Quality Forum 2013

BC Provincial Lean Network

Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders

BC Provincial Lean Network:Background

• Lean Network established in January 2010• Provides expert advice to the Ministry on the Lean

KRA and deliverables• Coordinates Lean activities• Champions the use of Lean in HAs• Partners with the MOH to ensure KRA deliverables

are met

BC Provincial Lean NetworkNetwork Members

• Rena van der Wal (VCH)• Jennifer MacKenzie (PHSA)• Erin McGarvey (IH)• Mélie De Champlain (VIHA)• Bonnie Urquhart (NH)• Eric Demaere (FH)• Emmy Beaton, Frances Bryan and Kevin Samra (MOH)

BC Provincial Lean NetworkObjectives

• To promote the reduction of waste and increase value (efficiency and effectiveness) in the health care sector through the use of Lean methods.

• To create ways to share best practices, tools and promote collaboration across health authorities.

• To develop and share best practices in Lean education and training materials between the health authorities

• To foster an environment receptive to innovation, change and ongoing improvement.

• To document, quantify and monitor the gains of Lean initiatives.• To identify best practices (Lean initiatives) that should be implemented

system wide.• To integrate Lean thinking into new capital projects and planning.

Provincial Lean NetworkCo-Chairs: Kevin Samra (MOH) & Rena van der Wal

(VCH)

BC EducationWorking Group

Chair: Marg Seppelt (PHSA)

BC MetricsWorking GroupChair: Kate Yang

(VCH)

BC Community of Practice Working

GroupEric Demaere (FH)

BC Facilities Working Group

Rena van der Wal (VCH)

BC Provincial Lean NetworkSession Today

• Provide an opportunity to share our best practices and our learnings– What is working – what is an opportunity for

improvement

BC Provincial Lean NetworkSession Today

• Hear the presentations – it is not so much about the specific area of focus - listen for the themes– Successes– Challenges – Are they similar or different than yours

• Be prepared to share your learning and ask questions• Let’s talk about what you can take back to your practice on

Monday• What can the BC Provincial Networks do to support your work?

Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders – Part 1:

Improving Quality for Cardiac Device Implantation (Session E8)

Minnie Downey, Program Director, Cardiac ProgramShahzad Karim, Medical Director, Cardiac Surgery

Objective

• Cardiac and Surgical Services implemented a regional Implantable Cardiac Electrical Devices (ICED) program to:– improve patient access to services,– consolidate implant sites,– enhance efficiency of scheduling device implants

and replacement, and– standardize and integrate pre and post procedure

care in accordance with evidence informed practices.

Background• Patient dies waiting for a pacemaker,• Fasting for >3 days waiting for implant,• Implant cases cancelled/delayed due to

inconsistent physician availability,• Patients inappropriately prepared,• ISSUE:

– Capacity for 900 cases, actual 1400,– Budget for 1000 implants, actual 1400,– Inconsistent processes, and fragmentation,– Inconsistent physician availability.

Current State – pre change

• Pacemakers implanted at RCH, ERH, BH and SMH, ICD/CRTs implanted at RCH,

• SMH and BH worked independently,• All implants had an anethetist present for the

procedure,• IP frequently waited 10 days for implants and

were often added to OHS slate, or implanted during emergency OR time, and

• Pre and post orders were site based and not coordinated across the region.

Solution

Consolidation from four site model (RCH, ERH, SMH, BH) to two regional sites (RCH, JPOCSC),

Standardization of clinical practice tools, processes, inventory management, patient transfers, centralized intake,

Integration of Intra-Procedure care implant team, including the use of an AA for preselected cases.

Results

• Reduced duplications and redundancies,• Improved patient access – PPM wait list

reduced from 110 to 40, ICDs from 30 to 3,• Pacemakers are performed 5 days a week, ICD

CRTs weekly,• PPM IP implants within 72 hours and OPs 6

weeks – meeting or exceeding national stds,• No cancelled days due to resource availability,

Next Steps/Sustaining the Gains

• Comprehensive evaluation in progress,• Moving from project to operations,• ICED Phase 2 planning in progress:

– Post implant follow –up,– MUSE and PaceArt software integration,– Remote monitoring,– Integration of EOL care and ICD management,

• Continuous Quality Improvement• Share learnings internally and externally,

Lessons Learned

• Engagement with stakeholders early, • Cast the ‘net’ wide,• Develop the change in collaboration with

team members,• Prepare for the unexpected,• It is a lot of work – but it is worth it,• Effective communication, • Plan, Plan, Plan.

Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders – Part 1:

The Patient’s Journey Within the Continuum of Care: The New Nanaimo Emergency Department(Session E8)

Drew Digney, Executive Medical Direct, Site Chief, Nanaimo Regional HospitalSuzanne Fox, Director, Emergency Services & Trauma Care, Nanaimo Regional

Hospital

Objective

• Opening New Emergency Department

• Electronic Health Record

• New geography

Background

• 54,000 pts in small space 3x the size

• Vision development• Visionary Team • Engagement of team • LEAN – value stream mapping

Current State

• Integration

Change in staffing models Developed new patient flow (PES) Electronic methods Communication requirements Changed materials management

Solution

• Employee engagement/champions• Vision• Team approach established despite

the new ED • Implementation is key to success• Barriers were identified when the focus was

not on the patient/clinician interaction

Results

• A Place Where People Want to Work• MHAS – right patient, right place, right clinician• Better tracking, documentation and

communication • Legible clinical documentation to community GPs• Improved communication• Eliminated need for clinicians to deal

with stocking

Next Steps/ Sustaining the Gains

• Visioning session• Continued focus on patient/clinician

interaction• Sustainability of current solutions prior

to new initiatives• Revisit LEAN value stream maps

Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders – Part 1:

Improving Post-Renal Transplant services (Session E8)

Clare Bannon, Clinical Nurse Leader, Renal TransplantGary Nussbaumer, NephrologistTom Tautorus, Director of Quality

Disclosures

• None Relevant to this talk

Improving Patient SafetyRenal Transplant Clinic

• What is the problem• What was the approach• What is the solution

The Problem

• Exceptional Distribution Renal Transplants– Health Canada Regulations– Informed Consent

• Patients at increased risk of infectious disease transmission

– Inconsistent Communication• Organ Retrieval• Different Health Care providers involved• How is peri-transplant information communicated to

post transplant team?

Current State

• No clear or systemic process to ensure appropriate follow-up occurred.

• Communication/Documentation– Donor procurement – in-patient chart – post

transplant clinic – regional transplant center• Form was not 3-hole punched

Approach

• LEAN process used to document current state, identify problems, propose and implement solutions

Solution

• Standard Operating Procedure was developed and a process implemented

• Stakeholders involved– Pre-transplant Clinical Nurse Leader, BC Transplant Organ

Donation and Hospital Development (CDHD) Coordinator, BC Transplant Quality Assurance specialist, in-patient clinical leaders, post transplant care team, Infectious Disease leaders at BC Centre for Disease Control and SPH renal medical director

Solution

• Created a process that supports transfer of all pertinent information– Pre, peri, and post transplant areas (including

regional clinics)

Exceptional Kidney Distribution Process

Exceptional Kidney Distribution Process

Kidney Donation Identified

Donor Evaluation (MHSQ)

Risk identified and documented

Organ acceptedRecipient identified

Kidney in cooler with forms to OR

QA reviews ED form for disease

transmission

If risk, QA faxes follow-up form

Risks identified during retrieval

RPR not available STAT

Could require more tests

ED form part A (white) goes to

donor chart. Yellow copy to QA

(BCT)

Organ offered to nephrologist

Recipient arrives at hospital

Recipient informed of ED

Transplant surgeon/physician

signs part B

Pink and goldenrod forms go with cooler to

OR

Pink form surgeon signs part B and returns to BCT

Goldenrod goes to chart

Transplant occurs

Recipient goes to ward

Patient discharged day #4 and chart

to Medical Records

Non-standardized follow-up

Current ProcessAdditional

Information

ABO and virology results sent to 6B

- ODHD/BCTS send preliminary culture reports and final faxed cover sheet with

recipient name and donor ID- ODHD always pages nephrologist on

call if positive results

Where do faxes go?

