Creating a Model Line JBA Doc
Transcript of Creating a Model Line JBA Doc
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply V11032012
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
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What is a Model Line?
A value stream that achieves complete elimination of waste so that all activities
along the value stream create value.
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
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Why Have a Model Line?
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• A model line focuses the resources for lean improvement work in a defined value stream.
• A model line serves as a “model” to allow others to see lean principles in action.
• Allows more rapid improvement in an area of concern.
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Line Improvements Line Line
Vertical development
(Link processes to create a cell)
Plane Improvements Plane
(Link cells to produce a product)
50% today beats 90% tomorrow every time
Don’t require perfection - Fail forward quickly
Just do it! - You will learn as you go
Point Point Point
(Eliminate waste at source - Just start
somewhere)
Point Improvements
Height 3rd Dimensional
(Link all elements from concept to
customer)
Spatial Improvements
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© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
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Model Line Development The essential elements for developing a model line are: 1. Understanding and defining the future state of the business and
the associated goals and metrics
2. Applying the right resources and the right tools to achieve the three key principles – Takt-time paced, one-piece flow, pull
3. Implementing the six tactics – Understanding how value flows – Standardizing work procedures – Putting visual controls/management in place – Putting everything at point of use (supply chain) – Balancing the line (heijunka, takt time, SWIP) – Converting to a moving line (pull production)
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© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
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Model Line Value Stream
Developing a Lean model line means: Looking at the processes inside and outside the value stream applying the contributions of employees at the strategic points.
Patient care can be seen as a steady stream of interconnecting processes. A value stream describes the entire set of activities necessary to provide patient care from the time service is requested to when services are completed.
Each part of the model line must be Lean. By understanding how all of the processes affect each other, we can apply Lean practices strategically, leveraging improvement opportunities and allowing value to flow freely and rapidly.
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© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
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Model Line Key Lean Principles
Takt-Time Paced Production
One-Piece Flow Pull Production
Describes the rate of patient flow in the medical center. Lean does not mean doing things faster; it means doing things at the right pace. Essentially, the patient’s rate of demand establishes the pace, or takt time. So, rather than a race, Lean sets the pace in the medical center, ensuring that the patient’s needs are met on time.
The opposite of batch. Instead of serving many patients and then holding them in queue for the next step in the process, patients go through each step in the process one step at a time, without interruption. Processing patients one at a time continuously improves quality and lowers cost.
The opposite of push. It means that patients are processed only when they have requested or “pulled” it, and not before. Doing so prevents providing service that is not needed. Once you have a predictable pace of service, one-piece flow, and reliable processes, you can operate in a pull production environment, which allows you to provide services when the patient needs them.
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© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
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The Tactics
Tactic 1 – Understand how value flows
Tactic 2 – Balance the line
Tactic 3 – Standardize work procedures
Aligning to the vision and direction set by leadership, employees and managers must define a future state and the associated goals and metrics. Using value stream analysis, employees and managers can understand how best to apply resources and focus Lean tools in the places that will provide the most benefit. Understanding how value is created and flows ensures that changes are made systemically rather than randomly and independently of other organizations.
Balancing the line essentially means evenly distributing both the quantity and variety of work across available work time, avoiding overburden and underuse of resources. Work that is evenly distributed provides predictability and the ability to standardize work processes more easily. This eliminates bottlenecks and down time, which translates into shorter flow time.
Standard work procedures are the foundation of a Lean production system. A standard operation is a known, repeatable process that results in high-quality output. A standard operation ensures that everyone does the same job in the same way, in the best way possible. Standard work procedures also provide the ability to detect abnormalities or defects quickly. This tactic allows easier cross training and provides greater opportunities for all employees as they increase their abilities to perform more than one task.
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© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
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The Tactics
Tactic 4 – Put visual controls in place
Tactic 5 – Put everything at POU
Tactic 6 – Convert to a moving line
Visual controls can help people quickly and accurately gauge status at a glance. These visual systems fall into two categories: progress indicators and problem indicators. Visual controls allow everyone to instantly see the group’s performance and increase the sense of ownership in the area. Having these types of visual cues can help save time and improve work quality.
Point-of-use is a technique that ensures people have exactly what they need to do their jobs. Using this technique requires close partnerships with the entire supply chain. POU eliminates wasted movement and wasted space, and ensures that time spent on patients and processes adds value.
A moving line moves patients and procedures from one team to the next. The line stops only when a problem is detected. The ability of all employees to stop the line when an error is detected is critical. Equally critical is the ability to get the line moving again once a defect has been detected and corrected. The biggest benefit is the sense of urgency a moving line conveys. Employees can truly see and feel the pace. And a moving line further ensures discipline and commitment to sustaining improvements.
