sjmo_a3 deployment & adoption

A3 Thinking & Problem Solving St Joseph Mercy Oakland

Presented By: Dave Follis

Performance Excellence Leader

Date: August 12th , 2016

Education & Training Plan

2 ©2015

A3 Deployment: Training 2nd week of each month (1 hr.)

• Wave 1: June, 16th

− Target Areas: EVS, ED, CDU, 4G, 7S

• Wave 2: July, 14th

− Target: Areas: Food Services, OR

Transport, 2S, 3E

• Wave 3: August, 11th

− Target Areas: Pharmacy, Radiology,

3S, 4E, 5W / 5E

• Wave 4: September 15th

− Target Areas: ASC-OR, Cath. Lab,

4N, 5N, 6E

…continued for balance of 2015!

Share & Spread Learning Experience's and Best Practices

Wave 4

Wave 3

Wave 2

Wave 1

Pilot

A3 Deployment Plan

3 ©2015

Project: A3 Deployment Plan

Update Date: 12/22/15 Left-side Right-side

#Target Area

(Unit)Service Line Phase Responsible Owner A3 Start Date

Training

(Session 1)

Training

(Session 2)

Kata Coaching(Weekly)

Px

Support

Performance Measure

(KPI)

Baseline

Metric

Target

Metric

Financial

Benefit

1 2G Med Surg Pilot Tara Hegwood Dave

2 3G Med Surg Pilot Laura Keoppen Dave

3 4S Med Surg Pilot Patty Kerin Dave

4 6S Med Surg Pilot Daniel Broders Dave

5 Lab Lab Pilot Nancy Pelowski 02/16/15 Christie AM Draws

6 ED ED Wave 1 James Beck 06/16/15 Katie Culture of Safety (COS)

7 CDU ED Wave 1 Crista Walsh 06/16/15 Katie Culture of Safety (COS)

8Food Services

(Nutrition)Facilities/Services Wave 1

Jim Donnellon

Sonya Stanley06/16/15 Katie Tray Delivery (Time & Accuracy)

9 4G Med Surg Wave 1 Linda Borucki-Urban 06/16/15 Dave

10 7S Ortho/Rehab Wave 1 Sarah Simon 06/16/15 Dave

11 4E Ortho/Rehab Wave 1 Sarah Simon 08/11/15 Dave I's & Os'

12 Central Transport Ops Wave 2 Mehul Naik 07/14/15 Dave Cancelled Tranports

13 OR (Main) Surgery Wave 2 Trudy Lentini 07/14/15 Christie Pre-op Hand Off's

14 2S Med Surg Wave 2 Rebecca Trammel 07/14/15 Dave Bed Fall Alarms 85% 100%

15 Ethics Admin Wave 2 Beverly Beltramo 07/14/15 Dave Ethics Consultation Process

16 Respiratory Respiratory Wave 2 Paulo Fantin 07/14/15 Christie Hand Hygiene Compliance 65% 70%

17 Pharmacy (Retail) Pharmacy Wave 3 Phil Wein 08/11/15 Katie TBD

Status Key: Training

1 Not Started Completion 82.5% 78.9%

2 Barriers / Delayed / no progress

3 Scheduled / some progress

4 On-track

5 Complete

1 Pilot +7 Waves of Training for 58 Leaders from March to December’2015

Coaching & Mentoring

4 ©2015

Knowledge Transfer through Mentoring

Daily Management (Standard Work)

5 ©2015

Huddles, Gemba, & A3 Coaching Support

Tracking & Reporting

6 ©2015

#Target Area

(Unit)Service Line Responsible Owner A3 Start Date SLT Gemba?

Px

SupportA3 Title Leading Indicator Lagging Indicator

Baseline

Metric

Target

Metric% improvement

End Date

(Target Met)PX Comments

1 2G Med Surg Tara Hegwood 01/20/16 Yes AndyImprove flow from PACU to 2G (Joint

A3 with PACU)

Depends on Root Cause of Delay

(dirty beds, delayed discharges,

lack of notification)

Patient Transfer Time from PACU

(RTM to Arrival)

1 hr 44 min

(median time)<90min

4/19: Data analysis shows systemic issue (41% pts assigned to dirty beds,

no prompt in system for when bed clean based on the way tracker is used)

that may mean this is out of scope for unit level A3. Need to engage

logistics, PACU, and EVS to understand causes of delay.

