Continuous Improvement Methodology- PDCA Advocate Research and Innovation Forum 2012. October 2012

Continuous Improvement Methodology- PDCA Advocate Research and Innovation Forum 2012 October 2012

Operations Improvement Vision All Advocate associates become passionate about process improvement, embracing equality, excellence, partnership, and stewardship. Commitment to simplify our process Learning to work more effectively Learning to see things differently 1

Objectives Introduce the PDCA cycle Present tools and concepts to facilitate problem solving, which can be applied to any problem in any setting Illustrate the concepts with a healthcare application of PDCA 2

Continuous Improvement Continuous improvement is an ongoing effort to improve products, services, or processes. Continuous and incremental improvements remove unnecessary activities and variations providing increased capability, reduced costs, improved efficiency and quality over time. A complete transformation process takes time, but continuous improvement allows teams to change the organization one problem at a time. 3

A Method to Promote Continuous Improvement The Plan-Do-Check-Act (PDCA) Cycle is an iterative four-step problem solving model to promote continuous improvement. Brief History: Walter A. Shewhart first discussed the concept of PDCA in 1939 when he introduced the notion that constant evaluation of management practices is key to the evolution of a successful enterprise. In the 1950s, W. Edwards Deming promoted PDCA as a primary means of achieving continuous process improvement. He also referred to the PDCA cycle as the PDSA cycle ("S" for study). 4

Standardize if it worked, adjust if it didn t work. PDCA Alignment, identify problem, determine goal, cause analysis. Act Plan Check Do Progress, target vs. actual Action plan and execution 5

PDCA - Template Strategy: Strategic Initiative: Stakeholders (people involved/impacted by the initiative): Leader: Department/Branch: PLAN Background Information: DO See Action Plan: (add action plan title here!) CHECK Problem Statement: Goal (think SMART): ACT Cause Analysis: 6

PDCA Is Not New: Clinical Thought Process PLAN DO Background Information: Gather History and Physical information. Patient short of breath and swelling of lower extremities over last several weeks. Administer IV diuretics and electrolyte replacements Administer O2 and monitor intake and output Weigh patient daily Perform Echocardiogram Problem Statement: Patient is short of breath, elevated heart rate and swollen legs. Goal: Upon confirmation of heart failure diagnosis, treat patient until swelling in legs diminished and shortness of breath subsides. Achieve over next ~4 days. Cause Analysis: CMP Lab test drawn identified electrolytes level. Chest X-Ray showed enlarged heart, supporting diagnosis of congestive heart failure. CHECK Electrolytes in balance Intake and Output balanced Weaning off O2 Chest X-ray demonstrates improvement in patients enlarged heart ACT Ensure handoff to patients primary care physician 7

Key Tools and Concepts to Help You Problem Solve = Tool = Concept Go see visit the Gemba Process mapping Strategy: Leader: Strategic Initiative: Department/Branch: Stakeholders (people involved/impacted by the initiative): PLAN DO Background Information: See Action Plan: (add action plan title here!) CHECK Problem Statement: Brainstorming Action Plan Data analysis Goal (think SMART): Cause Analysis: ACT Problem Statement Goals: Specific Measurable Achievable Relevant Timely Root cause analysis: 5 why s What worked/ what didn t work Check against goal

Where do things stand today (current state)? What are the perceived symptoms that makes us believe we need to act? Act Plan Check Do 9

Visit the Gemba ( the real place ) What is it? Gemba walk, is an activity that takes management to the front lines to look for waste and opportunities. How to do it? While at the place where the work is happening (Gemba), ask the questions to the right. Results: Understanding of what is really happening Work Flow Errors Rework Visual Mgmt What disrupts the work? Where could mistakes be made? What keeps those mistakes from being made? Is it just vigilance? Or is there some mechanism to prevent mistake? Is there any backtracking, rework, looping around? Are things where they are actually needed? Do people have to look around for things? How do they know what they should be doing? What is their source of information? Do they have to hunt it down, or worse, guess at what should be done? Or is the right thing and the right way crystal clear to even the casual observer (that would be you). 10