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© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
DecOctSepAugJulJunMayAprMarFebJan Nov
Cancer Model Line Integrated Schedule & Timeline Chart
2004
DecOctSepAugJulJunMayAprMarFebJan Nov
VSMsTactic 1
Standard WorkTactic 3
Quality; PatientEducation &
Best Practices
Phone Access
Staff Education,Training &
Communication
Mistake ProofingTactic 6
Info Flow/IS--CPOE--Website
Visual ControlsTactic 4
PQ Level LoadTactic 2
Lead TimeReduction
PatientIdentification
5S & POUTactics
RPIWsBreast Pt FlowJan 26-30
Ancillary FlowMay 17-21
CPCCSep 27-Oct 1
VADNov 1-5
Check w/processowners for nextsteps by 1/31
Check w/processowners fornext stepsby 1/31
Current & FS VSM: BreastCurrent & FS VSM: Prostate
Analyze opportunities &assign teams for breast VSM
Analyze opportunities & assign teams for prostate VSM
F/U audits
Sort activities Initial 2004audit
F/U 2004audit
Continue sort activities
Adopt/implement "It Takes Two" for all cancer work unitsCreate detailed implementation plan
Implement
-Breast: analyze VSM ID opportunities
Prostate: analyze VSM ID opportunities
Breast pt survey createdPilot Pt Flow Ed Tool/brochure
1/9 Cancer Vis Room ID'd
1.31 Vis Room operational<--------------------------Metrics updated monthly (from Donna Wilker)------------------------------------>
3/1 planning meeting
12/31 Web basedtool in place
Phone metricsreporting
Phone metricsreporting
Phone metricsreporting
Phone metricsreporting
Update dashboards Update dashboards Update dashboardsUpdate dashboards
Final auditJan 2005
Publish 3prostateoutcomes
Do further 3P analysison 30 min pts/OIC
Link to space planning
BCT + on website; reviewedby Kathy Kaye
Current website info given to BCT
Pt support svcs
Publish 3 cancer outcomesStart Greeter program
All breast cancermaterials coordinated
KPO education assessment
Implement lean proposal system
Develop educ plan for staffDevelop educ planfor staff
Discuss Moonshine/pilotopportunities/Kaizen events
Rad Onc MD visitCSR rooming/scheduling
Chemo teach
MD consults
Flow of breast cancer pt
ARNP visit
Mistake-proofing kiosk
Correct VAD
Morning reportin Rad Onc
Pretreatment guidelines
Post treatment guidelines
Pt follow-up calendar
Mistake Proofing:complete chemo orders
Trial Med Onc morningreport (1/05)
Create andonsignals
Trial OIC morning report (1/05)
© 2004, Virginia Mason Medical Center
Establish follow-up guidelines
Post guidelineson V-Net!
Updated 5/16/05
Update BCT website
Appt access goal
Follow-up guidelinesposted on V-Net!
RoomingMoonshine event
Procedural Pausefor right site surgery
GIM CME
Blood draws
Medication order
RN chemo administration
Hem Onc RNcamp checklist
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© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply 11 V11032012
DecOctSepAugJulJunMayAprMarFebJan Nov
Breast Cancer Integrated Schedule & Timeline Chart
2005
DecOctSepAugJulJunMayAprMarFebJan Nov
VSMsTactic 1
Standard WorkTactic 3
Quality; PatientEducation &
Best Practices
Phone Access
Staff Education,Training &
Communication
Mistake ProofingTactic 6
Info Flow/IS--CPOE--Website
Visual ControlsTactic 4
PQ Level LoadTactic 2
Lead TimeReduction
PatientIdentification
5S & POUTactics
RPIWsBreast Imaging Center
Check w/processowners for nextsteps by 1/31
Check w/process owners for next steps by 1/31
Current & FS VSM: Breast
Analyze opportunities & assign teams for breast VSM
F/U audits
5S activities Initial 2005audit
F/U 2005audit
Continue 5S activities
"It Takes Two" ongoing for all cancer work units
Breast: analyze VSM ID opportunities
Pt surveys re referrals
<--------------------------Mammography metrics updated monthly (from Shannon Boswell)------------------------------->
Phone metricsreporting
Phone metricsreporting
Phone metricsreporting
Phone metricsreporting
Update dashboards* Update dashboards* Update dashboards*Update dashboards*
Final auditJan 2006
Do further analysis ofbreast clinic on the Eastside
Best practice resultreporting (radiologist)
Publish 3 cancer outcomes:ACR accredited BreastImaging Center
Implement Every Day leanproposal system
Path specimen labeling
Add radiology & plastic surgery materials to breast journal
SW screeningmammo scheduling
Core biopsy algorithm -breast center
Clip protocol - whichlessons need follow-up
Needle loc chairMammo result reporting
© 2004, Virginia Mason Medical Center
Establish adherenceto follow-up guidelines staging preop
Remeasure flow of breast cancer patient
Updated 6/6/05
Procedural Pausefor right site surgery
Diagnostic mammo <72°Screening mammo <24°Biopsy <72° quarterly
Pt educ materialson CD rom
*Note: Dashboard to include radiology metrics:1) Biopsies2) Screening mammo volumes3) Diagnostic ultrasound volumes4) Quality
Path consult availableto pts
1) Conservation rates-quality2) Survival rates3) Recurrence
Medication labeling
Mammosite in Breast Imaging Center?
Mammosite planning?
Note: Create Breast Imaging Center business plan.
Conciergeprogram
Update Radiology website
Mammo schedulingdefect tool
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Cancer Model Line 2004 Workplan Updated 9/27/04 (Phase I Model Line Implementation)
DELIVERABLE
ACTION NEEDED
RESPONSIBILITY WHEN
NEEDED %
COMPLETE
NOTES
1 VSM: Breast • Define our product: satisfied customer. What do we need to create that the customer has not thought of? Follow-up clinics?
