Post on 17-Apr-2022
2013 Annual Clinical Conference
Lean 101: Overview of the Basic Model and Tools to Improve Skills in Performance Improvement
November 19, 2013
Session Objectives• Identify tools and methods to develop evidence‐based, continual performance improvement within community health centers through measurable outcomes.
• Describe how to build the systems and structures necessary to support organizational capacity for quality improvement and change management.
• Recognize how to apply Lean tools and principles to support health centers’ current practice transformation work in the PCMH model.
Quality in Primary Care
“The extent to which health services provided to individuals and patient populations improve desired health outcomes. The care should be based on the
strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision making. “
As defined by the Institute of Medicine (IOM)
Page 3
What is Integrated Quality?Health Center Mission
Strategic Organizational Goals
Quality Improvement Plan
Annual GoalsAnnual Work Plan
Process Improvement EffortsCommunication
Evaluation
Page 4
Page 5GE Healthcare Performance Solutions
What can it look like?
Page 5Page 5GE Healthcare Performance Solutions
Page 6GE Healthcare Performance Solutions
Value Diamond
IDEALSTATE
Satisfaction
Time Quality
Finance
• Patient• Staff• Provider
Adapted from Health Performance Partners
Quality Improvement is Everyone’s Business!
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CHC Board
CEO/Executive Director
CMO/Medical Director
Quality Coordinator
Quality Committee
Department Heads/Directors All StaffChief Operating
Officer
Chief Financial Officer
Dental Director
Director of Behavioral Health
Where is the Problem?
In my area, the problems are
____% process, and
____% people.
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85
15
…From Your Change ExperiencesElements that Distinguish Successful from Unsuccessful Change:
1. Generate a list of essential characteristics of successful or unsuccessful change using only pictures/drawings.
5 min9
Exercise
2. Mark each picture on your flipchart with a “Q” for quality of the solution or “A” for alignment, acceptance or accountability.
What is Change Acceleration Process(CAP)?
A good technical solution is simply not enough for success
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GE’s Change Research
•100% of all changes evaluated as “Successful” had a good technical solution or approach
•Over 98% of all changes evaluated as“Unsuccessful” also had a good technical solution
or approach
•What is the differentiating factor between success and failure?
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Effective Change Equation
Effective Results (E) are equal to the Quality (Q) of the solution times the Alignment (A), Acceptance (A) and Accountability (A)
of the idea
Q x A3 = E
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CAP: The Basics
• A model for change leadership and employee engagement• A flexible non‐linear model used throughout a change process • Applies strategic thinking to the influencing of others• Facilitates commitment and behavioral change through team dialog and action
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Change Acceleration Process
Changing Systems & Structures
CurrentState
TransitionState
ImprovedState
Creating a Shared Need
Shaping a Vision
Mobilizing Commitment
Making Change Last
Monitoring Progress
Leading Change
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Leading Change
Having a sponsor/champion and team members who demonstrate visible, active, public commitment and support of the change.
Creating A Shared Need
The reason to change, whether driven by threat or opportunity, is instilled within the organization and widely shared through data, demonstration or demand. The need for change must exceed its resistance.
Shaping A Vision
The desired outcome of change is clear, legitimate, widely understood and shared; the vision is shaped in behavioral terms.
Mobilizing Commitment
There is a strong commitment from constituents to invest in the change, make it work, and demand and receive management attention; Constituents agree to change their own actions and behaviors to support the change.
Making Change Last
Once change is started, it endures, and learnings are transferred throughout the organization. Change is integrated with other key initiatives; early wins are encouraged to build momentum for the change.
Monitoring Progress
Progress is real; benchmarks set and realized; indicators established to guarantee accountability.
Changing Systems And Structures
Making sure that the management practices (Staffing, Development, Rewards, Measures, Communication, Organizational Design, and Information Technology Systems) are used to complement and reinforce change
Change Acceleration Process
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Patient Centered Medical Home Change Concepts
Page 16Adapted from Qualis Health
PCMH & Lean“ To facilitate this transformation,
Group Health adopted the principles and tools of the Lean Management System (Womack & Jones, 2005). Lean is based on the Toyota Production Model for quality improvement, and focuses on creating value for the customer and minimizing inefficiency. Lean combines major process redesign—using process mapping, gap analyses, and design workshops—with tools to monitor and improve upon changes including visual displays (eg, work processes, daily data collection), tiered measurement systems, regular in person visits to clinics known as “leadership rounding” and Plan-Do-Check- Adjust (PDCA) cycles. Lean emphasizes work standardization within roles and across job sites.”
