1 va pittsburgh healthcare system veterans engineering resource center (verc) & office of...

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Lean Yellow Belt Training

VA Pittsburgh Healthcare SystemVeterans Engineering Resource Center

(VERC) &Office of Systems Redesign (OSR)

Last Updated: June 2012

Introductions

Who are you?

Why are you here?

What do you want to learn?

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Overview of Training Objectives

Learn Process Improvement Understand Lean principles Use strong problem solving methodology

VA-TAMMCS Participate in hands on learning activities

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Insanity: doing the same thing over and over again and expecting different results.

We are here to change the way you think!

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Process Improvement Throughout Time

Measured Work Taylor, Gilbreaths, etc…

Toyota Production System Total Quality Management

Plan Do Check Act (Deming) Six Sigma Lean

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Systems

The term ‘System ‘ is frequently used in professional conversation

What does it mean ?

What system characteristics

are important to understand

from a process improvement

view?6

Systems• System: A collection of elements that

function together to achieve a desired goal• Key issue: functions as a ‘Whole’

• Systems thinking : The attempt to understand and describe the system as a whole by analyzing not just the individual components , but by understanding the complex structure of interrelationships among the components

• Systems thinking is often counter-intuitive7

Process Orientation Systems Thinking – understanding the

interconnections and pathways that define the system

Process Orientation – system resources and activities are organized around processes rather than functional tasks

Connections are complex in functionally oriented operations making systems thinking difficult if not impossible

Process orientation facilitates systems thinking by placing emphasis on connections (handoffs and flow)

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What is Lean?LEAN: • Eliminates waste to create more value with

less work. • Proven program derived mostly from the

Toyota Production System (TPS) used to improve work processes.

• Allow us to improve our organizational culture.

• Enable teams to define problems and create solutions.

Goals: o Define the problemo Evaluate current processes related to

the project focus areaso Utilize Lean tools and methodologies to

identify operational barriers and process failure modes

o Apply Lean tools to improve systemso Implement control strategies to insure

long term sustainability of process improvements and spread adoption

Team/AIM

MAP

Change

Sustain

Measure

Lean Improvement Model

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“Lean provides a way to specify value, line up value creating actions in the best sequence, conduct these activities without interruption whenever someone requests them, and perform them more and more effectively.”

-from Lean Thinking, by James Womack and Daniel Jones (1996)

What is Lean?

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Valueo Value is determined by the “end customer” – the patient

Identify and eliminate waste o Anything that does not add value from the patient’s perspective

Value flows without interruptiono Identify ideal patient experience – streamline process and eliminate

waste to achieve Allow customer to “pull” value from process

o Available when they want it – one piece flow Continuous pursuit of perfection

o Reliable and sustainable systems design

(Must know who the customer is…)

Lean Concepts

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What is Waste? The basis for Lean thinking is

systematically eliminating or minimizing waste in a process or system

Waste is defined as any resource expenditure that Does Not ADD VALUE

Value is an activity or expenditure of resource directly contributing to patient care

Start Step 1 WASTE WASTE Step 2 Finish

Total Cycle Time

Start Step 1 Step 2 Finish

Total Cycle Time

Lean is a systems redesign methodology that shortens the time between start and finish of any given process by eliminating sources of waste.

Eliminating Waste

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• System Redesign provides a team approach for VA staff to plan, redesign, map, measure and integrate processes and systems to deliver real-time improvements in VA Health care systems.

• System Redesign expands on the concepts established in Advance Clinic Access to broaden the scope to include all clinical and administrative processes.

VA Systems Redesign

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• Empower the workforce to make improvements• Improve Access To Healthcare• Improve Work Processes• Eliminate Waste• Focus improvement on customer needs• Evaluate centralization vs. decentralization of

functions

Systems Redesign: Goals

VA - TAMMCS

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Following a systematic process greatly increasesthe chances for successful implementation of systems redesign.

Team based approach.

To that end, VHA offers VA-TAMMCS, as a SOLID framework for success.

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Vision Role of leadership at the outset of process improvement and identifying the project's mission.

Analysis The analysis portion of the framework covers establishing priorities to identify the most important areas on which to focus improvement efforts and in evaluating performance.

Team Teams work best when they have clear sponsorship, consist of front-line staff, are passionate around improvement, possess a facilitator, and are unified around a common aim or goal.