• Post current state VSM in Jacobs’ office; finalize and post future state.
• Post pre-treatment guidelines on V-Net! • Label the RPIWs on the VSM. • Breast patient brochure: Why come to VM?
AJ/PM
Dubuque
DD/DW Dubuque
Michelle DeLancy
12/04
3/04
5/04 2/04 12/04
100%
100%
“When needed” based on C Cone availability.
VSM: Prostate • Create future state prostate VSM to include follow-up (tracking, PSAs, etc.)
• Update prostate fishbone.
Susie Creger
Dubuque
3/04
2/04
30%
100%
Dr Corman to work with Susie to create future state VSM
2 RPIW: Breast Patient Flow Dubuque/Sylvester to lead. DD/JS 1/04 100% RPIW: Flow of ancillary svcs Dubuque/Jacobs to lead. DD/AJ 5/04 100% RPIW: Flow of the CPCC clinic Jacobs/Sylvester to lead. JS/AJ 9/04 100% RPIW: Vascular Access Device Dubuque/Jacobs to lead. DD/AJ 11/04 3 5S and POU Tactics: Sorting is
focus in 2004 • Develop and communicate organizational 5S sort
education. • Take pre-sort photos. • Establish department visibility method. • Audits completed prior to July and December. • Final audit January 2005.
JS/DD
Managers Managers
PM/AJ/JS/DD
PM/AJ/JS/DD
3/04
6/04 6/04 6/04 1/05
90%
100% 100% 50%
4 Patient Identification All managers to review “It Takes Two” organizational materials. Each section to implement their program by March: • Med-Onc = check-in process; roomer process;
correct chart; bone marrow aspiration. • Rad Onc = utilization of photos in IMPAC.
o Use of isoloc treatment planning program. o Confirmation via patient stating their name at
time of treatment. • OIC = Confirmation of right patient for chemo
and blood administration: use name, birthdate, MRN (3 checks).
• Perioperative Services. The patient ID process states that each person
Managers
Bagdasarian
Lynch
Wetteland
Creger
2/04
2/04
1/04
1/04
1/04
100%
100%
100%
100%
100%
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V11032012
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Cancer Model Line 2004 Workplan Updated 9/27/04 (Phase I Model Line Implementation)
DELIVERABLE
ACTION NEEDED
RESPONSIBILITY WHEN
NEEDED %
COMPLETE
NOTES
two of the criteria from the ID grid: 1. Full name stated by patient or family member 2. DOB stated by patient or family member 3. Picture ID verifies full name and DOB against new
or existing VM records 4. Armband marked as verified by VM staff 5. Name, DOB and MRN on armband matches order
and/or medical record. 6. Armbands verified and initialed by VM staff. To
meet this criterion, the armband must be blue with initials. This indicates that the person who placed the armband used the "it takes two" process to ID the patient before placing the armband on the patient.
White armband, indicates that two of the five criteria could not be verified. As soon as possible, two of five criteria should be confirmed and the armband changed to a blue one and initialed by the person who has completed that ID process.
Unless contraindicated by patient care needs, place armband on the patient's right arm with label facing away from the patient.
• Pathology owned by Lab; imaging managed by Radiology
5 Phone Access • Install ACD line in Hem Onc. • Install ACD line in Rad Onc. • Each manager to report monthly. • Metrics: Abandonment rates and ASA.
Bagdasarian Lynch RB/LL RB/LL
6/03 4/04
monthly quarterly
100% 100% 100% 100%
6 Lead Time Reduction • Address patient flow with integration of all services on Buck 2.
• Analyze prostate VSM opportunities. • Analyze breast VSM opportunities.
DD/AJ/PM/JS
Creger/Corman
Wechter/DD
10/04
6/04 4/04
75%
50% 100%
Emphasis for Japan trip.
7 PQ/Level Load • Do further analysis of the 30 min. PQ 3P data. • Create a cell for <30 min. OIC patients. • Link to space simulations/space planning.
DD/JS Wetteland/Creger
Sylvester
4/04 3/04 2/04
100% 100% 100%
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V11032012
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Cancer Model Line 2004 Workplan Updated 9/27/04 (Phase I Model Line Implementation)
DELIVERABLE
ACTION NEEDED
RESPONSIBILITY WHEN
NEEDED %
COMPLETE
NOTES
8 Standard Work Create standard processes for: • Chemo teach • ARNP visit • Oncology MD consult • CSR rooming process • Blood draws • Patient check-in flow of the breast cancer patient
(pre treatment) • Rad Onc MD consult • Prescription refills • Pretreatment guidelines, post-therapy guidelines,
follow-up calendar and PCP follow-up tool
Dubuque Dubuque Dubuque
Bagdasarian Wetteland Dubuque
Creger/Taylor
Creger DW/DD/HO
5/04 7/04 12/04 6/04 9/04 8/04
12/04 8/04 8/04
90%
25% 100% 100% 50%
100%
9 Staff Education Training and Communication
• Create breast cancer patient follow-up guidelines for MDs and staff.
• 5S – Sort training for all staff. • Implement lean proposal system (employee
suggestion program) • KPO to assess each employee’s lean education. • Develop an education plan for employees (use
multi-skilled training chart).
