Establishing a Lean Thinking Capability: Early

ExperienceMark S. Kirschbaum, RN, PhDChief Quality, Pt. Safety, & Clinical Information Officer

Adam G. Spieker, MBAQuality Management Specialist

As a result of this workshop, you will be able to:• Identify the contributions of embedding a lean approach into

performance improvement efforts

• Understand what it takes to begin establishing an infrastructure to support the application of Lean

• Discuss practical pointers to establishing the infrastructure, including lessons about how to avoid or overcome hurdles

Workshop Overview

Forces Driving Reform

Introduction to Lean

UTMB Early Experience

Our Horizon

Improvement Structure & Deployment

Idea-driven Organization

Forces Driving Reform – Quality

No link between higher costs and quality or safety

• 98,000 to 195,000 people killed per year by medical mistakes

• 57,000+ deaths from inadequate care• 2M hospital-acquired infections with 90,000 deaths per

year• 55% overall adherence to recommended care• Health care costs rising 1.5 to 2 times the rate of inflation• Uninsured now total 45.5 million• Up to 2-fold variation in per capita spending across

communities• Ranked 37th in overall health system performance by

WHO; 22nd in life expectancy, 28th in infant mortality• US spends 52% more per person than next most costly

nation, Norway

5

Comparative Reliability Between Industries

1,000,000

100,000

10,000

1000

100

10

1

DEFECTS 50% 31% 7% 1% 0.02% 0.0003%SIGMA 1 2 3 4 5 6

PPM

• Low Back TX

•

Post HeartAttack

Medications

•Mammography Screening

• IRS - Tax Advice(phone-in) (140,000 PPM)•

Inpatient Medication safety

• Airline Baggage Handling

•

U.S. ANESTHESIA DEATHS

•

Domestic Airline Flight Fatality Rate (0.43 PPM)

Sigma Scale of Measure

Difficulty with Referral

•

Taken from David C Classen, M.D.,M.S. , Assoc Prof of Med U of Utah, VP First Consulting Group

6

Un-reliability in health care10-1 Beth McGlynn, NEJM: Beta blockers for acute

myocardial infarction>3 Hemoglobin A1c tests per two years

10-2 Polypharmacy in the elderlyMedication injuriesDeaths in risky surgery

10-3 Neonatal mortalityGeneral surgery deaths

10-4 Deaths in routine anesthesia

10-5 Deaths from major radiotherapy machine failures

10-6 Deaths from seismic non-compliance

Progress is Slow

1999/2001: IOM Wake-up Calls

• “To Err is Human”• “Crossing the Quality Chasm”

2007 AHRQ National Healthcare Quality Report, measures of patient safety, showed an average annual improvement of just 1 percent

Janet M. Corrigan, PhD, National Quality Forum, The National Quality Agenda: Leveraging Our Collective Efforts, 2008

Delivery System Inertia

Absurdly fragmented delivery system

Obsession with the services, not the outcomes

Predilection for autonomy over “systemness”

Lack of accountability for critical aspects of care

And so much more…

Janet M. Corrigan, PhD, National Quality Forum, The National Quality Agenda: Leveraging Our Collective Efforts, 2008

Common Themes

Outcomes-focused reimbursement will increase risks to revenue growth

Operating efficiency will be the driver of future inpatient profitability

Bundled payments will make specialty care more rare and less profitable.

Source: The Advisory BoardTop 10 implications of reform – 7.01.2009

The burning platform of healthcare

Pockets of excellence coexist with enormously variable performance across the delivery system.

Chassin and Loeb. Health Affairs, 30, no.4 (2011):559-568

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Pockets of excellence and enormously variable performance at UTMBNot unlike other health care centers nationally, UTMB is indistinguishably mediocre and unreliable…

Questions

How do your patients experience non-value added care?

What percentage of care does not add value?

JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362

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Quality Defined Components of Health Care Quality – STEEEPSafe—avoiding injuries to patients from the care that is intended to help them;

Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care;

Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse);

Efficient—avoiding waste, in particular waste of equipment, supplies, ideas and energy;

Equitable—providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status; and

Patient-centered—providing care that is respectful of and responsive to individual patient references, needs and values and ensuring that patient values guide all clinical decisions.

Institute of Medicine, 2001 – Envisioning the National Health Care Quality Report; March, 2001, Institute of Medicine released, "Crossing the Quality Chasm: A New Health System for the 21st Century." 

