Putting Patients First: Using Lean to improve the Patient Experience in Saskatchewan

Transcription

1 Putting Patients First: Using Lean to improve the Patient Experience in Saskatchewan CareOregon Portland, OR May 2011 Dan Florizone, Deputy Minister Saskatchewan Ministry of Health

2 Saskatchewan Context Current Health Care Climate Rising Costs Historical costs 8.6% Current 3.1% for Limited Financial and Human Resources Variable Quality of Services Wait Times Current and Projected Spending is Unsustainable Value for Money (less than expected) 13 Regional Authorities, SCA

3 Patient First Review Released October 15, 2009 Independent review led by Commissioner Tony Dagnone Asked two key questions: Is the system putting the patient first? Are we achieving best value in care delivery and system administration?

4 Commissioner's Recommendations A total of 16 recommendations: 13 recommendations on improving the patient experience 3 recommendations on improving system performance and leadership

5 If we keep doing what we re doing, we re going to keep getting what we re getting. Stephen Covey

6 Achieving the Triple Aim: The Simultaneous Pursuit of Population Health, Exceptional Patient Experience, and Controlled Costs Experience of Care Population Health Per Capita Cost

7 The Value Equation The Health Sector s Triple Aim A common characteristic of high performing organizations, in any sector, is a focus on continually examining and improving processes To really add value, we must simultaneously improve results, customer service and maintain or reduce costs Lean is a methodology that addresses all 3 components of the value equation

8 What is Lean? Lean is the continuous pursuit of improvement to create value from the perspective of the customer or patient by empowering employees to generate and implement innovative solutions It is a philosophy, not a tool

9 Lean Thinking A passionate belief that improvement is never ending A continuous drive to identify and eliminate waste A way of thinking that causes everyone to use their talent to improve the work environment every day A culture that extends the ideas of Lean thinking across all processes using a common toolset. Lean is most effective when it becomes the culture of an organization

10 The Lean Journey in Saskatchewan s Health Care System

11 Achieving the Triple Aim: To really add value, we must simultaneously improve results, customer service and maintain or reduce costs Experience of Care Population Health Per Capita Cost

12 Why Lean? To provide value and eliminate waste to. support our primary objective to create and maintain an unwavering focus on the patient improve quality of care and safety of patients and staff increase the effectiveness of our processes increase customer satisfaction with our processes raise employee morale increase productivity lower costs Ministry to also undertaking lean in order to lead by example and share the journey with RHAs/SCA

13 Our Beginnings VMMC Presentation at IHI and Site Visit in 2004 Pilot funding provided to one health region (Five Hills) to undertake lean region-wide in 2006 Sporadic uptake of lean across the province Ministry of Health launches lean internally in 2008 January 2009, all region / cancer agency CEOs agree to undertake lean May 2009, Ministry provides $5M funding and common framework

14 Provincial Approach to Lean Common high-level strategic framework provided to all regions; included these elements: Common preferred vendor JIT training learn and apply Senior leadership training Change management training Requirement to develop Organization-Specific Training Plan and Communication Strategy

15 Examples of Ministry Efforts IT Contract Management Claims Processing Provincial Lab (Inventory; 5S; and Specimen Management) Financial Services Flow of Information Drug Plan and Extended Benefits Applications / Claims Ministerial Referral Process Health Registration Provincial Vaccine Management

16 Provincially-Coordinated Efforts Ministry-led, region involvement: Addictions Services Mental Health Services (Waits) Mental Health Services (Complex Cases) Surgical Patient Flow Blood and Plasma Product Usage Special Needs Equipment Strategic Planning and Reporting Long-Term Care Capital Planning

17 Applying Lean Across the Surgical Patient s Journey of Care Health Promotion Prevention Primary Care Diagnostics Laboratory Referral to Specialist Pre-Op / PAC Diagnostics Laboratory Surgery Post-Op Recovery/ Ward Therapies Home Rehab Saskatchewan Surgical Initiative Goals Improve Patient Experience Better Outcomes Reduce Wait Times Sustainable Change

18 Addictions Services

19 Examples of Health System Lean Efforts Heartland Health Region Placement of Long Term Care Patients Surgical Patient Flow For Day Surgery Surgical Specialist Consults Materials Management Posting Job Vacancies Doctors Rounds in Long Term Care Diagnostics Specimen Management