RPIW Team
Managers Creger
Creger
Creger/Mgrs
1/04
3/04 12/04
4/04 12/04
100%
100%
100%
per organizational plan
10 Mistake Proofing • Establish morning report in Med Onc (Hem Onc & OIC on Buck 2).
• Document process in place in Rad Onc. • Rad Onc: decrease lead time/machine scheduling • Mistake proof vascular access device MD orders • Create andon signal to immediately respond to
problems such as: o Hem Onc access o Chemo admin delays o Incomplete scheduling info
• Return calls to patients
Otero/RB/MW
Hsi/Lynch Hsi/Lynch Dubuque
Bagdasarian Charge RN/MW Bagdasarian Bagdasarian
11/04
4/04 6/04 11/04
4/04 4/04 12/04 6/04
100%
50%
75%
Otero presentation 5/04 Work group formed to create SW
11 Quality • Institute greeter program for new breast cancer patients.
• Survey patients re breast services. • Survey patients re biopsy result reporting. • Define process for handling patient complaints.
Goal: prevention. Link to org. process.
DD/JS
DD/JS MA Madsen
AJ/PM
2/04
1/04 9/04 12/04
100%
100%
100%
Use organizational tools created by Sandy Novak.
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© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Cancer Model Line 2004 Workplan Updated 9/27/04 (Phase I Model Line Implementation)
DELIVERABLE
ACTION NEEDED
RESPONSIBILITY WHEN
NEEDED %
COMPLETE
NOTES Patient Education & Best
Practices • Create a general Cancer Services brochure. • Address outcomes, quality indicators, survival
rates, recurrence rates, conservation rates, number of cases presented at cancer conf.
• Create best practice for: o chemo teach o Med Onc MD consult o Rad Onc MD consult o General Surgery MD consult o ARNP visit
• Create a FAQ document for My Breast Cancer Journey.
• Education kiosks for patients: what to expect during each process: OR – OIC – Rad Onc.
• Mistake Proofing kiosk: o correct path o right site surgery o accurate chemo order o clinical trials?
DD/Wechter Wechter/Schwilke
Med Onc RNs
Creger/Hsi/LL/Taylor
Dubuque/Wechter Dubuque/Jacobs
Sylvester
Dubuque
pending
12/04 12/04
6/04 12/04 12/04 12/04 7/04 12/04
12/04
12/04
100% 25%
My Breast Cancer Journey Will include patient input. Consider for RN PRP project. Link to Medical Center mistake proofing communication with patients.
12 Visual Controls • Create patient flow visual controls for providers. • Create a standard process tool for patients
including patient flow map. • Update signage to reflect services delivered at
each site: Hem Onc, Rad Onc, OIC • Update visibility metrics to include number of
patients coming to OIC, Hem Onc, Rad Onc, today. • Monthly visibility room metrics.
Dubuque Dubuque/Creger
Managers
Managers
Wilker
12/04 12/04
12/04
daily
monthly
13 Info Flow/IS: CPOE • Implement CPOE per organizational workplan • Standard templates created for outpatient meds
Mgrs/Julie King Hem Onc RNs
12/04 7/04
100%
Website • BCT to review current website info. • Update the breast website. • My Breast Cancer Journey on web. • Chemo teach on web. • Links to cancer meds. • Create a model line website – to show the process
and the team (virtual experience). Patient Flow 6/14/2004
• Update the prostate website. • Update Cancer Institute website; feature disease
sites.
Wechter Breast Ca Team
Dubuque Dubuque Dubuque Dubuque
Corman/Tyler Dubuque
2/04 8/04 6/04 7/04 7/04 12/04
9/04 12/04
100% 85% 100%
50%
Responsibility Key: RB=Richelle Bagdasarian LL=Laura Lynch JS=Julie Sylvester DD=Denise Dubuque PM=Pat Maguire DW=Debbie Wechter AJ=Andrew Jacobs HO= Henry Otero MW=Michaelle Wetteland 15
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
The Cancer Institute at Virginia Mason Cancer Institute Model Line 2005 Workplan Updated 6/06/05
DELIVERABLE
ACTION NEEDED
RESPONSIBILITY WHEN
NEEDED %
COMPLETE
NOTES
1 VSM • Define future state VSM to include the flow of the providers
• All Cancer Directors to complete VSMs
Directors
DD/AJ/Dirs
10/05
2 RPIW: Claims payment for oncology medications
• Self-pay • Off label usage • Denial process • Team leaders: Dubuque, Sylvester
Sylvester/ Dubuque
5/05 100%
RPIW: Hem Onc/OIC paperless system or conversion to one flow; flow of information
Superflow: • Front Desk • Treatment room • Provider schedule • Ancillary services • Short stay infusion • On line nursing documentation • Cerner messaging • Allergy lists • Pain assessments • Cerner documentation • One flow hem onc/OIC
Dubuque/ Jacobs/
Wetteland
11/05
RPIW: EOL Outliers KPO 5/05 100% RPIW: Cancer Hospital Admits:
inpatient à outpatient setting • Deliver current inpt services in outpt setting • Prepare patients for admits to decrease LOS
Jacobs/Purrier 8/05
Kaizen Event OIC scheduling Dubuque 3/05 Rad Onc: IMPAC upgrade Lynch 3rd Qtr Med error prevention Dubuque 2/05 100% 3 5S and POU Tactics • Develop and communicate organizational 5S
• Take pre-measurement photos • Establish department visibility method • Audits completed prior to July and December • Final audit January 2006
Managers
4 Patient Identification • Secret shopper every two weeks Managers/MW 5 Phone Access • Ongoing access reports Managers monthly 40% 6 Lead Time Reduction Breast or CPCC clinic at Bellevue clinic location or
travel to outside region: • Address Dauway-Williams Eastside presence • Establish goals, standards, flow • Role of ARNP
Taylor/Hunter/Corman/ Wechter
Taylor/Hunter
6/05
6/05
12/05
50%
50%
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© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
The Cancer Institute at Virginia Mason Cancer Institute Model Line 2005 Workplan Updated 6/06/05
DELIVERABLE
ACTION NEEDED
RESPONSIBILITY WHEN
NEEDED %
COMPLETE
NOTES
• Breast cancer clinic analysis • Value of breast cancer clinic • Determine what Eastside breast cancer program
should be • How to increase outside referrals • Geographical referral patterns • Quality goal: Determine specialist presence
Taylor/Hunter “” “” “” “”
“” “” “” “” “” “”
4/05
50%
100%
Radiation Oncology • Consult to treatment • Billing – linked to IMPAC upgrade • Linac scheduling
Badiozamani Lynch
Hsi/Lynch
Alex Hsi to determine dates.
