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1
Lean at Rouge Valley Health System:
A Strategic Choice to Drive Quality
Improvement
Seminar on Regional Sharing of Lean Applications in Healthcare
Bangkok, Thailand
Presentation by Michele Jordan,
Vice-President, Quality Improvement and Transformation,
Rouge Valley Health System, Toronto, Canada
January 25, 2011
1
2
1. Lean in the Canadian Health Care Sector
2. Application of Lean at Rouge Valley
Health System
3. Lessons Learned
Outline
3
Lean in the Canadian
Health Care Sector
A Bit About Canada
Overview of the Canadian Health Care System
Use of Lean in Canadian Hospitals
4
5
Canada QuizTrue or False?
Canada is the second largest
country in the world in
geographic area.
The Prime Minister of Canada is:
a) Stephen Harper
b) Barack Obama
c) Gordon Lightfoot
d) Rik Ganderton.
The population of Canada is
approximately:
a)10 million
b)30 million
c)100 million
d)200 million
Canada has 2 official languages.
They are:
a)English and Spanish
b)French and English
c)English and German
The capital city of Canada is:
a) Vancouver
b) Toronto
c) Ottawa
d) New York City
True or False?
In Toronto, Canada the average
high temperature in the month
of January is 28ºF (or -2 ºC).
6
Overview of the Canadian Health Care
System
• Canada has a publicly funded health care system
• The delivery of health care is a provincial responsibility; each province
and territory has its own health care system and offers a health
insurance plan for its residents
• Most (but not all) health care services are provided free of charge
• The provincial and territorial governments fund health care services
with assistance from the federal (i.e., national) government.
• The Canada Health Act requires that provincial and territorial health
insurance plans must meet 5 criteria to receive full federal funding:
comprehensiveness, universality, portability, accessibility and public
administration
• $192 billion spent on health care in 2010 ($5614 per capita)
• Life expectancy in Canada has increased to 81 years
6
7
Lean in Canadian Hospitals
• Lean is being used in hospitals all across Canada
• Use of Lean in Canadian hospitals began around 2005
• Individual hospitals launched Lean initiatives for different reasons such
as to improve quality or to reduce costs
• Finding the funds to launch Lean programs was difficult; research
shows that those hospitals that hired consultants to help them who
were specialists in how to teach Lean had the most success
• Common areas of focus for Lean include: emergency departments,
inpatient medicine units, labs, diagnostic imaging, operating rooms
• More hospitals are starting to use Lean because:
• They have seen the success of Lean in other hospitals
• They are facing funding constraints
• Governments are endorsing Lean as a way to improve access to services,
increase patient satisfaction and cut costs
7
8
Lean in Canadian Hospitals• The Ontario government has Lean programs for
hospitals:
• The Emergency Department Process Improvement Project
(EDPIP) to help hospitals to reduce waiting times in emergency
departments
• The MRI (Magnetic Resonance Imaging) Efficiency Project to help
hospitals use Lean to reduce waiting times for MRIs
• The Auditor General of Ontario has recommended that
hospitals use visual management to improve the patient
discharge process
• After using Lean in hospitals for 1 year, the government
of the province of Saskatchewan has mandated the use
of Lean in all parts of the public service
– Direct Care Time provided by nurses was increased from 26% to
41% on the Oncology Ward of one hospital
– An equivalent of 1 FTE position was released on a Medical
Ward by improving shift handover processes alone
– 5S in the operating room added an extra 1/2 day capacity to do 9
more procedures each week
8
“As we've seen from
the Ministry of Health's
experiences, the Lean
approach is an
effective way to
streamline our
approach to service
delivery," Minister
responsible for the
Public Service
Commission June
Draude said. "I'm
confident that
incorporating Lean
across the public
service will improve
our processes and
enable us to provide
even better services to
residents of
Saskatchewan."
9
Application of Lean at
Rouge Valley Health System
About Rouge Valley
Our Catalyst for Change
Why Lean?
