frontline led, data-based improvement: lean daily management · frontline led, data-based...
TRANSCRIPT
Doug Thompson, MD, MMM
Sue Cannon, MSN, RN
Ken Wing, MS, CSSBB
Frontline Led, Data-Based Improvement: Lean Daily Management
The presenters have no
relevant financial relationships
with the manufacturer(s) of
any commercial products
and/or provider(s) of
commercial services
discussed in the CNE activity 2
• Describe the principles and process of LDM
• Utilize LDM tools
• Identify two ways that frontline staff can contribute to improvements in quality and patient safety
• Articulate three benefits of the daily Gemba walks with the use of the tools
Learning Objectives
What is Lean?
• Continuous pursuit of perfection
• Management system based on Toyota
• Body of principles, tools, and
practices that help organizations
be more effective
The Toyota Way
Continuous Improvement – Challenge (We form a long-term vision, meeting challenges with courage
and creativity to realize our dreams.)
– Kaizen (We improve our business operations continuously, always driving
for innovation and evolution.)
– Genchi Genbutsu (Go to the source to find the facts to make correct
decisions.)
Respect for People – Respect (We respect others, make every effort to understand each other,
take responsibility and do our best to build mutual trust.)
– Teamwork (We stimulate personal and professional growth, share the
opportunities of development and maximize individual and team
performance.)
• Anything that does not add value for
the patient
Activities that require time, resources,
or space, but do not add value
Daily frustrations
Non-Value-Added
Moving patients for tests and treatments.
Moving things.
Any supplies or materials on hand
Reaching / bending / lifting for a frequently used item.
Task switching. Fetching.
Waiting for a bed, room, person or equipment to be
available
Doing more than the patients needs or wants
e.g., medically unnecessary care, excessive
documentation, excessive approvals needed
Do an extra one just–in-case?
Anything with the prefix „re‟ such as:
re-work, re-test, re-do, re- write, etc.
Any error such as wrong med, patient, test, procedure
Inve
nt
ory
The 7 Wastes
Exercise 1 The
Waste Walk
“Waste walk” in Small Groups
• Identify examples of waste in your work
• Try to think of examples in different waste categories
What is Lean Daily Management (LDM)?
• Staff review their daily frustrations, and focus on a few they believe they can influence
• Staff choose metrics and set goals
• Staff collect data and use simple lean tools to understand root cause and develop and implement solutions
• Senior leadership rounds daily to learn what is going on and provide any needed support
How Staff Contribute to Improvements
• Staff identify problems
• Staff make problems visible to leadership
• Staff collect data to quantify and investigate problems
• Staff help identify root cause and develop and implement solutions
Give staff tools and support they need to solve problems
faced in their daily work
Why LDM?
Increase employee engagement and empowerment
Improve integration and alignment among all disciplines and departments
Ultimate goals
Provide care that is safe, high quality, prompt, courteous, respectful, and efficient
LDM –The GOAL
GOAL sheet Track daily performance along timeline to show progression toward mitigating identified problem
•Write clear goal If goal changes during month, write new goal on post-it and indicate on metric
Simple, dynamic visual aid makes it easy to – See progression of solution development
LDM –The RUN Chart
RUN chart Shows frequency and trends of the problem
Simple visual demonstrating improvement trend
•↓ frequency of negative event over time
Captures data in multiple formats
Upper x-axis: Days of month
Lower x-axis: Total daily events
Only recorded events can be recognized and receive appropriate attention to be resolved
Graph
Total #/day
LDM – The PARETO Chart
PARETO chart Graphic representation of the impact of specific reasons for missing the goal
# occurrences/reason/time period
LDM – The PARETO Chart
PARETO chart Graphic representation of the impact of specific reasons for missing the goal
# occurrences/reason/time period
To document a new occurrence, fill in a box with the date
A spike or trend should trigger a “5 Why” process
List every reason that causes the problem. Some days on the run chart may have multiple reasons for missing the goal.
The stone on the Jefferson Memorial was crumbling.
1. Why was it crumbling? Too frequent washings
2. Why was it washed so often? To remove bird droppings
3. Why were so many birds in the building? Abundant food supply: hundreds of little fat spiders
4. Why are there so many spiders? Spiders were attracted to black flies
5. Why were there so many black flies? Every evening at dusk they emerge in a mating frenzy. At the same time the Park Services turns on its powerful spotlights.
5 Whys Example
LDM –The Action Plan
Action plan List of changes identified by the team to mitigate issues affecting the goal
The action plan is usually developed after the 5 why process has occurred
Start with a verb to indicate the action that needs to be or will be implemented
Identify who and by when an action will be implemented
Give credit where credit is due! Each small success is a step toward better teamwork and patient care.