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What is Lean?
a set of operational concepts
a set of tools used in a variety of industries – including service & healthcare – to improve business processes
a philosophy that helps drive efficiency through employee empowerment and change at the grass roots
Jidoka
Just‐in
‐Tim
e
Standardization
Customer Focus
Continuous Improvement
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Create standards for all key processesFollow standard first, then continuously improve
Go & seeAsk “why” 5 timesDemand root cause action
Don’t accept, make or pass defectsStop and surface the problem
Standardize
Solve
Cannot recognize defects if standards are not defined
Preventabnormalitiesfrom becoming
the standard
The Underlying Principles
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There are 8 Types of Waste
Defects/Rework
Over-production
Waiting
Not Clear (Confusion)
Transportation
Inventory
Motion
Extra Processing Inventory
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Waste DefinitionsDefects Any operation that does not meet customer requirement
Overproduction Production of items beyond what is needed for immediate use
Waiting Any delay where the product/patient is not involved in a task
Not Clear People doing the work are not confident about the best way to perform tasks
Transportation Movement of patients, supplies, or information by staffInventory Having too little or too many supplies for the task at hand
or a build up of products, supplies, or patientsMotion Movement of people (bending, sitting, searching,
climbing, etc.)Extra Processing
Doing more work than is necessary to satisfy your customers often because of defects
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Examples of 8 Wastes
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Defects Medication errors; Retesting; Incorrect charges/billing
Overproduction Prepping for procedures not yet scheduled; Multiple forms with same information; Copies of forms sent to payers automatically when not needed/requested
Waiting Waiting for member of the care team; Waiting for patient test results; Waiting for pre-authorizations for treatment
Not Clear Same activities performed in different ways by different people; Unclear system for indicating charges for billing
Transportation Transporting patients for testing/treatment; Transporting equipment; Transporting documents
Inventory Excessive lab supplies; Excessive patient labels; Overstocked medications
Motion Looking for information, materials, people, equipment; Rearranging equipment/instruments
Extra Processing Redundant information gathering; Unessential regulatory paperwork; Clarifying orders; Excessive authorizations
Lean Concepts for Improving Processes
1. Remove process waste
2. Standardize the process
3. Implement visual management
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Visual Management
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Lean Concepts for Improving Processes4. Level load the process
5. Improve the process to be “Just in Time”
6. Build quality into the process
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Old Culture Lean Culture
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• No one really knows what to measure
• Who is responsible for the problem?
• Staff complain about problems
• Jump to the solution without doing any analysis
• Management rarely on site
• Policies rule
• Everyone knows what’s measured
• What is getting in the way?
• Staff identify opportunities for improvement
• Data is reviewed for root cause
• Management goes to the GEMBA frequently
• Standardized processes are essential
Page 27GE Healthcare Performance Solutions
Cultural Transformation
• Do the Standard Work
• Surfacing and Solving Problems
• Improve the Standard Work
Staff
• Observe, Measure, Analyze, Action
• Coach the Front Line• Support and Lead the
Improvements
Management• Align to Strategy• System and
Structures• Gemba and Coaching• Steward the Changes
Executive
Adapted from Health Performance Partners
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Value and Waste in Healthcare
• Value added (VA): Any activity that changes the form, fit, or function of a product/transaction or something customers are willing to pay for
• Value Enabling (VE) / NVA-Essential (NVA-E): an activity that doesn’t directly add value but one that must be performed to realize VA activity
• Non-value added (NVA): All other actions and unwanted features are by definition WASTE
EliminateMinimize
VA
VE +
NVA-E NVA
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Any process or value stream
Increased process velocity, reducedwaste, improved customer experience
After
Before
Wait / Waste Non Value Add Time
Lean attacks waste here
Work Value Add Time
Lead Time/Cycle Time
• Reduced cycles• Better delivery• More capacity• Better quality• Productivity
Higher customersatisfaction
Benefits of Lean
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Improve to Perfection
Keep the customer in focus…are we adding value?
Reducing waste brings us closer to perfection
As we reduce inventory/overproduction in the process, bottlenecks can be exposedand worked on as next steps
Continuously find ways to improve the process
Continuous improvement is the road to perfection
cycle time
months
days
hours
minutes
seconds
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Page 31GE Healthcare Performance Solutions
Actualizing Performance Improvement
Continuous ImprovementStandard Work Not Working
Not Following Standard WorkLack of Standard Work
Just Do It
Assume the role of the “product” and flow through the process. In manufacturing they are encouraged to “be the part”, so we should “be the
patient” and flow through the process as the patient does.
Once Value is Defined – Walk the ProcessLean searches for facts via observation
To learn the facts, the team must:• Physically go to the work• Actually observe the work being done• Talk directly to those performing the work
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Value Stream Mapping
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Value Stream Mapping
• A Value Stream Map (VSM) is a graphic map of all steps that occur from the specific request for a service to the actual delivery.
This provides us with a simple means to see!
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Understanding the Work
• Value Stream Mapping• Begins with observation• Map what you’ve observed• Draw by hand and in pencil/editable
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Page 36GE Healthcare Performance Solutions
Value Stream – ExampleChronic Disease Management VisitHow to get people on board: Show them what is happening in their organization!
But we have so many problems? How do we pick what to do first??