Aim An aim is an explicit statement summarizing what the team hopes to achieve during the project.

Map Mapping serves to identify a process clearly by clarifying the start, end, and key decision points.

Measure Measurement is important in order to know if changes teams make are really an improvement and fulfill our obligation to manage by fact not feel.

Change All improvement requires making changes, but not all changes result in improvement.

Sustain / Spread

Improvements that can be sustained will continue to provide value to veterans and employees who serve them.

VA-TAMMCS

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“Tools” Used In Systems Redesign

Basic Tools:• Lean

• Smooth flow• Eliminate waste

• Rapid cycle change PDSA• Small tests of change• Staff engagement

• Theory of constraints• Efficiency• Throughput

• Advanced Clinical Access

Advanced Tools:• Six sigma

• Reliability

• Queuing theory• Matching supply and

demand

• Human factors engineering• Error proofing

• Simulations• Modeling complex

solutions

Value Stream Mapping

VA-TAMMCS Framework

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A3 Worksheet

Basic Lean Exercise

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VA-TAMMCS Framework

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A3 Worksheet

Defining the Problem

What are you trying to fix?

How do you know you need to fix it?

Who are the best candidates to fix it?

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Theory of Constraints Definitions Flow: The rate at which patients or item related to patient

care (paperwork, materials, and information) are able to progress through the patient treatment processes.

Constraint: Any process step that limits the overall patient treatment flow Missing or incomplete information Materials or supplies Limited staffing capacity

Constraints are also referred to as ‘bottlenecks’.

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Theory of Constraints (TOC) Developed by Eli Goldratt to describe the impact of process

constraints on flow through a system or process

The neck of the funnel is the Constraint or Bottleneck.

Flow: The rate that items move through the ‘process’

Process and system throughput cannot be increased unless the throughput is increased at the bottleneck within the system.

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1. Identify the constraint• Physical Constraints• Policy Constraints

2. Decide how to exploit the constraint• How will the constraint be eliminated or managed?

3. Subordinate everything else in the process to the constraint• Adjust the rest of the system to enable the constraint to

operate effectively• Elevate the constraint

4. Invest time, energy, and money to eliminate the constraint5. Go back to Step 1, but beware of inertia.

Theory Of Constraints5 Steps To Focus Improvement at a Constraint

Source: H. William Dettmer, Goldratt’s Theory of Constraints: A Systems Approach to Continuous Improvement, ASQC Quality Press, 1997, p. 11.

Voice of the Customer Voice of the customer (VOC)

A term used to describe the in-depth process of capturing a customer's expectations, preferences and aversions.

VOC is: Market research technique that produces a detailed

set of customer wants and needs, organized into a hierarchical structure, and then prioritized in terms of relative importance and satisfaction with current alternatives.

Determine what the customer thinks of your product or service

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Value Stream Map A Value Stream Map is

used to visually represent thecurrent state of the process.

The Value Stream Map includesinformation about processing steps, processing times, wait times and # of items within the process.

Information and material flow may be added to provide a complete snapshot of the process.

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Value Stream Symbols

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ProcessBox

Physician/Service Chief

DataBox

Information/Computer System

Pull System Flow

ElectronicInformationFlow

Information Flow

Physical Flow

Queue/Inventory

Hospital

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Value Stream Map Steps to creating a Value

Stream Map:

1. Flow Chart the Process at a very high level (5-7 processing steps)

2. Add Suppliers and Customers

3. Collect/Add information about process times, wait times and queues.

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Value Stream Map

Chemo-Therapy/RadiationTherapy

CancerDiagnosis

Screening Work-up andSurgery

??Physician

??Physician

Surveillance

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Key Value Stream Metrics: Time Process time (PT)

The time that is actually takes to perform the work, if the work can be performed uninterrupted.

a.k.a ‘Touch Time’ (physical process) & ‘Think Time’ (analytical process)

Cycle Time (CT) The total elapsed time from entry into a processing

step until exit from that step and/or ready to go to the next processing step.

a.k.a – cycle time, turnaround time Total Cycle Time:

The total time that it takes to go from entry to exit within a system

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Cycle Time vs. Process TimeCycle Time

Cycle Time = Process Time + Wait Time (all blue) (all red)