Process Mapping Basics What is it? Visual step-by-step process flow outlining how work is done One Post-it note per process step to depict main activities, information flows, and interconnections Apply 80/20 Rule 80% stays in main path or flow Overlay Data, Value Added, and Waste Identification Results: Allows an observer to walkthrough the whole process and see it in its entirety. Process Step Decision Point Short, Simple, Specific Noun-Verb Yes, No It Depends Start & End Points = clearly define scope of the process RN Gets Gown for Patient Patient Available? No Yes 11

Performance % Data Analysis What is it: Baseline data analysis provides a view of how big the current problem is, where there is opportunity to improve. Re-measure data analysis demonstrates if the solution has improved the problem and is sustained. How to do it: Investigate various available reports, understand definitions Collect manual data if there is not electronic data available Analyze the data to quantify the problem Results: Data driven analysis that cannot be disputed to quantify the problem and sustain results. 12 SURGICAL CARE IMPROVEMENT PROJECT (SCIP) BUNDLE (January 2007-December 2008) 100 95 90 85 80 75 70 2 2 2007 Target: 77% 1 2 2008 Target: 79% Jan/07 Feb/07 Mar/07 Apr/07 May /07 Jun/07 Jul/07 Aug/07 Sep/07 Oct/07 Nov /07 Dec/07 Jan/08 Feb/08 Mar/08 Apr/08 May /08 Jun/08 Jul/08 Aug/08 Sep/08 Oct/08 Nov /08 Dec/08 2 2 UCL=98.07 _ X=85.58 LCL=73.09 2/9/09

PLAN Background Information: Inconsistent ED work practices create a chaotic and exhausting work environment. ED LOS metrics are too high, well above benchmark Problem Statement: Inconsistent practices contribute to inefficiencies for our ED discharged home patients with an average LOS of 181 minutes, well above the national benchmark of 90 minutes. Goal: Improve communication and optimize ED process, in order to provide timely quality care, with ED discharged home patient LOS of 90min by January 2012. Cause Analysis: No Communication Tool to communicate patient readiness No standard workflow No Standard Patient Assignment process for Physicians Chart is placed far away from care site 13 Pt Arrives Greet Triage Register To Room Initial Care PDCA Applied to Healthcare Processes Doctor Treat Disp Plan Discharge DO Chart Flow beginning in patient room RN, Tech, Physician assess patient together and share the plan of care Defined Roles and Standard Work Identify a communication tool with All-Call feature to communicate a new patient s arrival, and patient s discharge readiness. CHECK Metric Baseline Remeasure Target LOS Discharge 181min 136min 90min Process Map Door to Physician Door to Lab Received 55min 34min 30min 71min 61min 35min ACT Metrics trending positive, continue to implement. What worked Education before implementation Ownership of solution Buy-In to try What didn t work Need more time to trial process on various patient days

Write a sentence that defines the problem you are trying to solve. The problem is the gap between the current state and the goal. Select one problem per PDCA Act Check Plan Do 14

Patient Satisfaction Patient Satisfaction Problem: understanding the gap What is the gap that you are trying to close? New Goal Goal GAP OR Goal GAP Process that is declining in performance and currently not achieving desired target. Sustained performance compared to initial goal. New level of performance is identified. 15

Example Problem Statements BEST 78% of outpatients have missing/incomplete testing on day of procedure which results in 75% of the first cases to be delayed by more than 15 minutes. 38% of patients arriving at the Imaging Department Check-In desk wait longer than 15 minutes before being met by Liaison to take them to their CT scan. AWV reimbursement is new from Medicare in 2011. The Clinic has approximately 44,000 patients that qualify for an AWV. This represents approximately $14.8M Gross and $7.4M Net revenue opportunity. GOOD BAD Average OR room turnover is 32 minutes which is higher than the national average of 20 minutes. There are 200-300 calls on average requesting information, distracting the desk operators from their duties. OR staff and surgeon frustration with process breakdowns leading to performance for OR turn-around time, On-Time Starts, and associate satisfaction that does not meet national best practice Associate and physician satisfaction is low. 16

