applied systems improvement processes · • 5 principles of csi • value & waste • process...

1

Applied Systems Improvement

Processes

MTS – Day 2

Clinical Systems Improvement

www.warwick.ac.uk/go/csi

Yesterday’s programme

• 5 Principles of CSI

• Value & Waste

• Process Mapping

• Leadership & Teams

• Lean simulation

– Batch sizes

– Quality

– Improved flow

– Matching resources with demand (takt time)



Today’s programme

9.00am Review of Day 1 and simulation activity

9.15am Introduction to problem solving tools & visual management

10.15am Project management & action plans

11.00am Coffee

11.15am Managing change and sustainability

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TodayTodayTodayToday’’’’s Objectivess Objectivess Objectivess Objectives

By the end of today’s session you will:

• Have continued to challenge the way that you and your colleagues think and act in the workplace

• Have gained an understanding of project management, problem solving & visual management

• Have gained an appreciation of the integration between patient safety & systems improvement



“In God We Trust …

- all others must bring data”

W Edwards Deming

Problem Solving



Describe a Problem

As a variation from standard

Speak with Data

Do it yourself

Or see the operation in progress

3



Problem Solving

The actual place

The actual workstation

The actual thing

The actual facts

The actual peopleDon’t ‘problem solve’ in the office!(you can’t see 5S, SOPs, etc.Memory is short….)



Attitudes

Not

“we tried that before”

“it didn’t work”

“it can’t be done”

“why should I ?”

“it’s not my problem”

But

“we can always get

better”

“we can do it”

“lets work out a solution

together”

“it’s great to see our

improvements in place”



Problem Solving Steps

Concern

Problem definition

Data collection

Change Analysis and Barrier Analysis

Root Cause Analysis

Countermeasures identification

Countermeasures implementation

7 Tools Methodology

3C’s: Concern, Cause, Countermeasure(plus Who, by When, PDCA stage )

4



A well-defined problem

It focuses on the gap between what is and what should be

It states the effect

It is measurable

It avoids ‘lack of’ and ‘no’ statements (that imply a solution)

Can include the significance of the effects

Ammerman (1998)



Problem Analysis:

Task Analysis & Data

Go to and walk the area

Draw a map

Collect the 6 Honest Men



The 6 Honest Serving Men

– What do we need to do? Target/measure

– Why do we need to do it? Objective/aim

– When does it need to be done? Time frame

– Who should do it? Person/role

– Where should it be done? Location/place

– How ought it to be done? Method/logic

5



6 Honest Men with Is/Is NotIs / Is Not was developed by Kepner-Tregoe

What

(Why)

When

Where

Who

(How)

Is Is Not So...



6 Honest Men with Is/Is NotIs / Is Not was developed by Kepner-Tregoe

What

(Why)

When

Where

Who

(How)

Is Is Not So...Not 100%

satisfied with course

Too fast Content

Start time End time

Too cold Seats, visibility

John Norman



Problem Analysis:

Change Analysis & Barrier Analysis

Change analysis’ 3 Questions:

– What was different about this time from all other times?

– Why now, not before?

– Why here, not there?

Barrier analysis

A control barrier is an administrative or physical aids or devices to ensure safety or enhance performance. For example,

barriers to reduce road deaths include seat belts, speed

limits, driver’s licence, airbags

The method first identifies all barriers, then evaluates their

effectiveness or use, and how or why it failed. Ask what

barriers are necessary to prevent recurrence.

After Max Ammerman,

The Root Cause Analysis

Handbook, Productivity, 1998

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Problem Analysis:Root Causes

A root cause is the most basic reason for a

problem which, if corrected, will prevent

recurrence of the problem. A root cause is

different from a presumed cause and a

contributing cause.

Methods – include:

Barrier analysis

Fault tree analysis

After Max Ammerman,

The Root Cause Analysis

Handbook, Productivity, 1998



The 5 ‘Whys’

All problems have an immediate cause. This cause is usually a symptom – not the real problem

Using the 5 whys the root problem is identified

Only by identifying the problem can it be prevented

If a symptom is treated it could worsen the problem!

Use this 5 whys with brainstorming and as a way to gain buy in from the team



5-Why Analysis

What is it?

Asking ‘why’ several times over

Used to identify the root cause – help to see beyond the symptom of the problem

When do we use it?

To get to the root cause of a problem with an unclear solution

To understand why a situation might be getting worse

Why? Why? Why? Why? Why?Why? Why? Why? Why? Why?

7



5 Whys

Addressing the root cause should provide a sustainable solution (rather than fixing the

symptom)

Long term solution v short term fix

Never accept first reason – try and probe

behind the answer

If feels too confrontational – ask ‘How does

that happen” x 5 times



5 Whys

Problem

Why?

