Principles and Techniques for Sustained Improvement

Thursday June 13th at 1PM Eastern.

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Mistake-Proofing (or Poka Yoke) prevents mistakes from being made or makes the mistake obvious at a glance, so that corrective action can be taken before a patient is harmed. It’s a common sense approach tocreate low-cost, effective design changes that reduce errors.

Brian Nass has worked in quality and continuous improvement for over 20 years.  He held several leadership positions at Mayo Clinic in Rochester including Executive Director of Continuous Improvement and COO of Lab Services. Most recently as VP, Performance Improvement at Mission Health System in North Carolina.

Learn techniques for eliminating defects, improving quality and streamlining work.

Brian will discuss mistake-proofing within the specific context of healthcare; however, this webinar is not specific to only the healthcare industry. Many examples and references will come from healthcare, however this webinar will benefit managers from all industries who want to better understand the widespread application of mistake-proofing. Join Us!

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By identifying how health care organizations and other industries have both succeeded and failed at improving timely access across their organizations and examine how to improve timely access across your organization or the system in which it operates.

Click to learn more about the 2013 conference.

About Taming of the Queue

Since 2004, the annual Taming of the Queue (TQ) conference has brought together a community of interest from across Canada to discuss access and wait time issues. Representing a wide range of perspectives, conference participants assess progress being made on wait-time measurement and management. Sponsored by several national health stakeholders, these events have enhanced knowledge about the issue, while exchanging best practices and helping to shape the public policy agenda.

They are fighting fires while responding to pressures from both the organization above and staff below. Meanwhile, they are being told to cut costs, improve quality and improve service.

With so little hours in a day, where do they find the time?

Join us for our free webinar, “Management Capacity:  Creating Standard Leadership Roles for the Lean Supervisor.”

Mike Boucher, our Vice President of Client Services, will share his insights.

We will show you how to free up management time by understanding executive priorities and analyzing management activities, creating Standard Leadership Roles.

Date: Thursday, January 24th, 2013

Time: 1300 – 1345 EST

Space is limited.  Register Here!

About the Presenter: Mike Boucher, VP Client Services

Mike Boucher has had extensive experience with Lean in his role leading companies in their Continuous Improvement and Lean journey. Over 20 years, he held numerous operational positions with a major distribution and logistics corporation.  Mike has worked with various healthcare organizations and Government and College administrations including the Ministry of Health, Fleming College, Mayo Clinic, Toronto Sick Children’s Hospital, Marietta Memorial Hospital, Luther Midelfort Hospital and others. Lean applications within the healthcare setting include; Surgical Value Streams,Core Labs, Cytogenetics, Micro-Biology, Critical Care Units, Emergency Dept, Pre Surgical Center, Outpatient Clinics, Admissions & Discharge etc.  In the Government and College transformations, he worked on all administrative processes including policy, finance, human resources activities, quality etc.

Consistently, Lean applications in these settings focuses on optimizing service to the clients and improving turnaround times/lead times.  Through this endeavor, Mike has worked with teams to improve flow and truly identify the needs of the client. Unnecessary costs and wasteful activities are eliminated in order to better support staff in their efforts to provide service or value to their clients.

Mike’s greatest asset is his ability to simplify complex production and process issues through the application Lean principles and practice.  Mike is a strong promoter of Value Stream Mapping as one of the most important tools that companies can use to align their organization and promote a customer focused perspective. It is this approach that allows companies to best identify their waste and systematically remove it from their processes and value streams.

Challenge: Not all senior leaders have the vision, understanding and/or have “bought in” to making Lean a priority.

This is one of the critical steps and foundation blocks that must be in place to ensure the success of any Lean Transformation and Organizational Culture Change.

Root Cause: In our brainstorming sessions, the following were identified as some of the possible reasons this occurs.

