Going Lean
Agenda Introduction and Objectives Borgess Ambulatory Care and its Guiding Principles Overview of Lean Thinking Benefits of Value-Stream Mapping Transforming Office Practice Outcomes What We Learned Summary and Next Steps
We Are a Place People Can Call Their Medical Home Borgess Ambulatory Care 330,000 Provider Visits Per Year Over 650,000 Total Visits Per Year 10 Practices 16 Locations 98 Providers 58 Physicians 40 Non-Physician Providers Predominately Primary Care Practices Owned by Hospital System
Borgess Ambulatory Care Guiding Principles
Your Care Will Be Safe
We Know Who You Are and Are Ready For You
We Will See You When You Want to Be Seen
You Will Know What to Expect
We Will Be Your Trusted Partner in Health
We Will Exceed Your Expectations
Changing Priorities Ahead
Health Plan Partnership Support for Lean consultant Initially conducted Lean workshop Trained and mentored Lean coach Observe, partner, lead model Worked with Borgess Ambulatory Care leadership Initially disease focused Seen as core competency for process improvement
Change is like going to heaven, everyone wants to go but not right now!
What is Lean? Lean is a set of concepts, principles, and tools used to create and deliver the most value from the customer s perspective while consuming the fewest resources. From Mapping to See, Lean Enterprise Institute, www.lean.org
Encourages Front-Line Initiative Having a meeting that pulled people from each department and allowing them to work together was very beneficial. It was a great concept in which it allowed input and say from each department to create change and better the work place. We all felt valued. Implementing more meetings like we just had will create a great team environment. Maria, Medical Records
Develops Structured Thinking Around Problem-Solving
Your system is perfectly designed to produce the results you are getting - Frederick Taylor
Fosters Dialog Within the Organization
Even on the best day with the best team, the worst can happen because we re not really trained to talk to each other. If you re preparing for a concert, you would never ask the violins to practice on the third floor, the flutes on the second and the cellos in the basement, and then expect them to come together for a symphony. - Karyn Baum, University of Minnesota Medical School Molly Kelash, Closing In on Bad Communication, Pictures of Health, Fall 2006.
Overall Performance - Not Silos
Serves as an Organizational/Operational Learning Tool
Building Blocks of Lean Healthcare Continuous Improvement and Kaizen Events Total productive maintenance Just-in-time Cellular and flow Poka-yoke Pull system and kanban Autonomation Self inspection Standardized Work Layout Batch size reduction Visual 5S s Value-stream mapping Point of use storage Quick changeover Change management Teams and teamwork A. Manos, M. Sattler, and G. Alukal, Making Healthcare Lean, Quality Progress, July 2006, pp. 24-30. www.asq.org
Benefits of Value-Stream Mapping Helps people understand how the process works now Helps people understand and reach agreement on how well the process is working Helps uncover waste and problems with flow in the value stream Helps people reach agreement on what changes need to be made Helps people reach agreement on how to ensure that those changes are made From Mapping to See, Lean Enterprise Institute, www.lean.org
Roles for VSM or Kaizen Event Lean Coach Process Owner Executive Sponsorship Leadership Panel Workshop Participants
Capabilities for Selection of Lean Coach Social Aspects of Lean Thinking Problem Solving Group Process Change Management Conflict Management Technical Aspects of Lean Thinking Concepts and Tools Data Analysis Leadership of Lean Thinking Listening Influence Work Structures and Management Business Understanding General awareness of process Excellent coaching/facilitating skills Respected by organization Encourages humor and creates a fun environment Developed by Margie Hagene and Beau Keyte, Lean Transformations Group and Chris Wise, University of Michigan Health Systems
Identified Staff Educational Gaps Comprehension of the need to change QI terms and concepts Change management techniques Project management skills Lean terms are confusing
Structure of a VSM Workshop Pre-Work: Define Problem/Scoping 1.5 hr meeting Lean Coach Leadership Team Member Sponsor Process Owner Define Project Scope Determine VSM Participants Identify Key Decision Makers Develop Data Collection Plan Identify Concerns, Issues, and Barriers
Day 1: Current State Map
Common Problems Waiting/delay Rework Excessive handoffs Interruptions Many requirements for decisions and approval Poorly defined requirements From Mapping to See, Lean Enterprise Institute, www.lean.org
Day 2: Future State Map
Common Solutions Combine steps Manage interruptions Standardize processes Build in quality checks From Mapping to See, Lean Enterprise Institute, www.lean.org
Solutions should be Within your control Easy to implement Can be started immediately Low cost or no cost
Day 3: Implementation Planning
Develop a 90-Day Work Plan to: Clarify goals Develop action plan for each goal Determine who will be responsible Determine when reviews and checks will take place From Mapping to See, Lean Enterprise Institute, www.lean.org
30 60 90 Day Reviews 1.5 hr Lean Coach Leadership Team Member Sponsor Process Owner VSM Participants Leadership Team Other Providers/Staff Report Implementation Plan Progress
Your Care Will Be Safe Common Themes in Plan Develop standing orders/protocols Success Stories Test tracking Color-coding Vaccine Information Sheets Eliminate interruptions Physician sat with a scheduler and listened to calls for one day Increase IT functionality Labeled diabetic patients in practice management software
We Know Who You Are And Are Ready For You Common Themes in Plan Success Stories Team huddle Team has plan in place for the day Provide proactive care Schedulers provide patients with a lab slip for routine tests at the time of scheduling health maintenance exam Scripting Before: When was your last mammogram? After: Could please verify that your last mammogram was?