2 2G Med Surg Tara Hegwood Yes Andy Staff Brainstorming New A3 4/19: Staff brainstorming next A3 at huddle (1 week).

3 3G Med SurgStephany Powell-Bedell

Laura Keoppen02/01/16 Yes Dave Improve Shift Handoff % Overtime Budget Variance # of Instance w/OvertimeZero Overtime Nice progress & engagement of staff

13 4N (GYN, PEDs) OB/GYN Patty Tracy 09/15/15 Yes Christie ED report to Peds

RN availablity for report and

critical report components

present

Patient satisfaction. Patient

Safety95%

4n and ED staff are trialing the ED summary report sheet to give and

receive input from each other, starting 3/21/16 . ED will try to have same

RN who is caring for pt give report

15 4S Med Surg Leisa Krieger 01/16/16 Yes Andy Improve Hourly Rounding Patient Call Light Usage Pt PG Satisfaction Scores 56% 90% 34%

4/15: PG scores have improved for February, but while call light usage has

dropped from January, it is at baseline. Need to continue to work on

"purposeful" part of rounding. Many theories from staff regarding usage

of HillRom & RTLS. Will gather data to help drive testing of potential

ideas.

22 7S Ortho/RehabSarah Simon

Brad Neideck04/05/16 Yes Dave

1. JCC Patient Luggage Transportation

2. RN Patient Rounding

Parking Lot: Stocking Med Rooms

1. Define Standard Proces

2. Often Nurses checked on you

1. Patient Experience

2. Patient Perception of Rounding

1. SOME Belonging to

Room

2. 67.8 (2/1/16)

All Pt belongings

brought to Room

1. Create a process of moving JCC patient luggage from pre-op to post-op

rooms without asking family to transport luggage

2. Increase use of phrase I'm checking on you" during hourly rounds to

help change patient's perception of the overall experience of care.

23Accred. &

RegulatoryQuality Carol Bosch 01/29/16 Andy Joint Commission Preparedness

Environment of Care / Mock

Survey Results

SJMO Joint Commission Survey

ResultsTBD TBD TBD

1/29: PX met with owner and participated on EOC for two units. Owner

would like for departments to incorporate EOC in A3 priorities.

24 Cath Lab Cardiology Karen Bratton 03/11/16 Yes AndyStandardize post procedure handoff

from Cath Lab.3S Satisfaction with Handoff Tool

Cath Lab Utilization of Handoff

Tool0 90% TBD

4/18: Team decided to pursue standard handoff tool as iniatial solutions.

Draft handoff tool circulated to 3S for trial. Will utilize for 2 weeks and

gather feedback for improvement and % compliance to tool.

25 CDU ED Crista Walsh 01/14/16 Yes DaveStaffs pulls to ED

Nurse CommunicationRTM to Occupied ED ALOS 64 min. 30 min. Last Update: 2/19 - Processing time for patients from ED to CDU

26Central Supply

ProcessSurgery Stephanie Glover 01/08/16 Yes Christie OB equipment turnover Dept efficiencies

Improved physician satisfier- and

improved teamwork between

both depts Scoping

27 ED ED Sharon Silk 01/01/16 Yes Dave

Sepsis

EKG

Stretchers

4N Handoffs-Joint A3 with 4N

# notification of time 0

# EKG order deficencies

# shifts stretchers available

% bundle compliance

# EKG deficiencies

NA

14%

TBD

TBD

Discussed during CIC committee that preference would be to have no

more than 2 Active A3 at a time. Per Denise/Dave

1. Columns H through N are to be completed by the Process Owner. The PX support will help to coach and mentor the process owner in completing the

noted sections.