• Lack of Knowledge/Education about what lean truly is and its benefits.
• Not aligned with Strategic Goals
• No clear metrics or goals associated
• Unclear about the Return on Investment
• Lack of ongoing communication
• Cultural issues internally
• Conflicting priorities
• Control
• Trust
• Resources to support and sustain lean
• Fear of this being just another “flavour of the month”

Each root cause listed above impacts leadership support and each one of those challenges requires an investigation to determine what would need to be in place to most effectively address them.

Possible Solutions:

Some of the possible solutions or ideas that could help to begin to address the challenge of achieving Senior Leadership buy in were as follows:

• Help Senior Leadership understand the value and overall system impact to create the vision
• Learn to speak the language of the Sr Leadership team and what is important to them
• Demonstrate the ROI of Lean through metrics meaningful to Leaders and its Strategic Alignment within the Organization
• Create capacity with staff and allocate resources to support the vision
• Create small wins which tie into the larger picture and work towards winning over naysayers
• Establish Goals and Focused Scope of Project
• Within you sphere of influence, create a pro-active and empowered culture

These are some of the potential solutions that were identified from our session and are worthy of investigation and strategy. Lean Advisors employs senior consultants who are veterans in the industries they serve. To learn more about how we can help you make your organization everything that it can be, contact us.

With the objectives being to reduce stress on staff while meeting higher demands, being more responsive and lowering the cost of care and determining the technological advancements/innovation needed to support the new improved processes well into the future.

The end-to-end process in several areas will be assessed and redesigned in order to improve the flow of information, communication and the patient throughout the ‘system’.

In 2008, the Montfort Hospital emergency room was one of the province’s worst. Its sickest patients waited up to 20 hours to be admitted. Patients complained and nurses quit. Morale was low and turnover was high. The nurses who remained were overworked and burnt out.

Occasionally, staff frustration boiled over; patients either left without being treated, or went public with stories about rude behaviour and substandard care. The hospital became a focus of negative headlines. “It was a crisis,” admits François Lemaire, Montfort’s clinical director of the ER.

These days, Montfort is no longer a laggard among Ontario’s busiest ERs. Its wait time for the sickest patients is 10 hours — half of what it was in 2008 — even though the volume of patients continues to rise. From 35,000 patients in 2008, the ER now treats 52,000 annually. Many of them are sicker and harder to treat than patients in the past. Yet despite these challenges, Montfort’s wait time continues to fall.

A recent survey of Ontario hospitals indicated that nine out of 10 patients would recommend Montfort’s emergency department to their family and friends. And the turnover in ER nurses is so low that there are currently no full-time openings — a dramatic change from 2008 when there were 15 vacant positions.

The turnaround, aided by $3.7 million in provincial funding since 2008, is one example of how Montfort says it has improved patient care by using practices made famous by Toyota. With the hospital-wide introduction of checklists, streamlining, standardization and non-stop brainstorming with front-line staff, Montfort has joined a growing number of acute-care centres in bringing the efficiency of a factory floor to health care.

The approach, known as lean, has long helped the auto and aerospace industries reduce waste and boost value for customers through continuous small improvements. With a cash-strapped government trying to rein in health spending, Ontario hospitals are catching up, spurred by provincial directives to do more with less.

Nowhere is the need for improved efficiency more critical than in emergency rooms, where speedy care is a key component of good care.

Montfort’s transformation began in January 2009, to teach its staff the lean principles. The hospital paid for the lean consultants with some of the $687,000 it received that year for ER improvement.

The money was part of a four-year, $400-million provincial program called Pay For Results. When it was launched in 2008, Montfort was among 23 of Ontario’s poorest-performing ERs to receive the funding, which gets clawed out of their annual budgets if they don’t show improvement.

Hospital staff deconstructed every aspect of how patients moved through the ER, from the time they arrived by ambulance or car until they were discharged. They examined the “flow” of patients — how they were assessed at triage, how they got their lab tests and diagnostic scans, how they were discharged or admitted and how information moved with them at each stage. They attacked the problem in the same way that factory managers studied the parts of an assembly line.

