediocre and
unreliable…
11
Questions
How do your patients experience non-value added care?
What percentage of care does not add value?
JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362
Quality Defined Components of Health
Care Quality – STEEEP
Safe—avoiding injuries to patients from the care that is intended to help
them;
Timely—reducing waits and sometimes harmful delays for both those who
receive and those who give care;
Effective—providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit
(avoiding underuse and overuse);
Efficient—avoiding waste, in particular waste of equipment, supplies, ideas
and energy;
Equitable—providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location and
socioeconomic status; and
Patient-centered—providing care that is respectful of and responsive to
individual patient references, needs and values and ensuring that patient
values guide all clinical decisions.
Institute of Medicine, 2001 – Envisioning the National Health Care
Quality Report; March, 2001, Institute of Medicine released, "Crossing
the Quality Chasm: A New Health System for the 21st Century."
14
Introduction to Lean
Berwick, DM, and Hackbarth, AD. Eliminating waste in US healthcare. JAMA. 2012;307(14):1513-1516
Lean Pillars
Respect for People
• Fully utilize the talents of our staff (task-skill alignment)
• Empowering front-line staff to identify and solve problems
Continuous Improvement
Lean Thinking
Defining "value" from a customer and patient perspective
Identifying "waste" and non-value-added activity
Indentifying and improving "value-streams"
Creating better "flow" for patients and processes
Preventing errors and improving quality in a systematic way
Creating an environment of true "kaizen" (continuous improvement)
Credit: Mark Graban
Waste
Credit: virginiamasonblog.org (2012-04-18)
UTMB Experience
Lean Improvement in 2011
We added industrial engineering expertise in the Healthcare
Quality and Safety Department
Training we’ve provided:
• 4 day intense Lean facilitator training for 27 UTMB staff in
quality, nursing, surgical services, clinics, revenue cycle
• One day overview for ~ 40 leaders
• Half-day introduction for executives
21
Support
• Instituted monthly meeting for the Lean trained staff
• On-going training
• Peer project presentations
• Networking
• Developed Lean Toolkit and Templates
Initial Lean Projects
•
•
•
•
•
•
•
•
•
Cath. Lab Supply Management
Decentralized surgical case scheduling
Eligibility/benefits & authorization
Handoffs - L&D to Postpartum
Managing Medications & Supply Outdates
Radiology – Reducing clutter / Improved efficiency
Registration: requesting pre-certifications
TDCJ ICU Decreasing Clutter
Trauma room supply management & charging
“cLEANing up Waste” in Interventional Radiology
Team Members: Natalie Kennie, Kelly Bonhomme, Kevin Klages, Theresa Carrig, Cynthia Lucia
Sponsor: Sandra Murdock, PhD Team Leader: Belinda Escamilla Facilitator: Benjamin Dzialo
Lean Methodology
Lean is a process improvement approach
based upon systematic elimination of waste
to reduce cost and improve patient care.
Background
Waste in Interventional Radiology (IR)
occurred with expired medical supplies and
time spent by staff to find supplies. The
concern among staff was duplicated
supplies located in multiple areas, while
some supplies were over-stocked and other
supplies under-stocked. Within the past
year, IR had $113,134.25 in wasted
supplies.
Interventions
Lean Tools Utilized
1.
2.
2.
3.
4.
5.
Kaizen Event
Gemba- Waste walk through
Cause & Effect Diagram
Spaghetti Diagram
Kanban
5S
• Sort
• Straighten
• Shine
• Standardize
• Sustain
•
•
•
•
Educated team members on Lean
concepts, provided Lean Tool Kit and
example of Lean project
Relocated supplies and labeled all
drawers and cabinets with supply
description and min/max par levels
Developed inventory monitoring tool
In-serviced staff/nurses on
interventions, plus FIFO concept
Results
• 28% reduction of wasted supplies
• 32% reduction of steps taken by staff
looking for supplies
• Reduced the frustration of staff not
finding supplies in timely manner
Aim Statement
Conclusions
By the end of February 2012, the
annualized expired supply cost savings will
be reduced by 25%.
The key to sustaining effective and efficient
management of inventory is to automate
processes and to routinely monitor
processes and supplies for consistent
practice.
End-of-Day Balancing Process – Campus Clinics
Sponsor: Cash Receipting
Team Members: Nancy Polk, Linda Shin, Beth Quigley, Rose Herrera, Anita Laws, Trish Filer, Aimee Contreras
Team Leader/Facilitator: Cindy Barrs
Lean Methodology
Focused on flow, eliminating waste,
and standardizing work across UTMB
Clinics.
Background
A gap exists between EPIC functionality
and current practice with regard to the
end-of-day balancing of funds receipted
during patient registration.