PDCA Applied to Healthcare Processes PLAN Background Information: Inconsistent ED work practices create a chaotic and exhausting work environment. ED LOS metrics are too high, well above benchmark Problem Statement: Inconsistent practices contribute to inefficiencies for our ED discharged home patients with an average LOS of 181 minutes, well above the national benchmark of 90 minutes. Goal: To achieve timely and quality care for our ED discharged home patient with a LOS of 90min by January 2012. Cause Analysis: No Communication Tool to communicate patient readiness No standard workflow No Standard Patient Assignment process for Physicians Chart is placed far away from care site 17 Pt Arrives Greet Triage Register To Room Initial Care Doctor Treat Disp Plan Discharge DO Chart Flow beginning in patient room RN, Tech, Physician assess patient together and share the plan of care Defined Roles and Standard Work Identify a communication tool with All-Call feature to communicate a new patient s arrival, and patient s discharge readiness. CHECK Metric Baseline Remeasure Target LOS Discharge 181min 136min 90min Door to Physician Door to Lab Received 55min 34min 30min 71min 61min 35min ACT Metrics trending positive, continue to implement. What worked Education before implementation Ownership of solution Buy-In to try What didn t work Need more time to trial process on various patient days

How will you measure success? KRA goal or other goal that you are trying to impact. Think SMART! Act Plan Check Do 18

Goal How will we know if we are achieving the future state? How will we know if we are successful? Metrics must be SMART Specific Measurable Achievable Relevant Timely Metric Baseline Goal By When Patient Wait Time Room Turn- Around Time Example Metric Chart 50 minutes 30 minutes 12/31/2012 45 minutes 20 minutes 12/01/2012 Actual Performance 19

PDCA Applied to Healthcare Processes PLAN Background Information: Inconsistent ED work practices create a chaotic and exhausting work environment. ED LOS metrics are too high, well above benchmark Problem Statement: Inconsistent practices contribute to inefficiencies for our ED discharged home patients with an average LOS of 181 minutes, well above the national benchmark of 90 minutes. Goal: To achieve timely and quality care for our ED discharged home patient with a LOS of 90min by January 2012. Cause Analysis: No Communication Tool to communicate patient readiness No standard workflow No Standard Patient Assignment process for Physicians Chart is placed far away from care site 20 Pt Arrives Greet Triage Register To Room Initial Care Doctor Treat Disp Plan Discharge DO Chart Flow beginning in patient room RN, Tech, Physician assess patient together and share the plan of care Defined Roles and Standard Work Identify a communication tool with All-Call feature to communicate a new patient s arrival, and patient s discharge readiness. CHECK Metric Baseline Remeasure Target LOS Discharge 181min 136min 90min Door to Physician Door to Lab Received 55min 34min 30min 71min 61min 35min ACT Metrics trending positive, continue to implement. What worked Education before implementation Ownership of solution Buy-In to try What didn t work Need more time to trial process on various patient days

What is causing the problem? What prevents us from achieving the goal? Why does the cause exist? Is there a highest priority cause? Act Check Plan Do 21

Root Cause Analysis What is it? An identified reason for the source or origin of an event or defect. How to do it? An iterative, questionasking method used to explore the cause/effect relationships underlying a particular problem. Be sure to not stop at an artificial reason. Results: Ultimate goal is to determine a root cause of a defect 22 or problem.

Five Why s - Example Thomas Jefferson Memorial preservation: The National Park Service noticed the Thomas Jefferson Memorial in Washington, D.C., was deteriorating faster than other monuments. Park service rangers investigated the problem with the five whys technique, which keeps asking "Why?" for five or more times, and formed the following chain of causation:

Five Why s - Example Why does the memorial deteriorate faster? Because it gets washed more frequently. Why is it washed more frequently? Because it receives more bird droppings. Why are there more bird droppings? Because more birds are attracted to the monument. Why are more birds attracted to the monument? Because there are more fat spiders in and around the monument. Why are there more spiders in and around the monument? Because there are more tiny insects flying in and around the monument during evening hours. Why more insects? Because the monument illumination attracts more insects.