2. Pictures of the A3s are located in the SJMO A3 "picture" folder.

3. Comments in column "O" will be documented by the PX Coach.

4. Process owners are encouraged to schedule time with their designated PX coach to review their A3

8/10/2016

SJMO A3 Plans

A3 Deployment Scorecard

Strategy Deployment - Cascading Alignment

7 ©2015

Ensure alignment of A3 work with Team’s Strategic Goals

Leadership Audits - Gemba Walks

8 ©2015

AreaProcess Owner

(Lead Support)SLT Sponsor

TH Action

Planning

Group

Rounding frequency per

month

SLT Report Out

12/2015

Facilities (B&G) Aric Alexander Ken LePage 3 4

Highlights: A3 is moving along - length of open work orders.

Successes:

Barriers/Challenges:

4E Brad Neideck Kathy Brodbeck 3 4

Highlights:

Successes:

Barriers/Challenges: some are passive and not as engaged;

Need PX support on A3. Katie will take back to her team.

7S Brad Neideck Michael Smith 3 4

Highlights: handoff to MS from FF

Successes:


Cath Lab Cathy PorwollShannon

Striebich3 4

Highlights: lots of turnover. Various reasons - no patterns.

Using as opportunity to refresh staff structure (i.e. board runner)

Successes: going to set up Q breakfasts to have informal

discussions with the staff


2S

Dawn Hanson

(Nick

Nickolopolous)

Michael Smith 2 2

Highlights: meeting today. Report out next session

Successes:


SLT Sponsors:

GEMBA walks will be scheduled with the individual Process Owners/Leaders.

Frequency is listed below.

The goal is to review the unit/department A3, along with their Hoshin Kanri and

Huddle Boards, provide support as needed, then report back to the SLT group with

a summary of the improvement activities.

Leadership Audits - Visual Management

9 ©2015

Daily Huddle w/ A3 Problem-solving

Standard Method Hardwired into Culture

10 ©2015

3G Score Card

CAHPS Summary Information

2015-2016 as of 8-1-16 BL

TRINITY FOCUS DOMAINS

July August September October November December January February March April May June July

Rate Hospital 0-10 80.6 54.3 70.6 61 78.3 65 55.3 56.5 70.3 69.2 79.2

Communication with Nurses 81.6 74.7 75.5 78.6 82.6 74 76.9 66.7 84.5 74.9 76

Communication with Doctors 81.6 63.8 64.7 62.9 75.4 70.7 65.8 63.9 65.2 74.1 70.7

Pain Management 69.2 68.8 70.8 62.5 83.3 60 44.4 59.4 88.5 67.9 71.2

Discharge Information 87.1 75.8 76.7 87.6 88.6 90.8 85.9 81.2 80.1 85 81.3

GPA EP 2 0 0 0.4 EP 3 0.8 0 0 1.8 0 1.2

N size 30 35 34 41 23 40 40 24 38 26 25

A3-Improve Shift Handoffs

A3-Cleanliness & Rounding with Leaders

Overall Pain MD Comm RN Comm D/C

Except Perf 82% 78% 89% 86% 91%

Target 76%-81.9% 74%-77.9% 85%-88.9% 82%-85.9% 89%-90.9%

Better than Median 71%-75.9% 71%-73.9% 81%-84.9% 79%-81.9% 87%-88.9%

Median <71% <71% 81% <79% <87%

Focused A3 Problem-solving to Key Performance Measures

Focus & Engagement

A3 Sharing - 4 South SJMO Manager’s & Director’s Meeting

Presented By: Leisa Krieger (Clinical Leader)

Date: August 24th, 2016

A3 Approach

12

• Align with Hoshin Kanri (How)

• People Centered P7-Hand Hygiene

greater than 90%

• Choosing an A3 topic (What)

• Base line hand hygiene compliance

April 67%

• Timeframe (When)

• Goal was to complete A3 within 2

months

# Metric Status Exec # Strategic Initiative Status Exec

TOP 5 STRENGTHS X-FACTOR

P1 # of Attributed Lives (increase attributed lives by 5%) Weiner P9 Bundled Payment for Care Improvement $19k M. Smith

P2 Hospital BCBS collaboratives participation Weiner P10 Achieve PCHM neighborhood designation in specialty practices Cobb

