St. Joseph s Health Centre, Toronto Central LHIN, Toronto, Ontario 350 Bed Acute Care Community Teaching Hospital serving SW Toronto 86,000 Emergency Visits, 12,000 Urgent Care Visits and 7,000 Just For Kids Visits (Largest volume of Emergency Visits in a single site hospital in the GTA and 2 nd highest in Ontario) and best performing ER of full service hospitals in GTA 2 nd Highest population density in Toronto Higher % of seniors who live alone 2 nd highest % of low income households in Toronto 2 nd highest % of non English or French speakers in Toronto Higher mortality rates than the rest of Toronto
If everyone is thinking the same thing, someone isn t thinking. General George S. Patton
Be clear on what you are doing, why you re doing it, why are you doing it now and why you re not doing something else and who you are doing it for
ALIGNMENT: A KEY TO LEADERSHIP CAPABILITY FOR ACCESS AND FLOW
Our vision for Deliver better and safer care 1 Delivering a superior care experience by: Speeding up diagnosis and treatment Delivering better frontline care 1 Deliver superior care experience Set new standards in patient access and flow 2 Create a dynamic work environment IMPROVE PATIENT SAFETY 2 Creating a dynamic work environment by: Teaching staff how to more efficiently deliver care Enabling staff to mold their workplace to help the patients 3 Exceed accountability agreement targets 3 Exceeding accountability agreement targets by: Consistently deliver the best care Continue to improve our patient service levels 2
Be clear on what you are doing, why you re doing it, why are you doing it now and why you re not doing something else Why Bother Heightened awareness of the importance of reducing wait times for ED through GIM continuum Mounting pressure to deliver safer, more timely, high quality care with increasing volumes Patient Safety Strategy with Access and Flow as a predictor of Patient Safety nternal Greater desire by our staff to create a dynamic work environment - Internal Situation at initiation of effort Sheer volume Hospital Accountability agreement Pressure from Emergency to implement Full Capacity Protocol Hours of non value added time for patients and staff Patients exceeding wait time targets Patients May exceeding - July 2006 wait time targets Percentage, March 2006 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 67% CTAS 1 3 (6 hours) 75% CTAS 4&5 (4 hours) Target
Focus everyone: Why this? Growth in ER volumes will test our operations as will growth in volume of medicine admissions Patients treated in ER Visits per annum, thousands 160 140 120 100 80 60 40 20 Patients admitted in Medicine units*** Thousands per annum 10 8 6 4 2 Projected inpatient demand 0 2006 2007 2008 2009 2010 2011 2012 0 2006 2007 2008 2009 2010 2011 *Based on expected patient load for 2006 07: 80,000 **Estimated for consistent admitted/ discharged, acuity levels *** Includes 2E, 4E, 4M, 6G, 6M Source: Team analysis Assumptions: In patient admissions into 5 medicine units (2E, 4E, 4M, 6G, 6M) are 7.1% of ER visits Aggressive improvement potential in wave 1 targets capacity addition @8%
Focus the attention of everyone but remember that some people aren t interested in what interests you! Optimizing flow can increases ER capacity by over 30% to accommodate SJHC s annual 9.7% growth Improving discharge process can increase inpatient medicine capacity by over 20% Patients treated in ER* Visits per annum, thousands 160 Projected growth based on current rate Conservative improvement potential Aggressive improvement potential Medicine admissions** Numbers per annum 300 140 120 100 80 60 750 6,050 40 20 5,000 0 2004 2005 2006 2007 2008 Current capacity threshold 2009 2010 2011 Improved capacity threshold 2012 Current # of admissions Improvement in acute patient LOS Improvement in ALC patient LOS Potential # of admissions *Based on expected patient load for 2006 07: 80,000; estimated for consistent admitted/ discharged, acuity levels ** Based on improvements in ALOS for 94% of patients with ALOS < 20 days, reduced ALOS from baseline of 5.6 to 4.7 days (Jan 31 Feb 20, 2007) Source: Team analysis
Safer Care through Better Flow, Collaborative Practice and More Engaged Senior Leadership Our Challenge Exponential growth in ER visits 10% per year = 82,000 visits Patient dissatisfaction with access to care Staff feeling that there were no solutions sometimes we just pray Our Goal Safer and Better, More Timely Care by improving patient access and flow Our Approach 4 Cross functional teams Unlimited ideas GO
LEADERSHIP IS ABOUT ACCOUNTABILITY AND OWNERSHIP. Senior Leader McKinsey Arms and Legs McKinsey Team Limbs Lead Hospital Team Brains Lead Decision Support and Analytics Patient flow teams: The Brains of the Operation Senior Leaders ED working team Admission working team Discharge working team 15 staff 11 staff 8 staff
Do you know WHERE our patients are? The impact of our GPS Capital purchase identified as a just do it strategic issue by Vice President of Clinical Programs First hospital to purchase system in Canada Implementation of Bed Management Suite in September 2007 All patient care areas will utilize the system Work done to date has set the stage for this implementation Robust metrics to further support our work
Electronic Bed Board Right patient - Right bed - First time! BEDS Less paperwork and consensus solutions allow more time for care.