Use the supplied sample data • Divide group into pairs
• Each pair completes different sheet
• Define a specific goal
– e.g. Zero episodes of … Less than 2…
– Note on the Goal sheet Red vs. Green for each day
• Plot daily data on the run chart
• Complete the Pareto chart
– List reasons along the bottom
– Enter date in a box for each occurrence
Exercise 2 Building the Goal Sheet
and Run and Pareto
Charts
Example LDM Display Board Concept
S Q P C Run Chart Run Chart Run Chart Run Chart Run chart
Pareto Chart Pareto Chart Pareto Chart Pareto Chart Pareto chart
5 Whys/
Action
Plans
5 Whys/
Action Plans
5 Whys/
Action Plans
5 Whys/
Action Plans
5 Whys/
Action Plans
LDM Wins
Script
AREA KPI BOARD
G
MARKERS
Problem
Solving
Folder
Department
Name
Daily
performance
Living Pareto
Chart (built
daily for one
week or more
5 Whys
Action Plans
Up to Five KPI Categories
Miscellaneous
Information
Daily “Gemba Walk”
3 Benefits of the Daily Gemba Walks: 1. Bring senior leaders to the Gemba daily
2. Assist in coaching and developing people in problem solving/process improvement
3. Provide resources or other needed support for improvement
where the work is performed,
the source, the scene of the crime
Gemba
Example script
PRE-WALK PLAN: All metrics updated BEFORE the Gemba Walk!
GEMBA WALK SCRIPT for Presenters: • “Good morning. My name is ___ and I’m ___(role)”
• “Our first goal is _____. Yesterday we were Red (or Green). *point to top letter]
• If Green, move to next metric.
• “We had ______ occurrences [point to run chart]
• “The reasons for yesterday’s fallouts were ____, ____ and ____. *point to Pareto+”
• Our next steps are to _________________ (collect more data with the current Pareto, drill down into the tallest bar, try different Pareto categories, etc.)”
• Address each goal in the same manner.
• When complete, ask “What questions do you have for me or the team?”
Gemba Presenter Script
Wrap Up
• Learned the principles of LDM
• Practiced the tools to implement LDM
• Learned ways staff contribute to
improvement and benefits of Gemba
Walk
• We are willing to stay afterwards 25
Continuous Learning
Environment Review (CLER)
ACGME Milestones
• Systems-Based Practice (SBP)
• Practice-Based Learning and
Improvement (PBLI)
ACGME CLER
Patient Safety • Opportunities for residents to report
– Errors
– Unsafe conditions
– Near misses
Participate in inter-professional teams
– promote/enhance safe care
Quality Improvement
• Engage residents
– use of data to improve systems of care
– reduce health care disparities
– improve patient outcomes
ACGME CLER
Pathway 1: QI Education
• Progressive QI education
• Experiential learning
• Clinical site’s systems-based challenges are presented
• Techniques for designing and implementing systems changes
• Clinical site’s priorities for quality improvement
• Education program is developed collaboratively
ACGME CLER
• Actively involved in clinical site QI activities • Clinical site monitors trainee efforts in QI
• Actively involved in clinical site QI activities
– Selection of LDM goals
Trainee Engagement in QI Planning
Pathway 2: Trainee Engagement in QI Activities
ACGME CLER
Question
What organizational structures and
administrative and clinical processes
does the SI have in place to support
GME learning in each focus areas?
Lean Daily Management
ACGME CLER
How comprehensive is the involvement
of residents and fellows in using these
structures and processes to support
their learning in each of the six areas?
Our residents will share
momentarily…
Question ACGME CLER
Framework for Assessment
Knows
Understands
Basic knowledge
Knows How Shows
Demonstrates
Competence
(Workshop/ Simulation)
Does Demonstrates in actual practice
Performance
Applies
Integrated
knowledge
Knowledge Attitudes Skills Miller GE. The assessment of clinical skills/competence/ performance. Academic Medicine, 1990;65:563–567
LDM
System-Based Practice 4 (SBP4) Work in inter-professional teams to enhance
patient safety and improve patient care quality
Problem-Based Learning 2 (PBLI2): Systematically analyze practice using quality
improvement methods, and implement changes
with the goal of practice improvement
Resident and attending leaders conducted needs assessment with PI staff
Educational sub-group formed within resident leaders team to address identified needs
Educational materials developed
All residents receive global training
Residents receive monthly “just-in-time” training on data collection and reporting
Resident Education
Resident and attending leaders conducted needs assessment with PI staff
Implementation sub-group formed to develop plan for integration into one inpatient team
All residents surveyed on goals of LDM interest
Data collected on identified resident goals and addressed on daily “gemba” walks
Periodic monitoring, “5 whys” and action plans performed by core resident leadership team; resident collaborative time utilized
Implementation
Resident Involvement
Implemented October 2014
Participation
Data collection: 44/77 residents
(23/28 PL-1s)
Daily presentations: 14/26 PL-2s
Our Goals
Goals Actions / Successes
Zero occurrences of medication dosage errors
entered by residents
Tamiflu power plan
Albuterol ordering education
Zero instances of residents missing chief rounds
or noon conference
Staggered team sign out
Patient team “soft cap”
Minimal nursing interruptions
Standardized rounding times
Zero instances of residents being unable to
access the patient list
Improved sign out document
Zero instances of residents being unable to
access outside images
New disk drives in patient care areas
Year One
• Integrating resident goals in existing gemba walk sites strengthens interprofessional collaboration
• Maintaining a core team of resident leaders is critical for training and maintaining momentum
• Combining with a longitudinal experience creates continuity and promotes involvement
• Holding frequent trainings improves resident buy-in and data integrity
• Keeping flexibility is critical; goals change over time
• Eliciting resident feedback streamlines the process and promotes buy-in
Lessons Learned