Organization: Anne Arundel Medical Center

Solution Title: Driving Quality and Change through Implementation of Leadership Standard

Work

Program/Project Description, including Goals: Executive leadership at Anne Arundel

Medical Center (AAMC) identified that leaders in the organization were reactive in the

management of their business units. Leaders spent a large portion of their day problem solving

and taking on the problems of the front line staff. Leaders at AAMC did not have standard work

nor the tools necessary to proactively run their units. Executive leadership engaged the

performance improvement department to organize at team to create a proactive approach to

continuous daily improvements and implement sustainable standard work.

Goals of this program:

Shift leaders from reactive to proactive

Facilitate problem solving at the staff/frontline level

Increase staff engagement and development

Increase coaching and mentoring at all levels of leadership

Data driven process improvement via metrics

Process: The team used Lean methodology and started with a weeklong Rapid Improvement

Event (RIE). The solutions and subsequent projects were created and implemented using A3

thinking. A3 is a tool named for the size of the paper that becomes a communication tool. A3

thinking is a methodology for working through a problem that forces consensus building, unifies

culture, and promotes unit and organizational learning. The clinical nursing directors from the

Heart and Vascular Unit (HVU) and Neonatal Intensive Care Unit (NICU) implemented the

solutions identified during the RIE on their respective units, refined the process using A3

thinking, and continued to implement additional solutions over subsequent months.

Solution: The RIE team identified three key aspects of Leadership Standard Work (LSW) to

initially implement. LSW is standard work that directs leaders to know what to do throughout

the day, incorporates teaching, coaching, and mentoring, uses metrics to drive change and

improve quality, and requires leaders to create and deploy counter measures (Barnas, 2011). The

three initial solutions were Daily Prep, Huddle including Huddle Board with daily metrics, and

walking the gemba. Daily Prep sheets are a template used to capture the metrics data and

identify trends in defects, quality outcomes, productivity, processes and systems that impact

change. This template drives the business operations and key areas of work (Barnas, 2014).

Huddle is a gathering of unit leaders and staff to review the status of departmental metrics to

target for root cause, institute countermeasures at the process level in promoting and prioritizing

ideas at staff level. An evaluation of updated improvements from the previous day and how we

can do it better using the daily prep sheet (Barnas, 2014). Gemba means the “real place”; the

place where work is done, walking in the place to ask right questions, actively listening to

responses, following through on improvements and opportunities that is sustainable (Barnas,

2014). The clinical nursing director from HVU implemented these three aspects of LSW in

January 2014 after the RIE. The clinical nursing director from NICU was the next department

and implemented LSW in March 2014. Each director worked with the performance

improvement office to choose daily metrics. The daily metrics needed to be proactive measures,

easily obtained, that drove quality indicators, standard work, or processes. The directors worked

with their leadership teams to implement the Daily Prep and Huddle. Gemba by the directors

helped create engagement with staff for the huddle and daily metrics. Through Gemba, the

directors and staff, together, looked at processes and standard work.

Measurable Outcomes:

HVU implemented huddles, gemba, and daily metrics in January 2014. We chose quality

indicators, created action plans, and used daily metrics to drive improvement. We worked on

reducing the number of falls and number of injury falls and reducing catheter associated urinary

tract infections (CAUTI). For falls our daily metric was the percentage of patients that had all

aspects of fall prevention in place. Baseline data for HVU falls:

Total Patient Falls Per 1,000 Patient Days

Injury Falls per 1,000 Patient Days

Our most recent falls data for 2QCY14 is 6 falls, total falls per 1,000 patient days of 1.55, and

injury falls per 1,000 patient days of 0.39.

For CAUTI, our daily metric was the percentage of the foleys that meet criteria for continued

use. The criteria for continued use are strict output measurement, <24 hours postop, bladder

outlet obstruction, neurogenic bladder, prolonged immobilization, open sacral or perineal

wounds, alteration of perineum post procedure, epidural use, or comfort/end of life care.

Baseline HVU CAUTI data:

Catheter Associated Urinary Tract Infections per 1000 Catheter Days

HVU looked at this metric daily from January through April 2014. Once our compliance was

close to 100% for greater than a month, we moved this measure to the kamishibai board where

we randomly audited compliance once a month. A kamishibai board is a lean tool for visual

management of audits that promote sustainability and continuous process improvements (Barnas,

2014). HVU had three CAUTI in 1QCY14 for a rate of 9.35 total CAUTI per 1,000 catheter

day. HVU did not have any CAUTI for 2QCY14, 1 CAUTI in July 2014, and zero for August

and September.