Standardizing Discharge Processes PATIENT ACCESS AND FLOW WHAT DOES MY FACE SAY? Initial Multi-disciplinary screen Int. Dsn. Patient's information card stamped here Date: / / Thanks! Keep up the good work Falls risk Confusion Limited supports Evidence of care deficit Patient or family concerns Please start helping us send patients home on time > 3 days Pt. NEEDS REFERRAL FOR SW OT PT SLP Nutrition. Interdisciplinary team to circle request color on board Int. Dsn. We need to talk! David is eager to speak to you!! dd / mm / yy Date: / / Date: / / MD to Tick referral and sign / date Signature Date: / / Time: color in room Referral SMO Date: / / Working together to improve the St. Joseph s experience 2-3 days Pt. NEEDS REFERRAL FOR SW OT PT SLP Nutrition. Interdisciplinary team to circle request CCAC color on board Int. desn For questions/comments, please contact David Golding at goldrd@stjoe.on.ca dd / mm / yy color in room Date: / / MD to Tick referral and sign / date Referral SMO Date : / / Signature CCAC Informed WHEN CAN I GO HOME? Date: / / Time: Date: / / MY DISCHARGE PLAN Based on your current condition, you are likely to go home in Within 24 hrs REQUIRED DAY BEFORE DISCHARGE: Complete Int. Transport Inform Pt/ Int. I am likely to go home within More than 3 days More than 3 days dd / mm / yy Date: / / family of discharge Prescription Self Family Taxi color on board color in room 2 3 days 24 hours and before 11:00 am on: 2 to 3 days Date: / / Follow up Appointments Discharge education CCAC Ambulance Booked for / family coming at: Date: Time: ( ) ALC (please speak to Social Worker or Discharge Planner) 24 hours by 11:00 a.m. on the day of discharge ALC LTC CCC REHAB PALLIATIVE OTHER Working together to improve the St. Joseph s experience For questions/comments, please contact David Golding at goldrd@stjoe.on.ca Comments dd / mm / Date: / / Date: / / Note: This record needs to be removed from patient's permanent record prior to filing
12% 16% 5% 28% Total Length of all ER Visits From 6.5 hrs to 5.7 hrs Total Length of ER Inpatient Stay From 21.9 hrs to 18.3 hrs ER Arrival to Admit Time From 10.5 hrs to 10.0 hrs Admit to Transfer to Unit Time From 11.5 hrs to 8.3 hrs FLOW
Patients and families engaged in coordinated, safe discharge planning, every day of the week. Initial Multi-disciplinary Int. Dsn. Patient's information card stamped here screen Date: / / Patient or Falls Limited Evidence of family risk Confusion supports care deficit concerns Pt. NEEDS REFERRAL FOR Interdisciplinary > 3 days team to circle Int. Dsn. request SW OT PT SLP Nutrition. color on board dd / mm / yy color in room MD to Tick referral and sign / date Date: / / Referral SMO Signature Date: / / Date: / / Time: Date: / / Pt. NEEDS REFERRAL FOR Interdisciplinary 2-3 days team to circle Int. request desn SW OT PT SLP Nutrition. color on board CCAC dd / mm / yy color in room Date: / / MD to Tick referral and sign / date Referral SMO Date : / / Signature CCAC Informed Date: / / Time: Date: / / REQUIRED DAY BEFORE DISCHARGE: Within 24 hrs Int. Complete Int. Transport Inform Pt/ family of Self color on board discharge dd / mm / yy Family Prescription color in room Date: / / Taxi Follow up Appointments Ambulance Date: / / Discharge Booked for / family coming at: education Date: CCAC Time: OTHER LTC CCC REHAB PALLIATIVE ALC Comments dd / mm / Date: / / Date: / / Note: This record needs to be removed from patient's permanent record prior to filing 43% Home by 11am 75% Home by 2 pm HOME
Relentless Attention to Metrics and Visual Management at Every Level A GUIDE TO SOLVING ACCESS AND FLOW ISSUES FOR SENIOR LEADERS FROM SJHC PLACING METRICS ON THE DESKTOP OF EVERY LEADER AND ENSURING THAT THEY LOOK AT IT! E-MAILS FROM THE TOP FOCUS THE ATTENTION OF THE ORGANIZATION DISPLAYING IMPROVEMENTS AND SLIPPAGE FOCUSES ATTENTION FROM THE BOARD ROOM TO THE POINT OF CARE TEAM KEY MESSAGE: If Senior Leadership (CEO and Board) are not paying attention to the metrics, no one will pay attention for long something else will take its place CELEBRATING SUCCESS AT EVERY OPPORTUNITY ENGAGES STAFF AND ENCOURAGES BUY-IN
