crafting a system-wide lean effort what does work; what does not

Crafting a System -wide Lean Effort: What Does

Work; What Does Not

Robert W. Pryor , M.D., Chief Operating Officer and Chief Medical Officer

Scott and White Healthcare System

with Steve Hoeft , Lean Six Sigma DirectorAltarum Institute

Robert (Bob) Pryor, M.D., M.B.A., C.P.E., F.A.A.P., F.C.C.M., F.C.C.P.

• Certified in Lean Healthcare from the University of Michigan, College of Engineering, Center for Professional Development

• Presently Chief Medical Officer/Chief Operating Officer, Scott & White Healthcare, Temple, TX

• Previously Chief Medical Officer at St. Joseph’s Hospital & Medical Center, Phoenix, AZ

• Board Certified by the American Board of Pediatrics

• Fellow of the American College of Chest Physicians and The American College of Critical Care Medicine

• Graduate of Baylor University in Waco, TX and Medical Degree from The University of Texas Medical Branch at Galveston, TX

• MBA from the Arizona State University

• Member of the American College of Physician Executives

• Widely published

Steve Hoeft: Bio

Lean!

� 26 years of experience: Engineering, production, Lean, quality, continuous improvement efforts; plus facility design, simulation and scheduling

� Delta (Kogyo) USA – lean supplier to Mazda (Sensei: Joe Shimada)� Johnson Controls – developed internal Lean Office:

• Studied lean principles directly from Toyota in KY (with Sensei)• Co-authored JCI Manufacturing System (ASTD Award winner)

� Lean Enterprise coach/consultant (8 years):• Personally led 300+ Lean events; developed hundreds of successful Lean Facilitators• Helped establish Value Stream Visions with firms in many industries

� Presently: Altarum Institute (since Feb 2003):• Lean Six Sigma for Healthcare: UMass, Scott & White, Memorial Sloan-Kettering

Cancer Center, William Beaumont, University of Michigan Healthcare System, St. John's (IL) and the entire Hospital Sisters Health System, Blue Cross Blue Shield, Henry Ford Health System, Univ. Health System-San Antonio, Yale New Haven Health, Ontario Health Quality Council, Vancouver Coastal, Kaiser Permanente, Tri-City Medical Center, Lakewood Health System, hospitals in Singapore, and others

• Major Government transformation projects: OSD, Air Force-wide, Repair & Base Ops, Lean Purchasing-PSCM, Veteran's Health Administration (VHA), AF Surgeon General

� Principal Instructor for the University of Michigan’s Lean Manufacturing, New Product Design and Healthcare Certificate programs

What Do We Mean By “Works” ?

• Culture shift

• Critical mass of Leaders and staff “think” differently

• Staff that prevent problems or solve them as they arise; not by reactive, time-consuming work-arounds

– Staff bring problem, analysis and actions (A3 Thinking)

• Internal capacity for self sufficiency

• Year over year sustainment of changes/results

B4

Purpose

5

Agenda

• Who is Scott & White?

• 5 Questions as we deployed Lean “from scratch”

• Demonstration of Hansei (Reflection); tips

• Benefits and Challenges of being a “system”

• How to (or Not to) Spread standards to other sites

6

Scott & White Healthcare

Vision: “Most Trusted and Most Valued Name in

American Healthcare”

Scott &White Healthcare33 Primary Clinic Locations

Mason

ErathHood

Somervell

Johnson

HillBosque

HamiltonMills

San Saba

Llano

Hays

Blanco

McLennan

CoryellLeon

Robertson

FallsBell

Burnet

Travis

Williamson

Caldwell

Milam

Bastrop

Lee

Burleson

Brazos

Madison

Walker

Grimes

Washington

Austin

Waller

Lampasas

1. Bellmead2. Belton3. Burnet4. Cedar Park5. Cedar Park West6. College Station7. Gatesville8. Georgetown9. Georgetown Central10. Harker Heights11. Hewitt12. Horseshoe Bay13. Hutto14. Killeen15. Killeen West16.Kingsland17.Llano

18. Marble Falls19. Mason20. Moody21. Northside22. Pflugerville23. Salado 24. San Saba25. Santa Fe Family Med.26. Taylor27. Temple28. Temple Towne Center

