Presentation Transcript

1. Process Improvement Tools and Tactics

   Paul Convery MD, MMM, FACPE
2. First Day at Work for a New CMO Dr. Pat Jones, a new CMO, is told by the hospital President, that the Board Chair is very embarrassed by the report in the local paper that their CHF Readmission Rate from CMS Hospital Compare is one of the highest in the country. Dr. Jones is instructed to meet with Dr. Ronnie Everbrite, the chief of Cardiology, and “fix the CHF 30 day readmit rate, whatever that is.” Dr. Everbrite’s tells Dr. Jones that discharging CHF patients is very time consuming and filling out the multiple forms is tedious. The nurses are expected to schedule follow up appointments in Dr. Everbrite’s office, but they often do not schedule an appointment for four to six weeks. “It is the nurses’ fault that our rates of readmission are so high. I am very busy and cannot bother with this problem.” Nurse Chris Anderson tells Dr. Jones that Dr. Everbrite usually does not fill out the discharge forms correctly. Often the medication list is incomplete; the nurses’ instruction list is often left blank; and the social work follow up form is never completed. Also, when the nurses call Dr. Everbrite’s office for a follow up appointment for the patients, the earliest time is usually four to six weeks out. “Dr. Everbrite is a very busy physician and does not want to be bothered by the nurses.”
3. Some Definitions System – defined by the coming together of parts, interconnections and purpose Microsystem – small and self contained with relatively few interconnections Macrosystem – contains numerous microsytems that are linked to achieve a purpose Process – sequence of activities that transform input into outputs; the way work is done Flow – describes the sequential steps in a process; e.g. workflow

4. Systems Approach Baldrige Framework for Organizational Excellence

5. Baldrige Performance Excellence Program Award Established by Congress in 1987 Malcolm Baldrige was Secretary of Commerce from 1981-1987 Health Care Category established in 1999 17 Health Care winners Projected that 65% of Hospitals will use the Baldrige frame work and 41% will submit an application by 2018
6. Baldrige Health Care Winners 2002 -- SSM Health Care 2003 – Baptist Hospital, St. Lukes Health System 2004 – Robert Wood Johnson University Hospital 2005 – Bronson Methodist Hospital 2006 – North Mississippi Medical Center 2007 – Mercy Health System, Sharp Health Care 2008 – Poudre Valley Health Care 2009 – AtlantiCare, Heartland Health 2010 – Advocate Good Samaritan Hospital 2011 – Henry Ford Health System, Schneck Medical Center, Southcentral Foundation 2012 – North Mississippi Health Services 2013 – Sutter Davis Hospital
7. Baldrige Framework for Organizational Excellence Strategic Planning Staff Focus Organizational Performance Results Leadership Focus on Patients, Other Customers, and Markets Process Management Information and Analysis
8. The SSM Health Care Quality Journey
9. SSM Health Care “The vision that we could become a great organization!!”
10. Building a Culture of Improvement 1995 1994 1992-1994 1990-1991
11. “It is not about winning the award, it is about getting better” Sister Mary Jean Ryan, CEO SSM Health Care
12. CQI Principles in a Baldrige Framework CQI Principles Patients & customers are our first priority Quality is achieved through people All work is part of a process Decision making by facts Quality requires continuous improvement The Baldrige Framework for Excellence Organizational framework to link mission & goals Focus on stakeholders and their requirements Deployment, processes, standardization, measurements & benchmarks Accountability & results Feedback & Improvement
13. Lessons from the Baldrige Process Framework Focus Balance Discipline Linkages Accountability
14. SSM Mission Through our exceptional health care services, we reveal the healing presence of God.
15. Love the mission statement ... By the way, how do you define “exceptional?”
16. Characteristics of Exceptional Health Care Through our exceptional health care services, we reveal the healing presence of God. Exceptional clinical outcomes Exceptional Patient, Employee & Physician Satisfaction Exceptional financial performance
17. System Network Performance Indicators Exceptional Results Entity Department Cascading Indicators
18. Deploying the SSM Mission Passports Poster
19. Hospital Operations Performance Indicator Report
20. Summary Leadership Commitment Framework for organizational improvement Need to Focus Linkage of mission & strategy Balanced approach & measurement Results
21. Baldrige Framework for Organizational Excellence Strategic Planning Staff Focus Organizational Performance Results Leadership Focus on Patients, Other Customers, and Markets Process Management Information and Analysis