How we used Lean to Transform Our Hospital
10
11
Rouge Valley Ajax and Pickering (RVAP)
580 Harwood Avenue, Ajax
Rouge Valley Centenary (RVC)
2867 Ellesmere Road, Scarborough
Rouge Valley Health System
(RVHS)
12
• 2 acute care hospital campuses
o 24,000 Inpatient weighted cases
o 100,000 Emergency Department visits
o 105,000 Ambulatory clinic visits
o 22,000 Operating Room cases
o 3,600 Births
• $270 million annual budget
• 2700 staff
• 224 general practitioners and 325 specialists
12
About Rouge Valley
13
10 years of recurring deficits reaching projected $13 million for 2008
Board appoints new Chief Executive Officer in 2007
Some new Board members also appointed
Peer Review (July-December 2007)
Major cultural and operational change required at every level
We needed to improve leadership, management and accountability
Can deliver existing services within our funding envelope
(inefficient compared to others)
New Strategic Plan
Required to develop/implement Deficit Elimination Plan immediately
Started in early 2008, 3 year plan
Same volumes with less resources (eliminate 220 positions & 54 beds)
Transformation, constant improvement
Began in mid-2008, 5-10+ year journey
13
Our Catalyst for Change
14
Why Lean?
• Provides a tool set for managers to use
• Focus is on long-term sustainability
• Comprehensive approach to change
• Drives operational efficiency and cultural change at the same time
• Looks at processes from the patient perspective and flow across
departments
• Frontline staff are involved and empowered
• Specific metrics and targets established at the outset of improvement
initiatives and tracked throughout
• Process change is rapid (days not months)
14
15
How we used Lean to transform our
hospital
• We adopted Lean Thinking as our
hospital-wide management philosophy
• Lean training and management
development gives all managers a
consistent approach for how we expect
the organization to be run
• All leaders are required to lead and
manage using the Lean Management
Philosophy
• Lean thinking helps in moving leaders
from crisis management mode to a
greater focus on improvement, innovation
and strategy
15
" In a lean environment, the expectation is
that everyone has two
responsibilities. The first is to run the
business on a day-to-day basis. The
second is to improve the business, or
contribute to improving it
continuously."
(David Mann in “Creating a Lean Culture: Tools to
Sustain Lean Conversions”)
16
Lean as a Management PhilosophyShifting from Firefighting to Continuous Improvement
Top Management
Middle Management
Line Management
Front line
Maintenance
Innovation
Traditional perception of job functions
Top Management
Middle Management
Line Management
Front line
Maintenance
Improvement
and
Innovation
World class perception of job functions
“Kaizen”, Imai, 1986
1717
Lean as a Driver of Cultural Change
Lean transforms culture through:
• Defining „value-added‟ steps from the customer (patient) perspective
• Staff empowerment and engagement
• Kaizen events
• New ways of solving problems
• Emphasis on accountability for results
• Supports critical thinking and real-time actions
Transformation is seeing, thinking, and acting differently…….
Old Habits + New Tools = Same Results
(Mark Graban)
“What makes Lean difficult is not that it is so
complicated but that it is so different from what
we’ve learned”(David Mann in „Creating a Lean Culture: Tools to Sustain Lean
Conversions‟)
Organizations don’t change – people do
18
Maria Jingco – Charge Nurse, Medicine
“At first, I was a little reluctant to participate in the kaizen events as it took me away from my daily work, however, after participating in the events, I realized that being able to have input in the improvements that effect my area is quite a privilege. I believe that transformation has definitely begun to make a difference within the organization .”
Janice Yorke – Manager, Health Information Management
“My participation in Transformation has changed some of my habits that needed changing, it has opened my eyes to another positive way of thinking, everything we touch each day is a new opportunity to improve. I choose to improve and increase my skills and improve upon processes in my department for the benefit of the patient, as our doors would not even be open if it weren't for our patients!”