Patient EntryintoProcessstep

Patient Exitout ofProcessstep

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Key Metric: Reliability

% Complete and Accurate (%CA)

% of the time that the downstream customer can perform the processing step without having to:

Correct information or materials Add information or materials Clarify information

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Value Stream Map


CancerDiagnosis

Screening Work-up andSurgery

??Physician

??Physician

Surveillance

Scheduled

Occurred

Results

Documented

%CA = % of patients that specifictreatment(s) were documented within the step

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Value Stream Map


CancerDiagnosis

ScreeningColonoscopy

Work-up andSurgery

??Physician

Primary CarePhysician

SurveillanceColonoscopy

PT=2 hrs

WT=10 hrsPT=4 hrs

WT= 44 hrs

PT=8 days

WT=52 days

PT=2 hrs

WT=10 hrs

PT= 4 hrs

WT=4 hrs

2 days .3 days 60 days .5 days.5 days

5 days 27 days 81 days 90 days

%CA=60% %CA=20% %CA=50% %CA=80%%CA=90%

Wait Time Between Steps36

Value Stream Map


CancerDiagnosis


Work-up andSurgery

??Physician



PT=2 hrs

WT=10 hrsPT=4 hrs

WT= 44 hrs

PT=8 days

WT=52 days

PT=2 hrs

WT=10 hrs

PT= 4 hrs

WT=4 hrs



Cycle Time through each step

%CA=60% %CA=20% %CA=50% %CA=80%%CA=90%

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Value Stream Map


CancerDiagnosis


Work-up andSurgery

??Physician



PT=2 hrs

WT=10 hrsPT=4 hrs

WT= 44 hrs

PT=8 days

WT=52 days

PT=2 hrs

WT=10 hrs

PT= 4 hrs

WT=4 hrs



Total Cycle Time = 266 days

%CA=60% %CA=20% %CA=50% %CA=80%%CA=90%

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ACTIVITY

Create a Value Stream Map and then ID the constraints

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ACTIVITY


VA-TAMMCS Framework

A3 Worksheet

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Successful Teams

• Need Senior Support, Front Line and staff empowered to implement change

• Need Coach and Team Leader• Need Team Facilitator• Define roles and rules • Have a schedule and plan • Meet frequently

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Developing a Team CharterProject Charter • States the scope, objectives and participants • Defines the team membership • Provides a preliminary description of roles and

responsibilities • Identifies the main stakeholders • Serves as a reference for team members and leadership

• It is a working document…

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• Specific• Measurable (time, $, units, or %)

• Achievable • Realistic • Timely

Example: The number of routine work orders greater than 30 days

in the AC shop at UD will be no more than 50 by September 1,

2009.

AIM = S.M.A.R.T. Goals

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ACTIVITY

Review Team Charter Team

Problem Statement AIM(s)

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Measure:

What will you be measuring?

Where will the data come from? (ie. Data Warehouse, VISTA, CPRS, Observations, etc.)

How will you collect the data? (Manual collection, Automated Data Warehouse report, etc)

What is your current baseline data?

Project Scope:Where does the process under investigation start?

Where does this process stop?

What is inside of the project scope?

What is outside of the project scope?

Deliverables: What end result(s) do you expect to achieve from this project?

How will you know that any changes have resulted in improvements?

Plan for Achieving Results:

Facility Name: Date Chartered:

Service Line / Department:

Submitted By:

Project Title:

Project Start Date:Project End

Date:

Team Member Name: Phone Title Position within Team

Project Owner

Project Facilitator

SR Point of Contact

Member

Member

Member

Member

Problem Statement: (Problem & Plan)

Describe the problem, opportunity, or objective in concise, measurable terms. Include a summary of the problem and impact (a.k.a. PAIN). Problem: Linkage to Strategic Priorities:

Goal/Aim Statement: (SMART – Specific, Measurable, Attainable, Relevant, Timely) Describe the team’s improvement objective (What is the team GOAL) Begin with the words “reduce, increase, eliminate, control”

AIM #1:


VA-TAMMCS Framework

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A3 Worksheet

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Process Flow Map• A flow map is a graphical representation of a

process. It represents the entire process from start to finish.

• Mapping a process out helps you clarify your understanding of the process, and helps you think about where the process can be improved.