20 Health System Lean Efforts Five Hills Health Region Hip and Knee Surgical Pathway Operating Room Organization Absenteeism, WCB, Sick Leave Medication Reconciliation Prairie North Health Region Surgical Discharge Planning Process Outpatient Discharge Form Standardization Kelsey Trail Health Region Lab Processes Hiring Process

21 Health System Lean Efforts Cypress Health Region Linen Supply Occupational Therapy Waits Mental Health Patient Registration Regina Qu Appelle Health Region Patient Flow through Acute Care Facilities Maintenance Saskatchewan Cancer Agency Colorectal Screening Radiation and Medical Oncology Wait Times

22 Health System Results Improvements in patient experience (e.g., access, safety, quality) Regina Qu Appelle Health Region s Oncology Ward increased time nurses spend with patients during a shift from 26 per cent to 41 per cent. Breast cancer patients will see a 20% reduction in wait time from the time the plan for radiation therapy is complete to when therapy begins, resulting in a 50% reduction in exposure to radiation by reducing the number of radiation treatments they require. One ward in the Five Hills Health Region reduced falls from 15/week to 5/week.

23 Health System Results Improvements in capacity / productivity: By reducing the number of radiation treatments required by breast cancer patients, 235 CT appointments slots were reallocated, freeing up the equipment for other procedures. Five Hills Health Region added an extra 1/2 day capacity to do an additional 9 scope procedures each week or approximately 470 more scopes each year using existing resources. Regina Qu Appelle Health Region reduced cancelled MRIs from 12 to 1 per week, a 7% increase in productivity or capacity to perform an additional 650 scans / year using existing resources.

24 Health System Results Cost savings / avoidance: The Prairie North Health Region examined staff scheduled processes at the Battlefords Union Hospital and determined that scheduling practices had a significant impact on the costs incurred for overtime. They achieved 95% - 100% reduction in costs due to missed meal break overtime, resulting in annual savings over $200K. They are now rolling this initiative out across the region. Provincial Vaccine Program saved $1,277,395 in by applying lean to their inventory management practices. The team expects to see additional annual savings as they spread the new practices to other health regions.

25 Health System Results Employee safety, engagement and empowerment: An orthopaedic ward in Regina Qu Appelle decreased staff injuries by more than 50%. Reductions in premium hours have been shown to be related to improved employee engagement. (See result above: One RTC ward in Saskatoon Health Region has seen a 32% reduction in overtime hours, a 5% reduction is sick time, and a 67% reduction in family leave hours, as well as reducing orientation hours to 59%.)

26 Health System Results Improved Systems Thinking: Saskatchewan Surgical Initiative - beginning with family physician to post recovery care, including home, transfer to home region and other discharge options. Efforts are being coordinated at the provincial level, with the input of regions, to tackle this problem. In addition, regions have local efforts underway to improve the surgical experience. Lean is being used to improve strategic planning processes at the SCA and to assist staff to better understand patient flow through their entire service continuum (from prevention to screening, diagnosis, treatment, and follow-up).

27 Health System Results Improved Systems Thinking: The delivery of addictions services across the province is being examined. The inter-regional, Ministry-led team is focused on reducing wait times for clients by streamlining internal processes (e.g., referral handling, initial intake and assessment procedures, flow through treatment and identification and supply of alternate levels of care and support services) that could support more timely and efficacious client flow through the system.

28 Summary of Progress In less than 2 years, 24 teams trained and engaged in improvements in the Ministry of Health Of the 24, NINE are provincial in nature e.g., flow of surgical patients, addictions services, blood / plasma product use, etc. 90+ initiatives in the RHAs (40 from our early adopter )

29 Releasing Time to Care TM Nurse led, module-based program developed by the National Health Service (NHS) in the UK Based on Lean methodologies specifically for improvement of acute care ward-level processes Aim is to enable direct care providers to bring in quality improvement strategies into their workplace to improve patient outcomes and overall job satisfaction. Doing more with the same amount of resources

30 Increasing Direct Care Time One SK ward found that nurses spend about 28% of their shift time on direct patient care (average of minutes per patient per 12-hour shift) Youtube: Setting Up Suction, Cypress Health Region