Pediatrics 29. S&W Round Rock30. Waco31. Wells Branch32. Belton Pedi Clinic33. Hillcrest Pedi Clinic

8

Scott &White Healthcare24 SpecialtyClinic Locations

Mason

ErathHood

Somervell

Johnson

HillBosque

HamiltonMills

San Saba

Llano

Hays

Blanco

McLennan

CoryellLeon

Robertson

FallsBell

Burnet

Travis

Williamson

Caldwell

Milam

Bastrop

Lee

Burleson

Brazos

Madison

Walker

Grimes

Washington

Austin

Waller

Lampasas

Primary Clinic

Specialty Clinic

1. Cosmetic Surgery Center – B/CS2. Sports Therapy and Rehabilitation Center – Hewitt3. Killeen Cancer Center4. Killeen Dialysis Center5. Killeen Dialysis West6. Killeen Ob/Gyn Clinic7. S&W Cardiology at Metroplex8. S&W Gastroenterology at Metroplex 9. S&W Orthopedic Services at Metroplex10. S&W Urology Services at Metroplex11. Round Rock Cosmetic Surgery Center12. Round Rock Dialysis Clinic13. Ambulatory Pediatric Clinic – Temple14. Center for Diagnostic Medicine – Temple15. Dermatology Clinic – Temple16. Mental Health Center – Temple17. Cosmetic Surgery Center – Temple18. S&W Pavilion – Temple19. Santa Fe Center – Temple20. Watson Wise Dialysis Center – Temple21. Ob/Gyn – Waco22. Health Express – Temple23. Pediatric Urgent Care Clinic – Temple24. Georgetown Sports Medicine Clinic

9

Scott &White Healthcare

10 HospitalLocations

1. Scott & White Memorial Hospital – Temple2. Continuing Care Hospital – Temple3. Scott & White Healthcare – Round Rock4. Coryell Memorial Hospital – Gatesville5. Metroplex Hospital – Killeen6. Rollins Brook Hospital – Lampasas7. Hillcrest Hospital – Waco8. Llano Hospital – Llano9. King’s Daughters – Temple 10.Proposed Lake of the Hills Hospital –

Marble Falls

Primary Clinic

Specialty Clinic

Hospital

Mason

ErathHood

Somervell

Johnson

HillBosque

HamiltonMills

San Saba

Llano

Hays

Blanco

McLennan

CoryellLeon

Robertson

FallsBell

Burnet

Travis

Williamson

Caldwell

Milam

Bastrop

Lee

Burleson

Brazos

Madison

Walker

Grimes

Washington

Austin

Waller

Lampasas

10

Becoming a Multi-site System: Timeline View

11

1897

1904

1908

19221923

1949

1963

1977

1979

1997

2000

Scott & White Clinic founded

Temple Sanitarium opens

Electric Cautery experimental

Hospital is renamed Scott & White Hospital Dr. Scott recognized as discoverer of electric cautery

S&W Hospital chartered as not-for-profit organization

Hospital relocates to current location

Texas A&M Medical School opens on S&W campus

S&W Health Plan created

S&W adds 18th satellite clinic; still 1 Hospital

S&W Hospital and S&W Clinics integrated

1978 First “satellite clinic” open in Moody in 1978

2010 Named “Top 100 Hospitals” – 7 th year in a row!

1920 AMA approves Scott & White as teaching hospital-first in TX

1940 Scott & White trained 112 Interns and 20 Resident Physicians

Innovation

2005

2006

20082008

Bob Pryor returns as CMO (Dec)

Built Center for Advanced Medicine (Feb)

Partnership w/ Metroplex Hospital-Killeen

Partnership w/ Rollings Brook Hospital-Lampasas

2010 Today: 10 Hospitals; Numerous Clinics

2006 Built Round Rock Multi-Specialty Clinic

2007 Built Continuing Care Hospital-Temple (May)2007 Built Round Rock Hospital

2010 MOU: John’s Comm’y Hospital-Taylor2010 MOU: Trinity Hospital-Brenham

2010 Acquired Llano Hospital2010 Hospital in planning: Lake of Hills-Marble Falls

2009 Acquired Hillcrest Hospital-Waco (Apr)2009 Acquired Kings Daughters Hospital (Apr)

to be converted to Children’s Hospital

Acceleration!