We Will See You When You Want To Be Seen Common Themes in Plan Realign responsibilities and clarify roles Eliminate duplication of work Success Stories Removed unnecessary paperwork from physicians duties Provider charts are screened and organized by priority Time and date stamping faxes Review scheduling templates and protocols Eliminating appointment types Having schedules in the computer seven months in advance
You Will Know What To Expect Common Themes in Plan Patient education Success Stories Empowering and enabling patients pediatric vaccines Letter explaining the group s policy, includes current vaccination schedule, list of billing codes, instructions on how to contact insurance company to see if they are covered, and options if they are not covered. Standardized work Forms were standardized at all pediatric sites
We Will Be Your Trusted Partner In Health Common Themes in Plan Increase communication Success Stories Providers and staff building relationships with other providers/services within the organization/community Department at hospital was able to provide a solution Increase post-visit contact with patient Developing care management protocols
We Will Exceed Your Expectations Common Themes in Plan Schedule diagnostic and referral appointment before patient leaves Success Stories Family practice sites are currently doing live referrals Create a visit summary sheet for the patient Visit summary sheet was created in electronic health record Realign meeting structure Problems are solved more efficiently and effectively
5S Workplace Organization Sort: Sort out unneeded items Straighten: Have a place for everything Shine: Keep the area clean Standardize: Create rules and standard operating procedures Sustain: Maintain the system and continue to improve it
ProMed Pediatrics: Provider Interruptions Organized and labeled cabinets Removed doors where applicable Posted an inventory form Created a stocking checklist Inserted blood pressure cuff shelving Determined who is responsible for restocking Placed frequently used handouts/forms in the room
Woodbridge Family Practice Medical Records 5S Event Pursue to Perfection
Medical Records Improvements Reduction in Chart Pull Prep Time 67% Reduction in Loose Filing 100% Kanban System Created for Incoming Mail Increase in 5S Scorecard rating 100% Pre 5S = 11; Post 5S = 22 Significant Reduction in Wasted Floor Space Significant Reduction in Transportation Waste for Transcription Process Data provided by Ed Blackman, MA, CSSBB
Before and After
Staff Satisfaction: Gallup Survey Gallup Questions How satisfied are you with Borgess Health as a place to work? This last year, I have had opportunities at work to learn and grow At work, my opinions seem to count I always trust my organization to be fair to all associates My organization treasures diverse ideas and opinions % Improvement (Post- Lean Workshop) 22.4% 17% 27.8% 27% 34%
Your Care Will Be Safe ProMed Internal Medicine Diabetic Patient Immunizations 85 Lean Workshop Percentage 75 65 55 45 2007 Baseline 2008 Q1 2008 Q2 2008 Q3 2008 Q4 Timeframe Pneumo Vac Td/Tdap
We Know Who You Are and Are Ready For You Mammography Two Business Days from Screen to Initial Pt. Call Back Days (avg/mo) 3.5 4.1 Average Screening Mammograms per Month: 370 3.3 Lean Workshop 1.8 1.0 2.0 2.0 2.0 2 days 10.8 Lean Workshop Day (avg/mo) 8.8 7.3 6.8 5.0 2.1 1.0 1.0 Jul Aug Sep Oct Nov Dec Jan Feb Jul Aug Sep Oct Nov Dec Jan Feb 2 days # of Screening Mammograms by Month Mammography Two Business Days from (postscreen) Contact with Patient to Offer Date for Additional Views
We Will See You When You Want to Be Seen Pediatrics 3rd Available Appointment for Well-Child Visit 100 80 60 40 20 0 Provider A Provider B Provider C Provider D Provider E Provider F Provider G Provider H Provider I Provider J Provider K Provider L Provider M Provider N Provider O July 2008 Sept 2008 Jan 2009 # of days out
You Will Know What to Expect 98 96 94 92 90 88 86 Patient Satisfaction Expectation Questions Before I came to my doctor's office, I expected high quality care. 2007 Lean Groups 2008 Lean Groups 2007 Non-Lean Groups 2008 Non-Lean Groups Before I came to my doctor's office, I expected the doctor's office to meet my personal needs extremely well. Before I came to my doctor's office, I expected things not to go wrong.
