Lean Management Systems in Action Scott & White Memorial Hospital September 14, 2013

Lean Management Systems in Action Scott & White Memorial Hospital September 14, 2013 1

Why Lean Management System? The Ultimate arrogance is to change the way people work, without changing the way we manage them John Toussaint, MD On the Mend Lean Management focuses on process: 1. Leader Standard Work 2. Visual Controls (SQDCM) 3. Daily Accountability (Huddles) 2

Lean Management System Leader Standard Work Provides structure and routine to duties Allows leaders to shift from results only, to process and results Process dependent, not person dependent Visual Controls (SQDCM Boards) Visual controls translate performance into expected vs actual Data recorded daily, visible and accessible Quickly spot and move to action where performance not at expected. Daily Accountability (Huddles) Meet with team, facilitate performance improvement Prioritize efforts, control pace Engage staff David Mann, Creating a Lean Culture 3

Daily Accountability: Leaders have a daily, brief, focused huddle at a results board (SQDCM) Safety Quality Delivery Cost Morale 35 25 20 20 18 16 14 GOAL 20 18 16 14 25 20 GOAL 25 15 10 12 10 8 12 10 8 15 10 15 GOAL 5 0 GOAL 6 4 2 0 6 4 2 0 GOAL 5 0 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 Develop a balanced set of process measures The 4 Key Questions for every Daily Accountability Huddle 1. What are your metrics, and targets? 2. Are you meeting targets? If not.. 3. What is your plan (what actions are you taking)? 4. How can I help you? Repeating this daily, drives to results 4

LMS implemented to Improve Our SWAT (Scott & White Alignment Tool)Goals Yearly System Goals Goals cascaded through every layer to the front lines LMS focusses on process improvement to drive towards goals 5

SWAT Goals on Patient Satisfaction Getting Alignment to the Front Line Pat Currie, System COO Shahin Motakef, CEO Improve overall inpatient Top Box percentile to 53% (stretch 55%). Achieve Top Box Score for SWMH on Overall Rating of Hospital Feb 2013- Aug 2013: Actual 69, Target 72, Stretch 74 Cyndy Dunlap, CNE/CNO Achieve Inpatient Top Box Score of 72 for Overall Rating of Memorial Hospital Annilyn Donnell, VP Periop and OB Improve Top Box % of Always responses on Overall Rating of OB to 65.66 or better than FY12 score (Actual =65) Improve Top Box% of Overall rating of Day Surgery by 5% or better from FY12 score Improve Top Box % of Overall rating of Pavilion by 5% or better from FY12 score Shonna Bracco, Nurse Director OB Services Achieve HCAHPS overall Top Box score of at least 65.66 for FY 2013 from an actual of 65 for FY 2012. Audra Vinson & Kayla Skala, Nurse Managers Achieve HCAHPS overall percenta ge score of at least 65.66 for FY 2013 from an actual of 65 for FY 2012. Staff Nurse Achieve HCAHPS overall percentage score of at least 65.66 for FY 2013 from an actual of 65 for FY 2012. This document may not be copied without the permission of the Vice President of Quality & Regulatory Services.

LMS IN ACTION Shonna Bracco, MSN, RN Nurse Director, Inpatient Obstetrics Audra Vinson, RN Nurse Manager, Inpatient Obstetrics This document may not be copied without the permission of the Vice President of Quality & Regulatory Services.

Patient Satisfaction

3 N/L&D Patient Satisfaction SWAT Goals & Results Overall Rating

3 North/L&D HCAHPS Results by Domain FY13 YTD This document may not be copied without the permission of the Vice President of Quality & Regulatory Services.

OB Services Huddle Board 11 This document may not be copied without the permission of the Vice President of Quality & Regulatory Services.

Call lights/patient/day This document may not be copied without the permission of the Vice President of Quality & Regulatory Services.

Ideas to Implement 13 This document may not be copied without the permission of the Vice President of Quality & Regulatory Services.

Call Light Response This document may not be copied without the permission of the Vice President of Quality & Regulatory Services.

Summary: Satisfaction Metrics Performance Actions Response of hospital staff. Huddles on call lights, noise level at night, pain med timeliness, and educating on pain meds. Call button help as soon as wanted it. Overall rating Meaningful rounding-tend to all patient needs when you are in the room. HUC/DCN check that all Ascom phones are linked to the nurse and patient rooms within 30 minutes of starting a new shift. Change Ascom phones for call light to rollover to HUC desk if not answered by nurse in 30 seconds. (previously rolled over in 60 seconds). Nurse Manager rounding to focus on opportunities for improvement. Focus on improving timeliness and quality of discharge through education and handouts. Next Steps/Help Needed New evidence based discharge couplet care books ordered and began using in January 2013. Need help with temperature and quality of food and cleanliness of environment. Continue to review weekly Press Ganey report as well as patient comments from discharge phone calls and satisfaction reports to note trend in scores related to actions. 15 This document may not be copied without the permission of the Vice President of Quality & Regulatory Services.