22. Micro System Approach Continuous Quality Improvement

23. Continuous Quality Improvment
24. History of CQI 1900 – Ford Assembly Line and Frederick Taylor 1930 – Process Control - Shewart SPC (statistical process control) 1950 – Deming in Japanese Automobile Industry; CQI and Toyota Production System 1990 – Motorola introduced Six Sigma 1990 – CQI introduced to Healthcare; “Curing Health Care” Berwick, et al 1991 – The Institute for Healthcare Improvement 1992 – Brent James started the Advanced Training Program for Health Care Delivery Improvement (ATP) in IHC 2000 – LEAN Manufacturing in USA 2002 – Virginia Mason – Toyota Production System
25. PDCA Model For Continuous Improvement 25
26. Importance of Team Size and Roles 2 Person Group coaching, reinforcement, simple problems 3 Person Group Two on One, Majority Rule Most Ruthless of All 5-9 Person Group Less Tension Problem Solving, Avoid Deadlocks Larger Groups for Information Sharing, etc. Roles: Executive Sponsor, Team Leader, Facilitator, Staff and Technical Experts
27. Aim Statement S – specific M – measurable A – actionable R – realistic T – time bound Example: We will increase the number of correct patient information forms from 60% to 90% within thirty days in one PCP office.
28. CQI Tools to Analyze the Problem Process Flow Chart Patient arrives at front desk Receptionist asks for patient’s name & searches database for his/her file Receptionist asks patient to complete paperwork for new clients and return it to front desk Patient in system? NO YES Ask patient to be seated in the Waiting room ETC. Medical assistant takes patient into exam room
29. Brainstorming Everyone participates Group activity First to come to mind Take the time Defer judgment Do not jump to solution Withhold criticism Welcome unusual ideas Combine and improve List possible solutions
30. CQI Tools to Analyze the Problem Fishbone or Ishikawa Diagram Skeleton Equipment Environment Computer System down for routine maintenance Low show rate for appointments Patients Patient unaware of appointment Procedures People
31. Some Categories to Fill Out the Fish Bone Diagram (Cause and Effect Diagram) Methods, Materials, Machines, Manpower Place, Procedures, Policies, People Surroundings, Suppliers, Systems, Skills Equipment, Environment
32. CQI Tools: Pareto Chart to Prioritize Improvement Efforts
33. Plan the Intervention Using the information from the analysis (the PLAN stage) Select one or two interventions to test (the DO stage) Collect metrics for feedback (the CHECK stage) Revise the plan based on feedback data and repeat the cycle (the ACT stage)
34. Data Collection Keep the collection tools simple; a check list, not a spread sheet Collect useful data, not everything It does not have to be perfect or scientifically accurate; you will not publish this data Do not make this a burden for your staff
35. Run Charts for Data Display
36. Upper and Lower Control Limits
37. Plan the Intervention Using the information from the analysis (the PLAN stage) Select one or two interventions to test (the DO stage) Collect metrics for feedback (the CHECK stage) Revise the plan based on feedback data and repeat the cycle (the ACT stage)
38. PDCA Model For Continuous Improvement
39. D S P A D S P A A P S D A P S D PDCA Cycles: Lead to Continuous Improvement “The shorter the timeframes between test cycles, the more tests can be conducted and therefore, more opportunities for learning will emerge.” - HIVQUAL Workbook Standardize the Process across the clinics DATA Cycle 1D: Repeat in each PCP office and then move across the clinic Cycle 1C: Double checking the forms filled out by patients improved rate to 95% Cycle 1B: Requirement to verify information in the system improved correct number to 85% Cycle 1A: Achieved 70% correct information forms

