Leading a Healthcare Lean Transformation. Jill Case-Wirth, VP Operations, CNO Raymond Georgen, MD, FACS Heather Murphy, ICU Manager

Transcription

1 Leading a Healthcare Lean Transformation Jill Case-Wirth, VP Operations, CNO Raymond Georgen, MD, FACS Heather Murphy, ICU Manager

2 ThedaCare as a healthcare delivery system 4 Hospitals, including a Cancer Center, Heart Institute, Level II Trauma Center Stroke 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 Appleton Medical Center Copyright All Rights Reserved Theda Clark Medical Center 3

4 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

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6 What is Lean? 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 forever source: LEAN THINKING, Womack and Jones, Intellectually these principles are easy to understand, making them routine in your organization is never easy

7 True North Metrics Safety/Quality - Preventable Mortality - Medication Errors People - OSHA Recordable Injuries - HAT Scores - Employee Engagement Index Customer Satisfaction - Access - Turnaround Time - Quality of Time Financial Stewardship - Operating Margin - Productivity

8 Ideal State Information Flow Staff Staff Staff Level 1 Lead Level 2 Status of the Business: Information Continuous Improvement Metrics Escalation Supervisor Manager Executive Functions Strategic Innovative Weekly/Monthly Assessment 10-25% Standard Work Goals Tactical Management Control Daily assessment 50-75% Standard Work VP Sr VP Level 3 Level 4 Level 5 Level 6 Strategy Goals Purpose Mentoring Teaching Barrier Removal Strategy True North CEO Level 7 Copyright 2010 All rights reserved

9 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

10 Measurably Better Value ThedaCare s Strategic Plan Deploying Level 1 Priorities to Level 2 ThedaCare s Breakthrough Objectives People A3 (level 1) Problem statement, background and targets deployed People People (level 2) level 2 A3 Safety A3 (level 1) Shared Growth A3 (level 1) Productivity A3 (level 1) Plan Plan Plan Plan Safety Shared Growth Productivity Safety Shared Growth Productivity (level Safety 2) Shared (level 2) Growth (level 2) (level Safety 2) Shared (level 2) Growth level 2 A3 (level Safety 2) Shared (level 2) Growth (level Safety 2) Shared (level 2) Growth (level Safety 2) (level 2) (level 2) level 2 A3 level 2 A3 Cross Cross Function Functional Team Team Cross Cross Function Cross Function TeamCross Function TeamCross Function TeamCross Function TeamCross Function Team Functional Team Team Cross Cross Function Cross Function TeamCross Function TeamCross Function TeamCross Function Team Functional Team Team Cross Cross Function Functional Team Team

11 A3 or PDSA: What Are We Talking About? Background Why are you talking about it? Current Situation Where do we stand? Goal Analysis What s the problem? Where we need to be? What is the specific change you want to accomplish now? - What is the root cause(s) of the problem? - What requirements, constraints and alternatives need to be considered? Recommendations What is your proposed countermeasure(s)? Plan What activities will be required for implementation and who will be responsible for what and when? Follow-up How we will know if the actions have the impact needed? What remaining issues can be anticipated?

12 What does GOOD look like? 12

13 What is Lean? 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) SUPPORT (shared support of the Delivery, Demand and Development value streams)

14 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 Step 1 Identify waste Step 2 Eliminate waste 1st week after - Capture the savings 2nd week after Update Standard Work 3rd week after CFO validation

15 Continuous Improvement SW A P S D A P S D SW Performance Team VP Mgr Time

16 CODE STEMI 100 AMC Code Stemi Door to Balloon (Goal 60 min) Minutes Year

17 Collaborative Care Results 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 Copyright 2010 ThedaCare. All Rights Reserved.

18 Collaborative Care Alpha Results Over Time Measure Pre- Collaborative Care Desired Medication Reconciliation Admission Pneumonia Bundle 1.05 defects/chart 0.01 defects/chart 0 defects 0 defects 38% 100% 95% 95% CHF Bundle 92.5% 85% 92% Patient Satisfaction Average Length of Stay 68% 87% 90% 99%* Cost Per Case $5669/N/A $4467/-21% $4946/-24% $5567/-28% * Metric changed in 2009, 99% approximated Copyright 2010 ThedaCare. All Rights Reserved.

19 Doing Lean versus Becoming Lean Doing LEAN Becoming LEAN Focus on reducing costs Growing the business by improving processes Summary Project Delegated Leadership Tools only used during event weeks Business Strategy Top led, constant reinforcement Waste ID and elimination part of everyone s job Set of tools Strategy for improvement Complex measures Internally focused Simple, brief, visual, customer focused metrics Customer focused Pushing to sustain results Wondering are we LEAN? Organizational inertia, everyone owns the results Knowing this is never ending journey, it is not about getting there

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21 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 Copyright 2010 ThedaCare. All Rights Reserved.