2010 Hospital in planning: Bryan-College Station

2005 Converted from staff-model HMO to all-payors

2010+ Healthcare Reform; lower reimbursements,35M more people need care, fewer MD’s…2005

Scott &White HealthcareJuly 21, 2009 Conference in DC: “How Do They Do That? Low-Cost, High-Quality Health Care in America.”Leaders were brought to Washington, D.C., by national health care improvement experts to describe their efforts to reduce medical costs in 10 communities where they work.

Dr. Nancy Nielsen of Buffalo, past president of the AMA, characterized as “some Utopian land” the compact between managers and physicians at the Scott & White Clinic . She asked how it would be possible to take “this culture” that had developed and form similar organizations across the United States. “I have to tell you,” she said, speaking colloquially, “this ain’t where it is at in other places.”

Health Affairs Blog, July 28, 2009, “Low-Cost, High-Quality Care In America”

Scott & White leaders invited to D.C.

Scott & White – Keeping Healthcare AffordablePrice-adjusted per-capita Medicare spending

$10,250 to 17,184 (55)9,500 to < 10,250 (69)8,750 to < 9,500 (64)8,000 to < 8,750 (53)6,039 to < 8,000 (65)

Not Populated

Everett, WA

Sacramento,CA

Temple, TXTalla-hassee,

FL

La Crosse,WI Cedar

Rapids, IA Sayre,PA

Portland, ME

Richmond, VA

Asheville, NC

13

Why Change?

Why Altarum Institute?

• Not for Profit (matched our values)

• Expertise in leading and teaching

• Works with your staff to transfer knowledge and skills and then leave; gives us their materials and tools

• Flexible – can provide more or less support as required

• A learning organization – adapts to create our “model”

14

Hansei

“Those who cannot remember the past are condemned to repeat it”

George Santayana

Definition: reflection, reconsideration, introspection.

(Toyota) The conscious individual and group reflection required to learn from episodic activities.

•Note: Very few organizations do this well• Note: Effective organizations do this well

Hansei

15S

How Common is Lean in Healthcare?

ASQ study of 77 hospitals :* 53% of hospitals report some level ("minor," "moderate" or "full") of Lean deployment* 42 percent report some level of Six Sigma deployment* Few hospitals reported "full deployment" of Lean (4 percent)

In order for Lean management to truly be effective, all staff need to believe and act Lean. * 59% lack resources* 41% lack information* 30% lack leadership buy-in* 11% are not familiar with either method

Hospitals Embracing Lean and Six Sigma Strategies, March 24, 2009, Richard Pizzi, Editor, Healthcare Finance News.

16

5 Reasons Why Hospitals Struggle With

ALL Change Efforts

Only 4% of hospitals reported "full

deployment" of Lean

1. Why Change?

B17

The Clinic Appointment• Patient calls central S&W phone number• Operator transfers call to a clinic (at random); Clinic transfers calls to

appropriate clinic; put on hold – recorder says to leave a message• Clerk calls Patient back; sometimes reaches them• If reached, Clerk searches for open appointment; can’t find one; says,

“we will send you an appointment by mail”• {4-5 days} Appointment arrives; Patient is unavailable at that time• Patient calls central S&W phone number; finally reserves appt.• Patient arrives for the visit, checks in, sits in waiting room• Patient is called into the exam room, waits for doctor• Doctor diagnoses a URI, and BP is worse• Doctor prints antibiotic prescription, walks all the way to the only

printer (staffroom); upon return, patient says.”I’m allergic to that drug.”• Doctor says to return in a week to check the BP problem• Medical assistant does an EKG• At check out, patient asks the cost; Clerk says. “we’ll bill you”• No appointment is available next week• Upon reaching Pharmacy, clerk says, “Your insurance requires a

generic drug.”• Is there a problem here?

Reflection

• What We Learned (Do, Don’t):

1. Why Change?

S19


ALL Change Efforts

2. Why TPS/Lean?

B20

Reflection

• It works very well! (creativity over capital)• Lean requires very little specialized training• Lean can be deployed in any process, any type of

organization and at all levels• Lean has an infectious quality, usually with quick, visible

results that cause natural replication• Like medicine, Lean is “learned by doing” (culture shift)• …

2. Why TPS/Lean?

21


ALL Change Efforts

3. How Long; How Much?

B22

Reflection


3. How Long/How Much?

S23


ALL Change Efforts

4. All Staff & LeadersThink and Believe

Lean?