7 PQ/Level Load • Do further analysis of Infusion Center demands (Pac Med, Neuro, Rheumatology)
Wetteland/ Dubuque
6/05 30% 3/05: Pac Med sending blood transfusions
8 Standard Work Document standard processes for: • Hem Onc front desk check-in, rooming: beginning
and end of day prep • OIC scheduling • OIC medication delivery • Rad Onc: ARNP weekly visit • Rad Onc: CT/Fluoro/HDR to treatment • Chemotherapy/biological agent administration • Phlebotomy services • Coordinator metric reporting • Self-pay/uninsured patient
Bagdasarian
Wetteland Wetteland
Lynch Lynch
Dubuque
Sylvester/Dub
uque
5/05
12/04
2/05
5/05
100%
90%
100%
To be updated.
To be updated.
9 Lean Staff Education Training and Communication
• Develop/implement lean education plan for employees
• Develop RN residency program • Hem Onc CSR scheduling • Referring MDs CME • Publicize PSA info to staff • All managers through lean mastery • All managers trained in mistake proofing
DD/Mgrs/KPO
Dubuque/Mgrs Bagdasarian Sylvester
RB/LL/MW Dubuque Managers
2/05 3/05
6/05
100% 100%
10 Mistake Proofing • Establish morning report in Med Onc (Hem Onc & OIC on Buck 2) and Rad Onc
• Zero incomplete chemo orders • MD dose calculations • Medication solution and labeling • Bone marrow labeling
Managers
Wetteland Otero
Bagdasarian Bagdasarian
ongoing
ongoing 2/05 4/05 4/05
100%
40% 100% 100% 100%
17
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
The Cancer Institute at Virginia Mason Cancer Institute Model Line 2005 Workplan Updated 6/06/05
DELIVERABLE
ACTION NEEDED
RESPONSIBILITY WHEN
NEEDED %
COMPLETE
NOTES
• Zero incomplete medication dosage calculations • Vacation coverage • Rad Onc treatment errors • Cerner messaging • Electronic billing – Rad Onc • Eliminate shadow charts in Rad Onc • IMRT: Compare to other organizations • IMPAC upgrade • Charge review/missed charges/coding/
documentation • Order sets for translation to CPOE • OIC RNs 4-hour training in chemo booth
Wetteland RB/Lynch
Song
Lynch Lynch Lynch Lynch
11 Quality (Patient Education & Best Practices)
• ACoS certification requirements • Establish 2005 ongoing list of accomplishments • Colon and liver mets guidelines/pathways • Evaluation of nutrition visit – Rad Onc • Nutrition support group • 12 cancer outcomes • Mistake proofing: defect checklist for new
patient consults • Defect checklist for OIC scheduling errors
RB/LL/Mizuki DD/AJ/JS
Thirlby/Culp Lynch Lively
TM/Whiteside Bagdasarian
Wetteland
8/05 3/05 5/05
3/05
100% 100%
Standard Chemo Certification of RNs through ONS
• Monthly courses offered Wetteland/ Purrier
May/Jul/ Aug/Oct
25%
End of Life • Creation of EOL business plan for role of ARNP • CNE, Grand Rounds presentations • Communication/website • Advance Care notes in Cerner
DD/JS
DD/Headings DD/Malpass
5/05 5/05 6/05 4/05
90% 100% 75% 100%
Darrel Owens
Radiation Therapy • Post consult follow-up calls to patients • Patient survey: radiation oncology • Stereotactic therapy: SHARP, stereotactic lung,
cranial • IMRT – refine technique, expand uses, establish
IMRT program at FROC • HDR – create protocols, establish flow; discuss
mobile unit • Prostate brachytherapy – expand to other sites
Rad Oncologists
Lynch Madsen/Song/
Pham Madsen/Esagui
/Song/Pham Badiozamani
Badiozamani
4/05 biannual
18
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
The Cancer Institute at Virginia Mason
Cancer Institute Model Line 2005 Workplan Updated 6/06/05
DELIVERABLE
ACTION NEEDED
RESPONSIBILITY
WHEN NEEDED
% COMPLETE
NOTES
12 Visual Controls • Establish morning report Hem Onc front desk • Establish morning report OIC supervisor/charge
RN • Continue Rad Onc morning rounds • Create quarterly cancer dashboards • Create visual control for delays at front desk • Create visual control for status of pt in tx
room
Bagdasarian Wetteland
Lynch
JMS/Ca Coord Bagdasarian
Dubuque
3/05 2/05
1/05
6/05 2/05
30% 100%
100%
100%
13 Info Flow/IS: CPOE • Implement CPOE per organizational workplan? 7/05 Website • Review current website info:
o Cancer Institute o Service lines
• Chemo teach on web • Create a model line website – to show the
process and the team (virtual experience). Patient Flow
• Cancer webmaster • Web training for Mizuki • Virtual tour: Rad Onc, Hem Onc, OIC
Dubuque
JMS/Ca Dirs Dubuque Dubuque