31 Releasing Time to Care: Removing Barriers to Best Practice and Increasing Time for Direct Care Everything I need to do my job is conveniently located Role Time (e.g. nurse) The paperwork is We have the easy to understand information we need to and quick to solve our own complete I am not interrupted problems, and by find out people if requesting we were successful It is information clear to everyone or looking Handovers are who is responsible for thingsfor concise, timely and what provide all the information I need Opportunity to increase safety and reliability of care Total Time Motion Admin Discussion Handovers Roles Information Direct Care Time

32 Regional Health Authority Success Stories

33 RTC Results An equivalent of 1 FTE position was released on the Medical Ward at Moose Jaw Union Hospital by improving shift handover processes alone An estimated 270 hours of nursing time will be released by improving physical access between the IV and medication rooms on the surgical ward of the hospital in Prince Albert A minimum of 1,900 km of walking will be saved in a year with the installation of a new door release on the admissions unit at Saskatchewan Hospital (North Battleford)

34 Health System Results Five Hills Health Region Operating Room 5S completed in the OR added an extra 1/2 day capacity to do an additional 9 scope procedures each week or approximately 470 more scopes each year Regina Qu Appelle Health Region Oncology Unit 112km of walking distance per year saved for nurses and increased the time nurses spend with patients during a shift from 26 per cent to 41 per cent. Regina Qu Appelle Health Region Orthopedics Unit decreased staff injuries by more than 50 per cent Prince Albert Parkland Health Region reduced time spent in report by 42% on the surgical unit (from 50 minutes to 21 minutes on average). Staff say they know patients better, feel they have more time to spend with patients, and can more easily identify those Faster at risk Safer for falls. Better Secure

35 Five Hills Health Region Mental Health Unit Reviewing RTC measures during a Board Walk

36 Regina Pasqua Hospital: Main Storage room BEFORE 5Sing AFTER

37 Relocating the IV pumps, blanket warmer and personal care products SAVED: ~ 13 minutes/shift ~ 158 hours/year ~ 13 nursing shifts/yr

38 Improving Patient Experience with RTC Kim Ebert s husband has had two hip operations in the past five years, involving stays on the orthopedic unit at the Pasqua Hospital. She noticed a striking difference in the care on the ward during his most recent stay. I saw definite improvements in every aspect of care. The staff and ward seemed more organized, they worked well as a team, and I could see that they were making an effort to provide exceptional care for patients and their families.

39 Improving Safety with RTC

40 Provider Engagement The great thing about RTC is that it s us directing the change, directing the improvements. That s what going to make it sustainable. ~ Nurse, Prairie North Health Region

41 Releasing Time to Care TM Status of Implementation Strategic Goal: RTC will be implemented on all adult medical/surgical wards in all regional and tertiary hospitals in Saskatchewan by June 30, As of March 31, 2011, 90% implementation. CIHR / U of S Evaluation of RTC First in world to implement RTC in LTC

42 Other RHA Lean Initiatives Regina Qu Appelle: Patients transferred to hospital for MRI Before: Target: Current: Before: After: 12.5 scans cancelled each week 0 scans / week cancelled 1 scan / week cancelled 74% of MRI forms completed inaccurately 0% completed inaccurately Represents a 7% increase in productivity or an additional 650 scans / year

43 Other RHA Lean Initiatives Regina Qu Appelle: Patients transferred to hospital for MRI Staff Quotes Patients are no longer in pain or missing their medication waiting for EMS to pick them up; they are happier. Before this Value Stream, a patient travelled via EMS for 3 hours in a snowstorm. It was an absolute contraindication for an MRI and they were sent back home without having the test. A patient was brought in via EMS and could not have the MRI and it was cancelled. Patient paid approximately $1,000 for a round trip and had no testing.

44 Lean in the Government of Saskatchewan

45 Government of Saskatchewan Lean Initiative Commitment to lean across Government May 2010 Foundational training to SLT (Summer 2010) Value Stream selection 2 per Ministry and 2 cross-ministry initiatives 36 value streams across 17 Ministries / Crowns Value Stream mapping and staff training (Fall 2010) Improvements implemented (Fall-Winter 2010) Spread and culture change Building self-sufficiency

46 Government of Saskatchewan Lean Initiative Improvements in direct citizen service, services to businesses and third party agents, corporate services, administration Linked to Public Sector Renewal: 1. Citizen-Centered Service 2. Simplification 3. Enterprise-Wide Approach 4. Core Services 5. People Management