“We were a whole bunch of people with Post-it notes on the floor that showed all the different steps,” recalls Sophie Audet, an ER nurse. “After it was done, everybody looked at each other and started saying, ‘Oh my God. No wonder we’re so tired.’ There were so many steps. When you see it, you actually realize that.”

Audet and her colleagues worked to simplify the journey for patients and reduce unnecessary tasks for staff. To their surprise, the best ideas were not necessarily flashy, or expensive to implement.

Among other things, a daily activity report was introduced that gave every hospital worker — from the chief executive to department heads, physicians, nurses and housekeeping staff — a snapshot of the traffic in and out of Montfort. It listed the number of patients waiting to be admitted and discharged.

For the first time, staff got a bird’s-eye view of where the hospital’s bottlenecks were. They could also see which departments needed extra help to move patients along. “You see the big picture, not just your own little department,” says Audet.

In the ER, a low-tech whiteboard was introduced. It tracked the location and status of every patient and listed what services they were waiting for. For the first time, method and transparency were imposed, allowing the nursing team to manage patients more quickly and effectively. The approach also reduced the chances of patients being lost in the shuffle.

“Before, we used to write down everything by hand,” says Johanne Gougeon, the ER’s lead nurse. “Now, we write on magnets. If we have a patient go somewhere, we just move the magnet around. It’s on the board, it’s written out, it’s all standardized and everybody can see what’s happening.”

In addition, the triage process was simplified for patients with minor complaints. And the workflow of the diagnostic imaging department as well as the work schedules of housekeeping staff were adjusted to conform with the ER’s busiest times of the day.

Other changes related to inconveniences in the physical layout that added up to hours of lost productivity every day.

For example, the storage and labelling of medical supplies were standardized so that nurses did not waste precious time searching for surgical dressings or catheters. A method was introduced to manage wheelchairs, which were never available when staff needed them, leading to longer-than-necessary delays for patients waiting to be moved or discharged.

“We (drew) a line on the floor and we put up a sign: ‘Three wheelchairs here,’ ” says Lise Vaillancourt, director of clinical services. “All of a sudden, when somebody was done with a wheelchair, they knew what to do with it.”

Even a simple procedure like urine analysis often kept patients waiting because the fridge where the samples were stored was far from the nursing station. “We calculated that the nurse had to walk something like 150 steps and another 150 steps back an average of 75 times per day,” says Vaillancourt. “So we just took the fridge and put it under the counter. Now, it’s zero steps.”

Based on these seemingly minor improvements, ER wait times at Montfort fell by 10 per cent within three months.

Meanwhile, other changes happening hospital-wide also helped to ease some of the ER congestion. Physicians and nurses started to emphasize discharge planning almost as soon as patients were admitted. In the past, discharge planning only took place toward the end of a patient’s stay, which often led to extra days spent unnecessarily in the hospital. The resulting bed shortages triggered a backlog of patients waiting in the ER to be admitted.

Another change involved introducing a system of early-warning signs that flagged hospital staff about imminent overcrowding, giving them more lead time to plan for a higher number of patients.

By 2010, two years after Montfort introduced lean, its ER was among three that were recognized as the most improved in the province. That year, the department was awarded a $200,000 bonus under Pay for Results. By then, the ER had left its cramped and aging space for a brand new facility that was double its previous size, part of the hospital’s $300-million expansion of its premises on Montreal Road.

The new space allowed for even more ER efficiencies to be introduced.

These days, when patients walk into the Montfort’s ER, one of the first things they see are signs telling them what the estimated waiting time is. Based on how serious their illnesses or injuries are, they are directed to different waiting areas and treatment zones. They take a number to wait so they know how many patients are ahead of them.

Instead of having nurses or porters accompany the walking wounded to get their diagnostic scans, there are colour-coded lines on the floor that guide patients to where they need to go. In the past, patient care suffered in part because staff spent so much time shuttling patients back and forth.