Why?

Why?

Why?

Why?

Why?

Why?

Why?

Why?

Why?

Why?

Problem Root causeWhy? Irrelevant do not explore further

Why?Found root cause look no further



5 Whys

Discharge

Was delayed

For 2 days

Patient

Needed a

Cardiac

Referral –

Which

Could not

Happen

Until 2 days

later

The cardiac

Referral

Note was

Not sent

Out until

The day of

discharge

The referral

Was not

Handed

Over

During the

Shift change

When it was

Handed over

Not known

Patient to be

Discharged

Next day

Oversight

During shift

handover

No expected

Date of

Discharge

given

No handover

Checklist

To prevent

oversights

No system

For capturing

Expected

Date of

Discharge &

Displaying it

Problem

Why? Why?

Why?

Why?

Why?

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Need to prioritisethe issues

Need to identify those solutions that will have greater impact for minimal effort

Resources will not allow us to implement all

the solutions at once

So need to prioritise our efforts



Problem/countermeasureAnalysis

Aids project management

Assist to systematically list and prioritise problems & solutions

Provides a timeline & identifies

responsibilities

Keep visible and accessible



Cost-benefit Analysis

T T

T T

BenefitHigh Low

Co

st

Hig

hL

ow

OS

OS

OS

OS

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Cost-benefit Analysis

T T

T T

BenefitHigh Low

Co

st

Hig

hL

ow

OS

OS

OS

OS

Low cost but high

Benefit area

Low cost but low

Benefit area

High cost but highBenefit area

High cost but lowBenefit area

Team – no outside support

required

require outside

support

1 2

3 4

5

6

7

8



Problem/Countermeasures

No Concern/ideaRaised

by

Countermeasure/Action

Resp Timing StatusSign

off

Shade one quadrant each for1. Responsibility identified

2. Trial done3. Discussion had4. Implementation completed

1

23

4



Measures of Success

Try and devise TEN key measures that will demonstrate:

• the success you are having in your job,

• the value you are giving to your customer

• the waste you are eliminating.

Handout-ten measures

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Visual Management

“I hear, I forgetI see, I remember

I do, I understand”



Visual Management

What is visual management?



Visual Management

There are two forms of visual management:

Visual organisation in the ward area to make it easier to visualise (operational):� what is happening – flow of patients in the ward (ward board)

� If a problem occurs – equipment missing

� Guidance and control – where to put trolleys, maximum stock levels

Graphical data and information� Day to day operational data – shifts, meal rounds, medicine

rounds, discharge planning

� Reference data –ward blueprint, standard operating procedures

� Planning information – holidays, rotas, training

� Project progress sheets – problem follow ups/ corrective actions

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Visual Management

Has two main functions:

To manage the process

� To maintain the current operations

� Identify and communicate abnormal conditions

To improve the process

� Operations – defines and communicates known standards

� Communicates – allows informed improvement

decisions to be taken



Visual Management

Visual Management is the back bone of systems improvement

It builds on all tools like 5S, PDSA, SOPs etc to enable

– System Maintenance (maintain current position) and

– System Improvement (move to ideal state)

Visual Display versus Visual Control



Visual Management

Visual management involves the clear display of charts, lists, process etc. so that

all staff are continuously reminded of all

elements that make safety, quality, cost

and delivery of care successful.

Important to remind ourselves where we

started from…(storyboards)

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Sort

Straighten/Simplify (Set in order)

Shine

Standardise

Sustain

5 S standards

Not

Used

Sustain the gains

1 2 3 4 5

5s used to create a highly visible and

organised working area

Handout-5S



Sort (Organisation)Separate what is needed from what is not needed. Keep only what is needed, only in the amounts needed, and only when it is needed. Remove unnecessary items.

Not

Used

S1

Set in Order (Orderliness)S2Arrange needed items so they are easy to find and use. Label items so their storage sites are easily understood by anyone. “A place for everything and everything in its place.” Implement visual control. M

ake things

easy to find and

use



Remove dirt, mess, clutter and dust from the workplace. Keep everything clean and tidy.

Sweep & Shine (Cleanliness)S3

Clean the work area

Make sure that Organisation, Orderliness, and Cleanliness are being maintained and incorporated into everyday activities.

StandardiseS4

Operate according to standards and procedures

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Making a habit of properly maintaining correct procedures and continuously improving workplace conditions.

