2013 Annual Clinical Conference Lean 101: Overview of the ...

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)

What is Integrated Quality?Health Center Mission

Strategic Organizational Goals

Quality Improvement Plan

Annual GoalsAnnual Work Plan

Process Improvement EffortsCommunication

Evaluation

GE Healthcare Performance Solutions

What can it look like?

Page 5Page 5GE Healthcare Performance Solutions


Value Diamond

IDEALSTATE

Satisfaction

Time Quality

Finance

• Patient• Staff• Provider

Adapted from Health Performance Partners

Quality Improvement is Everyone’s Business!

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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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

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?

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

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

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

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

Patient Centered Medical Home Change Concepts

Adapted 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.”

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

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

There are 8 Types of Waste

Defects/Rework

Over-production

Waiting

Not Clear (Confusion)

Transportation

Inventory

Motion

Extra Processing Inventory

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

Examples of 8 Wastes

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

Visual Management

Lean Concepts for Improving Processes4. Level load the process

5. Improve the process to be “Just in Time”

6. Build quality into the process

Old Culture Lean Culture

• 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


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

Page 27

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

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

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


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

Value Stream Mapping

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!

Understanding the Work

• Value Stream Mapping• Begins with observation• Map what you’ve observed• Draw by hand and in pencil/editable


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??

• 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

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

DEFINE

• 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

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.

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

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

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

Mobilizing Commitment Tool:

Stakeholder Analysis

Used For: Identifying stakeholders and understanding resistanceDeveloping strategy to eliminate or lessen resistance

Name(Key

Stakeholders)

Issues / Concerns “Wins” Influence

Strategy

Mobilizing CommitmentStakeholder analysis & resistance tool

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

• 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

In order to know if a future state is an improvement, we must first measure and understand the present

Measure/Analyze

• 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?

...

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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)

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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

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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.

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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!

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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.)

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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

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(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

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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.

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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.

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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

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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?

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What pattern do you see with a “scatter plot” graph?

83

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

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Traffic

Lottery Tax CollectedCustomers

HistogramsMeasure: time to process applications (increasing registration time)

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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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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

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.

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

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

?

5S Example – Bowdoin Street Before 5S After 5S

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

The team has many ideas for how to improve the situation. Now what?

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

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)

Prioritization/Ranking Variations

The team did great work. Can they stop and move on to the next thing now?

SustainSustain

• 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

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.

All Variation is Not Alike

• Common (Chance) Cause variation

• Special (Assignable) Cause variation

Walter Shewhart

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.

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.

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?

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

Factors that make spread successful127


• 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…

External environment: factors that influence spread

128


• 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?

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 engagement

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

Thank You!!

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