- recipient chart- doctor’s file

Need to determine

Solution

• Safety Checks Established– BC Transplant faxes ED form to Post-Transplant as

a cross-check to ensure no cases are missed.– If patient transfers to another clinic, the ED status

is now included on the transfer form– Yearly audit done for all patients to ensure

screening bloodwork has been completed

Results/ Expected Results

Expected results are that 100% of patients will have appropriate follow up in the post transplant period at 4, & 8 weeks, 6 months and 1 year

Acknowledgements

Clare BannonJennifer ChowAmable Cruz

Camille RozonTom TautorusMichele Trask

• With the support of the Entire Kidney Transplant Team

Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders – Part 1:

Leading the Transfer of Care for Cardiac Patients from Cardiac OR to Pediatric Intensive Care Unit (Session E9)Tracie Northway, Strategic Project Manager, BC Children’s & Sunny Hill Health

CentreBarb Fitzsimmons, Senior VP Patient Care Services, BC Children’s Hospital &

Sunny Hill Health Centre

Objective

• The aim of this initiative was to streamline & standardize a safe admission and handover process of cardiac patients from the Operating Room to the Paediatric Intensive Care Unit.

Background

Background• Historically, post-op cardiac surgery

patients unstable• Identified need• Largest post-op group• Cluster/flock care• Chaos• No clear communication• Missed critical information• Delays in care• Previous improvement attempts had failed

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Current State

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0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5 4.2

2.8

1.5 1.51.2 1.3

0.7

Cardiac OR to PICU Handover of Care: Pre-Kaizen Average Defects per Handover

(6 Handovers)

Defect Category (n=# of occurences over 6 handovers)

Aver

age

Defe

cts/

Hand

over

• Team selectionPICU: staff nurse; charge nurse; quality & safety

lead (lead)Cardiac OR: anaesthesia assistant, anaesthetist; clinical resource nurse; perfusionistExternal: imPROVE facilitator (sub-lead); vice president; corporate executive assistant

Content experts: PICU physicians; cardiac surgeons; respiratory therapist;

professional practice leaders

Solution

Solution

Set and met 4 targets:1. Determine characteristics of a safe patient

handover from OR4 to PICU2. Define standard work (process,

roles and responsibilities) for a safe patient handover

3. Develop tools to guide & support standard work

4. Test standard work tools

SolutionActivity Day 1 Day 2 Day 3 Day 4 Day 5

Orientation to Lean principles

Team goal setting for the week

Define “standard work” for Cardiac OR to PICU safe handover of care

Development of Handover Tool

Bed Set-up (crib) defined, prototyped & tested on admission

Protocol for handover drafted

Education for OR #4 Team and PICU staff admitting CVS Patient

Digital recording of admission

Debriefing with OR & PICU staff about admission

Review of debriefing notes

Areas for improvement discussed

Strategies brainstormed

Handover Tool (Checklist) revised & tested

Protocol for handover revised & tested

Admission recording reviewed, standard work documented & defects counted

Daily “report out” to Sensei Iwata

“Stamping” of project work by Sensei Iwata

Practice for “Final Report Out”

Team “Final Report Out” to Sensei Iwata, other teams, sponsors and administration

Creation of sustainment plan Ongoing

Results of Kaizen

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ver

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here needed

Increase

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eople

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r 0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.54.2

2.8

1.5 1.5

1.21.3

0.7

0.0

0.3

1.0

0.0 0.0 0.0 0.0

Cardiac OR to PICU Handover of Care: Comparison of Pre-Kaizen to RPIW Average Defects per Handover

Pre Kaizen (6 Handovers)

Kaizen Wk (3 Handovers)

Ave

rage

Def

ects

/Han

dove

r

Results of Kaizen

Results of Kaizen (2 Years Post)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.54.2

2.8

1.5 1.5

1.21.3

0.7

0.0

0.3

1.0

0.0 0.0 0.0 0.00.0 0.00.1

0.0 0.0 0.00.2

Cardiac OR to PICU Handover of Care:Comparison of Pre-Kaizen to RPIW to 2 Years Post Kaizen