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• Look for what’s relevant• Look for a high impact opportunity• Start simple• Align with other initiatives, strategic
goals, and/or deliverable requirements
Activity1. Pair up with someone close to you2. Introduce yourselves3. Look at each other for 30 seconds and
then turn around4. Change 3 things about your appearance5. Turn around and look at each other6. Find what the other person changed
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Define Measure /Analyze Improve Sustain
•Create project charter
•Complete stakeholder analysis
•Communication
•Create & validate process map
•Collect & analyze data
•Root cause analysis
•Communication
•Brainstorm & select improvements
•Test improvements•Collect results•Implement improvements
•Communication
•Create sustain plan
•Develop run chart•Communication
Create the Improvement DNAA Framework for Performance Improvement
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DEFINE
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• Identify the current state, current problem• Consider using the checklist in the toolkit• Determine if you will use a project charter or an A3 • Determine Key Stakeholders• Create a communications plan (elevator speech)
Sponsor Approval & DateSponsor Approval & Date
Charter updated: <Fill in date updated>
Problem Statement:• Why is this project important to the organization?• One or two sentences that describe the gap between expected
performance and actual performance
Aim Statement:• Major goal(s) of project (limit 1-2)
Measures of Success:• Key metrics (how will you measure the goals?)
Scope:• What’s in and out of scope? (Which pt types, which procedures,
which test types, etc.)• Process Begin & End
Boundaries:• Constraints (anything non-negotiable for the project such as “FTE
neutral” or “no capital expenses > $500”)
Facilitator(s) / Practitioner(s):••••
Team Members:• Names and roles/depts
Start Date:Planned End Date:
Project Charter forProject Charter for:
Sponsor(s):•
Sponsor Approval & Date
Coach(es):•
• Initial activities or significant change in membership/charter• Lack of clarity about purpose• Members do not know each other• Members rely on external roles and status• Superficial discussions
• Disagreement, express frustrations, challenge ideas• Learn to use conflict constructively – or will have passive
resistance
• Create new guidelines• Re-establish relationships• Re-interpret goals• “Competitive cohesion” develops (“We’re the best”)
• THE PAYOFF!• Agreement on goals, roles, norms• Creative confrontation and innovative
approachesBased on Tuckman, BW, “Development Sequence in Small Groups”, Psychological Bulletin, 1965, 63 (6)384-399.
Forming
Storming
Norming
Performing
Adjourning
Developing High Functioning TeamsTuckman Team Development Model
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Team
A small group of people with complementaryskills who are committed to a common purpose, performance goals and approach for which they hold themselves mutually accountable.
Jon Katzenbach, Douglas K. Smith
The Wisdom of Teams
Katzenbach, J., & Smith, D. (1993). The Wisdom of Teams. HarperCollins: New York.
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Team Performance
• Team performance is dependent on clarityand communication during planning and implementation
• A diversity of perspectives increases the probability of reaching high-quality solutions
• There are opportunities to demonstrate leadership during times of stress, conflict, success and failure
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Helping Behaviors Active listening Dialogue first, problem solve
second, persuade last Connect vision to interests Reward and recognize early
adopters Provide hands-on, “kick the
tires” experience Honor the past
Hindering Behaviors Ignore or discount feelings Hammer with logic and data and
presume objectivity will carry the day
Change focus and priorities Attack people vs. problems Ask others without first asking
yourself Ask for new, but measure the old
Mobilizing Commitment: Moving through Resistance
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Facilitatating Change: Key Questions
Who should be involved in the change?• Practice staff• Others?
How do we communicate about the change?• Elevator speech• Communication plan
When will the change happen?• Are there other initiatives/major changes occurring?
What obstacles or challenges do we anticipate?• Staff resistance or pushback
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Mobilizing Commitment Tool:
Stakeholder Analysis
Used For: Identifying stakeholders and understanding resistanceDeveloping strategy to eliminate or lessen resistance
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Name(Key
Stakeholders)
Issues / Concerns “Wins” Influence
Strategy
Mobilizing CommitmentStakeholder analysis & resistance tool
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Page 49
Mobilizing CommitmentStakeholder Analysis & Resistance Tool: Example – Pt. Cycle Time Reduction Initiative
X: Current level of commitment. :Level of commitment we need.
Name(Key
Stakeholders)Issues/Concerns “Wins” Influence Strategy
R. Jones, MA
X Project taking 16 wks to complete
Project shows results quickly
Keep informed, Ask for help as needed
B. Smith, CMO
X Impact of project on current staffing
Project completed without delays
Continue to engage during each phase
T. Alsop, IT X ∗
Loss of Autonomy Increased recognition of skills and value on team
Involve in long term process monitoring and reinforce value brought to initiative
K. Laws, RN Manager
X 30-yr employee –resists change
Load of work is leveled for staff
CMO to show how work will be more evenly distributed
P. Wills, RN X Sees new duties of medical assistants as risky
Fully understand MA abilities and strengths
Involve both RNs and MAs in huddle to highlight competencies
B. Kiles, MD X Thinks providers should conduct vitals on their own pts
More time for SMG planning with patient during visit
MA Manager explains rigorous training and supervision for MAs
Audience Message Media Who When/Where(inform, persuade,
influence)(written, events, one-on-one,
etc.)