Mizuki
Mizuki/Phillips Dubuque
8/05
12/05
3/05 12/05
100%
14 Other • Address Rad Onc patient parking – dissatisfier • Housing fund for Rad Onc patients
Lynch/Dubuque
Foundation/LL/DD
6/05
15 Growth Radiation Oncology: • Bremerton: Prostate brachytherapy • Alaska: Brachytherapy, HDR, stereotactic
services • Pac Med: Prostate brachytherapy • GHC: IMRT, prostate brachytherapy • Polyclinic: Rad onc services • Peninsula: Prostate brachytherapy, HDR • Valley Medical Center
Hsi Date to be determined by Alex Hsi.
Responsibility Key: RB=Richelle Bagdasarian TM=Trudi McKenzie DD=Denise Dubuque JS=Julie Sylvester AJ=Andrew Jacobs DW=Debbie Wechter LL=Laura Lynch MW=Michaelle Wetteland 19
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Breast Cancer Model Line 2005 Workplan Updated 6/06/05 (Phase I Model Line Implementation)
DELIVERABLE
ACTION NEEDED
RESPONSIBILITY WHEN NEEDED
% COMPLETE
NOTES
1 VSM: Breast • Define our product: satisfied customer. What do we need to create that the customer has not thought of? Eastside plan.
• Breast patient brochure: Why come to VM?
Taylor/Hunter
Wechter
12/05
6/05
50%
50%
2 RPIW: Mammography Center Shannon Boswell 6/05 3 5S and POU Tactics: Sorting is
focus in 2004 • Develop and communicate organizational 5S sort
education. • Establish department visibility method. • Audits completed prior to July and December. • Final audit January 2006
Managers
Managers Managers
SP/DD
3/05
6/05 7/05 1/06
77
4 Patient Identification All managers to review “It Takes Two” organizational materials. Each section to implement their program by March: • Med-Onc = check-in process; roomer process;
correct chart; bone marrow aspiration. • Rad Onc = utilization of photos in IMPAC.
o Use of isoloc treatment planning program. o Confirmation via patient stating their name at
time of treatment. • OIC = Confirmation of right patient for chemo
and blood administration: use name, birthdate, MRN (3 checks).
• Perioperative Services. The patient ID process states that each person accepting the patient into a new area, or treating the patient for the 1st time will ID the patient using two of the criteria from the ID grid: 1. Full name stated by patient or family member 2. DOB stated by patient or family member 3. Picture ID verifies full name and DOB against new
or existing VM records 4. Armband marked as verified by VM staff 5. Name, DOB and MRN on armband matches order
and/or medical record. 6. Armbands verified and initialed by VM staff. To
meet this criterion, the armband must be blue with initials. This indicates that the person who
Managers
Bagdasarian
Lynch
Wetteland
Saltzer
1/05
2/05
1/05
1/05
1/05
100%
100%
100%
100%
100%
Breast Cancer Model Line 2005 Workplan Updated 6/06/05 (Phase I Model Line Implementation)
20
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Breast Cancer Model Line 2005 Workplan Updated 6/06/05 (Phase I Model Line Implementation)
DELIVERABLE
ACTION NEEDED
RESPONSIBILITY
WHEN NEEDED
% COMPLETE
NOTES
placed the armband used the "it takes two" process to ID the patient before placing the armband on the patient. White armband, indicates that two of the five criteria could not be verified. As soon as possible, two of five criteria should be confirmed and the armband changed to a blue one and initialed by the person who has completed that ID process. Unless contraindicated by patient care needs, place armband on the patient's right arm with label facing away from the patient. Pathology owned by Lab; imaging managed by Radiology
5 Phone Access • Each manager to report monthly. • Metrics: Abandonment rates and ASA.
Managers Managers
monthly quarterly
40% 25%
6 Lead Time Reduction • Remeasure lead time gains from 2004. • Measure diagnostic mammo, screening mammo
screening mammo and biopsy metrics • Analyze breast VSM opportunities.
Rita Kelly Boswell
quarterly quarterly
25%
7 PQ/Level Load • Eastside assessment. Hunter/Taylor 6/05 50% 8 Standard Work Create standard processes for:
• Core biopsy algorithm • Clip protocol – which lesions need follow-up? • Patient check-in flow of the breast cancer patient
(pre treatment)
Boswell Boswell
9/05 9/05
9 Staff Education Training and Communication
• Linked remider tool for breast cancer patient follow-up guidelines for MDs.