22 Redesign of ICU Space and Process

23 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

25 The 2P (Preparation and Process) 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

26 Theda Clark ICU Room 2P Team Members: Beth Malchetske Heather Murphy Jill Menzel Mike Franz, Architect Kelly Jung, Trauma Services Dan Karlin, TC ICU RN Katie Klinke, TC ICU Secretary Christine Krizenesky, TC ICU RN Sarah Langjahr, Architect Participant Albert Park, Facilities Planning Jackie Phillips, Purchasing Team Role: Team Leader Team Leader Facilitator Participant Participant Participant Participant Participant Participant Participant Team Members: KC Schuler, Chaplin Dan Storzer, APAP David Yeazle, RT Jaime Ross, TC INU RN Randy Schoenrock, AMC ICU RN Shirley McGlin Dr. Burkett, Surgical Associates Dr. Georgen, Surgical Associates Dr. Greene, NeuroSpine Dr. Price, Neuro Science Dr. Sekhar, Surgical Associates Dr. Whiteside, FV Pulmonary Team Participant Participant Participant Fresh Eyes Fresh Eyes Customer Adhoc Adhoc Adhoc Adhoc Adhoc Adhoc

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

28 Initial State The current ICU process flows are a result of the 1 st 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.

29 Initial State The current ICU process flows are a result of the 1 st 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:

30 Rapid Experiments Broke into 3 groups to develop paper doll layouts Rated floor plans on criteria: Safety/Ergonomics Warm/Friendly Family Environment Common Footprint/Efficiency Security Line of Sight Privacy Flexibility Cost

31 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

32 Patient Rooms Old ICU Patient Room New ICU Patient Room

33 AA/Monitor Watch Station Old Monitor Watcher Station New Monitor Watcher Station

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

35 Quality Business Customer Employee Engagement Confirmed State Meeting target Not meeting target Measure Initial Target Achieved Quality Business Employee Engagement % of Patients Satisfied with ICU Family Areas % of ICU Patient Rooms that are in the care team s line of sight # Interruptions when charting in Nurses Station # of Interruptions to Patient Care per day to search for supplies and equipment TC ICU physical space supports a private consultation process Time for workforce response to team need 0% 90% Big Time Improvement 38% > 90% 100% 5.5/hour 2.8/ hour 2.5/hour 360 times per day 120 times per day 63 times per day No Yes Yes 0-5 minutes 0-3 minutes 0-3 minutes

36 The Business Performance System Daily Defect Huddle Monthly Scorecard Daily Stat Sheet Leadership Team Monthly Performance PDSA and Countermeasures Leader Standard Leader Standard Work Work Visual Management Review Meeting Copyright 2010 All rights reserved

37 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

38 Insert stat sheet

39 Manager Score Card 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. YTD Status (Fill in Red/Green Only No Numbers) Measure of Source SD, HD, HW Department Drivers 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% Automatic feed Financial Stewardship Productivity Watch Indicators: The Performance we are watching and may only respond to if the metric is changed to a DRIVER. MONTH AND YEAR To Date RED OR GREEN COLOR BOTH THE Measure of Source TN, SD, HD, HI HW Watch Indicators Owner Target or Trigger (only Previous Year or if there is one) Baseline Estimated Completion Date Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec YTD Avg YTD % Change vs Baseline) % 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% Safety/Quality Actual > 93.0% 93.0% 90.0% 92.0% -15% %Clinical triggers called appropriate to UW-OPO standards Sue 1.0 Plan > Safety/Quality Actual > #DIV/0! low rate for forceover hours per 24 hour period Heather Plan > 0.4 People Actual > % Emergent Airway situations Jenny Plan > rm 246/ICU Safety/Quality Actual > % Number of unmet competencies by due date Allyson Plan > People TN Actual > % OSHA recordable incident rate for Strains/Sprains Heather Plan > People Actual > % Patients readmitted to the unit after transfer Heather Plan > 2.20% 2.20% 2.20% 40% Customer Satisfaction Actual > 5.70% 5.90% 1.70% 100% Plan > Actual > #DIV/0! Number of Improvements Heather Plan > Safety/Quality Actual > #DIV/0! %compliance to standard work transfer checklist to floor to ICU transfers Rachel Plan > Safety/Quality Actual > %

40 Process Observation Calendaring Process Observation Pareto Processes Example Process White Board Nove Dece mber Janua ry Febru ary Marc h April May June July Augus t Septe mber Octo ber Nove mber Dece mber Sun Mon Tue Wed Thu Fri Sat PCB Problem Solving Tool (tollgates/delays) I&O Pain Management Environmental Safety Safe Patient Handling Care Plan Notes Purposeful Rounding Fall Bundle

41 Process: #1 Process: #1 Standard Work Observation Card Role: SW location: Process: #1

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43 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!

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47 Recipe for Success Tell the inspiring stories Speak to the value of teams and the results they can achieve Respect for People Excitement from Progress Passion Joy of Achievement 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 Continuous Improvement Appeal to what s right for patients Remove barriers/ headaches Copyright 2010 ThedaCare. All Rights Reserved. Candor with Respect Hold each other accountable Speak with accurate data that supports the results Provide continued coaching and mentoring

48 Thank You, Questions?