Communication Plan
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• Performance improvement (PI) practitioner (manager skilled in PI)
• Process experts (practice staff who understand today’s process and what the patient needs)
• Patient (wants highest quality, caring and efficient processes)
Working Together to Improve Processes
Observe Processes to find improvement opportunities
Other Depts.Patient
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In order to know if a future state is an improvement, we must first measure and understand the present
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Measure/Analyze
Page 53
• Utilize data to assist in understanding the current state
• Make a Process Map• Observe the process• Get to the Root of the Problem
Key Components of Understanding the Process:1.Observations
• Follow patients, products and staff to understand the value added steps and identify waste in process
2. Interviews and discussion• Gain insight from experts of the process (staff involved in
the process)
3.Data collection and analysis• Use process data to pinpoint causes and remove bias
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Chaos becomes clear.
A simple method to visually display the various steps, events, and operations that constitute a process.
What is Process Mapping?
...
55
Perceptions of a Process
What we think it looks like:
What we wish it would look like:
Do not jump to “What we wish it would look like”
What it actually looks like:
V0719156
1. Form the appropriate team, gather materials (banner paper, Post-It® notes, markers, dots) and find a wall space large enough to accommodate the completed map.
2. Define the process to be reviewed. Name it. Agree on the process start and end. The start and end should match the scope of the project written in the charter.
3. Determine how complex and detailed of a map you will need to give you what you want.
4. Assign symbols: - Rectangle for steps- Oval for start and stop- Diamond for decision
Steps to Develop a Process Map
57
5. Identify the process steps Start by rapidly writing process steps on Post-It® notes and placing them
on the paper. Write large with one process step or item per Post-It® note. Don’t worry about order, don’t worry about priorities, just list them!
6. Now sequence the steps - arrange the steps the way work is currently done and draw arrows.
7. Validate the map to ensure it represents the situation as it really is today. Change the process map to correspond with the physical process.
Steps to Develop a Process Map (continued)
58
Validate the Process Map1. Are the process steps identified correctly?
2. Is every feedback loop closed?
3. Does every arrow have a beginning and ending point?
4. Is there more than one arrow from an activity box? Perhaps it should be a diamond.
5. Is there anything missing?
6. Do the workers who do the process every day agree that the map reflects reality?
7. Ask the questions:• What happens if…?• What could go wrong?• Who…?• How…?• When…?
8. Update the map
Walk through the actual process with the entire
team.
TaskTaskDirectionDirection
StartEndStartEnd
Automated System
Answers
Automated System
Answers
PatientCalls
PatientCalls
Touch-Tone
Phone?
PatientChooses Routing Option
PatientChooses Routing Option
Call Placed In Queue,On Hold
Call EndsCall EndsCall Gets Routed To
Voice-Activated System
Patient Waits?
SchedulerAnswerPhones
ReviewOr Decision
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Change the process map to match the actual process.
Value added (VA) Activities that provide value to the customer or that the customer would be willing to pay for. Direct patient care activities are typically value added.
Value enabling (VE) or
Non-value added but essential (NVA-E)
Activities that enable value added activities to occur.
Activities that add no value to the customer but in today’s environment are essential for business such as regulations or compliance requirements.
Travel (NVA) Time and distance it takes for caregivers, patients, supplies/equipment, etc. to travel for each step of the process.
Wait (NVA) Time that patients, caregivers, or materials wait for equipment, supplies, to be transported, etc.
Non-value added other (NVA)
Any other non-value added activity that you observe such as duplicate sign-ins, going to multiple locations to register, documentation of same information in multiple locations, duplicate methods of communication.
Defining Value in a Process Map
60
How do we Find the Root Cause?
Asking 5 Whys is one way
What is the “5 Whys” strategy?
• A fundamental Lean principle used to identify the root cause(s) of problems in a process.
61
Ask the 5 “Whys”
Why are there delays in checking patients in?
If there are new patients, they have to be registered and the process takes a long time, especially in Adult Medicine.
Why does it take so long to register new patients in Adult Medicine?
Patients being seen for the first time at the health center have to complete a “New Patient” formand many patients require assistance.
Why do patients need assistance completing the forms?
Because of low reading levels and/or language barriers so the front desk staff has to assist new patients in completing the forms.
Why does the front desk staff have to be responsible for completing and entering the forms?
Because the front desk staff are the most appropriate staff to help since the forms are completed when the patients present to the health center.
Why do the forms have to be completed when the patients present to the health center?
This has been the protocol for all new patients in adult medicine…… in other words, they don’t have to be completed at that point!
62
Cause-Effect Diagram
Women not receiving yearly cervical cancer screening
Patient Communication
Provider Engagement
Program Scheduling
Staff Engagement
Transportation issues
Language barrier
Requires additional appointment
Awareness and Education
Access to proper equipment
No pt consent form
Improper documentation
Access to proper equipment
Lack of pt hx/improper documentationVariation of
practice
Scheduling conflicts
Restricted time slots
No reminder phone call
Too many exams scheduledExams
conducted 2 days/wk
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No dedicated physician to conduct screenings
Creating a Shared Need Tool:
Three D’s Matrix
Used For:Building your case for change with
evidence using data, demonstration & demandAnswers the question: “Can I prove it?”