47 Summary of Progress In less than 2 years, the Ministry of Health has 24 teams trained and engaged in improvement Of the 20, EIGHT are provincial in nature (e.g., flow of surgical patients, addictions services, blood and plasma product use, special needs equipment, etc.) 90+ teams across all 13 health regions / cancer agency (40+ from our early adopter ) Government-wide lean initiative launched May 2010

48 Hoshin Kanri Hoshin Kanri is a visual management approach to: Focus on priorities Align all functions Discover issues early Inspire accountability Create linkage and fit for all initiatives Drive the strategies and impact the goals of the organization Hoshin Kanri helps the organization: Adapt to change Measure the system Set core business objectives Resource initiatives properly Prioritize the strategic work of the organization Communicate the strategic vision Build consensus A management approach to deploy strategy across an entire organization Policy Deployment

49 How Does Hoshin Work? Step-by-step planning: standardized process to determine goals, strategies and initiatives Rapid implementation: Concentrated efforts on fewer initiatives Visual management of strategic plan and resources with standardized tools

50 Lessons Learned

51 Applying Lean in Healthcare Toyota Production System Healthcare Processes thousands (complex) thousands (complex) Customer Satisfaction Staff Satisfaction Safety Quality Cost Effectiveness Errors may cause fatality

52 The Three Myths as to why governments don t need to radically improve Myth 1: We don t make widgets Therefore we can t really measure, manage, or improve but we do have systems of work to produce deliverables Government widgets = policies, laws, protocols, investigations, pay cheques for employees, distribution processes, contracts, arrests, bridge repairs, permits Adapted from: Ken Miller (2006). We Don t Make Widgets.

53 Myth 2: We don t have customers They didn t choose us, they don t want to come back and it doesn t matter if they are happy or not but we do have people whom we serve Government customers (the end user of our widgets) = prosecutors, doctors, foster parents, drivers, SA recipients, patients and families, police officers

54 Myth 3: We are not here to make profits and do not measure our work in terms of dollars made but we do seek to produce outcomes; it is just that they are typically measured with a different denomination Government profits (the results we are striving to achieve) = new jobs created, crimes reduced, increased export sales, percent with health care coverage, a healthier population, successful prosecutions, reduced hours of work lost

55 What s in it for our customers? Ease of use Timeliness Accuracy Cost Choice Results

56 What s in it for employees? More meaningful work Sense of empowerment Greater autonomy Ability to identify and address problems with their work using consistent methods Leadership and team skill development Support from others in organization (managers, internal experts)

57 Requirements for Success Customer First as the key driver for all we do Employment Guarantee Policy (does not negate the need for job change) Use of lean as a transformational methodology Encouragement of innovation (create learning organizations) Create a sustainable economic organization primarily by eliminating waste Accountable leadership and frontline engagement

58 Lessons Learned Start somewhere! Waste is everywhere just start Lean is not a project it is a journey Engagement of everyone is critical as is communication Top-Down commitment and Bottom-Up participation Change management cannot be underestimated Focus on doing, not just planning Expect resistance and failures Anchor improvements to a Value Stream to avoid sub-optimization Provide training just in time not just in case Measure! Keep measurement simple and VISIBLE Lean is not about performance management, it is about process and system performance Link lean with other strategic initiatives it is complementary

59 Putting the Pieces Together

60 Connecting the Dots Patient and Family Centered Care Quality Safety Efficiency Employee / Provider Engagement Value for Money Leadership ( Quality as a Business Strategy )

61 To Change Your Service, Change Your Thinking Old Thinking Provider First Waiting is Good Errors are to be Expected At-risk Employment Diffuse Accountability Add Resources Reduce Cost Retrospective Quality Assurance Management Oversight We Have Time New Thinking Patient First Waiting is Bad Defect-free Medicine Guaranteed Employment Rigorous Accountability No New Resources Reduce Waste Real-time Quality Assurance Management On Site We Have No Time

62 Focusing on Customers and Transforming the Delivery of Care A customer is the most important visitor on our premises, he is not dependent on us. We are dependent on him. He is not an interruption in our work. He is the purpose of it. He is not an outsider in our business. He is part of it. We are not doing him a favor by serving him. He is doing us a favor by giving us an opportunity to do so. Mahatma Gandhi