Introduction to Lean

Berwick, DM, and Hackbarth, AD. Eliminating waste in US healthcare. JAMA. 2012;307(14):1513-1516

Lean Pillars

Respect for People

• Fully utilize the talents of our staff (task-skill alignment)• Empowering front-line staff to identify and solve problems

Continuous Improvement

Lean Thinking

Defining "value" from a customer and patient perspective

Identifying "waste" and non-value-added activity

Indentifying and improving "value-streams"

Creating better "flow" for patients and processes

Preventing errors and improving quality in a systematic way

Creating an environment of true "kaizen" (continuous improvement)

Credit: Mark Graban

Waste

Credit: virginiamasonblog.org (2012-04-18)

UTMB Experience

Lean Improvement in 2011

We added industrial engineering expertise in the Healthcare Quality and Safety Department

Training we’ve provided:

• 4 day intense Lean facilitator training for 27 UTMB staff in quality, nursing, surgical services, clinics, revenue cycle

• One day overview for ~ 40 leaders

• Half-day introduction for executives

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Support

• Instituted monthly meeting for the Lean trained staff

• On-going training• Peer project presentations• Networking

• Developed Lean Toolkit and Templates

Initial Lean Projects

• Cath. Lab Supply Management • Decentralized surgical case scheduling • Eligibility/benefits & authorization• Handoffs - L&D to Postpartum • Managing Medications & Supply Outdates • Radiology – Reducing clutter / Improved efficiency• Registration: requesting pre-certifications • TDCJ ICU Decreasing Clutter • Trauma room supply management & charging

“cLEANing up Waste” in Interventional RadiologyTeam Members: Natalie Kennie, Kelly Bonhomme, Kevin Klages, Theresa Carrig, Cynthia Lucia Sponsor: Sandra Murdock, PhD Team Leader: Belinda Escamilla Facilitator: Benjamin Dzialo

Lean Methodology

Background

Results

Lean Tools Utilized

ConclusionsAim Statement

Interventions

Lean is a process improvement approach based upon systematic elimination of waste to reduce cost and improve patient care.

Waste in Interventional Radiology (IR) occurred with expired medical supplies and time spent by staff to find supplies. The concern among staff was duplicated supplies located in multiple areas, while some supplies were over-stocked and other supplies under-stocked. Within the past year, IR had $113,134.25 in wasted supplies.

1. Kaizen Event2. Gemba- Waste walk

through 2. Cause & Effect Diagram3. Spaghetti Diagram4. Kanban5. 5 S

• Sort• Straighten• Shine• Standardize• Sustain

• Educated team members on Lean concepts, provided Lean Tool Kit and example of Lean project

• Relocated supplies and labeled all drawers and cabinets with supply description and min/max par levels

• Developed inventory monitoring tool

• In-serviced staff/nurses on interventions, plus FIFO concept

• 28% reduction of wasted supplies

• 32% reduction of steps taken by staff looking for supplies

• Reduced the frustration of staff not finding supplies in timely manner

The key to sustaining effective and efficient management of inventory is to automate processes and to routinely monitor processes and supplies for consistent practice.

By the end of February 2012, the annualized expired supply cost savings will be reduced by 25%.

End-of-Day Balancing Process – Campus ClinicsSponsor: Cash ReceiptingTeam Members: Nancy Polk, Linda Shin, Beth Quigley, Rose Herrera, Anita Laws, Trish Filer, Aimee Contreras Team Leader/Facilitator: Cindy Barrs

Lean Methodology

Background

ResultsLean Tools Utilized

Conclusions

Aim Statement

Interventions

• Small hard dollar savings realized.• Gain in cultural change for Lean &

Epic iConnect were huge.• Changes in process take

tremendous tenacity to implement • Maintain the gain relies on data

which is then fed back to the users.

• 1 – 2% error rate maintained.• Standardized forms and process • Reduced paper consumption by

50%• Freed up 2 hrs./wk. of Cash

Receipting staff time.

Align current process with Epic functionality.   Success will be measured by:• Achieving a change in process that reflects the functionality of Epic

registration processes• Implementing standardized processes across the UTMB Health system • Eliminating waste in the end-of-day balancing process • Maintaining the accuracy of the financial information reported as measured by

Clinic Deposit QA data

A gap exists between EPIC functionality and current practice with regard to the end-of-day balancing of funds receipted during patient registration.

• Value Stream Mapping• Standardized Work

Training• 5S• Mistake Proofing

Focused on flow, eliminating waste, and standardizing work across UTMB Clinics.

• Streamlined documentation requirements.

• Developed an on-line Epic based form.

• Provided training.