64
3 D’s Matrix:Communicating/Proving the NeedTypes of Proof What do we have? What do we need?
Data/ Facts:Numbers / Trends / StatisticsGraphs / FinancialsBenchmark / Competitive data
Demonstrate:Best PracticesVisiting other Organizations / Panels/ Pilots/ Testimonials
Demand:Dynamic Leadership (Setting High Standards/ Accountability)Customers / Suppliers / Competition (Int. / Ext.)
65
3 D’s MatrixData/Diagnosis (What data do we have to convince them?)Refers to the degree to which internal and/or external sources of data frame the need for change (such as facts, surveys, benchmarking or competitive data).
Demonstration (give me examples – show me where it’s working)Refers to a specific example you can point to. Such as the role that Leaders are showing, role of Best Practice sites or pilot projects can play in creating the need for change.
Demand (Government regulations, I’ll lose my job is I don’t do this)Refers to actions/ behaviors/goals set by senior leaders or others that will signal a need for people to change (such as making Quality the first topic discussed at every staff meeting and incorporating participation in the Quality initiative part of the compensation process). Could also be the demand the Customer, Competition, or internal Employees are placing on the change.
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So much possible data, so little time. How do teams choose and avoid analysis paralysis?
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Q. What are we Looking for?
Data collection is essential any time you undertake a performance improvement, and in each phase the goals will differ:
In Define Phase, to understand the problem and get an idea of the magnitude of the problem
In Measure and Analyze Phase, to dig deeper or investigate additional possible variables
In Improve Phase, to validate that improvements are successful
In Sustain Phase, to be sure that improvements are sustained
A. Meaningful data
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Data Collection Plan
• Data are representative of the process• Short term and long term• All subgroups within the population are represented
• Only the relevant data are collected
• Resources are used effectively
• Clear definitions are given
• Enough data are collected
• Data collection procedures and forms are simple and easy to complete
A data collection plan is an organized, written strategy for gathering information.
Characteristics of a good data collection plan:
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Observations
Conduct Interview/ Focus Group
IT systems
Surveys
Check sheets
Data Collection
70
(Voice of the Customer)
Spaghetti Mapping: What is it?
A diagram that shows the motion of the patient, family, caregiver, and/or supply throughout the care experience or process
It shows us where the operators go throughout the observation
71
Spaghetti Mapping: Getting Started
Identify the area, task or function that needs to be evaluated.
Obtain or create a layout of the area where the task is held (e.g. layout map of the urgent care department including the waiting room).
Talk to the person(s) that you are planning to follow so they understand the process and are not uncomfortable, share your observations after observations are done.
Identify landmarks in the layout so you can quickly find your way.
72
Spaghetti Mapping: Getting Started
In pairs, take a pedometer and the layout of the area (If you are working alone, then concentrate on the layout portion first, and do measurements later).
Pick a typical case and follow your ‘mark’ as he/she goes through the various steps.
Replicate the path of the ‘mark’ on the layout and document total distance.
NurseStation
RegistrationArea
Locker
charts
Travel distanceCharge RN (1 hr) 1456ft(trip to locker, trip with checked charts)
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What does Spaghetti Mapping tell us?
Central Sterile Storage
General Storage
ReplenishAnesthesia
Count
Admin/ PACU/ Peds
Receive
Case Cart Prep.
Central Sterile Storage
General Storage
ReplenishAnesthesia
Count
Admin/ PACU/ Peds
Receive
Case Cart Prep.
Spaghetti maps show where patients/staff move during a process. This tool provides a visual mechanism to identify physical bottlenecks, excess motion, unnecessary motion, rework, etc.
In this case, multiple functions need access to two supply rooms, so a possible improvement will include opening access to these rooms.
74
What are you Looking for in Observations? Variation in the process
• From how the process was communicated• Between caregivers/staff
Waste
Opportunities for improvement
Feedback from staff
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Voice of the Customer (VOC)Engaging the Patient in the PCMHVoice of the customer is a process used to capture the requirements or feedback from the customer (internal or external) to provide customers with the best service/product quality.
This process is proactive and constantly innovative to capture the changing requirements of the customer with time.