“In order for Lean to truly be effective, all staff need to believe and act Lean”

S24

Reflection


4. All Staff/Leaders Believe?


ALL Change Efforts

5. What Resources?

“59% lack resources”

S26

Central vs. Embedded Coaches; CLIP Office; Training ; Roles & Responsibilities

Reflection


5. What Resources?

27

Some Lean Successes

(Site 1: Temple Campus)

S28

Teams Do Things Right:

Leaders Do the Right Things

Steering Committee

29

Key Steps: •“Go See”; observe; understand programming criteria and forecasts (demand, fte’s, etc.)•Review current OR process and waste •Analyze support and adjacent department impacts on OR•Develop SIPOC for general OR process•Review the 7 Flows – Spaghetti diagrams•Review current/expanded floorspace; revisions•Benchmark other OR’s (Pavilion)•Apply Lean to OR Value Streams/support processes (1 year)

• In advance of final layout for 36 new OR’s, conducted a Lean Layout design review for greatly improved flow

• 24 Current OR’s at Temple were undersized and underperforming• As designed, new SSB layout would not have produced even half

of their expected results• Lounges and other non-value-added space was larger than OR’s• Clean corridor/staging area was too narrow/small; hindered flow• New PACU area appeared to be an unexpected bottleneck• Changes were needed and were caught before ground-breaking• Designs were delayed until the current OR processes were

improved, understood, and a lean design was developed (1 year)Goals:• Improve overall flow• Reduce non-value added space• Improve utilization

Case for Action What We Did

Expectations/Results

Unique

Application

Lean Layout : Surgical Suites Building (Study)

• (Est.) $100M+ saved in new lean-designed SSB• Improved current processes and flow, made some

current OR’s larger, staging wider, lounges smaller• “New” SSB: get 12 more fully functional OR’s!• Building 16 new rooms (vs. 36 new), renovating

16, and leaving 4 alone (total: 36)• Whole project done in 4 years (vs. 6)• Utilization will improve from 50% to (est.) 75%• 70 Proc’s/day up to (est.) 110 (57% ��)

Turning c runch, c hase, c haos to Flow…

• First Cases do not start on time• Key information not available timely • Preference Cards (DPC) not updated/accurate, delays

Goals:Increase number of on time First time startsDecrease missing elementsUpdate DPC cards

Process Owners:Donna, NursingHeather, Nursing

Pre-OR Flow -1: Decision to Incision (VSM)What We DidCase for Action

First time on time starts (before): 33%

First time on time starts (after): 65%

Increased first time starts by32%

Missing elements (before): 156

Missing elements (after): 100

Reduced missing elements by36%

DPC Cards (before): 5538DPC Cards (current): 3260

Reduced DPC cards by 41% (1000’s updated)Neuro service reduce active cards from 182 to 28 … 85% reduction

Gu service reduced active cards from 257 to 60 … 77% reduction

Transplant service reduced cards from 78 to 12 … 85% reduction

Expectations/Results Team

• VSM Plan; worked the Plan• Created Pareto charts on delays by reason• Initiated “Director’s Cup” and “Free Ruth” campaigns as

fun ways for carrot/stick• Incorporate WHO Checklist into standard work• Continue to update and combine DPC cards (Librarian)• Order Scan time from 20 min to 1 min• “One stop shop” layout• 100 % compliant AAU call-ahead for H&P and Consents• Improved marking of patient in Day Surgery• Eliminated paper charts

• Robert, M.D.• Jack, M.D.• Andrea, DaySurgery• Ruth, HUC• Michael, Analyst• Selena, PSEU RN• Mark, IT Specialist• Rosemary, Surgical Tech• Jacqueline, Periop. Support Tech• Jessica, OR Nurse• Gerry, Supply Chain• Carole, OR Scheduler

• Chris, Instrument Processing• Lindsey, Admissions Office • Jo Ann, Embedded Coach• Scott, M.D., Surgery• Debra, Clin. Surgery Scheduler• Darla, M.D., PSEU Provider• Sheila, RN Ortho Clinic• Paula, Patient Rep• Sunnita, M.D., Hospitalist • Katen, M.D., Hospitalist