The NICU implemented huddles, gemba walks, and daily metrics in April 2014. The unit chose a

quality indicator that impacted daily care needs: % of emergency equipment available 100% of

time during deliveries for neonates. The team worked on improving the availability of needed

airway supplies at deliveries with the Labor and Delivery department and developed a template

of supplies expected at deliveries. We tracked daily the number of deliveries in 24 hours, and

identified supplies missing on the pareto chart. For example, in the month of June for a ten day

period the unit did not have the warmer on and ready for the delivery. This impacts the

thermoregulation of the neonate at delivery. In addition, the next drill down was missing handles

and blades ready in the room for airway management. Methods to improve the outcomes to have

100% of the equipment ready and available with Labor and Delivery or a process to provide the

sustainability for meeting the goal were developed. During gemba walks, staff provided reasons

for missing equipment, and identified better processes for always having the supplies. There

were 233 deliveries during the month of June with 10 days showing missing equipment. Each

day in huddle we discussed missing supplies, identified root causes, and developed action plans

to improve outcomes. For the month of October only three days did not have the necessary

equipment.

Sustainability: The team is using audits, daily metrics, and a kamishibai board to ensure that

results can be sustained. The team is currently creating a systematic leader onboarding process

to ensure successful spread and sustainability of leadership standard work to other departments.

The onboarding process will consistent of leadership education, lean mentorship, and

performance improvement department support.

Role of Collaboration and Leadership: The idea for this project came from collaboration

between the CMO, Dr. Mitch Schwartz, and the Vice President of Clinical and Support Services,

Jennifer Harrington. The CMO and VP launched the rapid improvement event (RIE) and set the

goals and vision for success. The RIE team was a multidisciplinary team consisting of the CMO,

VP of Clinical and Support Services, VP of Human Resources, Clinical Nursing Director of

HVU, Senior Nursing Director of Women and Children’s, staff nurse from Labor and Delivery,

Medical Director of Women’s and Children’s services., manager of the ED, lead physical

therapist, manager of IS support services, Director of Food and Nutrition, the administrative

fellow, and a performance improvement facilitator.

Innovation: This solution is innovative because it attempts to change leadership management

from reactive to proactive. Successful implementation of leadership standard work will

transform leaders from problem solvers to coaches, mentors, and barrier removers. Leadership

standard work helps create and support engaged staff, who drives quality improvement

outcomes. We have successfully implemented a proactive approach for continuous daily

improvements and sustainable standard work by developing a standard leadership huddle board

with daily metrics, walking the gemba, and transformational leadership tools for driving change.

This structural management system will provide the standardization in daily work and align the

unit activities with the hospital vision, mission, and true north metrics.

Related Tools and Resources

The Daily Prep - NICU

6/16 6/17 6/18 6/19 6/20 6/21 6/22 Notes

Date Mon Tue Wed Thu Fri Sat Sun Monday Tuesday Wednesday Thursday Friday Fri/Sat Additional Notes

Qu

alit

y

#of Pts discharge on time/# of patients for discharge each day.