1919
Some of Our Lean AchievementsPercent
mm-yy Measure mm-yy Measure Improvement
RVC Coding Inpatient Coding Turn Around Time (TAT) Jan-10 43 days Aug-10 22 days 49%
RVC Coding Day Surgery Coding TAT Jan-10 43 days Aug-10 28 days 35%
RVC Coding Emergency Coding TAT Jan-10 43 days Aug-10 24 days 44%
Transcription (Corporate) Transcription Backlog Apr-10 3652 min Aug-10 353 min 90%
RVC MRI Patients scanned per week Apr-10 170 patients Aug-10 193 patients 14%
RVC MRI MRI Efficiency (scan time/available scan time) Apr-10 87% Aug-10 89% 2%
RVC Ambulance Offload Transfer of Care (TOC) Time Jan-08 93 min Sep-10 36 min 61%
RVC Ambulance Offload % Compliance with recording TOC time Jan-08 71% Sep-10 95% 34%
RVC Ambulance Offload Average minutes waiting in ER Jan-08 51 min Sep-10 39 min 24%
RVC Emergency % CTAS 4 and 5 patients seen in less than 4 hours - RVC Site Apr-09 61% Aug-10 81% 33%
RVAP Emergency % CTAS 4 and 5 patients seen in less than 4 hours - RVAP Site Apr-09 78% Aug-10 92% 18%
RVAP Medicine Time spent on Hospitalist daily patient assignment and work flow Mar-10 125 min Apr-10 35 min 72%
RVAP Ambulatory Care Unit Bronchoscopy Clinic Patient Touch Time (excluding recovery time) Jun-10 4 hr Jul-10 2 hr 50%
RVAP Ambulatory Care Unit Bronchoscopy nursing hours requirement Jun-10 8 hr Jul-10 4 hr 50%
RVAP Operating Room OR Changeover Turnaround Time Feb-10 15.6 min Mar-10 12.7 min 19%
RVAP Operating Room OR Changeover Manual Cycle Time Feb-10 53.3 min Mar-10 33 min 38%
RVAP Pre-Op Number of OR Cancellations due to patient not fit for surgery 2008/9 37 cancellations 2009/10 7 cancellations 81%
RVAP Pre-Op Pre-Operative Patient Visit- Number Patient Walking Steps/visit Jan-10 493 steps Feb-10 157steps 68%
RVAP Pre-Op Prescreening Process- Non Total Joint Network patients Feb-10 360 min Mar-10 60 min 83%
Before After
Program/Department Improvement Measure
20
Improvements in the Surgical Program
Pre-operative Screening Visit Redesign
Before:
•7.56 hours
average visit
length
•Patients
travelled to
various
departments
(Lab, ECG, DI)
•493 patient
steps
After Kaizen:
Patients stay
in one room
Visit length is
60 – 180
minutes
21
Before:
20% of patients
screened pre-
operatively
Surgery delayed due
to missing
documentation
Cancellations of
surgery because patient
not fit
After Kaizen:
90 – 100% of patients
screened pre-
operatively; some by
telephone
Surgeons‟ secretaries
book directly into pre-op
clinic schedule
95-100% of charts
complete one day prior
to surgery
100% of patients given IV
antibiotics pre-Total Joint
surgery as per national
guidelines
93% of patients ready by 30
minutes pre-booked Operating
Improvements in the Surgical Program
2222
Start of Kaizen End of Kaizen
Manual cycle time
(sum of time spent
for all staff
involved)
53.3 minutes 33 minutes
OR changeover
time
15.6 minutes 12.7 minutes
# of room exits to
clean room
12 5
# of operating
procedures
performed each
year at RVAP
6700
Reducing OR changeover time
on every procedure by only 3
minutes saves 335 hours per
year!
Operating Room Changeover Kaizen
Event
23
Hospitalist Worklife Improvement Kaizen Event
Start of
Kaizen
End of
Kaizen
Duration of
Hospitalist Meeting
(min)
35 5
Total Hospitalist
Time for Hospitalist
Assignment
(min/day)
35 10
# Process Steps 34 29
# Wastes 37 3
24
6S on Inpatient Medicine Unit - Before
24
Overall level of workplace organization and physical layout in the target areas
0%
0%
50%
42%
8%
0% 10% 20% 30% 40% 50% 60%
Excellent or
Very Good
Good
Poor
Non-existent
Number of Responses
50% of nurses
surveyed feel the level
of workplace
organization is poor
or non-existent!