Hospital officials say patients, especially those with minor complaints, are now so savvy that they’ll call ahead to check Montfort’s wait times against those of The Ottawa Hospital or Queensway Carleton. “Now, people are shopping around,” says Lemaire, the ER director. “This is our reality.”

Excerpt from the Ottawa Citizen
To Read more: http://www.ottawacitizen.com/health/Toyota+style+management+helps+Montfort+wait+times/7427615/story.html

“This is a time of real transformation. If we don’t change how we deliver universal health care it won’t be there for [our grandchildren] as they grow up.” —Deb Matthews, Minister of Health and Long Term Care, Province of Ontario

What’s true in Ontario is true across Canada. Spiraling costs, an aging population, and deficit and debt reduction at all levels of government challenge the very survival of effective universal care. Now’s the time to address the sustainability issues, and begin the transformation that will guarantee effective care for future generations.

These changes will affect every Canadian and every employer, as organizations increasingly foot the bill for health through employee benefit plans and wellness initiatives.

To read more about the Summit click here.

Toyota, the Japanese auto giant, pioneered the concept of lean management in manufacturing, where employees look for efficiencies both big and small that don’t compromise the product but save the company time and money.

In Regina, hospitals are applying the idea to everything from stocking medicines to hospital design, CBC’s Cameron MacIntosh reports.

Steve Read, VP Corporate Services and CFO of Brockville General Hospital in Brockville, Ontario, draws on his background in the manufacturing sector as his organization adjusts to a tough fiscal environment.  “The economy influences how governments choose to fund healthcare,” says Read, “and right now the industry is going through a transformation where resources are tight and there’s pressure on all aspects of the healthcare system to rethink their processes and rethink the way they operate.”

In Read’s previous role, having to adapt was a given – manufacturing in particular has been transforming itself for decades, drawing on methodologies such as Lean, Six Sigma, Just in Time, and Total Quality Management.  Today, these approaches are commonplace in virtually every industry, including healthcare.

The fact that these methods, Lean in particular, help organizations do more with less makes them particularly applicable to today’s healthcare challenges. “In hospital administration specifically, the options to deal with financial constraints are fewer than they are in industry,” says Read.  “We cannot, for example, make a unilateral decision to not provide a particular service because it is not contributing to our financial plan.”

The need to provide the best possible care with limited resources prompted the CEO of St. Joseph’s Health System in Hamilton, Ontario, Dr. Kevin Smith, to engage the Lean consulting arm of Japanese automaker Toyota.  While there were initial questions as to why hospital administrators were visiting a car plant, Smith’s management team found that when they looked at Toyota from a process perspective, there was much to be learned.

“We saw that they had very good systems in place for creating flow, improving processes, and standardizing their work, all of which are very relevant to our work looking after patients,” says Smith.  “They also had very clear models for course correction when that may have been required, and rapid intervention in case of a problem.”

The processes were underlined by a continuous drive to do things “better, faster, cheaper”, and the empowerment of employees.  “Toyota really took people who do the work, gave them training and skills, allowed them to make changes in how they do their work as a team,” says Smith.  “The attitude was, ‘if it works, continue, if not, let’s figure out why, or move on to the next idea.’”

Seeing the Big Picture

The key to the common ground between hospital and industry is the customer, says former plant manager Larry Coté, whose firm, Ottawa-based Lean Advisors Inc., provides Lean consulting and training to healthcare providers across Canada.  “It’s not about cars and whether that’s similar to healthcare,” says Coté  “It’s that they both have processes that provide something of value to a client.  As far as the analysis, the thinking is very similar because you are looking at what is value from the perspective of the client, or the patient going through the medical system.”

The healthcare experience, of course, transcends many functional groups as the patient interacts with doctors, nurses, lab personnel, and administrators.  “Looking at all these interactions from the patient perspective forces decision-makers to consider the big picture that starts when a patient approaches the hospital or clinic seeking help, and concludes when the patient is dispatched after having received the required care,” says Coté.