• 5S – Sort training for all staff. • Implement lean proposal system (employee
suggestion program) • Remeasure flow of breast cancer patient.
Pittinger/Otero
8/05
10 Mistake Proofing • Standard work for screening mammo scheduling. • Needle loc chair: Mammo Center. • Medication labeling. • Procedural pause. • Mammo result reporting. • Mammo scheduling defect tool
Boswell Boswell
Surgeons Boswell Boswell
2/05 2/05
100% 100%
21
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DELIVERABLE
ACTION NEEDED
RESPONSIBILITY
WHEN NEEDED
% COMPLETE
NOTES
Breast Cancer Model Line 2005 Workplan Updated 6/06/05 (Phase I Model Line Implementation)
11 Quality • Institute concierge program for new breast
cancer patients. • Survey patients re breast services. • Define process for handling patient complaints.
Goal: prevention. Link to org. process. • Establish path consults as needed.
Madsen
Kelly Dubuque
T. Jacobs
6/05
8/05 1/05
2/05
100%
100%
Use organizational tools created by Sandy Novak.
Patient Education & Best Practices
• Address outcomes, quality indicators, survival rates, recurrence rates, conservation rates, number of cases presented at cancer conf.
• Create a FAQ document for My Breast Cancer Journey.
• Mistake Proofing kiosk: o correct path o right site surgery o accurate chemo order o clinical trials?
• Add radiology and plastic surgery materials to My Breast Cancer Journey.
• Best practice result reporting. • ACR accredited Breast Imaging Center. • Alternative therapy in Hem Onc.
DD/Wechter/ CDS
Rita Kelly
pending
Boswell/Paige
Boswell Boswell Dubuque
9/05
12/05
12/06 8/05
25%
Waiting for statistician/CRAB Will include patient input.
12 Visual Controls • Update BCT dashboards. • Monthly mammography metrics.
McKenzie Boswell
quarterly monthly
13 Info Flow/IS: CPOE • Implement CPOE per organizational workplan • Standard templates created for outpatient meds
Mgrs/Julie King Hem Onc RNs
12/05 7/05
100%
Website • Create a model line website – to show the process and the team (virtual experience). Patient Flow 6/14/2004
• Update Cancer Institute website; feature disease sites.
Dubuque
Dubuque
12/05
12/05
50%
Responsibility Key: RB=Richelle Bagdasarian SB=Shannon Boswell DD=Denise Dubuque AJ=Andrew Jacobs LL=Laura Lynch
SP=Sarah Patterson JS=Julie Sylvester DW=Debbie Wechter MW=Michaelle Wetteland
Breast Cancer Model Line 2005 Workplan Updated 6/06/05 (Phase I Model Line Implementation)
22
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
BREAST IMAGING LINE TACTICS
Tactic 1 – Understand How Value Flows
Tactic 2 – Balance the Line Tactic 3 – Standardize Work Procedures
Ø Goal: All services will be delivered
to the patient. Ø Goal: To meet customer demand for
high quality breast imaging by ensuring all activities in the value stream are value added with 0% defects.
Ø Service: Designed to minimum
delivery time, minimum material consumption and maximum quality.
Ø Result: Cost reduction through the
elimination of waste.
Ø Service Lines
o Screening Mammography o Diagnostic Mammography o Stereotactic Breast Biopsy
Ø Balancing the line
o Mixed model appointments based on demand in alignment with resources
o Autonomation utilize computerized screening programs
o Self explanatory patient instructions
o All hard copies of images produced and stored by the radiology film room
o Level load work between Radiologist, Mammographer, CSR, MA, & Film room
Ø Standardize and document all
processes with clear instructions, illustrations (photos) that are simple and easy to follow.
o Convert to all digital imaging o Standardize all biopsy
supplies & trays o Standard scheduling
protocols o Standard forms o Standard rooming protocols o Standard imaging protocols o Standard radiologist work
flow o Standardize process of JIT
results reporting to patient & PCP
o Standardized reminder system
23
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Tactic 4 – Put Visual Controls in
Place Tactic 5 – Put Everything at POU Tactic 6 – Convert To a Moving Line
Ø Develop visual controls that easily
explain service flow and current status.
Ø Progress indicators
o Visual control that indicates production to Takt Time
o Room availability
Ø Problem Indicators (using light and/or sound)
o Abnormal pathology o Calling all Mammographers o Patient call button o Code Button o “Running Late”
Ø Post radiologist specific productivity
and quality outcomes.
Ø Supplies will be at POU in the exact
quantity, right time, and in the right place.
o Biopsy Supplies standardized and in kits
o Kanban driven supply renewal
o Providers on gemba o Previous images readily
available o COW’s or PC’s in room
Ø Pull System that incorporates lights
and sound that signals the downstream process is ready for the next patient
Ø Re-evaluate Takt Time on a
continuous basis throughout the day to ensure demand is being met.
Ø Create Poka-yoke methods and
devices that create O% defect environment.
o Films labeled with correct patient ID.
o Eliminate unread exams.
Ø Arrange equipment in a sequence that facilitates the flow of patients, providers & information
Ø Preventative maintenance schedule
to maximize the uptime of the mammography machines.
Ø Minimize room changeover time
between patients.