P3 Uninsured Medicaid eligible individuals in SJMO's market (increase 1-2%) Weiner P11 Technology to support patient care improv (PRISM, Sotera, RSVP…) Fregoli

P4 UEM Clinical Indicator Scorecard (3.2 or greater) 2.6 Fregoli P12 Reduce observation admissions by 5% M. Smith

P5 Mortality Index (< 0.66) 0.77 Fregoli P13 Expand the network by 10% Cobb

INTENTION P6 Patient Experience index (target: 76% Overall Rating) 71.1% Striebich / Weiner P14 Continue integration of IT plan Fregoli

P7 Hand Hygiene (90%) 76.7% Brodbeck P15 Implement initiatives from CIN / ACO Weiner

P8 Readmissions (Reduction in avoidable readmissions by 20% of baseline) 16.00% Fregoli P16 Deploy Athena Cobb

PLAYGROUND

EC1Colleague Engagement score (No baseline set for 2015/ 2016 target 4.09) TH

2015 3.98 4.01 Davis EC6 Implement Work Day Davis

TOP 5 WEAKNESSES EC2 Annual Total Turnover % 11.70% Davis EC7 Implement Kronos Work Analytics Samyn/Davis

EC3 Participation in Promoting Catholic Identity (PCI) Beltramo EC8 Leadership Gemba Walks Striebich

EC4 Culture of Safety (Target FY16 69% OPS) 62.9% Davis EC9 Enhanced Department level A3 Striebich

EC5 First Year Turnover % 19.3 Davis EC10 Pursuit of Magnet Designation in collaboration with Regional partners Brodbeck

O1 Operating cash flow margin (12.3%) 9.8% Samyn O6 Transforming Operations Striebich

BRAND PROMISE O2 Case Mix ALOS (Target 3.00) 2.96 M. Smith O7 Outcomes Logistics Redesign Project LePage

TOP 5 OPPORTUNITIES O3 ED throughput (10% improvement) T/R 145 Striebich O8 Implement RTLS for asset management and patient logistical tracking Jones

O4 ED throughput (10% improvement) Admit 275 Striebich O9 Support regional deployment of electronic management operations (iDashboard) Fregoli

O5 CMI (1.575) 1.66 M. Smith

PC1 P4P Collaborative Performance (>95% for each) Fregoli PC4 Redefine the peer review redesign and alignment process M Smith

VALUES & CULTURAL THRUSTS PC2 Expand FQHC Clinics / relationships Weiner PC5 Enhancement of Physician Leadership Development - +2 groups through HS M Smith

PC3 Medical staff development (recruitment to fill) Weiner PC6 Educate physicians on bundled payment and next generation ACO Cobb

PC7 Complete implementation of centralized verification office Cobb

L1 Achieve FY16 Community Benefit Goals Beltramo L5 Complete Master Facility Plan Striebich

L2 Maintain Regulatory Compliance (achieve certifications) Bosch L6 Develop Hybrid OR & expand structural heart program Striebich

L3 Leapfrog (Maintain Group Hospital Safety Grade "A") B Fregoli L7 Expand Telemedicine network Weiner

TOP 5 THREATS L4 Community Health & Wellness Striebich L8 Expand and enhance Oncology Striebich

L9 Develop Expanded Neurology service line Striebich

L10 Develop expanded cardiac EP program Striebich

L11 Reevaluate behavioral medicine programming Striebich

ES1 ICD10 (implementation) Samyn ES5 ICD10 implemetation Samyn

ES2 Total Cost of Care / Member Cobb ES6 Paid Hrs/CMAED (79.9) 81.1 Striebich

ES3 Network Financial Performance - achieve budgeted net income for the network Cobb ES7 Supply Expense/CMAED ($1,203) Striebich

ES4 Market share Weiner ES8 Implement Growth Program Weiner

Next Scheduled Plan Review:

Comments: Updated: 2/25/16

People Centered

Engaged Colleagues

Operations Excellence

Physician & Clinician Engagement

Leadership Nationally

Effective Stewardship

SJMO Organizational Objective Alignment (Hoshin Kanri) - SLT/Board

Planning Document (FY16)

BUSINESS THRUSTS

Competencies/Processes

- High quality

- Low cost

- High Satisfaction

- Ease of use

- Population Health (patient centric)

KPI - Key Performance Indicators KSI - Key Strategic Initiatives

Faith based heritage, member of the 2nd largest

Catholic healthcare system in the country,

community hospital, exceptional quality outcomes

leveraging the latest available technology.