40. Macro System Approach Lean Methodology

41. Background on Lean Lean comes out of the industrial engineering world Taiichi Ohno – Toyota Production System. 1940s-1950s company was on verge of bankruptcy Dynamics of industry were changing – moving from mass production to more flexible, shorter, varied batch runs (people wanted more colors, different features, more models, etc). Ohno was inspired by 3 observations on a trip to America Henry Ford’s assembly line inspired the principle of flow (keep products moving because no value is added while it is sitting still) The Indy 500 – Rapid Changeover The American Grocery Store – led to the Pull system – material use signals when and how stock needs to be replenished
42. Lean Foundations Standardized Work – people should analyze their work and define the way that best meets the needs of all stakeholders. “The current one best way to safely complete an activity with the proper outcome and the highest quality, using the fewest possible resources” Standardized not Identical – mindless conformity and the thoughtful setting of standards should not be confused Written by those who do the work. Level loading – smoothing the workflow and patient flow throughout the hospital.
43. Lean Process Improvement Initial Perception of Problem Clarify Problem Locate Point of Cause Root Cause Analysis Design Solutions Measure Effectiveness Standardize
44. Lean Methods Kaizen Events (or SCORE events) Planned and structured process that enables a small group of people to improve some aspect of their business in a quick, focused manner. Select Clarify Organize Run Evaluate 5S – this methodology reduces waste through improved workplace organization and visual management Sort, Store, Shine, Standardize and Sustain
45. More Lean Methods Kanban – a Japanese term that can be translated as “signal,” “card,” or “sign.” Most often a physical signal (paper card of plastic bin), that indicates when it is time to order more, from whom, and in what quantity. Standardize work and streamline the process to eliminate nonvalue activities Muda – “waste” – goal is to eliminate activity that consumes resources but does not add value to the customer Jidoka – immediately stop work to correct a defect in the process – “stop the line”
46. Path To Lean
47. Value Stream Mapping to Eliminate Waste
48. Five S Methodology in Lead 5S – this methodology reduces waste through improved workplace organization and visual management Sort, Store, Shine, Standardize Sustain
49. Prepare to Conduct a Five S Exercise Observe the process first hand (Gemba walk) Create a spaghetti diagram - a hand drawn map of your process including: Tasks in the sequence they are done Location of supplies and equipment Measure distance traveled and time spent searching or waiting
50. Dedicated Staff 100 feet 16 min 200 feet 16 min 150 feet 11 min 250 feet 11 min 200 feet 1 min 150 feet 31 min 200 feet 1 min 300 feet 21 min 1,550 Feet 108min Spaghetti Diagram Time & Distance Traveled - Before 15 min – searching For supplies Supply Room Chart Rack 20 min – searching For printer paper Printer Ancillary Testing Patient’s Room 15 min – searching for meds 10 min – searching for PT chart Med Room Tube Station Nurse’s Station Report Room 10 min – waiting for meds tube system What forms of “Waste” can you identify?
51. How Can We Improve? What would you do to improve? Sort out the need from the not needed Have a place for everything so there is no searching (Store) and same on each unit (Standardize) Move supplies or equipment closer to where they are needed and well marked (Standardize, Shine) Co-locate tasks or people (Standardize) Change the sequence in which tasks are done (Sort) Be creative with your solutions – you, after all, are the expert! Use the Five S Method to eliminate waste!
52. I’ve found my “dream” job! 1.5 min 50 feet 2 min 50 feet Dedicated Staff 1.5 min 50 feet 1.5 min 50 feet 1 min 50 feet 30 min 50 feet 1 min 50 feet 1.5 min 50 feet 40min 400ft Spaghetti Diagram No Searching or Waiting - After 30 sec – 6S on supply room Supply Room 60 sec – 6S on Med room Report Room Med Room Chart Rack Tube Station Ancillary Testing Patient’s Room Nurse’s Station Printer 30 sec – 6S on chart rack 30 sec – Paper checked @ end of each shift 30 sec – Indicator light installed on tube system Reduced travel by 1150 ft & search time by 68 min.

53. Lean Six Sigma

54. Lean Six Sigma Process Improvement Lean Six Sigma Seeks to improve the quality of manufacturing and business process by: identifying and removing the causes of defects (errors) and variation. Identifying and removing sources of waste within the process Focusing on outputs that are critical to customers
55. What Makes a Good Lean Six Sigma Project? There is no known solution The root cause is not known The problem is complex and needs statistical analysis The problem is part of a process The process is repeatable A defect can be defined Project will take 3-6 months There are data available
56. The DMAIC Methodology Define – describe the problem quantifiably and the underlying process to determine how performance will be measured. Measure – use measures or metrics to understand performance and the improvement opportunity. Analyze – identify the true root cause(s) of the underlying problem. Improve – identify and test the best improvements that address the root causes. Control – identify sustainment strategies that ensure process performance maintains the improved state.
57. Lean vs. Six Sigma Lean tends to be used for shorter, less complex problems. Often time driven. Focus is on eliminating wasteful steps and practices. Six Sigma is a bigger more analytical approach – often quality driven – it tends to have a statistical approach. Focus on optimizing the important steps – reducing defects. Some argue Lean moves the mean, SixSigma moves the variance. But they are often used together and should not be viewed as having different objectives. Waste elimination eliminates an opportunity to make a defect Less rework means faster cycle times Six Sigma training might be specialized to the “quality” department, but everyone in the organization should be trained in Lean
58. Real World Examples
59. “Where there is no standard, there can be no improvement. For these reasons, standards are the basis for both maintenance and improvement” Masaaki Imai