• Survey/comments• Patient and family participation in teams• Interviews
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Sources of Data
Existing Data: always start here! Things like…• Patient Satisfaction
• Continuity With Care Team
• Call Abandonment Rates
• Expenses
Benefits of using existing electronic data• Easier to collect and analyze
• Not dependent on a few people and can be easily accessed by many helps sustain gains in the long run
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When Existing Data Aren’t Available
1) Find a collection point in the process (use process map)
2) Consider how the data collection will integrate with jobs and the surroundings
3) Design a form:a) Check Sheet: simple mark captures data
for easy tally
b) Data Sheet: enter values for later tally and calculation
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DefinitionDefinition
Elements of acheck sheet
Things to remember
– Check sheets organize data collection when values can be simply “checked off”
– Check sheets standardize both the data that are collected and the data collection process
– Description of what data are being collected– Places to put the checks or values– Room for comments and annotations
– The simpler the better– Avoid including irrelevant data– Test the form in the early stages of form design
and involve the data collectors in the design of the form
Check Sheets
79
When Existing Data Aren’t Available
4) Flow of forms:a) Follows the process attached to chart or carried by patient
b) Kept in one place and completed at one point in the process (next to phone, taped to door)
c) Initiated when some event happens (phone rings, patient arrives)
d) Record data on existing form (encounter form, schedule)
5) Prepare a procedure and review it with anyone involved in collecting data
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Why Draw a Histogram?
Definition:
A histogram is a picture of how the process works (technically, a frequency distribution).
Purpose:
• Variation is natural – it’s a part of every process.
• Variation has a pattern, and reveals something about the way the process works.
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Can You Detect a Pattern?
Your patient flow team collected data on how long a patient waits in the exam room before the provider enters. Here are the results, in minutes:
8 6 5 12 1511 4 15 2 916 18 2 8 1511 10 10 9 810 9 15 7 88 8 9 7 9
12 13 9 8 99 10 10 10 811 9 8 10 129 11 10 9 9
Can you detect the pattern in these numbers?
82
What pattern do you see with a “scatter plot” graph?
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A Histogram Would Reveal the Pattern
Histogram Example A:Patient Wait in the Exam Room
05
10152025
1-3 4-6 7-9 10-12 13-15 16-18 over18
Wait (number of minutes)
num
ber o
f vis
its
Frequency
Measure of the process
84
Histogram Samples – How to Interpret
Centeredness – what point looks like the center of the data?
Width – How spread out are the data? More spread = more variation
Shape – Does it take on a common shape, like “normal” or “skew” for example
Normal
Skew Truncated
Bimodal
85
Traffic
Lottery Tax CollectedCustomers
HistogramsMeasure: time to process applications (increasing registration time)
86
Sample Size = 55
February 1-11, 2012
Stratified Histograms
Patient Visit Delays: Adult Medicine
0
5
10
15
20
25
4-5 6-7 8-9 10-11 12-13 14-15 16-17 18+
Delay in minutes
num
ber o
f vis
its
Patient Visit Delays: Pediatrics
02468
101214161820
4-5 6-7 8-9 10-11 12-13 14-15 16-17 18+
Delay in minutesnu
mbe
r of v
isits
Sample Size = 72 Sample Size = 72
Measure: Patient Delay Time
Stratification Variable: Department
Notice that the cells must be the same size for both graphs, but the scale for the number of visits (height of bars) can look different
87
Pareto Introduction and Example
• Vilfredo Pareto (1848-1923): 80% of the wealth in Italy was concentrated in 20% of the populace – hence, the “80/20 rule.”
• 80/20 applies often in performance improvement: among a group of factors contributing to a problem, 20% of those factors contribute 80% of the undesirable effect.
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Pareto Charts in Action
http://www.xtremelean.us/consulting/
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Example of Pareto Chart
Pareto Chart: Patient Delays
0 20 40 60 80 100 120 140
Ins Problem
Session Backup
Report Missing
No Room
Translate
Supplies
Chart Missing
Cau
se o
f del
ay
# patients delayed
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When to use a Pareto Chart
Purpose:
• Use when you’ve brainstormed a list of plausible causes, and you have data on the effect of these causes
• Juran: principle of the “Vital Few” and “Useful Many”
How to Draw:
• Pareto: a simple bar chart (not a histogram)
• Create a table of causes, with the frequency of each cause
• Sort the causes by the frequency
• Graph the data
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How to Interpret a Pareto Chart
How to interpret:
• Look for the “Vital Few” and “Useful Many”
• The “Vital Few” often add up to 80%, but they don’t have to – use the picture to see what stands out, not just the 80% point
• Look more carefully into the “Vital Few” causes
Pareto Chart: Patient Delays
0 20 40 60 80 100 120 140
Ins Problem
Session Backup
Report Missing
No Room
Translate
Supplies
Chart Missing
Cau
se o
f del
ay
# patients delayed
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Activity: Line up by birthdate
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Rules1.Line up in order of birth
month and date (no year needed)
2.Do not speak to each other
3.Everyone raise your hands when you are in birth order!
The Team Understands the Present State: How Can it Possibly be Fixed?
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Reduce Non-value Added Steps Using Lean Concepts Lean is the relentless pursuit
of the perfect process through waste elimination • Higher customer satisfaction
and experience> Reduced cycle time> Improved delivery > More capacity> Better quality> Productivity
• Increased process velocity• Reduced waste
Achieves:
Any process or value stream
After
Before
Wait / Waste . . .Non Value Add Time
Lean attacks waste
Work . . . Value Add Time
Lead Time / Cycle Time
Page 95
Standard WorkWhat is it?The best known combination of people, materials, machines and space carrying out production in the most efficient method.