25
1
79%
TBD
TBD
77%
68%
59%
Post-6S
35%
TBD
TBD
5%
18%
11%
Pre-6S
81%2W Audit Score – Clean Utility
Room
73%2W Audit Score – Medication Room
TBDAvg Monthly Medication Cost
TBDAvg Monthly Medical Supplies Cost
93%2W Audit Score - Hallways
44%Staff Satisfaction (n=12)
% ChangeMetrics
79%
77%
68%
59%
Post-6S
35%
5%
18%
11%
Pre-6S
81%2W Audit Score – Clean Utility Room
73%2W Audit Score – Medication Room
93%2W Audit Score - Hallways
44%Staff Satisfaction
% ChangeMetrics
79%
TBD
TBD
77%
68%
59%
Post-6S
35%
TBD
TBD
5%
18%
11%
Pre-6S
81%2W Audit Score – Clean Utility
Room
73%2W Audit Score – Medication Room
TBDAvg Monthly Medication Cost
TBDAvg Monthly Medical Supplies Cost
93%2W Audit Score - Hallways
44%Staff Satisfaction (n=12)
% ChangeMetrics
79%
77%
68%
59%
Post-6S
35%
5%
18%
11%
Pre-6S
81%2W Audit Score – Clean Utility Room
73%2W Audit Score – Medication Room
93%2W Audit Score - Hallways
44%Staff Satisfaction
% ChangeMetrics
26
Reducing Time that Ambulance Crews Spend At
Our Hospital
Email dated December 4, 2009:
“Here is a graph showing average in-hospital [ambulance offload] times at Centenary for the period January 2006 through November 2009. The system wide average (which includes RVC) is also on the graph. As you will see, you average time have plummeted, and are now substantially below the system average. Great numbers that show the work you have put in and the commitment of the hospital to work on the problem.
Thanks for all you help.”
Peter
Manager, Hospital Offload Delay Program, Toronto EMS
Average In-Hospital Time (Minutes)
30
35
40
45
50
55
60
65
70
75
80
Jan-
06
Mar
-06
May
-06
Jul-0
6
Sep
-06
Nov
-06
Jan-
07
Mar
-07
May
-07
Jul-0
7
Sep
-07
Nov
-07
Jan-
08
Mar
-08
May
-08
Jul-0
8
Sep
-08
Nov
-08
Jan-
09
Mar
-09
May
-09
Jul-0
9
Sep
-09
Nov
-09
RV Centenary System Average
Kaizen Event
27
Key Success Factors for Sustainability
of Lean Transformation
27
Clear Strategy and Expectations
Invest in Building Internal Capacity
Leadership Attention
Performance Measurement
28
Clear Strategy: Our Lean Transformation Model (4x4x4)
4 Transformation
Themes
4 Lean Strategies
Access to Care
•Length of Stay in
Emergency
Department
•Wait Times for MRI
and Surgery
Service
Excellence
•Mortality Rate
•Infection Rates
•Patient
Satisfaction
Team
Engagement
•Employee Sick
Time
•Participation in
Lean activities
Fiscal
Responsibility
•Operating Margin
•Cost per Case
•Working Capital
Access to Care
•Length of Stay in
Emergency
Department
•Wait Times for MRI
and Surgery
Service
Excellence
•Mortality Rate
•Infection Rates
•Patient
Satisfaction
Team
Engagement
•Employee Sick
Time
•Participation in
Lean activities
Fiscal
Responsibility
•Operating Margin
•Cost per Case
•Working Capital
4 Dimensions to
Measure Our Success
Patients First
One Team Inspired & Involved
No Waste
Earn Our Reputation as the Best Every Day
Engagement
Sustainment
Spread
Improvement
2929
Clear Strategy: Our House of Rouge
30
Clear ExpectationsSTAR: A framework to promote the continuous evolution of Lean
STANDARDAll of the following are in place:
• Process Control Boards
• Performance Trending
Boards
• 6S
• A3
• Rounding
• Kaizen Participation
• Leader Training
ADVANCEDAll of the following are in place:
• Sustainment of Standard
level
• Kamishibai
• Safety Calendar (could be
part of kamishibai system)
• Idea Board with problem-
solving huddles
• Department leads and
sustains its own kaizen
events (at least 2 per yr)
ROLE MODELAll of the following are in place:
• Sustainment of Standard and
Advanced levels
• Internal knowledge sharing(joint kaizen with another dept;
facilitator for another dept‟s Lean
event; lead an in-service; internal
article or poster presentation)
• External knowledge sharing(e.g. joint kaizen event with
external partners; conference
presentation; published article)
• Use of one or more higher-
level Lean tools (e.g. Kanban,
Andon, SMED/changeover, etc.)