SustainS5

Sustain the gains



BEFORE 5S

AFTER 5S

Source: NHS Institute



More appropriate stock levels – based on clinical need

BEFORE 5S

AFTER 5S


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Endoscopy team undertaking a 5S activity to create a visible, high performing workplace

Excess stock that is not required (Sort) – How much does this cost to

keep?Source: NHS Institute



All this was in the cupboard but what not required – over 60 packs

Endoscopy Room 1 – Hereford Hospitals




Endoscopy Room 1 – Hereford Hospitals

BEFORE AFTER

Sort, set in order, clean, standardise


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Stock levels reviewed and standardised. Clearly labelled

Sort, set in order, clean, standardise

Endoscopy Room 1 – Hereford Hospital




Where can you use 5S?

Have a go at using 5S to organise your e-mail inbox

Handout lean e-mailing



Visual Management

Should be integrated into 5S and Standard work

Aim is to be able to gain maximum operating information and control without having to go off the ward, or go into a computer system

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Advantages of Visual Management

Simply provides rules/guidance for daily working (ward boards etc)

Simply provides information to stimulate focused improvement and decision making (transparent)

Identifies and tracks problems/issues enabling root cause improvement –reduces errors

Informs all about current performance and trends (see how we are doing)

Assists those new to the system (Bank and Agency, Locum, Junior Doctor etc) to learn quickly

Contributes to sustainability

Source: Rich et al., 2006



Operational Visual Management

People – a skills matrix (or I L U O chart)

Material – Stock replenishment, footprints

Maintenance – A red tag board showing all outstanding concerns

Problem solving boards and Andons (stop the line authority)

5S – Charts, audits

SOPs – Visual if possible, T-Cards (coloured cards – reversed when checks completed)Source: Rich et al., 2006



Operational Visualisation

3 boxes max.

Rich et al, 2006

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ILUO Chart

Name Mapping 5S Problem Mentoring

Solving

J BloggsI I I

T Smith L L U O

I

I I L

L Jones

P Clark

U U O OR Thomas

Projects

Meals

Well organised ward, meals, medicines

Well organised ward

Medicine round

Meals, well organised ward, toolkit

Key

I

L

U

Not yet started

Awareness, education

Participated in activity, completed with support

Led an activity

O Able to train others

Source: Adapted from Rich et al., 2006



Communications Board Measures

Displaying data relating to daily operating and the strategic vital few (limited number of measures)

Usually the responsibility of the area supervisor/manager

to update

Is the basis for understanding if the system design is fit for purpose and enables responsiveness to change (does the system deliver the desired outcomes?)



Visual Management

Visual Management is the ‘Litmus test’ for Lean (Bicheno, 2004)

If you find that the following are not immediately apparent and up to date

Standard Work

Work (patient) flow

Problem Solving Process

Quality

Maintenance

Safety

Then it is unlikely the organisation is ‘lean’

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Examples of visual Examples of visual

managementmanagement

Safety, Quality, Cost & Delivery should be the main measures displayed

Handover times, meal round times etc – regularly reviewed/graphed to avoid slippage

Skills matrix – beginner to instructor

Employee suggestions

5S – display area for responsibilities & 5 minute clean up plans – use shadow boards

Storyboards – stages of RIE events – successes



What the patient display board looks like

The consultants are

colour-coded so you can see who is caring for which

patient

The board is a map of the ward so you can see

the physical location of the patient

A traffic light

system is used for patient status

Magnets are used for patient status so they can be easily added

and changed

The ward

team areas are clearly

marked

Board is now used in shift handover – time cut from ~90 min

to ~60 min

Used for quick patient information reference

Allow staff to work backwards from EDD

The nurses on each

team are listed on the board



A ‘good’ patient display board

3

Status

8 Feb

9 Feb

CBC, Chem

X-ray

CBC

CT Scan

Bed #

N Ahmad

J Smith

I Taylor

C Stone

EDD

Dr.

XD

r. Y

Dr.

Z

Name* Tests done –

Waiting for Results

Tests to be done –

date due

Discharge Steps

A Adams

B Brent

C Clarke

M Stewart

T Walton

A Waters

1

2

3

4

4

5

6

7

8

9

8 Feb

12 Feb

8 Feb

8 Feb

9 Feb

X-Ray

UA

CT Scan – 8 Feb

CBC – 7 Feb

Status

8 Feb

9 Feb

CBC, Chem

X-ray

CBC

CT Scan

Bed #

N Ahmad

J Smith

I Taylor

C Stone

EDD

Dr.

XD

r. X

Dr.

YD

r. Y

Dr.