• The team then identifies value added and non-value added tasks.

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Process Flow MapWhy map out the process?

• Sometimes there are surprises

• Problem areas

• Unnecessary steps

• Rework

• Group consensus on how the process really works: a meeting of the minds

• Understand the present before you define the future

• Decide where data can be collected and investigated

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Steps in Creating Flow Map• Map the process “as is” (not what you want it to

be)• Identify scope of process to flow map• Write each step on a Post It note

• Each color Post It can depict a different Service Line, Department, position, or owner involved in the process

• Identify Internal and External Customers• Internal = other employees, Service Lines, etc… • External = patients, vendors, etc…

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Steps in Creating Flow Map Plan to use a different colored post-it for each

department doing the task No open-ended tasks (all paths must terminate) Use decision symbol for two choices or yes/no decisions Use brackets with multiple lines if there are more than

two choices or paths Use pencil for connectors at first Make copy of each document used in the process and

tape to bottom of map Once you are satisfied that it is finished and correct, go

over connectors with sharpie Make critical notes on map

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Questions to ask when creating Process Flow Map

• Maintain process perspective• What, where, how, role – not why

• Does this step work like this all the time?• Do some people do things differently than others?• Where does the information / material come from?• How does the material or information get into the

process?• Who makes the decision?• What happens if the decision is “yes”• What happens if the decision is “no”• What test or checks are done?• What happens if the test or check fails?

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Situations to consider when creating Flow Map

• Flow of people, information, equipment

• Inventory or supply problems

• Unnecessary motion

• Waiting / delays

• The right amount of information at any step

• Work that may not be necessary from the customer’s standpoint

• Errors

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Process Flow Map Symbols

- Process: Show a Process or action step.

- Decision Point: Usually two options (yes/no, pass/fail, etc).

- Terminators: Shows the start and stop points in a process.

- Document: Step that produces a document.

- Storage of Information: Electronic storage of data.

- Connector: Shows a jump from one point in the process to another.

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Example of Process Flow Map: VAPHS Work Order Process

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Example of Process Flow Map

Swim Lane Diagrams

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Metrics Based Process Map

◦Type of process map depicting process flow, process durations and staff members and/or departments involved in processing steps.

◦More detailed representation of a sub-process within a Value Stream Map, often used to investigate specific sub-processes

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Metrics Based Process Map Steps to creating a MBPM1. Review the process under investigation and establish

boundaries as outlined in the project charter.2. Using brainstorming techniques, identify steps in the

process as well as personnel/departments involved in the process.

3. Arrange the processing steps in order, align to resources.

4. Validate the process flow either by showing the process map to a non-team member involved in the process, or by physically observing the process.

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Out-Patient Registration Processes

RegistrationClerk

Registrar

Escort

PatientArrivesAt RegistrationDesk

PatientPre-registered?

YesClerk RequestsID and MedicalCard

PatientAssignedTo Registrar

Patient escorted to radiology

RegistrarEnters patientinformation

No

PT = 1 min

WT =12 min

%CAC=30%

PT = 2 min

WT =2 min

PT = 1 min

WT =12 min

%CAC=30%

Wait forRegistrar

Wait forEscort

PT = 5 min

WT =13 min

%CAC=10%

Fishbone: Cause & Effect

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ACTIVITY

Create:

- Process Flow Map

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Lean• Proven process improvement method that

considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful

• Focuses on the continual reduction of non-value added activities

• Directly improves speed and productivity

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8 Sources of Waste

The Eight Forms of Waste

1. Defects

2. Overproduction

3. Waiting

4. Not Utilizing Employees

5. Transportation

6. Inventory

7. Motion

8. Extra Processing

Hospital-acquired illness Wrong-site surgeries Medication errors Foreign objects remaining in patient

after surgery Problem orders Misfiling documents Dealing with service complaints Mistakes resulting from miscommunication Illegible, handwritten information Collection of incorrect patient information

Defects

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Too many meal trays delivered Asking the patient the same questions

multiple times Large supply of forms Extra floor space utilized Unnecessary carbon copying Batch printing patient labels

Overproduction

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Idle machines/people Large waiting rooms Patients waiting to see physician, nurse,

etc. Waiting on the phone to schedule patients Early admissions for procedures later in

the day Waiting for internal transport between

departments

Waiting

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Not using people’s mental, creative, and physical abilities