Hospitals perform best when processes are in place that allow patients to flow through the system at a steady, manageable pace.  When patient flow is achieved, staff don’t get spikes of activity where they are overworked, patients don’t have to wait between processes, and the best quality is achieved at the lowest cost.  This kind of process environment can be implemented in a hospital, a factory, or virtually any other work scenario.

Two other components – information flow and communication flow – are also essential, as they make it possible for different functional groups to perform as a unified entity from the patient perspective.  These flows are also key to eliminating the waste that occurs throughout the system.

“By focusing on these things as a system, as a process that goes beyond functional centres and specific tasks, I think the healthcare sector is finding the same things that industrial sectors found,” says Read, “ – that there is waste to be found, and there are ways of eliminating it, and there are techniques that can be used to facilitate that.”

Managing Between the Processes

One of the most visible symptoms of waste in healthcare is patients sitting around in waiting rooms, taking up space in already-crowded facilities.  Smith recalls a simple question posed by a visiting advisor from Toyota who was viewing their ER – if waiting is not a good thing, why are there waiting rooms?  Smith says he was initially puzzled by the question, but then saw its implications.

“If you don’t have a waiting room, much like not having storage capacity in a car line, things are going to start backing up, and you’re going to have to start to figure out a different way of doing things,” says Smith.  By reducing the available space to conveniently “tuck patients away”, St. Joseph’s subsequently found ways to reduce ER wait times, save valuable space, and furthermore, to use the space to provide treatment on the spot for children’s ear infections and other routine, non-confidential situations.

When implementing Lean, how can your organization handle change when they are already working at capacity and everything is a priority?

The thoughts and ideas that emerged from the participants of our Lean Executive Day were so valuable we have consolidated the notes for the benefit of our online community.

Create a product family matrix (in offices too) that will identify the value streams; ensure each one has a leader, and with key metrics point to the most important value streams to improve. This will help to prioritize your resources, and get consensus from senior staff.

Make sure to use value stream mapping to plan improvements to ensure the most important issues are prioritized

- Without a value stream approach you may be wasting your improvement resources in areas that will not yield an end-to-end improvement (or even make things worse!)

- A value stream plan also provides important improvement sequencing to make sure the product or service flows smoothly as improvements are made.

- A future state value stream plan is based on critical system design principles (not random brainstorming) that a good consultant will transfer to your improvement teams. (Teaching them to fish – so to speak)

Make sure that there are strong champions in place to ensure that value stream improvements keep moving and have resources

- The champion should break through barriers that are hampering progress

- The champion can assign resources to the improvement teams

- The champion should meet with the improvement leaders at least biweekly to keep things moving

- Champions show the right amount of impatience, and demand great results

Use consultants to grab attention.

-A consultant being on site tends to focus the attention of internal staff, often because the improvements are getting outside scrutiny. Usually this means that improvements happen more to schedule, and get the resources needed.

Make sure that lean is not a second cousin to the overall corporate strategy

- Make sure that lean is embedded in the organization’s key strategies so that it is not an afterthought receiving poor resourcing

- Measure your improvements and make them part of regular reviews. What gets measured gets attention. One good way to do this is with A3’s (one page reports for each improvement)

Make sure that lean is part of leader’s business plans and scorecards

- It is more likely that lean improvements will get the attention and resources needed if they are part of the written goals of the leaders

- Make sure in communication and change planning to continually reinforce how lean improvements are helping to achieve organizational goals

Communicate! Keep lean on everyone’s mind, so that they keep moving forward.

When management (especially middle) or staff is over loaded and can’t handle any further new demands on their time, use a ‘Managing Capacity’ Value Stream Analysis to determine what the management and staff are forced to do day-to-day in order to meet the current pressures and responsibilities.  Sometimes called an Activity Value Analysis, the next step is to design a future state plan that eliminates the non-value and allows them to work on more value – must be done with exec support as part of the strategic deployment charter.