Lean Tools Utilized
•
•
•
•
Value Stream Mapping
Standardized Work Training
5S
Mistake Proofing
Interventions
• Streamlined documentation
requirements.
• Developed an on-line Epic based
form.
• Provided training.
Aim Statement
Align current process with Epic functionality. Success will be measured by:
• Achieving a change in process that reflects the functionality of Epic registration
processes
• Implementing standardized processes across the UTMB Health system
• Eliminating waste in the end-of-day balancing process
• Maintaining the accuracy of the financial information reported as measured by
Clinic Deposit QA data
Results
• 1 – 2% error rate maintained.
• Standardized forms and process
• Reduced paper consumption by 50%
• Freed up 2 hrs./wk. of Cash Receipting
staff time.
Conclusions
• Small hard dollar savings realized.
• Gain in cultural change for Lean & Epic
iConnect were huge.
• Changes in process take tremendous
tenacity to implement
• Maintain the gain relies on data which
is then fed back to the users.
Lessons Learned
• Lean education ≠ Ability to lead lean projects
• Lack of structure to select projects led to varying degree of project
alignment with organizational goals
• The targeted projects approach didn’t allow staff to “see the whole”
or understand that lean thinking should be taking place daily
Horizon: Systematically
Eliminating Waste
Quality Leadership
Ideas
Will
Execution
• Utilize a solid model for testing, adapting, and
implementing new ideas in the systems of care.
• Continually develop capacity for improvement, project
management skills, and highly disciplined methods for
design and redesign of the structures, processes and
services needed to implement, sustain, and spread the
good ideas.
A Framework for Leadership of Improvement, Institute for Healthcare Improvement, February, 2006.
28
Is Lean a…?
a set of operational concepts
a set of tools to improve business processes
a philosophy
• that helps drive efficiency and speed through employee
empowerment and change at the grass roots
• the relentless pursuit of the perfect process through waste
elimination… every step in a process is either value added or it
is waste.
Leverage Point Three: Channel Leadership
Attention to System-Level Improvement*
The currency of leadership is attention. To achieve system-level aims,
leaders must actually pay attention to them. All potential resources for
channeling leadership attention, whether formal or informal, should be
connected to the aim: personal calendars, meeting agendas, project
team reviews, executive performance feedback and compensation
systems, hiring and promotional practices, membership by patients in
design teams and committees. In other words, the signals sent both
by the “body language” of individual leaders and by the organization’s
leadership systems must change, if leaders are to expect system-level
results to change. Note: One of the most powerful known methods for
channeling attention inside your organization is to become transparent
about your quality performance outside your organization, so some
leadership “channel attention” work must be done outside the
boundaries of your system.
* Seven Leadership Leverage Points For Organization-Level Improvement in Health Care
Innovation Series 2005, Institute for Healthcare Improvement
Unifying Principles
Put patients and families first
Provide a safe environment for
patients, visitors, and staff.
Demand excellence by continually
improving clinical care, service,
and operations, and levels of
service.
Provide an integrated continuum of
care, optimizing system
interactions to better deliver
valued services.
Base clinical care, delivery methods
and operational processes on the
best available evidence from the
best available sources.
Focus on results.
Maintain a systems perspective.
Achieve breakthroughs via
multidisciplinary teamwork. Foster
engagement and respect expertise
by directly involving medical staff
and employees in the improvement
of their work processes.
Commit to effective, timely, open and
honest communication and
information sharing.
Use resources optimally and
efficiently, eliminate all forms of
waste, and recognize that poor
quality is costly.
Commit and involve leadership,
including the board, medical staff,
administration and managers.
Standardized practices
Standardized operations are safely carried out with
all tasks organized in the best known sequence
and by using the most effective combination of
resources (people, materials, methods, &
machines) (each step value-added, something
the ultimate customer is willing to pay for)
Driven by evidence (empirically tested practices)
and lean production designs
GM Picos project, 1994
32
2010 – 2015 Performance Improvement Initiatives
Lean Timeline
Structure
• Develop and deploy Strategy Deployment Boards
• The boards will consist of:
•
•
•
•
•
•
Balanced Scorecard Perspectives & Goals
Key Performance Indicators
Value Stream Map
Improvement Project Spotlight
Everyday Lean Ideas
Idea Project Action Items
Cascading Strategy Deployment
Boards
• Executive Board (Level 1)
• Service Line Boards (Level 2)
• Department/Unit Boards (Level 3)
Break Out
• Develop, for your span of influence, the Balanced Scorecard part
of the Strategy Deployment Board
• Perspectives
• Goals
• Key Performance Indicators
Performance Improvement Strategy
Three pronged approach:
• Value Streams
• Rapid Improvement Events / Targeted Continuous
Improvement Projects
• Front-line identified ideas and improvements
Value Stream
• Value Stream Defined: The entire end-to-end process for patient
care or the flow of a product, typically crossing multiple hospital
departments.