2010/11
2011/12
2012/13
90%
100%
10%
100%
0%
10%40%
67% 33%
31
System of Daily Audit
Checks Completed by
Staff
Note: Check the items listed on this card to
assess compliance. If good, insert the card
into the slot with “green” side showing. If
issues are found, please place card in slot
with “red” showing and document corrective
actions on board.
Note: Check the items listed on this card to
assess compliance. If good, insert the card
into the slot with “green” side showing. If
issues are found, please place card in slot with
“red” showing and document corrective actions
on board.
Please check for all of
following:
1 Ultrasound machine in
Resus
1 Glucometer in Resus
2 Thermometers in Triage,
1 Thermometer in Resus
1 EKG in Triage 1,
1 EKG in Resus
3 Vital Sign towers in Triage
2 Portable Monitors
1 IV/Lab tray in Triage,
1 IV/lab tray in Resus
Fail Criteria:
Equipment is not being used
and is not in designated area.
(Please return found
equipment to designated
areas and document issues
and corrective actions on
board.)
Please check for all of
following:
1 Ultrasound machine in
Resus
1 Glucometer in Resus
2 Thermometers in Triage,
1 Thermometer in Resus
1 EKG in Triage 1,
1 EKG in Resus
3 Vital Sign towers in Triage
2 Portable Monitors
1 IV/Lab tray in Triage,
1 IV/lab tray in Resus
Pass Criteria:
All equipment is in designated
area(if not in use).
Area: Triage and ResusArea: Triage and Resus
Card: #4A
Equipment
Card: #4A
Equipment
Note: Check the items listed on this card to
assess compliance. If good, insert the card
into the slot with “green” side showing. If
issues are found, please place card in slot
with “red” showing and document corrective
actions on board.
Note: Check the items listed on this card to
assess compliance. If good, insert the card
into the slot with “green” side showing. If
issues are found, please place card in slot with
“red” showing and document corrective actions
on board.
Please check for all of
following:
1 Ultrasound machine in
Resus
1 Glucometer in Resus
2 Thermometers in Triage,
1 Thermometer in Resus
1 EKG in Triage 1,
1 EKG in Resus
3 Vital Sign towers in Triage
2 Portable Monitors
1 IV/Lab tray in Triage,
1 IV/lab tray in Resus
Fail Criteria:
Equipment is not being used
and is not in designated area.
(Please return found
equipment to designated
areas and document issues
and corrective actions on
board.)
Please check for all of
following:
1 Ultrasound machine in
Resus
1 Glucometer in Resus
2 Thermometers in Triage,
1 Thermometer in Resus
1 EKG in Triage 1,
1 EKG in Resus
3 Vital Sign towers in Triage
2 Portable Monitors
1 IV/Lab tray in Triage,
1 IV/lab tray in Resus
Pass Criteria:
All equipment is in designated
area(if not in use).
Area: Triage and ResusArea: Triage and Resus
Card: #4A
Equipment
Card: #4A
Equipment
Advanced Level Lean Tools:
Kamishibai
32
Advanced Level Lean Tools:
Safety Calendar
GYR
7 8 9 1 0
1 3 1 4 1 5 1 6
1 9 2 0 2 1 2 2
2 5 2 6
2 7 2 8
2 93 0
M o n th /Y e a r:
N o In c id e n ts
N e a r M is s
6
3
1 7
2 3
1 2
1 8
2 4
1 1
P A T IE N T S A F E T Y C R O S S
1 2
P a tie n t In ju ry
4
5
3 1
33
Advanced Level Tools: Idea Board
34
Invest in Building Internal Capacity
1. Transformation Management Office (TMO)
2. External Expertise (Sensei)
3. Training and Coaching
35
35
Michele Jordan,
VP Quality Improvement
and Transformation
Julie Goldstein
Director, Transformation
Vivian Chan,
Change Management
Specialist
Rita Frost
Project Coordinator
Fred Koeman
Change Management
Specialist
Catherine McConnachie
Change Management
Specialist
Transformation Management OfficeROLE OF THE TMO
Support program and
department leaders in
making successful
transformational change in
their areas including:
Facilitate improvements in
quality and processes;
provide a “safety net” for
Deficit Elimination Plan
resource reductions
Build capacity in the
organization to ensure
sustained excellence with
strengthened leadership
and a renewed culture
36
• Teaching through questions
• Challenging paradigms
• Keeping you from making big mistakes
• Guiding from experience
• Helping you learn from little mistakes
• Encouraging learning-by-doing
• Leading the team from the back
• Leadership by example
Role of A Sensei:
External Expert Resources - Reduced
Reliance on External Resources Over Time
37
Leadership Attention
38
Personal Business Commitments (PBCs) Provide
a Leadership Accountability Framework for
Transformation
Extract from 2010/11 Chief Executive Officer PBCs:
Dimension SERVICE EXCELLENCE
1 a) Lead the continued rollout of Lean as our enterprise-wide management
philosophy to support the transformation of RVHS culture and sustained
improvement of RVHS processes.