Staff not involved in redesigning processes in their workplace

Workarounds Nurses and Doctors spending time locating

equipment and supplies Staff rework due to system failures

Not Utilizing Human Potential

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Poor workplace lay-out for patient services

Carrying files from location to location Moving equipment in and out of

procedure or operation room Patient transportation

Transportation

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Office supplies stored in hallways Charge slips piled up to be dictated Physician orders building up to be entered Unnecessary instruments contained in

operating kits Multiple quality control checks Much rework

Inventory and Inspection

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Leaving patient rooms to o get supplies or recordo document care provided

Large reach/walk distance Documenting in more than one place Nurse checking electronic medication

record to see if order entry is completed

Motion

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Multiple signature requirements Extra copies of forms Multiple information systems

entries Printing hard copy of report when

digital is sufficient Multiple steps to get pre-approval

for urgent treatments Overstocking inventory

Extra Processing

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Non-Value Added

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Identify Non-Value Added Steps In Flow Map

Identify each step with the following:

Red Tag = Non-Value added process

Yellow Tag = A required process, but not value added

Green Tag = Value added to customer

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Activity

Evaluate each step in the Flow Map with either a red, yellow, or green dot

“If you keep doing what you are doing, you will keep getting what you’ve gotten.”

Unknown author, heard it on WIBC Radio morning show, Indianapolis, Indiana

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Eliminating all waste, barriers, obstacles, variation, and non-value adding necessary, and non-value adding unnecessary process steps in the current state

The ideal state is designed

in the pursuit of perfection A constant goal

Designing the Ideal State

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Example Ideal State Map

LP draws blood from

patient

Core lab tests blood

sample

MD determines

need for blood draw

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Future State Mapping

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The future state is designed to the best known process – pursuit of perfection

Consistently brings value (what the patient needs) to the patient when they need it (pull)

Requires elimination or minimizing of as many non-value adding process steps as possible

Must be achievable Continuous improvement required

Designing the Future State

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Detailed Process Map – Current State

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Future State With Elimination of Non-value Adding Steps = 6 Steps92% of the process steps were identified as non-value adding

Process Map: Future State

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Activity

Create a Future State Map

What is stopping us from reaching the future state?

o Non-value added process steps o The eight forms of wasteo Bottlenecks/backups

o Process variations

Gap Analysis:Future State vs. Current

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Activity A rapid generation of ideas by all group participants.

AVOID DISCUSSION! AVOID SOLUTIONS! Remember team dynamic rules

Write down as many ideas as possible on the star-shaped post-its of the waste, bottlenecks, obstacles, barriers, variation present in the current state

o Place “Star Shaped Post-It” on the current state map where they occur

Prioritizing Opportunity• Affinity Diagram

o A simple process of identifying and grouping like information

o Powerful tool to use when working as a groupo The Process

Brainstorm ideas (completed earlier) Group like ideas

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Affinity Diagram Example

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Multi-voting is used to prioritize greatest to least

Each participant has 10 pointso Each participant votes on the opportunities

with their pointso Each participant can use all the points on one

opportunity or spread it across multiple opportunities

o Point totals will be added to determine priorities

Prioritizing Opportunities Multi-voting

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Activity

1) Complete Affinity Diagram

2) Vote


VA-TAMMCS Framework

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A3 Worksheet

“Not everything that counts can be counted, and not everything that can be counted counts."

-- Albert Einstein

Einstein on Data Collection

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Sources of Data: IT System

VSSC (VHS Support Service Center)

Data WarehouseCPRS (Computerized Patient Record System)

VistAetc…

Manual Collection

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Check SheetDescription It measures frequency by unit of time A check sheet is a structured, prepared form for collecting and analyzing data. This is a

generic tool that can be adapted for a wide variety of purposes.

Check Sheet Procedure Decide what event or problem will be observed. Develop operational definitions. Decide when data will be collected and for how long. Design the form. Set it up so that data can be recorded simply by making check marks or

Xs or similar symbols and so that data do not have to be recopied for analysis. Test the check sheet for a short trial period to be sure it collects the appropriate data and is

easy to use. Each time the targeted event or problem occurs, record data on the check sheet.

