Integrated Task Assessment: A Tool to Improve Healthcare Performance MLC February 28, 2014

1. Integrated Task Assessment: A Tool to Improve Healthcare PerformanceMLC February 28, 2014 Larry Osentoski Mike Taubitz

2. Topics of Discussion • Continuous Improvement • Integrated Task Assessment • Standard Work • Individual Exercise • Integrated Task Assessment • Individual and Team Exercise • Round table and Report Out

3. Continual Improvement Lean facilitates critical thinking for continual improvement…. Standard Work Time 3

4. The Checklist Manifesto:How to get things right… AtulGawande 2009

5. Standard Work • Checklists • Written Instructions • Visual Aids • Agendas • Templates • Meeting schedules • Emergency procedures • Etc….

6. Identifying the Problem • Complexity and variety in healtcare • Split tasks into specialties • Harvard Vanguard Clinic (number per year) • Each physician: 250 different primary disease diagnoses (many classified “other”) • Patients: 900 active medical problems • Prescriptions: 300 • Laboratory tests: 300 • Office procedures: 40

7. Intensive Care • 50 years ago – barely existed • Today: 155 of 700 patients are ICU • Avg. stay: 4 days • Survival rate: 86% • Individual actions / day: 178 • 1% error rate = 2 errors / patient • Atul Gawande, surgeon and author, set out to see if he could reduce errors..

8. B 17: the origin of checklists • Oct 30, 1935: Boeing’s “flying fortress” crashed during test flight: • “pilot error” – forgot to release rudder lock • Plane • 103 ft. wingspan • Four engines • Each with own oil-fuel mix • Landing gear, wing flaps, electric trim tabs all require adjustment • Checklists created – fit on index card

9. Johns Hopkins Checklist • 2001 Pilot for central line infections • 5 Steps • Wash hands with soap • Clean patient’s skin with antiseptic • Put sterile drapes over patient • Wear mask, hat, sterile gown and gloves • Place sterile dressing over insertion site • Nurses authorized to challenge if step skipped • 10 day infection rate went from 11% to 0

10. Sinai – Grace: Keystone Initiative • Mentored by Hopkins • Senior exec required to go to ICU and listen to problems • Discovered: • Chlorhexidine soap in short supply • Full size drapes often unavailable • 2006: Keystone Initiative published in New England Journal of Medicine • 66% reduction in infection rate • $175 M in savings and 1500 lives saved

11. Observations • Under conditions of complexity, checklists are not only helpful but required for success • Must always be room for judgment aided by procedure and empowerment by top management

12. Good & Bad Checklists Bad Checklists • Vague and imprecise • Scope too large Good Checklists • Precise and efficient • Easy to use in difficult situations • Above all - practical What kind of thinking is required?

13. Good Checklists Good Checklists also address: Content Frequency Sequence Where work is done with output in mind! 13

14. Developing Checklists: CPDCA • Check – What is current state? • Plan – What is needed? / stakeholders? • Do – Create the checklist • Check – Have a person use checklist • Act – Adjust as appropriate

15. Checklist Use • Plan – Confirm availability of latest checklist • Do – Use it • Leader initiates “Use it”: • Surgeon • Healthcare Professional • Pilot • Any Subject Matter Expert • Check – is everyone clear on what / how? • Act – Adjust as you deem appropriate Sets tone for open communication

16. WHO Safe Surgery Checklist • 19 total checks • 7 before anesthesia • 7 before incision • 5 post operation • Tested in 8 hospitals around the world • 4 modern and 4 in low / middle income countries • 4000 patients • None had routines for high blood-loss risk

17. WHO results • Major complications reduced 36% • Deaths fell 47% • 93% agreed they wanted to use the checklist • 2010 – only 10% of US hospitals using checklist • Robots (high cost) are getting more attention

18. Criteria for Lean Standards • Content • Frequency • Sequence • Where work is done - with output in mind! • Simple • Easy to change (continuous improvement) • Easy to understand

19. Standardized work removes barriers to communication • Hierarchy of authority • Functional silos • Geographic separation of individuals who must work together • “not invented here” • “not my problem” • Data / procedures too complex to understand • Different staffs / generations using different “language”

20. Visual Aids / Tools Controls

21. Visual Aids

22. Visual Tools Usually don’t need a computer to be effective…

24. Visual Tools for Safety

25. We take visual Aids for granted

29. Electric panel well marked

32. A lean culture is more productive and less stressful • Use of lean tools and process is “acting your way to a new way of thinking” enroute to a true lean culture • 5S • Process or value stream mapping of • Salaried business processes • Lean Council • Safety for salaried workers • Metrics for waste / visual wall to display • Projects and metrics • Standardized one-page reports • Standardized work • Visual aids/controls • Knowledge folders • Teamwork and balanced workloads • Quality and problem solving training • Continuous improvement efforts • Management system Lean Tool kit Lean offices are more productive and less stressful

33. Standard Work means that we find the best combination of people, equipment, tools and materials and then set up simple visual controls to ensure that everyone performs the work the same way every time

34. Variation What happens when you try to apply a standard to a situation where there is unknown variation??

35. Exercise #1 On a blank piece of paper, draw a pig

36. Compare your drawings……

37. Standardized Work • Are all the pigs the same? • Were the work directions clear? • How was the training you were given to draw your pig? • Do you think we could improve the training and directions to get our result to be closer to the same? • Did anyone come around to watch and help you with your drawing?