PDCA Applied to Healthcare Processes PLAN Background Information: Inconsistent ED work practices create a chaotic and exhausting work environment. ED LOS metrics are too high, well above benchmark Pt Arrives Greet Triage Register To Room Initial Care Doctor Treat Disp Plan Discharge DO Chart Flow beginning in patient room RN, Tech, Physician assess patient together and share the plan of care Defined Roles and Standard Work Identify a communication tool with All-Call feature to communicate a new patient s arrival, and patient s discharge readiness. Problem Statement: Inconsistent practices contribute to inefficiencies for our ED discharged home patients with an average LOS of 181 minutes, well above the national benchmark of 90 minutes. CHECK Metric Baseline Remeasure Target LOS Discharge 181min 136min 90min Door to Physician 55min 34min 30min Goal: 5 Why s: Door to Lab 71min 61min 35min To achieve timely and quality care for our ED discharged Why? home Time is wasted Received looking for charts patient with a LOS of 90min by January 2012. Why? Charts never in central designated location Why? Care givers would take chart to see patients by bedside Cause Analysis: Why? Chart ACT information is needed for patient care Why? Chart Metrics is placed trending far away positive, from care continue site to implement. No Communication Tool to communicate patient readiness No standard workflow No Standard Patient Assignment process for Physicians Chart is placed far away from care site What worked Education before implementation What didn t work 25 Ownership of solution Buy-In to try Need more time to trial process on various patient days

What are the solutions to address the root cause? What activities need to take place? Who will be responsible? When? Document in the action plan! Create the WIIFM Act Check Plan Do 26

Brainstorming What is it: Group technique for generating many ideas in a short period of time An invitation to think outside of the box How to do it: Clearly state the topic and brainstorming guidelines Give people plenty of time on their own at the start of the session to generate as many ideas as possible. Collect ideas on Post-Its or Flipchart. Encourage people to develop other people's ideas. Encourage an enthusiastic, uncritical attitude among members of the group. Ensure that no one criticizes or evaluates ideas during the session and welcome creativity! Results: A collection of ideas (no idea is too big or too small) 27

Brainstorming: Affinity Diagram Group ideas and create solution categories/themes 28

Action Plan What is it: Tool that specifies the necessary tasks that must be executed to implement the solution to your problem. It contains the name(s) of person(s) responsible and a time frame for completing the task. What (Tasks) Who When Status Start End How to do it: Define the key steps to implement the solution Who will do each step When the step should be completed Identify plan to follow up and review the status of all assigned tasks Results: Critical to document and make visually available all action items planned by the team.

Action Plan - Example # What (Tasks) Who When Status Comments Start End 1 Create new Standard Work to include Gloria 11/1 11/7 process change 2 Begin placing patient charts in ED Susan 11/1 11/7 patient s room 3 Teach ED associates the new process Gloria 11/8 11/14 4 Implement data tracking log Susan 11/15 Ongoing 5 Obtain Walkie Talkie s Steve 11/7 11/14 6 Go-Live with new process ALL 11/15 Ongoing What (start with verbs) Who (one person) When 30

PDCA Applied to Healthcare Processes PLAN Background Information: Inconsistent ED work practices create a chaotic and exhausting work environment. ED LOS metrics are too high, well above benchmark Problem Statement: Inconsistent practices contribute to inefficiencies for our ED discharged home patients with an average LOS of 181 minutes, well above the national benchmark of 90 minutes. Goal: Pt Arrives Greet Triage Register To Room Initial Care Doctor Treat Disp Plan Discharge To achieve timely and quality care for our ED discharged home patient with a LOS of 90min by January 2012. Cause Analysis: No Communication Tool to communicate patient readiness No standard workflow No Standard Patient Assignment process for Physicians Chart is placed far away from care site 31 DO What (Tasks) Who When Chart Flow beginning in patient room Start End Create RN, new Tech, Standard Physician Work to assess include patient Gloria together 11/1 and 11/7 process change share the plan of care Begin placing patient charts in ED Susan 11/1 11/7 patient s Defined room Roles and Standard Work Teach ED associates the new process Gloria 11/8 11/14 Implement data tracking log Susan 11/15 Ongoing Obtain Walkie Talkie s Steve 11/7 11/14 Go-Live with new process ALL 11/15 Ongoing Identify a communication tool with All-Call feature to communicate a new patient s arrival, and patient s discharge readiness. CHECK Metric Baseline Remeasure Target LOS Discharge 181min 136min 90min Door to Physician Door to Lab Received 55min 34min 30min 71min 61min 35min ACT Metrics trending positive, continue to implement. What worked Education before implementation Ownership of solution Buy-In to try What didn t work Need more time to trial process on various patient days