Why is it important?•Basis for consistent quality
•Reduce variation
•Process stability
•The foundation for improvement
•There is no improvement in the absence of standardization.
Moves us towards predictable, high quality outcomes with repeatable steps
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Standardization Questions
1. Are there any standards?2. Are intended users aware that they exist?3. Are the standards enforced?4. Are the intended users following the
standards?5. Has there been adequate training on the
standards?6. Do the standards need to be revised?7. Even if the standards are clear is it so easy
to make a mistake that we need to fool-proof the process?
Yes No
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Using Tools to Create a Standard Work EnvironmentStandard work will establish the “best practice” activities which minimize waste and variation.
• Established in the workplace by those who actually do the work
• Each employee is expected to actively participate in the improvement of the standardized work on a continuous basis.
Components of standard work include:• Work sequence• Standard set up
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Standard set up
Components of Standard Work
The standard equipment and supplies set up in the way they will be used
e.g. standard set-up of supplies and equipment needed to assess vital by medical assistant
Page 99
Things to Remember about Standard Work• Enables all employees to identify problems• The foundation for consistent and stable quality• Living, dynamic tool that makes changes and
improvements possible• Standardized work should be changed:
• After improvements are made to a process• If external customers demand changes
• Work must be written down to be standardized• Established in the workplace by those who actually
do the work
Page 100
Lean Demands Simplification
The challenge is to simplify: • Processes… too many steps • Products… unneeded
complexity • Policies and procedures…
1,000s of pages• Reports… too much data, too
little information• Metrics… too many
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Parallel Processing
Step 5
Steps performed as a seriesEach step takes 1 hour. Total process time = 7 hours.
Steps performed in parallelEach step takes 1 hour. Total process time = 4 hours.
Steps 5 and 6 start at the same time as Step 4.
Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7
Step 1
Step 6
Step 4Step 2Step 3 Step 7
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Disperse Peak Load - Goal
Preparation steps Finalize stepsDirect patient care steps
Step 1
Step 2
Step 3
Internal process stepsExternal process steps External process steps
Get items, have what you need ready
Exam, diagnosis, services provided, etc.
Put items away, complete paperwork, etc.
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Cycle time
Page 103
Disperse Peak Load Principles
Shift as many internal elements as possible to external elements
Streamline the remaining internal elements
Streamline the external elements
This should be an ongoing continuous improvement process.
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Why is Leveling Important?
Removing unevenness in the system improves staff and customer satisfaction. It helps to:
• Set expectations with customers; steady process
• Reduces “burn out” among employees; less fire fighting
• Better utilization of resources and, less downtime and/or overtime
Muri
Muda
Mura
Waste
Unevenness Overburden
Page 105
Leveling Processes
Look to level processes within a department at first. Some ways to level include:
• Redistributing tasks within department to even out workload
• Eliminating waste from the current operation
• Flexing resources as customer demand increases
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Leveling: How to Start
• Understand the process -observations and data are crucial!
• Remember to engage the process experts (they know process and will sustain it).
Example of using data for leveling
Time Analysis
100 360
2100
1040542730
1990
5520
0
1000
2000
3000
4000
5000
6000
7000
Tim
e (s
ecs)
VA NVA
Registration Exam Prep Exam Discharge
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What is Visual Management?
Visual management is the practice of making all standards, targets and actual conditions highly visible in the workplace, so that everyone can see and understand the actual conditions vs. requirements.
Make it visible to everyone
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Types of VisualsType of Visual Visual Indicator Visual Signal Visual Control Visual Guarantee
Power LevelPassive
(tells only)
Assertive(grabs our senses
by changing)
Aggressive(narrows our
response options)
Assured(allows correct response only)
Impact on Behavior
Influences / Informs / Indicates / Shows /
Suggests
Alerts / Warns / Alarms / Signals /
Prompts / Announces
Confines / Contains / Obstructs / Constrains /
Regulates / Restricts / Directs / Hinders / Controls / Limits
Compels / Forces / Eliminates /
Prohibits / Inhibits / Guarantees
Visual Examples
Work Place Examples
Directions / Instructions / Maps / Displays /
Shelf Numbers / Bin Address / Floor Tape /
Painted Borders / Bench Markings
Alarms / Lights / Digital Boards / Control Boards
Shelf Height / Shelf Width / Bin Size / Container Size / Weight / Raised
Borders or Edges / Aisle Width
Sensors / Limit Switches / Guide Pins / Locators /
Templates
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What is 5S?
5S is a process and method for creating and maintaining an organized, clean, safe and high performance workplace.
Visual management and standardization are key elements of 5S.
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5S and Visual Management
to maintain and improve sort, set-in-order, shine, and standardize
Sort to separate the needed items from the un-needed items which are then removed to a "red-tagged" location
Set InOrder to arrange in a way for how the remaining items will
be used
Shine to maintain the work area for the already sorted and set-in-order items
Standardize to ensure sort, set-in-order, and shine are consistently followed across all users
Sustain
5S
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Strengths of 5S/Visual Management
Workplace that is• Clean, organized, orderly• Safe and pleasant• Visually appealing• The basis for all other improvements
Resulting in• Improved efficiency• Improved quality• Workplace control• Optimal view of what is going on
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?