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Process Observation WorksheetProcess Observation Procedure List the steps from the process map in sequential order.

Identify the specific activities, decisions, motion and transport steps

Observe the process and collect information on process step durations, wait times, and travel distances.

Perform multiple observations in order to determine the range of variation in processing steps and times.

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Spaghetti Diagram

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Helps to visually identify wasteful steps

Spaghetti Diagram: Office Layout and Traffic Flow Acquisitions and Contracting

Lean Project Team

Original After 5S

► Relocated Offices► Eliminated 36 Hrs/Yr from AO task

by moving printer► Eliminated 2 Hrs/Yr from Lead PA

task by moving printer

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• This answers the following question:

How do you know that you made an improvement?

• It allows for continuous monitoring (Sustaining)

Why Develop Measures of Success?

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ACTIVITY

Determine Measurements:

(Go Back to Project Charter and complete)

1. Measure

2. Project Scope

3. Deliverables


VA-TAMMCS Framework

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A3 Worksheet

Change Types of Change

External (Imposed by outside force or condition)

Planned Change Our Topic of Interest

Going from a current state or condition to a proposed state or conditionChange management requires strategic

thinking, planning, decisive implementation and stakeholder consultation

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Change

At this point in the improvement process your team has:Defined the current process stateAnalyzed the current process and determined

causes of waste and ineffectivenessDesigned a desired future state

Now what?

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Change Designing an implementation plan

It must be thoughtful and specific The following elements are essential:

WhatWho When

Sequence Duration

HowResources needed

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Change Thoughts on Planning:

“If you don’t know where you are going, any road will get you there”

Lewis Carroll“If you don’t know where you are going you

will probably end up somewhere else” There is no substitute for a well thought

out specific objective

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Root Cause Analysis Aims improvement at root cause Avoids addressing symptoms Performed systematically Continuous improvement tool Systems focused

o The “5 Why’s” not the “5 Who’s”

Change

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The Washington Monument is deterioratingo Why?

• The use of harsh chemicals on the surface.

o Why?• To clean up after the pigeons.

o Why?• Pigeons eat spiders and there are a lot of spiders here.

o Why?• Spiders eat gnats and there are a lot of gnats here.

o Why?• Gnats are attracted to the display lights at dusk.

o Why?• We never change the timers during different seasons.

5 Why Example

SOLUTION: Program the lights to come on later.105

Multiple needle sticks are occurring with piggyback intravenous medicationso Why?

• Staff are recapping the needles.

o Why?• To safely unscrew the needle from the IV tubing so the needle can be

placed in the sharps container without getting stuck by the needle.

o Why?• All needles are to be disposed of by placing them in the sharps

container.

o Why?• To avoid who ever is handling the trash from being stuck by a needle.

5 Why Example

SOLUTION: Needleless intravenous medication administration system

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Identifying Solutions Brainstorming technique:

Each participant to write down as many SOLUTIONS as possible

There are NO bad ideas No gate keeping or filtering

Individual activity (No talking, just write)

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ACTIVITY

Fill Ins(Quick Fix)

(LL)

- Take each solution and place it in the quadrant that best reflects the impact expected and the effort it would require. - Establish priority by using Multi-voting technique if needed.

Low

Activity: Solution Impact/Effort Grid

Quick Wins(Focus on

these as much as you can)

(LH)

EFFORT High

IMP

AC

T

HighMajor Projects(Complex/Time

Consuming)(HH)

Thankless Tasks

(Time Wasters)

(HL)

Highest Priority

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Integrated Lean Exercise

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Change PDSA (Plan, Do, Study, Act)

Small scale experimental in nature Improve your solutions Improve implementation skills Uncover barriers that need to be addressed Elevate organizational receptivity to change

Pilots Sometimes used interchangeably with PDSA Generally larger in scope

Implemented to demonstrate proof of concept

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Change On PDSA’S and Pilots

“proven results speak loudly”“Creating initial success sets the table for

long term success” Demonstrating success is a critical

element of successful implementation Failure is an educational experience

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PDSA Cycle Plan the improvement:

Select a process to improveFlow Chart the processWrite aims (goals)Develop an action plan to track improvements

Remember: it’s a cycle

Plan

DoStudy

Act

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PDSA

Does placing sanitizer outside room increase hand-sanitizing?