What is the progress/result in light of your original goal? Do the actual results match the planned results? Act Plan Check Do 32

Check Make sure you are making progress Update action plan accordingly Review metric chart Did you achieve your goal? Continue for 30/60/90-day sustainment Metric Baseline Goal By When Patient Wait Time Room Turn- Around Time Actual Monthly Performance 50 minutes 30 minutes 12/31/2012 55 minutes 45 minutes 20 minutes 12/01/2012 19 minutes 33

PDCA Applied to Healthcare Processes PLAN Background Information: Inconsistent ED work practices create a chaotic and exhausting work environment. ED LOS metrics are too high, well above benchmark Problem Statement: Inconsistent practices contribute to inefficiencies for our ED discharged home patients with an average LOS of 181 minutes, well above the national benchmark of 90 minutes. Goal: Pt Arrives Greet Triage Register To Room Initial Care Doctor Treat Disp Plan Discharge To achieve timely and quality care for our ED discharged home patient with a LOS of 90min by January 2012. Cause Analysis: No Communication Tool to communicate patient readiness No standard workflow No Standard Patient Assignment process for Physicians Chart is placed far away from care site 34 DO What (Tasks) Who When Chart Flow beginning in patient room Start End Create RN, new Tech, Standard Physician Work to assess include patient Gloria together 11/1 and 11/7 process change share the plan of care Begin placing patient charts in ED Susan 11/1 11/7 patient s Defined room Roles and Standard Work Teach ED associates the new process Gloria 11/8 11/14 Implement data tracking log Susan 11/15 Ongoing Obtain Walkie Talkie s Steve 11/7 11/14 Go-Live with new process ALL 11/15 Ongoing Identify a communication tool with All-Call feature to communicate a new patient s arrival, and patient s discharge readiness. CHECK Metric Baseline Remeasure Target LOS Discharge 181min 136min 90min Door to Physician Door to Lab Received 55min 34min 30min 71min 61min 35min ACT Metrics trending positive, continue to implement. What worked Education before implementation Ownership of solution Buy-In to try What didn t work Need more time to trial process on various patient days

Adjust if it didn t work, reassess and make changes. Standardize if it worked, document standard process if solution solved the problem. Expand implementation to other areas as appropriate. Ensure ongoing PDCA to sustain results. Act Plan Celebrate 35 WINS! Check Do

What Worked/What Didn t Work What is it: A simple tool to capture what you learned. What worked What didn t work Results: A list of positive and negative outcomes of your attempt to solve the problem. 36

PDCA Applied to Healthcare Processes PLAN Background Information: Inconsistent ED work practices create a chaotic and exhausting work environment. ED LOS metrics are too high, well above benchmark Problem Statement: Inconsistent practices contribute to inefficiencies for our ED discharged home patients with an average LOS of 181 minutes, well above the national benchmark of 90 minutes. Goal: Pt Arrives Greet Triage Register To Room Initial Care Doctor Treat Disp Plan Discharge To achieve timely and quality care for our ED discharged home patient with a LOS of 90min by January 2012. Cause Analysis: No Communication Tool to communicate patient readiness No standard workflow No Standard Patient Assignment process for Physicians Chart is placed far away from care site 37 DO What (Tasks) Who When Chart Flow beginning in patient room Start End Create RN, new Tech, Standard Physician Work to assess include patient Gloria together 11/1 and 11/7 process change share the plan of care Begin placing patient charts in ED Susan 11/1 11/7 patient s Defined room Roles and Standard Work Teach ED associates the new process Gloria 11/8 11/14 Implement data tracking log Susan 11/15 Ongoing Obtain Walkie Talkie s Steve 11/7 11/14 Go-Live with new process ALL 11/15 Ongoing Identify a communication tool with All-Call feature to communicate a new patient s arrival, and patient s discharge readiness. CHECK Metric Baseline Remeasure Target LOS Discharge 181min 136min 90min Door to Physician Door to Lab Received 55min 34min 30min 71min 61min 35min ACT Metrics trending positive, continue to implement. What worked Education before implementation Ownership of solution Buy-In to try What didn t work Need more time to trial process on various patient days