Lessons Learned

• Lean education ≠ Ability to lead lean projects

• Lack of structure to select projects led to varying degree of project alignment with organizational goals

• The targeted projects approach didn’t allow staff to “see the whole” or understand that lean thinking should be taking place daily

Horizon: Systematically

Eliminating Waste

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Quality Leadership

Ideas

Will

Execution• Utilize a solid model for testing, adapting, and

implementing new ideas in the systems of care. • Continually develop capacity for improvement, project

management skills, and highly disciplined methods for design and redesign of the structures, processes and services needed to implement, sustain, and spread the good ideas.

A Framework for Leadership of Improvement, Institute for Healthcare Improvement, February, 2006.

Is Lean a…?

a set of operational concepts

a set of tools to improve business processes

a philosophy

• that helps drive efficiency and speed through employee empowerment and change at the grass roots

• the relentless pursuit of the perfect process through waste elimination… every step in a process is either value added or it is waste.

Leverage Point Three: Channel Leadership Attention to System-Level Improvement*

The currency of leadership is attention. To achieve system-level aims, leaders must actually pay attention to them. All potential resources for channeling leadership attention, whether formal or informal, should be connected to the aim: personal calendars, meeting agendas, project team reviews, executive performance feedback and compensation systems, hiring and promotional practices, membership by patients in design teams and committees. In other words, the signals sent both by the “body language” of individual leaders and by the organization’s leadership systems must change, if leaders are to expect system-level results to change. Note: One of the most powerful known methods for channeling attention inside your organization is to become transparent about your quality performance outside your organization, so some leadership “channel attention” work must be done outside the boundaries of your system.

* Seven Leadership Leverage Points For Organization-Level Improvement in Health CareInnovation Series 2005, Institute for Healthcare Improvement

Unifying Principles

Put patients and families first

Provide a safe environment for patients, visitors, and staff.

Demand excellence by continually improving clinical care, service, and operations, and levels of service.

Provide an integrated continuum of care, optimizing system interactions to better deliver valued services.

Base clinical care, delivery methods and operational processes on the best available evidence from the best available sources.

Focus on results.

Maintain a systems perspective.

Achieve breakthroughs via multidisciplinary teamwork. Foster engagement and respect expertise by directly involving medical staff and employees in the improvement of their work processes.

Commit to effective, timely, open and honest communication and information sharing.

Use resources optimally and efficiently, eliminate all forms of waste, and recognize that poor quality is costly.

Commit and involve leadership, including the board, medical staff, administration and managers.

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Standardized practices

Standardized operations are safely carried out with all tasks organized in the best known sequence and by using the most effective combination of resources (people, materials, methods, & machines) (each step value-added, something the ultimate customer is willing to pay for)

Driven by evidence (empirically tested practices) and lean production designs

GM Picos project, 1994

2010 – 2015 Performance Improvement Initiatives

Lean Timeline

Structure

• Develop and deploy Strategy Deployment Boards

• The boards will consist of:

• Balanced Scorecard Perspectives & Goals• Key Performance Indicators• Value Stream Map• Improvement Project Spotlight• Everyday Lean Ideas• Idea Project Action Items

Cascading Strategy Deployment Boards• Executive Board (Level 1)

• Service Line Boards (Level 2)• Department/Unit Boards (Level 3)

Break Out

• Develop, for your span of influence, the Balanced Scorecard part of the Strategy Deployment Board

• Perspectives• Goals• Key Performance Indicators

Performance Improvement StrategyThree pronged approach:

• Value Streams

• Rapid Improvement Events / Targeted Continuous Improvement Projects

• Front-line identified ideas and improvements

Value Stream

• Value Stream Defined: The entire end-to-end process for patient care or the flow of a product, typically crossing multiple hospital departments.

• Why use a value stream map?

• Promotes systems thinking / seeing the whole• Provides a link between product/patient flow, timeline, and

information flow• To set strategy before diving into the tactics

Current State Value Stream Map

• 10 process steps• Value-added time: 63.4% (revised)

Future State Value Stream Map

• 7 process steps (30% reduction)• Value-added time: 81.7%

Change Log

ACTION ITEMS PROCESS OWNERS

Warning in HL at order entry for Lab: patient has a referral/doesn't include lab - reduce number of patients sent away by Lab. Geri Murphy

Decrease multiple questions asked ? educate staff on search (3,3). [minimum identifiers to be asked, add if necessary] Geri Murphy

Update appointment reminders ? still indicate a stop at Info Desk for a pager for Registration. Geri Murphy

Script for all (identification points) explaining patient safety reason for (name/dob). Lisa Holly

Reduce number of stops for Lab only patients - hand pager out at Lab reception desk. Mary SiebelEnter MRN in pager. Mary Siebel