Scheduled Cesarean Section Wait Time 16

Causes of schedule procedure delays 17

Ideas to Implement 18

Looking at Outliers 19

Summary: C-Section Wait Times Performance Actions Average wait time for schedule cesarean section. Goal is 30 minutes wait or less from scheduled time. Track wait times and keep log of reason for delays. Check with MD on admit to ensure all labs completed. As soon as patient arrives notify anesthesia provider 1st thing. Contact night anesthesia provider and give him schedule for next day. Contact staff physician on admission and keep updated on start time. Work with residents and staff to limit elective interventions during surgeries (AROM). Anesthesia requested same type of tracking for Labor epidurals. Started 2/1/13 tracking this information to improve pain control and satisfaction. Next Steps/Help Needed 20 Continue to track times and log reasons. If data continues to show trend in delays related to anesthesia coverage will ask Director to involve anesthesia department. L&D operating room over-booking and conflicts with providers schedule. Huddled with clinic leadership for areas of improvement.

Summary: Labor & Delivery to OB Clinic Huddle Performance Actions Improve the process for L&D operating room scheduling to decrease incidence of overbooking and provider schedule conflicts. Huddled in late October 2012 with L&D leadership, OB Clinic leadership, and physician leadership on overbooking of schedule and its impact on wait times for scheduled procedures. Made one person in clinic responsible for OR scheduling in mid November 2012 to provide more control over scheduling. Clinic representative responsible for OR scheduling provides weekly summary to L&D Nurse Manager so conflicts can be resolved before day of surgery and staffing be appropriate for days of increased procedures. Next Steps/Help Needed 21 Continue to track number of days of overbooking each month and make changes in process as needed to achieve goal of 0 days of overbooking each month.

Right Furniture in Rooms 22

Summary: Right Furniture in Rooms Performance 3 patient rooms on Mother/Baby without sleeper sofa. 2 patient rooms on L&D without sleeper sofa. Waiting list in hospital due to multiple floors without sleeper sofa or cots. Actions During daily huddle identified complaints due to lack of sleeper sofa or cot in some patient rooms. Notified Director Began tracking percentage of patients each day without sleeper sofa or cot. 23 Next Steps/Help Needed Due to cost of sleeper sofa s assistance requested in steps to purchase furniture for each room. Future needs for replacement of all sleeper sofa s due to wear and aging.

1.05 Achieve HCAHPS overall Top Box score of at least 65.66 for FY 2013 from an actual of 65 for FY 2012 Performance Actions Schedule meeting with System Director of Food & Nutrition Services, toured kitchen and reviewed their goals and action plan. Improve quality of food Formed committee with EVS, Dietary, and OB services. Improve temperature of food Ensure dietary notification of lactating patients. Improve cleanliness of environment Improve staff response to call lights Auto consult for expectant mothers who are potential long term guest for menu variety and selection options. Hospitality program started on OB floors 12/31/2012 Improve overall rating Trays being delivered faster with hospitality staff, only one tower trays being brought up at a time. Gemba walks and Huddles with staff and/or Nurse Managers. Weekly review of report from Press Ganey and tracking of opportunities. Huddle boards reviewed in each monthly unit meeting and each bi-monthly Charge Nurse meeting. Tracer tags purchased for L&D and Post Partum to assist with call light tracking and management. Trialing iphones in OB to replace Ascom phones Sleeper sofa in 100% of rooms 24 Next Steps/Help Needed Changed tray delivery time for OB patients Dietary-Lactation juice/snack baskets, menu for healthy mothers, Celebration meals/cupcake Capital for furniture-completed Continue to track weekly data on quality/temperature of food and cleanliness of environment to measure effectiveness of actions. Care boards ordered for Mother/Baby to include hospitality and EVS staff information: Ask what excellent care means to the patient to individualize care.

PAN Continuous Improvement Projects Utilizing the Lean Management System Alma L. Johnson RNC-TNP, BSN Clinic Nurse Manager Communications/PAN

Patient Advisory Nurse (PAN) Overview After Hours Telephone Triage and Health Information Triage Potential Urgent Calls for Contact Center Critical Lab Reporting for Regional Clinics After Hours CHF Post Discharge Calls After Hours Resource for S&W Patients, Surrounding Community, Medical Home Patients, Signature Patients Communication Center for S&W special needs 26

Monthly Call Volume 2012-2013 27

28

Increasing Service Levels for Potential Urgent Calls from Contact Center Problem: Service Levels for Urgent Call Line inadequate Plan: Staffing mix and adjustments/meeting with Contact Center & Clinic Nurse Managers, daily tracking, review Red Flag List Do: Revise schedule/request additional log in/education/additional information to be gathered by Contact Center Specialist Study: Batching, wasted time, non urgent encounters Act: Implement education, visual controls, Avaya call functions, shared drive, staffing adjustments, CCS information collection, updated Red Flag List 29

Urgent Calls Service Levels 30 30

Decreasing Patient Call Back Time Utilizing the Lean Management System Goal: Reduce average call back time improving patient care to an average of 30 minutes or less by increasing average RN calls to 3.5 encounters per hour or more 31