Pre Kaizen (6 Handovers)

Kaizen Wk (3 Handovers)

2 yrs Post-Kaizen (19 Handovers)

Defect Category

Ave

rage

Def

ects

per

Han

dove

r

Next Steps/Sustaining the Gains

• Adopted for spinal surgery handover• Plans for spread to 100% of surgical teams for

2013-2014• Agreement from Surgical Council• Improvement planning group meeting

Lessons Learned

• A pull for change is easier to make happen

• Right people on the team• Value of senior leader on team • Create a process dependent protocol;

not person dependent• Don’t reinvent the wheel• Live quality improvement cycle; be

responsive

Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders – Part 1:Improving Mental Health Patient Flow in Emergency(Session E8)

Andrew Janiec, Patient Care Coordinator, Vancouver General Hospital Psychiatric Assessment Unit

Patti Maisonet, Psychiatric Triage Nurse, Vancouver General Hospital Psychiatric Assessment Unit

Objective

• To provide timely and quality care to mental health and addictions clients who arrive in ED and require hospitalization.

• To enhance our ability to pull patients into our care from the ED as soon as safely possible while meeting P4P target timelines

Background

• Problem Statement: Currently some patients are not admitted within 10 hours of arriving in the ED - even when we have beds.

Current State% of PAU Admissions Meeting Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Period

% M

et

% of Patients Meeting Admissions Target

Issues Identified• Patients are asked to repeat their story to multiple

clinicians

• Redundant information gathering on forms

• Code white or agitated patient in the quiet rooms can delay admissions

• Admission delays due to not having empty beds available – no capacity

• Staff are being taken away from the unit to escort patients for diagnostic testing

• Timing of meals can delay patient transfers to inpatient units

• Staff time spent searching for charts, patient belongings, keys, forms etc.

• Patients/Families do not consistently have the information they need about the unit

SolutionImprovement Trial Benefit

Revised nursing assessment forms decrease redundancies and simply the forms with check boxes

Created nursing care plan template reduce repetitive handwriting

•Created laminated chart finding cards,

•Ordered keys for all staff,

•Established process for PTNs to collect old charts & indicate if patient has personal belongings

Decrease searching time

Developed guidelines for when staff accompanying patients for diagnostics testing

Decrease time staff spend away from the unit

Establish process to expedite after hours bed cleaning through Patient Access Decrease admission delay

Inpatient unit to call PAU when bed available or discharge planned Inpatient “pulling” patients & increase PAU bed capacity

Unit clerk to enter all orders & MAR requests & prep patient charts in AM Improved skill task alignment

SolutionImprovement Still Under Development Benefit

Conduct a 5S of PAU to make space for patients to be admitted beside the Quiet Rooms not through them

•PAU Open Side staff can admit patients •Decreases admission delays

Revise/ update PAU welcome booklet and provide to all patients / families

•Provides patients/family information they need•Decreases time clinicians spend answer the same question, multiple times

Work with food services to align PAU & Inpatient unit mealtimes and for bag lunches to be on the unit in case patient still needs to be transferred during mealtimes.

• Decreases transfer delays• Increases PAU bed capacity

Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4 5 6 7 8 9 10 11

11/12 12/13

% M

et T

arge

t

VGH PAU - % of ED Admissions with Target

Project implementation

Next Steps/Sustaining the Gains

• Continue implementing improvements eg. 5S

• Continue PDSA & sustain gains using Lean Management tools – Improvement huddles– Continuous improvement board– Gemba– Break through lanes

Lessons Learned - Challenges

• Communicating outcomes of RPIW to all staff and ensuring they are engaged through entire journey

• Accepting there are some quick wins but will be a journey to achieve the results we want – Rome was not built overnight!

• Finding a patient to participate in the RPIW

• Gaining buy-in from external stakeholders and support services to support improvement ideas (eg: change of meal times)

Lessons Learned - Benefits

• Staff have better understanding how their efforts impacts how long patients have to wait to get into the right bed

• Staff can see progress and impact of their actions (improvement board)

• Patients are getting to the right care sooner

Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders(Session F8)