Lab staff - check for registration status "verified or needs review." Mary Siebel

A sign at Information saying: If you have not been called to Lab check-in within 20 min. of receiving your pager, please feel free to let Lab check-in personnel know. Mary Siebel

Color coded directory of clinics with Registration Hub destination. Shawn Arneson

Redesign Lab walk-in process - can register, enter lab appointment, and avoid duplicate questions? (ONC Model) (Reg. does Prel/Cadence) Chris ReuterTurf order delays to back/other desk. Chris ReuterRedesign appointment letters (add web site). Jeff IversonGreater use of volunteers to direct patients. Sue Sanford-Ring

ACTION ITEMS PROCESS OWNERS

Warning in HL at order entry for Lab: patient has a referral/doesn't include lab - reduce number of patients sent away by Lab. Geri Murphy

Decrease multiple questions asked ? educate staff on search (3,3). [minimum identifiers to be asked, add if necessary] Geri Murphy

Update appointment reminders ? still indicate a stop at Info Desk for a pager for Registration. Geri Murphy

Script for all (identification points) explaining patient safety reason for (name/dob). Lisa Holly

Reduce number of stops for Lab only patients - hand pager out at Lab reception desk. Mary SiebelEnter MRN in pager. Mary Siebel

Lab staff - check for registration status "verified or needs review." Mary Siebel

A sign at Information saying: If you have not been called to Lab check-in within 20 min. of receiving your pager, please feel free to let Lab check-in personnel know. Mary Siebel

Color coded directory of clinics with Registration Hub destination. Shawn Arneson

Redesign Lab walk-in process - can register, enter lab appointment, and avoid duplicate questions? (ONC Model) (Reg. does Prel/Cadence) Chris ReuterTurf order delays to back/other desk. Chris ReuterRedesign appointment letters (add web site). Jeff IversonGreater use of volunteers to direct patients. Sue Sanford-Ring

Discussion

• How many of your organizations have identified and mapped value streams?

• How did you determine which value streams are important to your organization?

• How many value streams can your organization focus on improving?

Dartmouth-Hitchcock Clinical Microsystems

Pre-Entry Access Assessment/Diagnosis

Intervention/Therapeutics Continuum Neuroscience

PrimaryCare

SurgicalServices

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Med

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Value Stream

• Select strategically important value streams

• Orthopedic Elective Surgery• Inpatient Flow (ED – D/C)• Ambulatory Clinic Access• Patient Centered Medical Home• Revenue Stream

Value Streams

• Value Streams are mapped over 2.5 day period with operational staff, executive sponsor, and lean facilitator

• Map current state & future state• Identify improvement opportunities on the value stream maps

• Opportunities will be categorized by scope: Just-do-its, Rapid Improvement Events, Continuous Improvement Projects

• The team uses a project selection matrix to determine which opportunities will be worked on over the next year

Project Selection Matrix

…current approaches are not producing the pace, breadth, or magnitude of improvement that all stakeholders desire.

What’s required:

Leadership

Safety Culture

Robust Process Improvement

 

Chassin, MR and Loeb, JM. The ongoing quality improvement journey: Next stop, high reliability. Health Affairs, 30, no.4 (2011):559-568

Robust process improvement

Identifying the problem to be solved; defining precisely a successful goal; measuring performance in relation to goal; assessing the causes of shortfalls; implementing interventions targeted to the most important causes; and embedding effective interventions into the everyday work of caregivers so that they are sustainable.

FOCUS-PDSA A3 Template

Rapid Improvement Events (RIE)• Identified from Value Stream Map or Strategy Deployment Board

• Scheduled three months in advance (collect baseline data, identify metrics, plan to back-fill staff attending RIE, etc.)

• Event duration:1-5 days

• Follow FOCUS-PDSA A3 Template

• Multidisciplinary team

• Facilitated by Lean trained Quality staff member

Continuous Improvement Projects• Targeted projects

• Identified from Value Stream Map or Strategy Deployment Board

• Projects that require more than one-week to complete PDSA cycles

• Project duration: ~100 days (time bound)

• Follow FOCUS-PDSA A3 Template

• Multidisciplinary team

• Led by middle management supported by Lean facilitator

Discussion

• How many of you have participated in a rapid improvement event?

• What challenges did you face?

• How did you overcome them?

• How did this feel different than other improvement teams you have participated on?

• How well did you sustain the improvement gains?

The Idea-Driven Organization Outline

• Why bottom-up innovation is where the action is

• How to run a high-performing idea system in your area of responsibility

• How to help yourself and your people come up with more and better ideas

Source: Alan Robinson

The Problem

• Front-line workers see a great many problems and opportunities that their

managers don’t.