24
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Guiding Vision
Hippocratic Oath First, do no harm
Henry Otero MD
Priority Zero Defects
First priority, zero defects
25
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Stop the Line
26
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Hepatic Embolization Problems
• No standard work- “anything goes” § e.g. pain, symptom management, use of antibiotics,
bowel preps, chemo vs. bland embolization
• No single owner of patient’s overall experience
• Critical information not available when needed
• Poor patient education
• No physician role definition
27
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Hepatic Embolization Our Improvements…
28
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Current SAFE Process Hepatic Embolization
Oncologist or Surgeon Radiologist
Hospitalist and Hospital Nurse
Radiology Nurse
Radiologist (Procedure)
Standard order sets
Standard indications for procedure
Hospital plan of care
29
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Example #3
Problem:
We need to treat a higher volume of patients with the same resources
30
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Radiation Oncology
• Problem: § Record volumes forced us to focus on
increasing capacity § Hours of operation did not match customer
requested times § We worried about safety with staff working
overtime
31
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Theory => Level Loading, Lead Time Reduction, & Standard Work
• Applied concept of waterfall scheduling § Staggered start
times
32
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Theory => Level Loading, Lead Time Reduction, & Standard Work
• Created standard work § Radiation
therapist § Physician § Patient
Process
33
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Radiation Oncology Summary
Improvement Before After % Change
Lead time (arrival to completion
of treatment)
21 minutes
18 minutes -14%
Patients treated per Therapist
8.1 patients
12.75 patients +57%
Idle time of accelerator
140 minutes
32 minutes -77%
Staff walking distance
488 feet
192 feet -61%
• Increases accomplished with: § No additional staff, equipment, or space
34
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Example #4
Problem:
We need to treat a higher volume of patients with the same resources
35
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Oncology Infusion Center
• Problem: § Poor utilization of treatment
rooms • Sometimes over-scheduled • Sometimes empty • Cumbersome scheduling
process • Scheduling errors • Unnecessary hospital admits
36
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Theory => Level Loading
Waterfall scheduling § 30 minute intervals § Staffed according
to patient demand
37
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Theory => Level Loading
• Schedule adjusted to match expected treatment times • Ongoing audits to validate actual treatment times
Example Treatments
Before After
Remicade 4 hours 2 hours
Carbo/Taxol 4 hours 3 hours
Carbo/Gem 5 hours 3 hours
38
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Oncology Infusion Center Summary
• Additional capacity created § With existing treatment space § No additional staff
• Allowed new services to be offered
Improvement Gain Remicade 200 min/day
Schedule Updates 1092 min/day Waterfall Schedule 3023 min/day
Total Capacity Gain
4315 min/day (160 minutes per treatment
station per day) 39
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
What has all this done for us?
• We measure our success… § Staff satisfaction
§ Patient satisfaction
§ FTE’s
§ Program growth
§ Financial performance
40
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Measuring our Success Patient Satisfaction
Overall mean score = 92.0%
0102030405060708090
100
2005Nov
2005Dec
2006Jan
2006Feb
2006Mar
2006Apr
2006May
2006Jun
2006Jul
Satis
fact
ion
Scor
e (%
)
41
© 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply © 1996-2012, John Black and Associates LLC Licensed Materials – USA Copyright Laws Apply
Pat. Returns to Function
In Patient Hospital
TBD
Pre-
Op
Prep
arat
ion
Pre-visit L/T
Day of Clinic Visit L/T
Post-Visit L/T
Day of Surgery L/T
Pre-Surgery L/T
Dai
ly M
anag
emen
t Boa
rds
Mat
eria
ls F
low
Use
of N
on-S
urge
on C
linic
ians
Stag
gere
d St
arts
OR
Sch
edul
ing
Proc
ess
Stag
gere
d St
arts
Cas
e C
arts
: Sta
ndar
dize
, Was
te
Stan
dard
ize
Roo
ms
Staf
f Cro
ss T
rain
ing
Visu
al C
ontr
ol
Pull
Sign
als
Primary Care
14.8 days
Total Surgical Services Patient Lead Time
415.5 minutes 15.1 days TBD 43.8 minutes
Acc
urat
e Su
rger
y Ti
mes
Inte
rope
rativ
e St
anda
rd W
ork
for M
Ds
Pre-
Op
Prep
arat
ion
Def
inin
g B
est P
ract
ice
Gui
delin
es
PICIS: Surgery Information System
Implemented Underway Not Started
Inst
rum
ent r
oom
Pre-
Op
Patie
nt P
rep
Load
Lev
el D
urin
g D
ay
Load
leve
l by
DO
W
Turn
over
Tim
e
Red
uced
Sur
g./s
taff
NVA
Tim
e
OR
21
Stan
dard
Roo
min
g
Med
. Rec
.
Nur
se P
ost-o
p C
linic
s
Example Park Nicollet’s Plan for 5 Year Block (Point): Surgical Specialties
42
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Next Steps
43 V11032012
1. Look at your Future State 2. Choose a model line 3. Create a communication plan 4. Develop the Future State Target Sheet 5. Develop the 6 Tactics document 6. Develop the Integrated Timeline 7. Develop the detailed plan with names and dates
• First do this process for the long-range Future State. • Follow with yearly target sheets, tactics, timelines, and plans.