Duct Tape to wall outside three rooms

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PDSA

Does having a place to put things down increase hand-sanitizing?

Place table outside door with sign(ignore clutter)

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PDSA

Do color-coded labels help to differentiate lotion from sanitizer?

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PDSA Cycle Act on the knowledge:

Adapt (Adjust): Improve the change and continue testing plan (additional PDSA cycles)

Adopt: Select changes to implement on a larger scale and develop an implementation plan and plan for sustainability

Abandon: Discard this change idea and try a different one

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Use of the Rapid CycleChanges That

Result in Improvement

A P

S D

APS

D

A P

S D

D SP A

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

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A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P A

Spec

ific T

est C

ycles

Daily DC Planning

Discharge appts.

Doc. DC plan Day 1

Inpt. priority x-ray studies

Rapid Cycle Change

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– Brent Seeley, Seattle

“It’s better to get a little better today than to wait months for perfection”

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PDSA: Plan, Do, Study, Act

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ACTIVITY

Develop PDSA’s

Implementing Change

A critical element for successStake holders and process owners must be

involved in the entire problem solving process; with special emphasis on development and implementation of solutions

Ignoring this will generate failure

The best change is what people think they did themselves

Lao Tzu

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Implementing Change Educate and Communicate Relentlessly

Stake holders and those effected by proposed change

Include organizational leaders: Develop sponsorship Create a sense of urgency

Uncover leadership personalities and give them special focus

They can exert positive or negative influence

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Implementing Change Sustaining change requires fundamental

shifts in mind set and behavior by the process ownersProcess owners must believe the change

benefits themWIIFM (What’s in it for me)

“People cannot be expected to support and care for things they do not own”

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SORT • Eliminating unnecessary items from the workplace• Team tags everything as follows:• Red Tag (Never used), Yellow Tag (Not often), Green

Tag (Critical)

SET IN ORDER• Focuses on efficient and effective storage methods• A place for everything and everything in its place

SHINE• Thoroughly clean the work area

STANDARDIZE • Concentrate on standardizing best practice in your work area

SUSTAIN• Make 5S a part of daily activity so it becomes part of culture • Continue 5S of all areas within the process

5 S

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How to get started with 5-S• Select team (appropriate size for the project)

• Including the “owner” of space, their supervisor, and project team member.

• Determine Area for 5-S• Conduct walkthrough of Area• Detail all problems and supplies needed for the

5-S• Start a timeline for the 5-S

Note: Begin and End 5-S with photo timeline

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5-S Examples

Before: After:

Before: After:

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5-S ExamplesUD Warehouse

Before: After:

5S Examples: ED Reception Desk

Before After

Placed all critical numbers in one location

Labeled drawer that storedall commonly used forms

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Pittsburgh VA – Equipment Room

BEFORE

BenefitsClean equipment = pathogen vector

Saves frustration, searching

Freed up $20K-worth of unused equipment for use elsewhere

IV Pumps (4)

Always Plugged In

AFTER

Whiteboard indicates location

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Benefits of 5-S Improve safety Decrease down time Raise employee morale Identify problems more quickly Develop control through visibility

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Action Item List• Develop a Action Plan that defines who is

going to do what, and by when…• Monday • Week 1• Month 1• Quarter 1• Etc…

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Example Action Item List

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Team Ass ignmen t Create Action Item List

Issues Action Item Benefit Implement Owner Start Completion Status

High / Low Easy / Diff. Date Date


VA-TAMMCS Framework

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A3 Worksheet

“We make errors when our actions do not agree with our intentions even though we had the capability for completing the intended action.”

- Institute for Healthcare Improvement

What is an Error?

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“Any task that requires human intervention and judgment to prevent mistakes is a mistake waiting to happen.”