– Metric: 90% of all departments achieving minimum standard for Lean at RVHS
by March 31, 2011.
– Metric: 70% of Kaizen improvement metrics to show they are meeting targets or
an upward trend in performance within 90 days of the completion of the event.
38
39
Other Strategies we use to Channel
Leadership Attention
• Transformation Rounds (twice per month by entire
senior team)
• Regular Senior team walkabouts with the CEO
• Transformation Updates in monthly Leadership Forum,
Town Halls and President‟s Blog
• Transformation Update standing agenda item in key
meetings such as Medical Advisory Committee; part of
President‟s Report to the Board
• Presentation on Transformation at every orientation
session for new staff
• Senior leaders deliver workshops on Lean topics
• Lean Leadership Culture Survey conducted every 6
months
Visibility
Communication
Role Models
Self-Reflection
4040
Performance MeasurementSome of the Lean Performance Indicators Tracked
40
Cumulative number of staff involved in at least one lean activity
Cumulative number of physicians involved in at least one lean
activity
% of kaizen metrics meeting target or on an upward trend 90 days
after the kaizen event
Average Score on kaizen event evaluation forms
% of departments meeting all standard level requirements in the
STAR framework
Annualized potential hours saved through kaizen events
41
The Patient Perspective on Lean
Email dated February 26, 2010:
“THANK YOU for inviting a „consumer/resident/volunteer/patient‟ to participate in this event. It is so refreshing to work with front line workers who really know the system and can make a difference for the patient and family. I have confidence that you will make progress in the future processes and touches with the patient and commit to advocating for many of the changes you have outlined to the various levels of government and agencies responsible for health care.
I am a believer in the lean process and hope to participate again with more agencies involved in the continuum of health care and in particular, in driving a “senior friendly environment” into our hospitals.
Again, thanks!”
Randy
Randy
4242
In Summary
Almost all areas of the hospital have made some form of Lean improvement
Financial and operational stability have occurred at the same time as we have preserved or enhanced the quality of care
We are building internal capacity to deploy and sustain Lean over the long-term consistent with LHIN and Ministry directions
Cultural Change is happening (greater trust, transparency and accountability; Lean terminology is widely used; high use of A3 thinking)
Voluntary turnover is down and 2010 staff survey results indicate that trust, involvement in decision-making and satisfaction with the organization have increased since 2008
Physician leaders are engaged
Lean used to support corporate priorities including accreditation, enterprise risk management, redevelopment, pandemic planning
Positive change in our reputation with our community partners (e.g. LHIN, CCAC, EMS, TSH); joint kaizen events with other health care organizations
Growing external recognition for our achievements
43
Lessons Learned
Challenges
Lessons Learned
44
Challenges
• Competing priorities
• Organizational fatigue
• Unionized staff
• Skepticism
• Negative perceptions of the term „Lean‟
• Staff concerns about job security
• Resistance to change
45
Lessons Learned
1. Strong, ongoing, united leadership commitment is ESSENTIAL
2. Lean is harder for leaders than for frontline staff
• They must learn to lead differently
• They must be visible in the „gemba‟
• They must empower staff to find solutions
3. Lean is 80% culture and 20% tools
4. Don‟t use Lean as a cost reduction mechanism – use it to drive quality
improvement and team engagement (good quality costs less!)
5. Lean must be embedded into the organizational strategy and
management approach – not an extracurricular activity
6. Lean is not a project – it is a journey
7. Physician involvement is critical – but be strategic about it
8. Communicate, Communicate, Communicate
45
46
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