MISSION We, Trinity Health, serve together in the spirit of the Gospel as a compassionate and

transforming healing presence within our communities.

VISION As a mission-driven innovative health organization, we will become the national leader in

improving the health of our communities and each person we serve. We will be the most

trusted health partner for life.

PDACO

Master Facility plan - campus refinement

Development of new relationships for service

delivery (Beaumont,

.Havenwick,…Ascension.)

Strong physician alignment

Physical Plant

Top decile clinical performance

World class clinical program

Strong nursing team

Technology

Emergency preparedness

Community engagement / EMS

Marketing program - media relationships

Total cost per member per month

Payer Audits

Poor Medical Records Documentation

Insurance Benefits Realignments

Unknowns in Healthcare Reform

Market Realignment

Be the premier healthcare provider in the region

Development of large multi-specialty group practices

Significant reduction in healthcare utilization

Key Product or Service Lines: Orthopedics,

Oncology, Cardiology, Neurology, Surgical Services,

Neonatology

Primary Competitors: Beaumont, Crittenton,

McLaren, Henry Ford

Strong revenue management

Operations / Performance Management

Growth & Innovation

Quality & Safety Competencies

Regulatory & Compliance

Financial Management

Technological Superiority

Information Transparency

Excel at SJMHS Tiple Aims

Respect, Social Justice, Compassion, Care of

the poor and underserved, Excellence

Process Excellence

Personal, Connected Journey

Culture of Safety & Employee Engagement

Physician Relationships

Just Culture

Personal Accountability

Professional Growth

Diversity & Inclusion

Regionalization

A3 Strategy

13

Structure

• A3 work part of daily huddle

• Posted hand hygiene RTLS metrics

• Engaged all team members in the process.

• Individual hand hygiene metrics to help identify root cause

• Recognition for staff with 90% compliance

• Staff assisted in investigation once root cause identified

A3 Outcome

14

• Week One/Two

• Hand hygiene compliance daily monitoring, root cause analysis and investigation (rooms identified as not including data)

• Week Three/Four

• Team reached out to Robert Jones. IT team evaluated RTLS system and determined “dimmer replacement needed

• Standard work developed for system maintenance

• Lessons Learned:

• What went well

• Staff collaboration/Increased morale

• Data accuracy

• Support from IT

• Decreased Infections

Who? When?

Leisa Huddle

Leisa Huddle

Leisa May

Leisa June

Leisa June

Leisa July

Leisa TBD

Leisa TBD

A3: Workout Process Summary1.) Information

6.) Containment Actions (short term): What must happen

immediately to contain the problem or minimize the impact?

Improvement Theme/Title: Hand Hygiene Improvement 1) Bad batteries in RTLS badges:

- Staff performed battery checks at huddle; unit replaced all low

or dead batteries.

2) Wall dispenser sensors not capturing badges:

- Nurse Manager contacted HillRom who came onsite 6/6/2016

to replace batteries in dispensers (problem not fixed).

- Nurse Manager contacted IT for assistance.

- Nurse Manager & IT contacted EcoLab who came onsite

6/9/2016 to investigate wall dispensers.

• EcoLab really only provides the soap for the dispensers.

• EcoLab representative utilized measured grid and testing to

determine dispensers WERE capturing badges, but location

tracking sensors in ceiling were NOTcapturing badges.

3) Ceiling tracking sensors not capturing badges:

- Nurse Manager & IT contacted Centrak who came onsite

6/15/2016 to fix dimmers in ceiling censors.

Department/Unit: Four South Date: May 2016

Champion: Leisa Krieger Update date: 8/10/2016

2.) Background/Problem Statement

• HillRom system in place to monitor hand hygiene since move to

new south tower in 2014.

