Improving Our Capacity to Improve Quality:Development and Approval Process for

Regional Pre-Printed Orders and Prescriber Guidelines

Joanne Solmundson, Janet Joy, & Carmen Dyck

Vancouver Coastal Health

Why did we focus on the development and approval

process of clinical guidelines?

We asked stakeholders at VCH,

“What are the key bottlenecks you face in the introduction of regionalclinical practice standards for QI?”

They pointed to long delays associated with approvals for pre-printed orders (PPOs) as their single greatest challenge.

We used Lean tools to tackle the challenge.

What is the process we sought to improve?

Medication related pre-printed orders and prescriber guidelines

•Scope of review:

…And all of the steps in between!

Background

• Standardized order sets have been used for many years.

• The goal of having these order sets standardized across the entire health authority is relatively recent.

• A review of 2 major processes revealed:

PPO Reviewed

Value Added Time

Non Value Added Time

Total Cycle Time as of January

2011

COPD 10 months 12 months 22 months

VTE 10 months 13 months 24 months

Initiation of Lean ReviewGoal:

Establish a standard process for

development and approval of documents, including target timelines for each phase

A process that will support the introduction of new regional standard order sets and support the implementation of best practice standards regionally

Supporters of the Initiative

Regional Programs and Councils

Regional Pharmacy & Therapeutics

Professional Practice

Quality & Patient Safety

Clinical Guidelines Initiative

Each of these groups “owned” a different component of the pathway.

Departmental Silos

• Each entity was operating with little knowledge of the others roles

• Process breakdown between departments was very common

Process breakdown

& delays at each

hand off

Key Themes

Prior to the Review

Post Implementation Goals

No clearly defined process

Defined process including way-finding, tools & templates

Varying support for documents

Process is “owned” by a Regional Council and support is confirmed (regionally) prior to development

Keys to Success: Defined Stakeholder Roles

and Process

The First Step is Standard Work

Source: Toyota Kata by Mike Rother, Ch 5, Page 113

StandardTarget Performance level

Actual Performance level

A “standard” = how a process should operate. The pre-specified, intended, normal pattern.

“Standardized work” = the process is actually operating as specified by the standard. It is a condition.

Standards vs. Standardized WorkStandards can be Target Conditions

Actual

Where are we now…

An Ever Changing Environment

• Technological advancements will impact this process

• Having a defined (standard) process will help us to adjust and accommodate those technological advancements

• There’s always room for improvement!

Lean Methods Can Be Used for Very Different Types of Process

E.g, decluttering

work spaces

E.g, patient transfers,or lab orders

E.g, a clinical pathway for stroke patients

Where we worked

there’s all this prep work,

then the baby is born,

and no one tells you

about the sleepless nights

that come after.“

“It’s like having a baby…