38. Standardized Work This time let’s use a paper template and standard work document

39. Pig 101 Standardized Work

40. Draw a PIG Instructions 1. Use the drawing template 2. Draw a letter “M” at the top left intersection. Bottom center of “M” touches the intersection. 3. Draw the letter “W” at bottom left intersection. Top center of “W” touches the intersection. 4. Draw the letter “W” at the bottom right intersection. Top center of “W” touches the intersection. 5. Draw an arc from the letter “M” to the top right intersection. 6. Draw another arc from the top right intersection to the bottom right “W.” 7. Draw an arc between the two bottom “Ws.” 8. Draw the letter “O” in the center left box. 9. Draw an arc from the top letter “M” to the top center of the letter “O.” 10. Draw an arc from the bottom left letter “W” to the bottom center of the letter “O.” 11. Draw an arc for the eye half way between the top “M” and the letter “O.” 12. Draw an arc for the mouth. Half way between the “W” and circle. Must be a happy pig!!! 13. Draw the cursive letter “e” near the top of arc on the right. 14. And finally… draw two dots in the middle circle for the pig’s nose.

41. Standardized Work

42. The Devil is In the Detail • What happens if we: • Do not understand variation • Miss some of the required steps in a task • Force people to use a “standard” when the standard doesn’t work

43. What Happens To Operational Performance… When legal requirements, paperwork and administrative tasks keep adding up over the years??? Let’s look at a process many are familiar with…. This is not a criticism of the organization, but understanding waste that has been added to regulation and changes in procedures…..

44. Blood Donation • Welcome • Sit, Read, Sign in • History • Wait, load file, instructions, interview, wait, nurse follow up • Screening • Vitals, iron level check • Donate • Wait, table, wait, review information, prep, donate, bandaging • Canteen - wait, cookies • Exit Compliments of Design Safety Engineering, Ann Arbor 37 Steps

45. Hidden Waste Without Lean Thinking Diminishes Performance • Actual donation time ~ 15 min • Total time • 1988 ~ 45 min • 1998 ~ 60 - 75 min • 2008 ~ 90 – 120 min • Doing more work with less result • Increased paperwork • Spiral – less staff, longer time, fewer donors, greater need, emergency request, more donors, longer lines…

46. Lean Thinking Could Offer Ideas For Improvement • Expand contact database to include History information • Military service • International travel • On line access for History • Day of donation • Secure web site • Eliminate at least 4 steps • No impact to safety Increased Donations

47. Individual Exercise • You are driving down the street at 35 MPH • You see a McDonalds head on the right and decide to stop for coffee • Having turned into the drive / parking lot, you see a long line in drive-through and decide to go inside • There is a small wait line inside • How many steps are there until you have coffee and are back traveling at 35 MPH? • For purposes of this exercise include the steps it takes walking inside, buying the coffee and going back to the car • Be very detailed – imagine teaching a young driver each step necessary to perform this task safely

48. How Many Steps?

49. Granular Thinking is Detailed Open door Proceed to wait line Move forward Place order for coffee Take wallet from pocket / purse Open wallet for money Take $$ and hand to cashier Wait for change Place change in pocket / purse Wait for coffee Take coffee Walk to napkins / Napkins are out Return to counter and ask for napkins Walk to door Open door Take foot off accelerator Activate RH turn signal Brake and slow car before turn Turn into entrance Seeing a long line for drive –thru, you decide to go inside Look for parking space Advance to open space Pull in space, apply brake & stop Put car in park Turn off ignition Take keys Open car door Get out Close car door Walk to entrance 49

50. Granular Thinking is Detailed Walk to car Open car door Place coffee in cup holder Get in car Close car door Secure seatbelt Open top of coffee cup Place key in ignition Start car Driver looks behind Place car in reverse Begin to back out Assure safety backing out Back out Place foot on brake • Place in Drive • Drive forward to exit • Stop • Look at oncoming traffic • Enter into traffic • Increase speed to 35 MPH We assume that others know what we know and usually underestimate the actual number of steps to perform a task… 50