Plan Goal: To reduce average call back time improving patient care to an average of 30 minutes or less by increasing average RN calls to 3.5 per hour or more. Plan: Weekly tracking of RN calls per hour on Huddle Board Nurses consistently falling below 3 calls per hour will have calls monitored weekly to determine root causes for lengthy calls. Individualized Performance Improvement (IPI) plans Shared drive will be implemented for quick access to resources 32

DO Gemba walk Huddle Ideas.Actions/ Gather baseline metrics Track weekly and monthly metrics on Huddle Board Daily huddles and Gemba walks to discover root causes and ideas Performance Improvement Plan for RN s with an average call per hour below 3 Continue to add resources to PAN shared drive Staff education: Determining the reason for the call in a timely manner Decreasing # of encounters that can be open at one time to reduce batching of documentation 33

STUDY Results: Increase in average calls per hour per RN resulted in decreased average wait time for a patient call back Lessons Learned: Visualization of trending metrics, individual calls per hour, individual performance improvements plans, and the shared drive for resources made a difference for our patients. IPI plans needed for several RN s Lean principles utilized: Why? Why? Why? Batching: Reduced number of open encounters allowed by 50% Waste: Real time typing,ability to determine the reason for call quickly, elimination of non value added conversation with patient Visual Controls: Weekly tracking and shared drive for resources and tools for department for easy access reducing call times, trending metrics 34

ACT Utilization of shared drive for PAN resources was a great success: adding other resources as needed Performance Improvement plan for RN s not achieving an average of 3 calls per hour in a month Will continue with limiting # of encounters that can be open at one time to encourage documentation in real time Will continue to track trending metrics on the Huddle Board for average RN call per hour and call back time Will add increased education during orientation process related to reducing waste in call times 35

RN Average Calls Per Hour November 2012 - August 2013 36

Average Transfer Time Goal 30 Minutes or Less 45 40 35 30 25 Goal 20 Average Transfer Time 15 10 5 0 Dec-12 37 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

Cost Benefit Decrease in RN call time equals increase in RN productivity reducing the cost per call. 2.5 calls per hour = average of $11.20 per call (RN FTE)* 3 calls per hour = average of $9.33 per call (RN FTE)* 4 calls per hour = average of $7.00 per call (RN FTE)* *Does not include differentials or other operational cost 38

Time to Repeat PDSA Cycle 39

A-3 Critical lab Reporting- Streamlining the Process Problem: Recent increase in frequency of reporting time outside the S&W system policy minimum 30 minute window Goal: 100% will be reported within 30 minutes or less Plan: Collect baseline metrics, time study, approval, education, identify root causes, implementation, repeat time study, calculate savings Benefits/Results: Increased patient safety, waste elimination, improved compliance Future Steps: Calculate benefits/saving, ongoing tracking implement new processes, staff responses, performance improvement options for provider response time Team: Debora Preputnik, Alma Johnson, Pearl Kotrla, Paula Smith, Denise Spoor, Tiffany Berry, Gretchen Davenport 40

A-3 Actions Elimination of faxed reports Elimination of encounter printouts Development of virtual log on shared drive Chain of Command standard work Resources published on shared drive Elimination of RN multi-tasking after receiving critical result Minimize escalation time 41

Huddle Board Critical Result Report Time Trending 42

Future Steps 43

Cost Benefit/Results Cost reduction of $16.43 per critical result encounter (RN time) One year savings of $14,061. Average Reporting time improvement by 51% 44

Huddle Board Ideas Shared K-Drive for resources Collection of onset, duration, and pain scale from Contact Center for potential urgent calls Staff Education: Mental Health Chain of Command for Critical Lab Workflow Process Priority Queue for Urgent Calls needing appointment with Contact Center 45

Average Patient Call Back Time November 2012-July2013 Goal 30 minutes or less 46

Huddles The Beginning 47 Current Huddle Board

System LMS Wins (Jan-Feb) Hillcrest Baptist Wins: Access: Appointment with Specialty clinic from 5 to 2 days Increased Referrals to Cardiac Rehab clinic from 17% 1QFY13 to 33% in January Reduced No Call/Show in Outpt therapy from 13% to 3.2% Round Rock Wins: Improved Patient satisfaction scores in EVS from 63.8 to 76.3 Nurse Triage Line calls answered by person from 20% to 50% Sun City clinic improved patient satisfaction scores on likelihood to recommend from 44% to 90% Brenham Wins: Hand Hygiene compliance from 20-30% lower than expected to 99% compliance. College Station Wins: Hand Hygiene compliance improved from 93% to 100% Contact Isolation compliance increased from 20% in Q2 to 58% in Q3 Temple Wins: Reduced GI backlog from 59 to under 30 in three weeks Chorioamnionitis Infections reduced to below national ave. in Labor & Delivery (5% S&W vs. 14% national) ED LWBS improved from >2% to < 1%. Hill Country (Llano) Wins: Nutrition Services Patient Sat improved by piloting a new tray and cart to keep food warm (4.0 to 4.4) Reduced ED length of stay to goal of 2 hours or less; Tracking Physician average cycle time 48

LMS Summary Feb 2012 Feb 2013 Lean Management Systems at Scott & White Healthcare >750 Leaders trained >610 Huddle Boards > 2000 improvement ideas tried out (while we work) LMS works 49

50