Removing the possibility of human error Often used in combination with visual controls

Examples: Decision support/clinical reminders within the EHR

system O2 line fittings

Poka-yoke (mistake-proofing)

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Examples

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Levels of Contro

l

Training andStandards

Building Information into the Workplace

Warnings thatProblems Exist

Physically Changing the Workplace

Eliminating the Causes of Problems

Hierarchy of Controls

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Provides step by step direction to problem solving or improving a processo Is also effective in addressing continuous improvement

opportunities Clear concise one page overview

o Consolidates large amounts of information in understandable format using visual displayo Challenges user to use as little verbiage as possible

Multi-purpose toolo Presenting project proposal or recommendationso Sharing and reviewing progresso Final report and Storyboard

A3

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VA Hospital Date: Author:

1. TEAM/AIM: Define the problem

2. MAP: Evaluate current state

3. MEASURE: Identify operational barriers and failure modes in the current process

5. SUSTAIN: Sustainability strategy

4. CHANGE: Improve systems

Create a future state process by applying Lean techniques to eliminate operational barriers and failure modes

Create a process control strategy – a strategy for insuring long term sustainability and spread adoption

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VA Hospital Date: Author:

1. TEAM/AIM: Define the problem

2. MAP: Evaluate current state

3. MEASURE: Identify operational barriers and failure modes in the current process

5. SUSTAIN: Sustainability strategy

4. CHANGE: Improve systemsCreate a future state process by applying Lean techniques toeliminate operational barriers and failure modes

Create a process control strategy – a strategy for insuringlong term sustainability and spread adoption

• What is the standard or desired level of performance?

• What is the current level of performance?

• What is the current performance gap?

• What is the extent of the impact/pain?

Fill in the Problem Definition

Give high level summary of sustainability and spread plan

• Describe the current state for your assigned scenario o High level mapping of current state

• Summarize current state with a few brief concise statements if needed

Fill in the Current State Map

Assign Each Step With a Value Using the Color-Coded Legend

Value Adding (VA)Non-Value Adding Nec. (NVAN)Non-Value Adding Unnec. (NVAU)

Value Legend

Add Root Causes for Primary Barriers/Waste

Quantify Value, Non-value and Waste in Current StateCurrent State Time /Distance• sec. total time for routine orders• sec. total time for STAT orders• total steps traveled

VA: StepsNVAN : StepsNVAU : Steps

Current State Value

Add Primary Barriers/Waste

• Fill in the Future State Map

• Add Time and Distance Required by Each Step

• Assign Each Step With a Value Using Value Legend

Add Time and Distance Required by Each Process Step to the Current State Map as Applicable

• Quantify Value and Non-value in Future State

VA: StepsNVAN : StepsNVAU : Steps

Future State ValueFuture State Time/Distance• sec. total time for routine orders• sec. total time for STAT orders• total steps traveled

• Quantify Impact of Improvementso % ↓ process stepso % ↓ distance

traveled

o % ↓ required timeo % ↓ NVAN and NVAU steps

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Spread/Diffusion Background

Some innovations spread like wildfire while others with great difficultyiPods vs. Zune (Microsoft version)

HospitalistsEMR (Electronic Medical Record) Innovations to improve quality of care

Klotz, K

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Spread/Diffusion Barriers

Difficult to change old habits Resistance in changing longstanding

routines Perceived need to work harder What is the organization’s culture?

Klotz, K

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How innovations spread throughout cultures

How, Why, What rate Highly studied Used in product marketing, public health Based on work by Everett Rodgers

Diffusion of Innovation Theory

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Diffusion Curve

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Adoption Process

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Diffusion Rate Factors

Innovation attributes Relative advantage (Cost/Benefit)Compatibility, Complexity / SimplicityTrialability, Observability

CommunicationThe “Early Adopter” Opinion LeaderSubjective perceptions influence diffusion

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Change Personalities

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Concluding Remarks“The significant problems we have cannot be solved by the same level of thinking with which we created them.”

“Vision without action is merely a dream. Action without vision just passes the time. Vision with action can change the world!” Joel Barker

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Remember

• Engage leadership support

• Involve and educate end-users and staff who do the work

• Spread the program to other departments

• Recognition for success• Schedule a weekly team

meeting

• Keep an open mind• Set S.M.A.R.T goals

(specific, measurable, attainable, realistic and timely)

• Develop a project timeline• Commit to an action plan

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Certification can be obtained in two ways:

1) Free certification through VA

2) Pay approximately $275 for Purdue University Certification

Both Require:- Completed A3

o Participation in improvement project - Passing a certification test

Certification

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For all your participation and hard work! We look forward to your results!!!

Contact Information Find us on our SharePoint Site

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Contact information found here (About us) tab…

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