0/0 0/1 5/5 2/2 N/A 1/1 2/4

% discharge time N/A 100% 100% 100% N/A 100% 50%

# of times airway management equipment not available (past 24hr)

0/3 0/11 4/10 4/6 0/5 0/4 3/4

% of airway equipment available 100% 100% 40% 66% 100% 100% 75%

# of pts/# of RN's staffing 17/7 22/8 20/8 18/8 18/7 16/7 18/7

Staffing metric of volume 2.43 2.75 2.5 2.25 2.57 2.29 2.57

% Productivity 97% 100% 100% 90% 100% 92% 100%

Co

mm

un

ity

Pt./ Family need extra support 2 2 2 2 3 1 1

Family concerns/complaints 0 1 0 0 0 0 0

Wo

rkfo

rce

Staff need extra support 0 0 1 0 0 0 0

Staff orientation 0 0 0 0 2 0 0

Staff floating in/staff floating out 0/0 0/0 1/0 0/0 0/0 0/0 0/0

Celebrations

Hot Cards

Mock

Survey

Inservices/competencies Magnet - - - - - >

Gro

wth

PT / RN 17/7 22/8 20/8 15/6 18/8 16/7 18/7

Staffing to Volume 2.42 2.75 2.5 2.5 2.25 2.29 2.57

Acuity (level 1/2 of care) 2/5 2/5 2/7 3/3 4/3 2/4 2/4

Transfers in / transfer out 0/0 1/0 0/0 0/0 0/0 0/0 0/0

Fin

ance

Staff callouts 0 0 0 0 0 0 0

Staff on call 0 0 0

2OC 1LC

2OC 0 0

Staff in overtime 0 0 0 0 0 0 0

Anticipated admissions 3 1 3 1 0 0 0

Anticipated discharges 1 3 5 2 1 0 2

Supply management needs

eye spec

00 Blades

00 Blades

Upcoming Week

KEY Staffing to Volume - Goal 2.4 PT/RN

current past 24 hours

The Huddle Board Standard Work

Frequency – Daily

5-7 minutes

Recognition - 1 minute

o Examples

Identify persons who have solved problems

Birthdays/anniversaries – let staff announce rather than the leader being

challenged to remember all

Review of Metrics – 3 minutes

Updates – 1 minute

o Examples

Flu shots due

Mandatory Education due

Evaluations due

Opportunities - 2 minutes

o Place on pick chart

o Team assigns priority

o Encourage staff member to take ownership

o Post completed items under success and leave for two weeks

Gemba

Monday:

• Is there Standard Work?

• Is Standard Work adhered to?

• Is it good Standard Work?

• Can it be improved?

Tuesday:

Wednesday: Thursday:

Friday: Saturday/Sunday:

Pareto Chart

Department: NICU

20

19

18

17

16

15

14

13

12

11

10

9

8 6/22/2014

7 6/22/2014

6 6/19/2014

5 6/18/2014

4 6/18/2014

3 6/18/2014 6/15/2014

2 6/15/2014 6/3/2014 6/19/2014 6/5/2014

1 6/2/2014 6/2/2014 6/18/2014 6/19/2014 6/19/2014 6/22/2014 6/8/2014 6/8/2014 6/2/2014 6/4/2014 6/4/2014 6/4/2014 6/2/2014 6/1/2014

Dir

ty B

lad

e/ H

and

le

War

mer

no

t h

eate

d

No

su

ctio

n

cath

eder

/ n

ot

turn

ed o

n

O2

no

t tu

rned

on

War

mer

no

t tu

rned

on

No

su

ctio

n t

ub

ing

No

BV

M

No

o2

tu

bin

g

No

neo

pu

ff in

resu

se r

oo

m

No

mec

on

ium

asp

irat

or

Dir

ty W

arm

er

Dir

ty E

qu

ipm

ent

In

sto

ck c

art

Emp

ty a

ir t

ank

Tran

spo

rter

no

t

turn

ed o

n

Start Date: June 2014

Reason for Missing Equipment Goal 100%Pareto Chart

Log of Missing Items in the Delivery Room

Patient sticker

Date

□Dirty warmer □ No suction tubing □ No ETT □ No BVM □Dirty blade (0 and 1) □ No appropriate mask □No handle □No meconium aspirator □No CO2 detector □Empty air tank □ No 6, 8 & 10 Fr suction □Warmer not heated

□Lack of shift to shift communication □Equipment borrowed by someone else and not replaced □Equipment used and/or not restocked Equipment not available □Do not know □Other______________________________

Patient sticker

Date

□Dirty warmer □ No suction tubing □ No ETT □ No BVM □Dirty blade (0 and 1) □ No appropriate mask □No handle □Meconium aspirator □No CO2 detector □Empty air tank □ No 6, 8 & 10 Fr suction □Warmer not heated

□Lack of shift to shift communication □Equipment borrowed by someone else and not replaced □Equipment used and/or not restocked Equipment not available □Do not know □Other______________________________

Contact Person

Title: Carol Lacher, Holly Sowko

Email: clacher@aahs.org, hsowko@aahs.org

Phone: 443-891-4331, 443-481-1523

References

Barnas, K. (2014) Beyond Heroes: A Lean Management System for Healthcare.

Appleton, WI: ThedaCare Center for Healthcare Value.

Barnas, K. (2011) ThedaCare’s business performance system: Sustaining continuous daily

improvement through hospital management in a Lean environment. The Joint

Commission Journal on Quality and Patient Safety, 37(9), 387-399.