Version 15.0 All dates are in DD/MM/YYYY format User Guide available on N:\Everyone\Access and Flow If you have further questions related to the DAIR please contact Boyan Kovic x6479 Yesterday's Date 04/17/2007 Start of running average date range (end date is set at left) 04/11/2007 (Should be prior to yesterday's date) 0 ED Area Admissions and Discharges Metrics Baseline (Oct 15 - Nov 14, 2006) Yesterday (Tue, 17/04/07) Average for 11/04/07 to 17/04/07 (7 days) ED visits (number) 217 242 226 Ambulance offload (minutes) 11.6 18.0 10.0 30 Patients left without being treated (%) 2% 2% 2% 2% Discharged patients: Discharged in < 4 hours (%) 55% 59% 53% 80% Patients admitted (number) 22 27 23 Admitted patients: Triage to unit in < 8 hours (%) 10% 15% 11% 70% Admitted patients: Triage to decision to admit in < 4 hours (%) 6% 11% 11% 70% Admitted patients: Decision to admit to unit in < 4 hours (%) 36% 37% 39% 70% Admits - no bed (number) 12 7 Patients discharged (number) OVERALL 24 30 27 Patients discharged (number) Medicine 14 15 14 Patients discharged (number) Surgery 10.0 15 14 Patients left before 11:00 am (%) OVERALL 20% 43% 37% 50% Patients left before 11:00 am (%) Medicine 22% 47% 25% 50% Patients left before 11:00 am (%) Surgery 18% 40% 48% 50% Patients left before 2:00 pm (%) OVERALL 57% 83% 73% 80% Patients left before 2:00 pm (%) Medicine 50% 87% 65% 80% Patients left before 2:00 pm (%) Surgery 66% 80% 81% 80% Average length of stay (days) - non-6g Medicine units 8.0 7.1 5.4 Average length of stay (days) - Surgery units 5.5 3.1 3.5 Planned discharges vs Actual discharges (%) OVERALL* NA 67% 63% 75-125% Planned discharges vs Actual discharges (%) Medicine NA 73% 57% 75-125% Planned discharges vs Actual discharges (%) Surgery NA 60% 70% 75-125% Bed assigned to next patient in (min) OVERALL* - MEDICINE FLOORS NA #DIV/0! #DIV/0! 70 Target
Management Forum Presentation: Ambulance Offload (minutes) 100 90 Demonstration Project 80 70 60 50 40 30 20 10 0 Nov 15/06 - Mar 4/07 Target Baseline 15/10/06 to 14/11/06 100 90 80 70 60 50 40 30 20 10 0 Sustained Performance Mar 5 /07 - Jul 31 /07 Data Source: DAIR Target Baseline 15/10/06 to 14/11/06
Management Forum Presentation: Patients left before 11:00 am (%) 60% 50% 40% Demonstration Project Target 30% 20% 10% Baseline 15/10/06 to 14/11/06 0% Sustained Performance Nov 15/06 - Mar 4/07 60% 50% 40% Target 30% 20% 10% 0% Mar 5 /07 - Jul 31 /07 Data Source: DAIR Baseline 15/10/06 to 14/11/06
Medicine Patients left before 2 pm (%) Demonstration Project 100% 90% 80% 70% Target 60% 50% 40% 30% 20% 10% 0% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Sustained Performance Nov 15/06 - Mar 4/07 Mar 5/07 - May 20/07 Target Data Source: DAIR
St. Joseph s Health Centre, Toronto Patient Satisfaction Results Q4 2006-07 vs. Q1 2007-08 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Corporate (Medicine & Surgery) Medicine Program Surgical Program Maternity Care Mental Health (Short Stay) Emergency Department Q4 2006-07 91.2% 89.0% 93.7% 90.9% 88.9% 79.2% Q1 2007-08 92.5% 95.1% 89.7% 97.1% 95.9% 75.9% Q1 Peer Target 91.8% 91.8% 91.8% 93.7% 85.7% 77.0% Data Source: NRC+Picker
St. Joseph s Health Centre, Toronto Patient Satisfaction Results Q1 2007-08 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Corporate (Medicine & Surgery) Medicine Program Surgical Program Maternity Care Mental Health (Short Stay) Emergency Department Q1 Actuals 92.5% 95.1% 89.7% 97.1% 95.9% 75.9% Q1 Peer Target 91.8% 91.8% 91.8% 93.7% 85.7% 77.0% Data Source: NRC+Picker
Patient Safety 90 Patient Satisfaction with Access to Care 2006/07 SJHC GTA Community Better Patient Care 85 Patient Flow 80 75 Timely Information 70 Satisfied Staff 65 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr NCR Picker Patient Satisfaction Survey Less Incidents CARE
Relentless attention to metrics (the right metrics). The Impact of Selected Metrics on the Senior Leader!