• Most managers either don’t realize the full power of employee ideas or have

never learned how to tap them effectively.

• To be truly excellent in any aspect of performance, lean, or good at execution,

you have to be able to capture and implement large numbers of employee

ideas.

Source: Alan Robinson

The Tip of the Iceberg

Source: Alan Robinson

Black-Belt Projects

$1 million

Green-Belt Projects $1 million

Idea System$9 million

Managing Ideas

• Most creative acts are not planned form or even anticipated at companies at

which they occur

• A Sam Stern study found:

1. The award-winning projects were more likely to have been initiated by

individuals

And

2. The not-especially-novel ones were far more likely to have been planned

for by management

Source: Alan Robinson

Leaving Command and Control Behind

• Top-down command-and-control has been part of mankind’s history since

the beginning

• Frederick Taylor: Those who think and those who do

• Problem: As organizations become increasingly more complex, knowledge

often resides in a different place from the power to do something about it.

Source: Alan Robinson

Expanding The Definition of Lean

When your employees are problem-solving and generating and

implementing ideas that further the organization’s strategic goals, on a

daily basis, and as a matter of the organizations culture and the way it

operates.

Source: Alan Robinson

How to run a good idea system

1. Go after the small ideas

• Small ideas are the best source of big ideas

2. Stay away from trying to reward individual ideas

3. Make ideas part of everyone’s job

• Document ideas and track them

• Teach your supervisors the value of ideas and their own four roles:

encouraging, mentoring, championing and looking for larger implications

of ideas.

• Goal: 12 implemented ideas/employee by end of first yearSource: Alan Robinson

How to run a good idea system (cont.)

4. Set-up a good idea process

• Design the process to discuss ideas within the workgroup first before they

go any further

• Work from problems and opportunities as much as possible

• Drive down decision-making and implementation to lowest possible levels

• Adequately resource support functions for the volume and types of ideas

that come in, and make supporting improvement ideas part of their jobs

• Escalate only completed staff work

• Ideas that need more money, are highly cross-functional or need more

authority will be escalated

Source: Alan Robinson

How to run a good idea system (cont.)

5. You need to do more than just install an idea-handling process

• Requires significant changes in leadership style and how you select,

develop and train your managers

• Requires significant changes in how you make decisions

• Requires significant changes in what you hold your managers and people

accountable for

Source: Alan Robinson

Realigning your Organization for Ideas

Is about eliminating the need for heroes and

champions to battle your own system

Source: Alan Robinson

Help your people come up with more and better ideas

• Constantly identify new ways to look at the work to increase their problem

sensitivity

• Teach them about creativity the creative process and creative thinking

• Use techniques such as Pre-mortems and After Action Reviews (AARs) to

develop new problem and opportunity areas

• Identify and develop idea activators

Source: Alan Robinson

Discussion

How many of your organizations have an institutionalized idea system or suggestion program?

What challenges have you faced?

How do you envision avoiding the pitfalls of past idea campaigns?

Next Steps

• Identify and communicate the impetus for change

• Engage Senior Leadership in the development of your Lean System

• Create a Lean/Performance Improvement Promotion Office

• Train senior leadership and middle management in Lean, change management, adaptive leadership

• Mentor middle management on initial projects

• Educate & Empower front-line staff to identify and solve problems

Questions?

Contact information:

Adam G. Spieker, MBA

Quality Management Specialist

University of Texas Medical Branch at Galveston

agspieke@utmb.edu

Mark S. Kirschbaum, PhD, RN

Chief Quality, Pt Safety and Clinical Information Officer

University of Texas Medical Branch at Galveston

mskirsch@utmb.edu

Suggested Further Reading

Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience, Charles Kenny, CRC Press, 2011.

On the Mend, John Toussaint and Roger A Gerard, Lean Enterprise Institute, 2010.

Execution, Larry Bossidy & Ram Charan, Crown Business, 2002.

Ideas are Free, Alan G. Robinson and Dean Schroeder, Berrett-Koehler, 2005.

References

What’s Right in Health Care | Evidence to Outcomes. The National Quality Agenda: Leveraging Our Collective Efforts. Janet M. Corrigan, PhD; President and CEO; National Quality Forum.

President’s Commission on Consumer Protection and Quality in the Healthcare Industry (1998).

“To Err is Human” (1999).

Leapfrog Group (2000).

“Quality Chasm” (2001).

McGlynn, NEJM, “The Quality of Healthcare Delivered to Adults in The United States” (2003).

The Idea-Driven Organization, Alan Robinson, PhD, IMS