• Why use a value stream map?
• Promotes systems thinking / seeing the whole
• Provides a link between product/patient flow, timeline, and
information flow
• To set strategy before diving into the tactics
Current State Value Stream Map
• 10 process steps
• Value-added time: 63.4% (revised)
Future State Value Stream Map
• 7 process steps (30% reduction)
• Value-added time: 81.7%
Change Log
ACTION ITEMS
PROCESS OWNERS
Warning in HL at order entry for Lab: patient has a referral/doesn't include lab - reduce number
of patients sent away by Lab.
Geri Murphy
Decrease multiple questions asked ? educate staff on search (3,3). [minimum identifiers to be
asked, add if necessary]
Geri Murphy
Update appointment reminders ? still indicate a stop at Info Desk for a pager for Registration.
Geri Murphy
Script for all (identification points) explaining patient safety reason for (name/dob).
Lisa Holly
Reduce number of stops for Lab only patients - hand pager out at Lab reception desk.
Enter MRN in pager.
Mary Siebel
Mary Siebel
Lab staff - check for registration status "verified or needs review."
Mary Siebel
A sign at Information saying: If you have not been called to Lab check-in within 20 min. of
receiving your pager, please feel free to let Lab check-in personnel know.
Mary Siebel
Color coded directory of clinics with Registration Hub destination.
Redesign Lab walk-in process - can register, enter lab appointment, and avoid duplicate
questions? (ONC Model) (Reg. does Prel/Cadence)
Turf order delays to back/other desk.
Redesign appointment letters (add web site).
Greater use of volunteers to direct patients.
Shawn Arneson
Chris Reuter
Chris Reuter
Jeff Iverson
Sue Sanford-Ring
Discussion
• How many of your organizations have identified and mapped value
streams?
• How did you determine which value streams are important to your
organization?
• How many value streams can your organization focus on
improving?
Dartmouth-Hitchcock Clinical Microsystems
Access
Assessment/
Diagnosis
Intervention/
Therapeutics
Continuum Neuroscience
Primary
Care
Billing Process
Medication Usage
Diagnostic Imaging
Surgical
Services
Scheduling
Pre-Entry
Value Stream
• Select strategically important value streams
•
•
•
•
•
Orthopedic Elective Surgery
Inpatient Flow (ED – D/C)
Ambulatory Clinic Access
Patient Centered Medical Home
Revenue Stream
Value Streams
• Value Streams are mapped over 2.5 day period with operational
staff, executive sponsor, and lean facilitator
• Map current state & future state
• Identify improvement opportunities on the value stream maps
• Opportunities will be categorized by scope: Just-do-its, Rapid
Improvement Events, Continuous Improvement Projects
• The team uses a project selection matrix to determine which
opportunities will be worked on over the next year
Project Selection Matrix
…current approaches are not producing the pace, breadth, or
magnitude of improvement that all stakeholders desire.
What’s required:
Leadership
Safety Culture
Robust Process Improvement
Chassin, MR and Loeb, JM. The ongoing quality improvement journey: Next stop, high
reliability. Health Affairs, 30, no.4 (2011):559-568
Robust process improvement
Identifying the problem to be solved; defining
precisely a successful goal; measuring
performance in relation to goal; assessing
the causes of shortfalls; implementing
interventions targeted to the most important
causes; and embedding effective
interventions into the everyday work of
caregivers so that they are sustainable.
FOCUS-PDSA A3 Template
Rapid Improvement Events (RIE)
• Identified from Value Stream Map or Strategy Deployment Board
• Scheduled three months in advance (collect baseline data, identify
metrics, plan to back-fill staff attending RIE, etc.)
• Event duration:1-5 days
• Follow FOCUS-PDSA A3 Template
• Multidisciplinary team
• Facilitated by Lean trained Quality staff member
Continuous Improvement Projects
• Targeted projects
• Identified from Value Stream Map or Strategy Deployment Board
• Projects that require more than one-week to complete PDSA
cycles
• Project duration: ~100 days (time bound)
• Follow FOCUS-PDSA A3 Template
• Multidisciplinary team
• Led by middle management supported by Lean facilitator
Discussion
• How many of you have participated in a rapid improvement event?
• What challenges did you face?
• How did you overcome them?
• How did this feel different than other improvement teams you have
participated on?
• How well did you sustain the improvement gains?
The Idea-Driven Organization
Outline
• Why bottom-up innovation is where the action is
• How to run a high-performing idea system in your area of responsibility
• How to help yourself and your people come up with more and better ideas
Source: Alan Robinson
The Problem
• Front-line workers see a great many problems and opportunities that their
managers don’t.