We Will Be Your Trusted Partner in Health 70 69 Net Promoter Score for Borgess Physician Practices 69 68 Score 67 66 65 64 65 66 63 FY07 FY08 FY09 NPS Formula SA - (SD+D+N) = NPS I would recommend this doctor's office without hesitation to others.
1 We Will Exceed Your Expectations Change in raw score CY07-CY08 2.00 1.50 1.00 0.50 0.00-0.50 Satisfaction Lean vs Non-Lean groups Non Lean groups - 0.34 Lean groups 1.64
What did problem solving look like 6 months ago at your clinic? Took a long time to resolve issues/problems We were basically on our own to figure out how to handle a problem because we did not know who to ask. I would tell my boss about a problem, I could not go to my co-workers with problems. We had no way to discuss issues with a provider.
What does problem solving look like at your clinic today? Improved Communication and Team Problem Solving Doctors are invited (and show up) at our staff meetings to be involved as well, this is great! People are more receptive to suggestions. We were able to make some much needed changes using Lean things staff had been adverse to try. Once we did it, everyone realized it was for the best. We now have time at our staff meeting to group-solve and talk about problems.
What does problem solving look like at your clinic today? Collaboration Between Staff Members Staff are making their concerns known while taking in other opinions. When suggestions are made, we try one to see if it works. Improved Patient Care We are more aware of making the patient/family happy and pleased with all aspects of the visit and care.
What are you learning? That change isn t always bad. I can learn new things even at my age. Become more aware of how good my coworkers are I knew they were good, but I truly appreciate all they do now. That just because we ve always done it that way doesn t mean we have to continue to do it that way. I have learned I can find something that I think may need change and I have a way to present and discuss the possibilities.
Leadership Key Learnings Front line associates are key to success Lean is a great way to break organizational silos Value-added work is in the eye of the beholder Waste is also in the eye of the beholder Allows inputs from others to influence perspectives on waste and value-added work It is important to be sure that stakeholders from other major projects/departments are included in the work
Leadership Key Learnings Transformation is a continual process Gaps in management of day-to-day work were discovered 90-day goals might involve closing those gaps Lean allows us to live our Guiding Principles and support objectives of IHI s Triple Aim
Ongoing Lean Organizational Roles Directors: Leadership cascades vision and strategy Drivers: Management approves action plans and serves as a coach/mentor Doers: Staff identify and solve problems From Mapping to See, Lean Enterprise Institute, www.lean.org
Next Steps Introduce new employees into the culture Identify and skill up coaches embedded at each of our locations Align organizational behaviors Introduce additional system integration workshops Central Billing Office Low Back Pain Physician Recruiting Childhood Obesity
Bottom Line = Changed Lives Your care will be safe We know who you are and are ready for you We will see you when you want to be seen You will know what to expect We will be your trusted partner in health We will exceed your expectations
Tools for Getting Started BAC Pre-Workshop Checklist BAC Lean Roles and Responsibilities BAC Lean Meeting Schedule BAC Communication Plan Template BAC Implementation Plan Template BAC Staff Homework BAC Staff Training Agenda BAC Post-Learning Cycle Evaluation
Improving Our Lean Process Evening meetings began to feel like a punishment Be mindful to include/inform staff not participating in workshop Be careful in combining this process with any other change out of your scope of control