ZD

r. Z

Name* Tests done –

Waiting for Results

Tests to be done –

date due

Discharge Steps

A Adams

B Brent

C Clarke

M Stewart

T Walton

A Waters

1

2

3

4

4

5

6

7

8

9

8 Feb

12 Feb

8 Feb

8 Feb

9 Feb

X-Ray

UA

CT Scan – 8 Feb

CBC – 7 Feb

Patient’s

location

Patient’s

name

Consultant’s Name

Estimated

discharge date

Current status

of the patient

Investigations to be done

Requirements for discharge

A ‘good’ patient board contains all the information required for its

specific purpose, e.g. shift handover or discharge management

A ‘good’ board is an importantpart of shift handovers and

discharge management. Please see the modules ‘Shift Handover’and ‘Discharge Management for

additional detail.

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Activity

What forms of visual management are used within your area of work?

What 10 measures could you employ and

display on your office board?



Project Management:

Allocating time & resources



Introduction toProject Management

Project management skills essential for those who manage complex activities &

tasks

Project management concerned with

anything: people, equipment, storage,

buildings, staffing & management, finance,

administration, training, quality of care, patient safety etc…..

20



Project management process

Agree precise specification for the project• Could adapt project poster template

Plan the project – time, team, activities, resources, financials

• Useful tip to work backwards from the end aim, identifying all the things that need to be put in place and done

• Brainstorming event will help gather most of the points & issues

• Establish the relationship and links between the issues/activities (some might run in parallel)

• Most projects do not complete on time – so don’t plan a timescale that is too ambitious. Ideally plan for some slippage if possible

Communicate the project plan to your team



Project management process

4. Agree and delegate project actions – once project starts ensure at project team meetings updates and actions are recorded (and the Gantt chart updated as necessary).

Manage, motivate, inform, encourage and enable the project team

Check, measure, review project progress, adjust project plans and inform the project team and others

7. Complete project, review and report on project performance, give feedback and thanks to project team



Critical path analysis

Is a logical and effective method for planning and managing projects

Start by noting down all the issues,

resources and activities in a rough order

– e.g. making a cooked breakfast

Note that some activities might happen in

parallel

Timescales can be applied to each activity

21



Critical path analysis

Start

Prepare ingredients

Prepare Cooking

equipment

Assemble

Crockery, Utensils &

condiments

Serve

Warm plates

Lay table

Toast bread

Poach eggs

Grill bacon & tomatoes



Gantt Charts

This can be constructed using MSExcel or a

similar spreadsheet

Every activity has a separate line

Create a timeline – usually weeks or possibly

months

You can colour code the time blocks to denote the

type of activity

You can schedule review points/meetings etc

Gantt chart can be used to track progress



Gantt Charts

You can use Gantt charts to report on planned versus actuals

But they don’t show the importance and

inter-dependence of related parallel

activities - the necessity to complete one

activity before another can begin – need to

use in conjunction with critical path

22



Serve

Toast bread

Poach eggs

Lay table

Grill

tomatoes

Grill bacon

Warm plates

Assemble crockery,

utensils etc

Prepare

equipment

Prepare ingredients

Gantt ChartActivity Time - minutes



RACI approach to project management

The ‘RACI’ model is used as a framework for project management. This model is used widely for both industrial and academic projects.

It states for effective collaboration, communication and coordination there is a need to establish who will be responsible, will be accountable, needs to be consulted and be kept informed.



RACI

Responsibility for a task refers to doing it or ensuring that it is done.

Accountability refers to the person who ensures that the tasks are done.

Consultation applies to a person/ team who provide an input or some involvement in the task. Can include a project team or steering committee

Information – how the outcomes of the project will be disseminated and to whom?

Can add these first three columns to your Gantt chart

23



JunMayAprMar

Project

team

Monthly

meetings

DRLC &

AE

Disseminate project

outcomes

DRAction -

DRSWCompile

countermeasures

DRSECost benefit analysis

DRSWCompile process map

DRAEVideo

process

Ward

mgrDRSWWaste walk

OctSepAugJulFebJanConsAccountability

RespActivities



Coffee break

11.15am Managing change and

sustainability12.00md Systems Improvement & Safety

1.00pm Lunch



Organisational change

Models of change:

e.g. Lewin’s – unfreeze, change & refreeze

Planned versus emergent change

Span of control

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Sustainability

Good

Poor

BeforeTime

Now Later

Idea

PDSA

PDSA

PDSA

Pe

rfo

rma

nce

Source: Improvement leader’s guide: Sustainability



Sustainability

“When new ways of working and improved outcomes become the norm” (NHSI 2007)

Maintain and hold the gains

Up to 70% of implemented organisational changes in industry fail (Daft & Noe, 2002; Beer & Nohria, 2001)

Up to 33% of health changes fail (1 in 4 fail to achieve objectives)

Initiative decay or improvement evaporation effect.