• Most managers either don’t realize the full power of employee ideas or have
never learned how to tap them effectively.
• To be truly excellent in any aspect of performance, lean, or good at execution,
you have to be able to capture and implement large numbers of employee
ideas.
Source: Alan Robinson
The Tip of the Iceberg
Black-Belt
Projects
$1 million
Green-Belt
Projects
$1 million
Idea System
$9 million
Source: Alan Robinson
Managing Ideas
• Most creative acts are not planned form or even anticipated at companies at
which they occur
• A Sam Stern study found:
1. The award-winning projects were more likely to have been initiated by
individuals
And
2. The not-especially-novel ones were far more likely to have been
planned for by management
Source: Alan Robinson
Leaving Command and Control
Behind
• Top-down command-and-control has been part of mankind’s history since
the beginning
• Frederick Taylor: Those who think and those who do
• Problem: As organizations become increasingly more complex, knowledge
often resides in a different place from the power to do something about it.
Source: Alan Robinson
Expanding The Definition of Lean
When your employees are problem-solving and generating and
implementing ideas that further the organization’s strategic goals, on
a daily basis, and as a matter of the organizations culture and the way
it operates.
Source: Alan Robinson
How to run a good idea system
1. Go after the small ideas
• Small ideas are the best source of big ideas
2. Stay away from trying to reward individual ideas
3. Make ideas part of everyone’s job
• Document ideas and track them
• Teach your supervisors the value of ideas and their own four roles:
encouraging, mentoring, championing and looking for larger implications
of ideas.
• Goal: 12 implemented ideas/employee by end of first year
Source: Alan Robinson
How to run a good idea system (cont.)
4. Set-up a good idea process
• Design the process to discuss ideas within the workgroup first before they
go any further
• Work from problems and opportunities as much as possible
• Drive down decision-making and implementation to lowest possible levels
• Adequately resource support functions for the volume and types of ideas
that come in, and make supporting improvement ideas part of their jobs
• Escalate only completed staff work
• Ideas that need more money, are highly cross-functional or need more
authority will be escalated
Source: Alan Robinson
How to run a good idea system (cont.)
5. You need to do more than just install an idea-handling process
• Requires significant changes in leadership style and how you select,
develop and train your managers
• Requires significant changes in how you make decisions
• Requires significant changes in what you hold your managers and people
accountable for
Source: Alan Robinson
Realigning your Organization for
Ideas
Is about eliminating the need for heroes and
champions to battle your own system
Source: Alan Robinson
Help your people come up with
more and better ideas
• Constantly identify new ways to look at the work to increase their problem
sensitivity
• Teach them about creativity the creative process and creative thinking
• Use techniques such as Pre-mortems and After Action Reviews (AARs) to
develop new problem and opportunity areas
• Identify and develop idea activators
Source: Alan Robinson
Discussion
How many of your organizations have an institutionalized idea system
or suggestion program?
What challenges have you faced?
How do you envision avoiding the pitfalls of past idea campaigns?
Next Steps
• Identify and communicate the impetus for change
• Engage Senior Leadership in the development of your Lean
System
• Create a Lean/Performance Improvement Promotion Office
• Train senior leadership and middle management in Lean, change
management, adaptive leadership
• Mentor middle management on initial projects
• Educate & Empower front-line staff to identify and solve problems
Questions?
Contact information:
Adam G. Spieker, MBA
Quality Management Specialist
University of Texas Medical Branch at Galveston
[email protected]
Mark S. Kirschbaum, PhD, RN
Chief Quality, Pt Safety and Clinical Information Officer
University of Texas Medical Branch at Galveston
[email protected]
Suggested Further Reading
Transforming Health Care: Virginia Mason Medical Center’s Pursuit of
the Perfect Patient Experience, Charles Kenny, CRC Press, 2011.
On the Mend, John Toussaint and Roger A Gerard, Lean Enterprise
Institute, 2010.
Execution, Larry Bossidy & Ram Charan, Crown Business, 2002.
Ideas are Free, Alan G. Robinson and Dean Schroeder, BerrettKoehler, 2005.
References
What’s Right in Health Care | Evidence to Outcomes. The
National Quality Agenda: Leveraging Our Collective
Efforts. Janet M. Corrigan, PhD; President and CEO;
National Quality Forum.
President’s Commission on Consumer Protection and
Quality in the Healthcare Industry (1998).
“To Err is Human” (1999).
Leapfrog Group (2000).
“Quality Chasm” (2001).
McGlynn, NEJM, “The Quality of Healthcare Delivered to
Adults in The United States” (2003).
The Idea-Driven Organization, Alan Robinson, PhD, IMS