Ambulance offload (minutes) 60 50 40 30 20 10 0 300 250 200 150 100 50 0 ED visits (number) 7/22 8/5 8/19 9/2 9/16 9/30 10/14 7/22 8/5 8/19 9/2 9/16 9/30 10/14 Patients left without being treated (%) 6% 5% 4% 3% 2% 1% 0% 7/22 8/5 8/19 9/2 9/16 9/30 10/14
Relentless attention to metrics (the right metrics). The Impact of the Right Metrics Over Time on the Senior Leader!
The tangled web of accountability for results to sustain and transform access and flow Moving from Project to Transformation: Who s job is it anyway? The Senior Leader, Editor
MOVING FROM A PROJECT TO A TRANSFORMATION Returning to his own office after the long-range planning meeting, Stanley immediately started viewing things from a different perspective.
Sustainability: The Elephant in the Room. A good implementation does not guarantee the sustainability of the change initiative Sustainability is little understood but central to any transformative journey Sustainabilty is about a change enduring over time and becoming part of the way we do things around here Sustainability refers to the incorporation of new programs or practices within the routines of an organization or healthcare setting, changing norms and maintaining outcomes over time Sustainability requires ongoing development of capability within the organization Sustainability benefits from external rules and incentives Sustainability is about organizational leadership, organizational learning and information and knowledge
MOVING FROM A PROJECT TO A TRANSFORMATION CULTURAL PROFILE OVERALL Percent strongly agree and agree Alignment Execution Direction 62% Accountability 65% Coordination and control 61% Renewal External Orientation 75% Leadership 66% Innovation 53% Capabilities 67% Motivation 70% Environment and values 66% Source: St. Joseph's Organizational Performance Profile Survey (N=696)
OVERVIEW OF CULTURAL DIAGNOSTIC FINDINGS Strengths to Build Upon 1. Alignment/Direction SJHC s values are well defined and deeply rooted in the organization The overall atmosphere at SJHC is perceived to be good 2. Execution/Accountability Staff and physicians feel a high level of individual motivation People understand what they are accountable for and feel a high level of personal accountability There is confidence in St. Joseph s core capabilities, especially around knowledge 3. Renewal/Innovation SJHC is responsive to patient needs and trends in Canadian Healthcare SJHC has a strong commitment to the community Opportunities for Improvement 1. Alignment/Direction Staff and physicians do not feel adequately involved in direction setting and decisions that affect them People do not believe their colleagues/ leaders consistently live the values There is a perceived split in the culture between old and new and different silos 2. Execution/Accountbility People are not held accountable, with little relationship between performance and consequences Staff feel that they have insufficient resources and support to be successful on a daily basis There is a perceived lack of coaching and recognition 3. Renewal/Innovation St. Joseph s is seen as slow to change Staff and physicians do not perceive that innovation is encouraged or supported Source: St. Joseph's Organizational Performance Profile Survey (N=696); leadership interviews; employees focus groups
BUILD CAPABILITY TO SUPPORT AND SUSTAIN CHANGE: GOALS To engage the senior leadership in the change To provide the organization with a common vocabulary for discussing change and a common approach to problem solving To focus on resolving organizational challenges rather than working around them To build and strengthen the capacity of the organization To sustain improvement To innovate
A Significant Change in Thinking: Changing the Culture and Empowering Staff to Improve the Patient Safety SEVEN TRAINING MODULES TO BUILD SKILLS Lean operations Root cause analysis Developing trust Influencing with integrity Meeting for impact Effective coaching and feedback Enhancing interprofessional practice to optimize health outcomes SKILL
BUILD CAPABILITY TO SUPPORT CULTURE CHANGE: 7 Modules Root Cause Analysis Building trust Influencing with integrity Meeting Management Coaching and Feedback Lean Operations Interprofessional Collaborative Practice
St. Joseph s Leadership Program Module 1 Introduction to Lean Operations 2007