• HillRom generated Hand Hygiene scores are noted to be very low

on 4S despite staff efforts to improve. - 67% Compliant April

• In early 2016, most staff members experienced dead or dying

batteries in their RTLS tracking badges (batteries replaced by unit

manager).

• Known high performers are experiencing large fluctuations in

scores depending on room assignments. 7.) Corrective Actions (Permanent): Process changes for

sustainable improvements

1) Standard Work: Nurse manager posts hand hygiene scores to

huddle board daily (monitoring for low scores indicating badge or

room failures).

2) Standard Work: Nurse manager to monitor HillRom data by

room weekly (monitoring for low scores indicating failure).

3) Preventative Maintenance: Reccomend Nursing & IT to

develop ongoing ownership, monitoring, and maintenance (i.e.

process / structure) for HillRom system for the entire hospital (task

for Clinical Technology Team?).

3.) Current Condition

• System uses RTLS staff badges, sensors in the soap & alcohol

dispensers on walls (EcoLab = vendor), and location tracking

sensors on ceiling (Centrak = vendor). Information is collected

and patient room entry & exit hand hygien is calculated by HillRom

software.

• Unit focus on improving hand hygiene in daily huddle, especially

since May 2016. Staff report issues with ceiling sensors not

capturing their badges and automatically turning off call lights.

• Room by room investigation of sensors. Discovered non-

functioning rooms: 4901, 4904, 4905, 4907, 4920, 4928, 4929,

4931 & 4932 (confirmed by IT).

8.) Implementation Plan: Major milestones

4.) Goals & Targets What? (Key deliverables) Outcome

1) Hand Hygiene compliance % greater than 90%.

2) All staff RTLS badges fully functional.

3) All sensors (wall dispenser, ceiling tracker) functional in all

rooms and hallways.

Badge Battery Replacement April 67% / May 72%

Meet w/IT Scheduled Vendors

Meet w/VendorsNew batteries &

dimmers June 82%

Posting Daily Scores April 67% / May 72%

Analyze broken rooms.

Bring A3 to Clinical Technology Team for

prevenative maintenance

5.) Analysis/Root Cause(s) - 5 Why's

Low hand hygiene scores in rooms 4901, 4904, 4905, 4907, 4920,

4928, 4929, 4931 & 4932.

WHY? Badges not interacting with wall / ceiling censors in the

above rooms.

WHY? Bad batteries in RTLS badges.

WHY? Wall dispenser sensors not capturing badges.

WHY? Bad batteries in wall dispensers.

WHY? Bad sensors in wall dispensers.

WHY? Ceiling tracking sensors not capturing badges

WHY? Bad censors/dimmers in trackers.

WHY? No preventative maintenance!

WHY? No owner of system, no process for monitoring.

9.) Performance Measure(s)

Measure/Metric Before After

10.) Yokoten - Best Practice sharing (application in other

depts/units)

Share A3 with Med/Surge Pod, CNO, at Nurse

Leadership Council, and with clinical technology

team.

May 72%

July 84%

Hand Hygiene Compliance April 67%

June 82%

Monitoring HillRom Weekly July 84%

Bring A3 to POD, NLC

A3 Sharing - 3 South SJMO Manager’s & Director’s Meeting

Presented By: Carolyn Maher (Manager CCU)

Date: September 28th, 2016

Our Approach on 3S

16

Structure:

• Huddle Daily @ 8:30

• See huddle board

• “Cuddle” board with

weekly updates

• Staff Ownership

• “Ideas in Motion”

• Staff project owner listed on board.

©2015

3S Approach Cont.

17

A3 Work:

• Choosing A3 topics

• Staff driven.

• Staff owned.

• Worked on independently.

• Shared at Huddle.

• “Knowledge Nook”

• A3s in process on wall.

• Binder for completed A3s.

Successful A3s

18

Top 10 Drawer

Improvements:

Alicia

Kanban Improvement: Paul

PST to RN

Standard Work &

Communication:

Khara & Mandi

sjmo_a3 deployment & adoption

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