12

Layout

• Nurses leave the room too many times • Searching for items outside of the room takes too much time• Takes too long to turn the room

Goals:• Decrease number of times the nurse leaves the OR

during a case• Eliminate the need to search for missing items (5S) • Decrease the time it takes to turn over the room

Process Owners:Brandi, NursingMissi, Nursing Education

OR Flow -2: Wheels-in to Wheels-out (Kaizen)What We Did

Team

Case for Action

Nurses leaving room before: __

Nurses/Circulators leave room after: TBD

Room turn beforeOR #3 … avg 26 minOR #17 … avg 42 min

Room turn afterOR #3 … avg 20 min 38%OR #17 … avg 30 min 40%

Expectations/Results

• Log times and reason nurse/circulator leaves room• Two 2-day Kaizen events: observe room turn, reduce

waste, and then “trystorm” improvements• Room turns have improved by 40% during pilots• Results Boards deployed; huddles daily

Next Steps:• Work with OR Team 1 on DPC card corrections to

decrease number of times staff leave OR • 5S OR 17 as a pilot for all OR rooms• Formalize room turn scripts and spread practice to all

OR’s beyond pilot

Roy, MDHarry, MDTheodore, MDGary, MDThomas, CRNAAdam, RadiologyEric, PSTJeanna, Cent. ProcessingSteve, Dispensing ClerkSharon, OR NurseRuby, Surgical Tech.Michael, OR AnalystMissi, Periop. Nursing Coord.

Teresa, Anesthesia Tech.Alisa, Director of NursingAshley, PSSVasillos, M.D.Kevin, PharmacistTheresa, Hem/Onc Assoc. Dir.Brandi, Periop. Nursing Coord.

• Delays in Med Admin• Potential for medication errors

Goals:Decrease Armband OverridesDecrease Medication Overrides

Process Owners:David Jones, Pharmacy Theresa Prather, Nursing

Medication Administration (VSM)What We Did

• Sabine, Coord. Hlth Unit CAM 8N• Judy, Clinical Ed. II• Melody, RN• Amy • David, Hosp. Pharmacy Svs• Carla, RN STC 1• Wayne, Mngr, IS Proj. I• Calvinette, Dir., Nursing• Kendra, Clinical Ed. I• Nabia, Resident Ed Admin.• Trenton, Charge Nurse CCH

Case for Action

Monthly medication overrides (before): 2951

January medication overrides (after): 1702

Reduced Medication Overrides by 42%

Monthly armband overrides (before): 877

January armband overrides (after): 238

Reduced Armband Overrides by 73%

Most common antibiotics now stored on the floor allowing for patients to start therapy more quickly

• Marla, Pharmacy• John, Internal Med Res.• Dianne, Clinical Ed. III/CNS• Julianne, Quality Improvement• Stacy, Mgr., Resp. Care• June, Clinical Ed. II PICU


• Reduced stock outs in Pyxis machines• Trialed new bar-code scanners; deployed best one• Used arm bands whose bar-codes do not “wash off”• Cleaned up PAR room (5-S) and created space to

add piggyback Pyxis for antibiotics

Next Steps:• Spread lessons learned/best practices to other floors• Add computer with articulating arms in the room to

allow nurses to chart in room

• No standard work for Couriers; duplication of efforts• Security is called to deliver items• Takes too long at locations

Goals:� Create standard drop locations with visual cues� Reduce amount of time security spends delivering items� Consolidate stops for couriers

Process Owners:Frank, Supply Chain

Courier Routes: Materials Transportation (mini-kaizen)What We DidCase for Action

Created visual management to eliminate unclear mail drops - pick up or drop off?

Courier 1 -number of stops (before): 18number of stops (after): 8Reduced stops by: 44%

Courier 2 -number of stops (before): 30number of stops (after): 9Reduced stops by: 30%

Created rules for using Security staff as a STAT courierReduced use of security by 50%


• Assigned team members to ride with couriers• Used spaghetti diagrams to show flow of materials • Met with management to discuss issues and get buy in• Evaluated who does what and why

Next Steps:• Review number of independent courier runs that occur• Establish a central oversight for all couriers • Create standard protocol for adding stops due to system

growth

Before

After

Ralph, Sr. Courier Referral LabRebecca, CourierFrank, Dir., SCS MgmtEddie (William), Sr. Materials HandlerIra, Dist. Mgr, SCS MgmtLarry, Security Officer, Eagle SecurityShannon, MIRS, Main File RoomTommy, Sr. Mailroom Tech.Peter, Assoc. Dir., Radiology

• From the end of the unit to the supply room was greater than 550 feet round trip .