NHS SustainabilityModel

Is a diagnostic tool that is used to predict the likelihood of sustainability for your improvement project(s)

Guide teams to things they could do to increase the chances that the change for improvement will be sustained.

Best time to use the tool– Design or selection of initiative

– Time of initial pilot testing

– A few weeks after the improvement has been implemented.

www.institute.nhs.uk/sustainability

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Sustainability

1. SupportiveManagementStructure

2. Structures to foolproofchange so that

embedding takes place.

e.g. change inpolicy, provision

of resources

3. Effective delivery supported by

robust, transparent

feedback systems +

PDSA cycles

4. Effective collaboration &shared sense

of the systemsto be improved

5. Culture ofimprovement with engaged

staff & patients

6. Formal

capacity –building

programmes

Training & application ofimprovement

methods

Source: Improvement leader guide: Sustainability



NHS SustainabilityModel

Training & involvement

Attitudes

Senior Leaders

Clinical Leaders

Fit with goals &

culture

Infrastructure

Benefits

Credibility of

evidence

Adaptability

MonitoringProgress

10 Factors – sustaining

Change in healthcare

Numeric value for

each factor

StaffOrganisation

Process



Enablers of CSI

Encourage and support team decision making

Make sure that there is time (10 minutes)

dedicated to maintaining 5S standard – (first

three Ss covered in training, final 2 elements can

only be adhered to on a day-to-day basis)

This can be done at the start or end of a shift or

during a quieter period

Team to create a weekly 5S check sheet that is

signed off by managerSource: Bateman & SMMT (2001)

26



Enablers of CSI

Ensure there are measures to monitor improvements – at ward level.

These need to be visible and kept up-to-

date.

Periodically review that these are still

appropriate and the data are being

presented in a useful way.

Source: Bateman & SMMT (2001)



Enablers for Continuous Improvement

Dedicated person to co-ordinator SI activities

Senior managers should be involved in SI activities (and stay focus on SI)

Ensure all new procedures or activities are formally introduced to all staff (include in induction?)– Not everyone will be involved in improvement

activitiesSource: Bateman & SMMT (2001)



Who is responsible for sustainability?

How long should a change be sustained?

Can you measure sustainability?

Do you perceive any issues around sustainability?

If so, how do you think these can be

overcome?

27



Video

Make notes on any learning from the scenario in the video that can be applied

to the NHS

The worksheet may help you

Please try to develop a root cause analysis

approach

Handout- Kegworth



Video



Lunch break

1.45pm Systems Improvement & Safety

2.15pm Lean meetings2.30pm Strategy & policy deployment3.00pm Tea

28



Group discussionImprovement and Safety



Group discussion –lean meetings

Handout- lean meetings



Strategy and Policy Deployment

29



Tea break

3.15pm Facilitated discussion - future application of learning 3.45pm Summary, feedback & questions 4.00pm Close



Future application of CSI

Completion of handout – reflection

What will you change/challenge

Your 10 noticeboard measures



Organisation:: Contact Name: Last Updated:

Project: Problem definition sheet

What do we need to do? What is the problem?

What wastes exist? Are they effects or root causes to the problem?Target/measure (vital few) and how will these help us know

that the problem is resolved?

What is the Current State?What is the Desired Future State?

Why do we need to do it? Objective/aimOne sentence statement plus two or three objectives/hypothesesSpecific

Measurable – data (quantify)Achievable

RealisticTimeframe

Customer identification & value

Who is the customer(s) of the project/process area

And what do they value (wants, needs, demand)?

When does it need to be done?

Timeframe

What does the team think will be achieved in the

CSI time frame?

Who should do it?

Members of the team & roles

Where should it be done?

BoundariesArea of improvement

How ought it be done?

Method

Available as handout

30



Models for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Plan

Do

Study

Act

Source Langley et al., (1996), The improvement guide: a practical approach to enhancing organisational performance.

Handout-Nolan



Some of the barriers to clinical systems improvement

Lack of top management buy-in

Failure to align to organisational goals

Short term view

Unrealistic expectations

Middle management blockages

Sustainability issues

Too many measures

Lack of empowerment

Cultural inflexibility



Have we achieved course objectives?Challenge current way of thinking

Introduce the key principles of clinical systems improvement

Understand the role of value and waste

Introduce problem solving & project management tools

Consider how patient safety & CSI are closely aligned

31





Evaluation & expectations



Questions:

[email protected]

Email subject: CSI MTS question

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Thank you & have a good journey home

applied systems improvement processes · • 5 principles of csi • value & waste • process...

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