5S Example – Bowdoin Street Before 5S After 5S
Page 113
5S Keys to Success
• Get everyone involved• Integrate 5S principles into daily work
requirements• Communicate need for 5S, roles of all participants,
how it is implemented• Be consistent in following 5S principles in all
areas.• Involve senior management• Follow through - finish what is started. 5S takes
effort and persistence• Link 5S activity with all other improvement
initiatives Page 114
The team has many ideas for how to improve the situation. Now what?
Page 115
Categorizing and GroupingA highly visible process of evaluating and organizing information.
Idea
Idea
Idea
Idea
Idea Idea
Idea
Idea
Idea
Idea
IdeaIdea
Idea
Category Category Category
• For selecting the theme or identifying the problem• For generating solutions
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Ease of Implementation
High
Low
Easy Difficult
Payoff / Benefit /Impact on your Aim(Increased Revenue, Decreased Costs or Cycle Times)
3. Priority/Pay-Off Matrix (Impact/Effort Matrix)
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Prioritization/Ranking Variations
The team did great work. Can they stop and move on to the next thing now?
Page 118
SustainSustain
Page 119
• Identify if any systems or structure need updating as a result of changes made
• Continue to measure• Identify a way to integrate monitoring the measure
into an existing structure (i.e. staff meeting, department meeting)
Keep up the Energy Level
ImprovementsMeasures
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23
3028
0
5
10
15
20
25
30
35
1-Mar 1-Apr 1-May 1-Jun 1-Jul 1-Aug 1-Sep 1-Oct 1-Nov
# of
Pat
ient
s
Month
Correct Contact Info
Correct Contact Info
Goal
Run Chart: A Key Tool for Sustain
Purpose: Watch a measure over time.Measure of
success
Interval of time
Up-and-down = variation
In this case, up is better.
Page 121
All Variation is Not Alike
• Common (Chance) Cause variation
• Special (Assignable) Cause variation
Walter Shewhart
Page 122
Common Cause Variation
Natural variation in the processEvery process experiences natural variation, even machines.
Example: Check-in – If we use the same process every time, will it always take exactly the same amount of time?
Leadership takes responsibility for maintaining a consistent process. A consistent process will exhibit Common Cause variation, and that is normal.
Page 123
Special Cause Variation
A special event, sometimes a one-time occurrence, changes the performance of the process.Something has changed – it’s not just normal variation.
A process improvement is a type of Special Cause variation.
Page 124
Changing Systems and Structures Force Field AnalysisLooking beyond the new process, changes to behaviors, etc. which of the currently existing Systems & Structures will: • Help? • Hinder?
What is your action-plan to leverage or overcome them?
Page 125
Helping Hindering ActionsStaffing/Development
MeasuresRewards
CommunicationOrganization
DesignsIT Systems
Resources Allocation
Sustainability planning goes hand in hand with PCMH transformationTheSustainabilityPlannerfromHealthQualityOntarioprovidesguidanceinsevenareas:
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Coach Medical Home: Module 6
• what you are sustaining1. Clarify• leaders and help them understand their role2. Engage
• and support frontline staff3. Involve
• the benefits of the improved process4. Communicate• the change is ready to be implemented & sustained5. Ensure
• the improved process6. Embed
• in ongoing measurement7. Build
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Factors that make spread successful127
Coach Medical Home: Module 6
• Is widely perceived to have relative advantage over other interventions.
• Is compatible with existing norms & values, and risks are manageable.
• May be complex, but can be split into manageable parts.
The innovation…
• Can try the innovation before adopting it—and can adapt it to some degree.
• See the benefits of the innovation in a reasonable timeframe.
• Receive appropriate knowledge and training.
All team members…
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External environment: factors that influence spread
128
Coach Medical Home: Module 6
• Is the innovation aligned with patient needs and preferences?
• Are there external incentives or mandates?
• What is the political & policy climate like?
• Are competitors doing similar things?
• Does organization work closely with other organizations?
• Is the external environment stable?
Page 128
Using the Framework to Build CHC Capacity• Fosters the development of the two foundational
change concepts for PCMH transformation: Cultivates ongoing Engaged Leadership, which is
essential for successful process improvement Creates a sound, organization-wide QI Strategy,
which is critical for practice redesign
• Engages all staff in process improvement efforts, which enables Improvement in outcome measures Streamlined clinical and operational processes Improved patient population health management and
patient engagementPage 129
Using the Framework to Build CHC Capacity
• PI initiatives that are well aligned with organizational strategic goals support accountability at all levels and therefore sustained practice transformation
• A common language around PI, practice transformation, and change management is important for successful NCQA PCMH certification
• Framework assists with alignment of PCMH transformation, NCQA recognition, and other PI/QI initiatives
• Enhanced capacity for workforce development among new and emerging roles
Page 130
Thank You!!
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