• 8 trips = 2.5 miles per shift; 654 miles per year . • The staff of 3 works 12 hour shifts • Searching for supplies took too long • Staff frustrated

Goals:� Reduce walking � Reduce searching � Increase morale

Embedded Coach:Scott , Nursing Manager

Progressive Care Unit (Waste Walk)What We DidCase for Action

• Created two rooms for supplies centrally located to the staff who used them on the unit; applied 5S

• Walking reduced by 1.5 miles per shift; 476 miles per year

• Time searching reduced by 57 minutes per shift; 114 minutes per day


• Waste walk in the area before the unit opened to look for issues

• Used spaghetti diagrams to show nurse walking to get supplies

• Identify alternate supply space to use• Evaluated and define new PAR levels• Clear labeling of what goes where

Next Steps:• Work with Supply chain to develop robust kanban to

prevent stock outs

Progressive Care Nursing Unit & Scott

dozens

• Need to improve transition of care for patient safety & satisfaction

• Need to decrease re-hospitalizations��Medicare will no longer pay for Re-Admits

w/in 30 days

Goals:• Reduce readmissions in all DRGs w/in 30 days by 20%• Reduce Fm1 to OBS by 50%• Reduce ED visits w/in 30 days after discharge by 20%• Improved patient satisfaction (Press-Ganey questions

related to patient discharge)

• Break HUC and Case Manager/Discharge Planner bottlenecks-NVA Analysis, work level loading

• FM1 team reviewing potential discharges at 8am• Developing dedicated number to call for patients after

discharge• Develop standard work for reviewing Rx with patients prior

to discharge

Next Steps: Implement Just Do-It’sReview NVA Analysis on Case Mgr. and HUC roles,

eliminate/reduce NVA and level load NVA-required items

Hospital to Home (VSM)What We Did

Team

Case for Action

Expectations/ResultsWill, Embedded coachSondra, 6N NurseMyra , 6N HUC

Terri, Case MgmtTod, I.T. AnalystNorma , Resident

John , Resident Dir.Beth , RNSean, Home CareJoy, PharmD‘PaulaBryan , Process OwnerTiffany , MD, Process Owner

• Reduce Re-Adm in all DRGs w/in 30 days by 20%• Reduce Fm1 to OBS by 50%• Reduce ED visits w/in 30 days after D/C by 20%• Improve Pt Sat (P-G Pt D/C) by mean score of 50%• Schedule all appts .and tests prior to D/C• Decrease no-show rate on D/C follow-ups

Alma, MDJulianne, QualityAllan , MDD. Scott , MDKristyCraig, Embedded CoachBrooke, Embedded Coach

Re-casts

Are There Any

Benefits of Being

a System ?

S37

“Spread” is Step 3

1. Standardize

2. Sustain

3. Spread

38

Levels of Spread

1. Educate:• Individual: classroom, exercises, test (Lean Thinking)• Top Exec’s, Leaders, front line Supervisors – to the “tipping point”• Develop a critical mass; common language; desire/pull

2. Educate by doing: see one, do one, teach one (JIT Ed)3. Apply knowledge in one’s own area

• Individual/Small Group: Waste walks, 5S, kaizens, A3’s4. Spread to local area: pilots, PDCA’s: standard work5. Spread to “System” (multi-sites, acquired, new

construction):• System Administrator Meeting: Highlight 2 Lean projects/week• Other sites try to incorporate new Standards• New Standards stimulate System changes; other sites “one-up”

6. Spread back: Improve original Standards

B39

Hansei (Reflection)


40

Crafting a System -wide Lean Effort: What Does

Work; What Does Not

Robert W. Pryor , 254-724-5359

with Steve Hoeft , 734-395-3687

41

crafting a system-wide lean effort what does work; what does not

Documents