PDCA Applied to Key Result Areas PLAN Background Information: In Press Ganey Q2 2012 report, Home Care Office identified that the question Family informed regarding progress presents a low mean score in the last two quarters. This question is rated as of high importance to patients in the same report. Problem Statement: Patient satisfaction mean score for the question Family informed regarding progress in Q2 2012 was 87.5. In order to achieve the 75 th percentile goal, the mean score for this question should be 91.7. Goal (think SMART): Increase Press Ganey mean score for question Family informed regarding progress by 4.2 points by the end of 2012. Cause Analysis: (5 why s) Patients do not perceive that we keep family members informed of progress Families are complaining they are not adequately informed of progress Staffs who care for patients are not informing the families of patient s progress No standard process for how staff communicates patient s progress with family/friends (root cause) DO See Action Plan: Action plan attached. CHECK Awaiting further results to evaluate success. Question: family informed regarding progress Baseline (Q2) Q3 Q4 Target 87.5 91.7 (75 th %ile) ACT What worked Team based approach to brainstorm issues and barriers Engaging team in the action plan development. Communication sheet facilitates the communication of progress because it helps summarize message. What didn t work Team perceives communication log as busy work, consider revising the process. 38

PDCA Applied to Key Result Areas Action Plan # What (Tactics/Tasks) Who When Status Start End 1 Create draft of communication log. Jenny 8/20/12 8/24/12 Completed 2 Create draft of communication sheet. Jenny 8/20/12 8/24/12 Completed 3 Review communication log and sheet with clinical staff for feedback. 4 Review with clinical managers and BSS how to incorporate communication log/sheet into folders. 5 Communicate new tools and how to use to field staff. 6 Educate field staff on communication tools for new and existing patients. 7 Survey field staff at September staff meeting to inquire if communications tools are helpful. Jenny 8/20/12 8/31/12 Completed Jenny 8/27/12 9/6/12 Completed Jenny 9/6/12 9/6/12 Completed Jenny 9/6/12 9/6/12 Completed Jenny 9/20/12 9/20/12 Started 39

PDCA Applied to Key Result Areas PLAN Background Information: In Press Ganey Q2 2012 report, Home Care Office identified that the question Family informed regarding progress presents a low mean score in the last two quarters. This question is rated as of high importance to patients in the same report. Problem Statement: Patient satisfaction mean score for the question Family informed regarding progress in Q2 2012 was 87.5. In order to achieve the 75 th percentile goal, the mean score for this question should be 91.7. Goal (think SMART): Increase Press Ganey mean score for question Family informed regarding progress by 4.2 points by the end of 2012. Cause Analysis: (5 why s) Patients do not perceive that we keep family members informed of progress Families are complaining they are not adequately informed of progress Staffs who care for patients are not informing the families of patient s progress No standard process for how staff communicates patient s progress with family/friends (root cause) DO See Action Plan: Action plan attached. CHECK Awaiting further results to evaluate success. Question: family informed regarding progress Baseline (Q2) Q3 Q4 Target 87.5 91.7 (75 th %ile) ACT What worked Team based approach to brainstorm issues and barriers Engaging team in the action plan development. Communication sheet facilitates the communication of progress because it helps summarize message. What didn t work Team perceives communication log as busy work, consider revising the process. 40

41 Key Takeaways Build confidence with the PDCA tools by applying to small problems. Different problems require different tools, you don t have to use them all. PDCA is to engage front line associates. Don t be afraid to experiment. There is no failure if you learned with your PDCA! Continuous improvement is an ongoing effort. Additional Questions Mariana Lipp Haussen, Operations Improvement Mariana.LippHaussen@advocatehealth.com 630.990.8114 Rebecca Lechowicz, Operations Improvement Rebecca.Hattle@advocatehealth.com 630.990.8389 Mike Virgilio Director Operations Improvement Mike.Virgilio@advocatehealth.com 630.990.2649 Amy Herbst Director Operations Improvement Amy.Herbst@advocatehealth.com 630.990.8389

Additional Course Information Change Acceleration Process (CAP) Data Analysis (Excel Basic & Excel Intermediate) WorkOut (WO) Effective Meeting Facilitation Statistical Process Control Project Management 101 Six Sigma Lean Fundamentals Search words: Performance Enhancement in ALEX AdvocateOnline > Divisions > Advocate Performance Enhancement > 42

43 Questions?