Module Goal Build basic understanding of lean principles Develop ability to apply identified concepts to process improvements Provide common language for discussing change and a common approach to problem solving
Moving from a Project to a Transformation: Lean Tools Visual Management Implement visual tools to speed up production and prevent errors Standardized operations Adjust and standardize the production steps and each person s job Error proofing Apply visual tools or change processes to prevent or detect errors Process/role redesign Change how many people are on one production line or how many lines are running Pull scheduling Change process & batch size of material to meet real demand and reduce time waiting
BASICS OF LEAN OPERATIONS Successful LEAN practitioners Take unnecessary work out of the system Take the perspective of the patient, to design our systems for the best care delivery Permanently change the way we work by eliminating waste, variability and inflexibility in each process Build the capabilities of the organization around system-design solutions, tools, analyses Change the culture and performance management systems of the underlying organization
1 VISUAL MANAGEMENT BROADCASTS A COMMON MESSAGE Wall charts
What LEAN is not Asking people to just work harder Driving operational improvement through one department Treat this as a project with a definite start and stop Expect to see sustained change in the organization as a result of a quick process fix
LEGO GAME Round 1
FORMS OF WASTE EXPERIENCED IN LEGO GAME ROUND 1 Wasted motion Wasted transportation Rework Excess processing Excess inventory Waiting time Wasted intellect Overproduction
LEGO GAME Round 2
GOALS AND APPROACH: Trust Module Module Goal Improve ability to build trust at St Joseph s Approach Self-reflect on elements of trust Discuss personal strengths/challenges with partners Identify and set personal goals to foster increased trust at St. Joseph s
POCT PLT NPC MAC IPAC P&T Operations Senior Management How is Rapid Cycle Change Possible? Transforming decision making.
Why can t we just plug and play? Unthinking reliance on he processes and results of another organization must be prevented: Plug and play is not sustainable Plug and play is ignorant of culture and context Plug and play ignores the leadership and capability development ingredients Welcome to the Found a New Solution For Us To Implement wizard
Patient Access and Flow: Next Steps Focused Work with Teams to Achieve Targets Implementation of Critical Incident Review on Admitted Patients > 24 hours in ED Implement Accountability Framework Roll Out to Mental Health and Women s, Children s and Family Health Program Implement Teletracking Electronic Bed Management System Capability Building for Staff
AN UNCOVENTIONAL GUIDE TO ACCOUNTABILITY FOR TRAHSFORMATION ANDIMPROVEMENT. Access and Flow is everyone s s business but the buck starts and stops with the CEO as the senior leader At SJHC Access and Flow Improvement is everyone s business BUT the buck stops with the CEO
We See a Significant Change in Thinking Throughout the Organization After Only Six Months of the Initiative Before We have tried this before, many times, and it is not going to work Focus group After I think the new way of working is to just try it. We can always work to make solutions better if we listen and act on the feedback we get. Team member Everyone works in their own group. People don t offer to help other units. Focus group We work better as a team now. You see people from the ER thanking the floors for their hard work, nurses on days thanking the nurse on night that prepared the discharge it is a better environment. PCM We already work too hard. The nurses are at their breaking point. The only answer is more resources. Focus group When we started it was more work and it was tough. But I like it now, and I think it was the right thing to do. Nurse
Management Forum Presentation: Patients left before 2:00 pm (%) 100% During Initiative 90% 80% 70% 60% 50% 40% 30% Target Baseline 15/10/06 to 14/11/06 20% 10% 0% Nov 15/06 - Mar 4/07 100% Post Initiative 90% 80% 70% 60% 50% 40% 30% Target Baseline 15/10/06 to 14/11/06 20% 10% 0% Mar 5 /07 - Jul 31 /07 Data Source: DAIR
LEAD FROM EVERY CHAIR The conductor in an orchestra is silent he does not make a sound Her true power derives from the ability to make other people powerful Sometimes an instrument only contributes a single note But the orchestra needs every seat in the orchestra to lead