Rapid Improvement Events (RIEs), A3 Problem Solving, and Voice of the Customer Judy Krempin, MS, CPHQ Manager Quality, Safety, Performance Improvement RAPIDIMPROVEMENT EVENTS (RIES) 2
Objectives State when a Rapid Improvement Event (RIE) should be used Name the people (roles) who should be involved in an RIE process Describe the timeline for an RIE cycle 3 Why use an RIE? Rapid improvement events enable you to: Learn and implement continuous improvement practices (i.e., Lean Tools) Work as representative team Focus on a targeted process/ area and patient population Improvement work is completed within a specific time period Reduce variation, improve flow, improve value for the patient 4
Who is involved? The hospital-wide Quality Improvement Committee, a high level steering committee commissions the team RIE team (project team) will be responsible for planning and implementing the Lean tools Note: All employees should do their own Kaizen (continuous improvement) daily they do not have to wait for a rapid improvement event to think about reducing waste. 5 Rapid Improvement Event 3 weeks 1 week 3 weeks Three-week preparation period Monday: Discuss current process flow Tuesday: Redesign flow and remove waste Wednesday- Friday: Implement changes Three-week post-event sustainment Create Team Team Charter Approval of Charter/ A3 Communicate To Staff Voice of the Customer Observation & Data Collection Current State Flow Chart/ Value Stream Map Identify Barriers Spaghetti Diagram COPQ 5S Brainstorm Improvements Future State Flow Chart/ Value Stream Map Benchmarks and Measures Mistake Proofing Leveling Standard Work Specific Task List & Timeline Report Results Teach Standard Protocols Update Policies Monitor Results Targeted Gemba Walks Huddle at the PI Board Source: Advisory Board interview, December 2006. 6
RIE Supports the Mission, Vision, Strategy of the Organization 7 Rapid Improvement Events Will accomplish the following: Quickly implement Lean tools to eliminate waste and non-value added work Train staff in Lean tools and application Improve work flow Improve productivity Reduce stress 8
Summary of Key Points for RIEs Must have all three phases - The planning phase and follow-up phase are just as important as the workshop ( hot week ) phase. These events can be focused on one area or process, or on multiple areas. Only successful if management (champion) is in support and there is cooperation from the staff. Keep events manageable with focused projects. Expand as you experience success. Always keep 5S as the initial part of any event. 9 A3 & PROBLEM SOLVING 10
Objectives State the principles of A3 thinking Describe the benefits of the A3 process Articulate how to use tools to document the A3 process 11 A3 Thinking A3 is structured problem solving Helps us to truly grasp the root of the problem before we determine a solution Transparency of thought and analysis Develop A3 for all RIEs hospital-wide and all department specific 12
Three Pillars of A3 Thinking 13 A3 Elements Plan Project Title Executive Sponsor Background Current State (Compelling Reason for Action) Goals/Measures Analysis/Root Causes Do Study Act Interventions / Future State Map Observations Results / Conclusions Follow up (Has this change resulted in improvement?) Plan to Sustain 14
Title: What you are talking about? Background Why are you talking about it? Cost of poor quality? Current Situation Where do we stand today? What s the problem? Goal Where do we need to be? What is the specific change you want to accomplish now? Analysis What are the root causes of the problem? A3 Recommendations What are your proposed interventions/ countermeasures? Actions What activities will be required for implementation and who will be responsible for what and when? Follow Up How we will know if the actions have the impact needed? What remaining issues can be anticipated? Authors: John Shook and David Verble. Lean Enterprise Institute. www.lean.org 15 A3 Background & Scope Why are we forming this team? How does the work of this group support the overall goals of the organization? Which patients? Which settings of care? Which process? What are the start and end points of the process? 16
A3 Background & Cost of Poor Quality (COPQ) What are the dollars at risk? Quantify the value of wasted staff time for non-value added activities What are the additional days in length of stay when patient harm events occur or care coordination activities fail? What are the risks to the organization if publicly reported data reflect poor performance? 17 A3 Current Condition (and Compelling Reason for Action) Problem Statement: One sentence stating the compelling reason for action Problem Description: Patterns, frequency, nature of problem Facts: Show graph or process map that describes problem 18
A3 Goals Aim Statement High level statement describing what we will improve? How? By When? Measures How will we know a change is an improvement? Process Goal? Outcome Goal? Note Benchmarks 19 A3 Analysis/ Root Causes 5 Whys: Ask why multiple times to identify the root cause 1 Why did the problem happen? 2 Why did that happen? 3 Why did that happen? 4 Why did that happen? 5 Why did that happen? 20
A3 Analysis/ Root Causes Place Policies Effect Process People 21 A3 Interventions / Future State Map Identify the most effective solution that can be implemented, considering time and cost Obtain approval from project sponsor If steps in a process will change, show flow diagram Consider standard work and visual controls 22
A3 Observations Assign tasks to specific people and set target date: Communicate plan to people affected by change Implement interventions (pilot) Collect data 23 A3 Results/ Conclusions Team meets to discuss results of the trial/ implementation Discuss unintended consequences Decide what input, sequence, or step needs adjustment 24
A3 Follow Up Tasks Target Date Responsible Person(s) Decide if new PDSA is needed 25 A3 Thinking The A3 Report THEME: WHAT ARE WE TRYING TO DO? Background Target Condition Background of the problem Context required for full understanding Importance of the problem To: By: Date: Diagram of proposed new process Countermeasures noted as fluffy clouds Measureable targets (quantity, time) Current Condition Diagram of current situation (or process) Highlight problem(s) with storm bursts What about the system is not IDEAL Extent of the problem(s), i.e., measures What? Actions to be taken Cost: Implementation Plan Who? Responsible person When? Where? Times, Dates Root Cause Analysis List problem(s) Most likely direct (or root) cause: Why? Why? Why? Why? Why? Plan How will you check the effects? When will you check them? Follow-Up Actual Results In red ink/pencil Date check done Results, compare to predicted 26
First Step: Hand Drawn A3 27 Electronic A3 (evsm) www.evsm.com 28
A3 with Photos Source: http://www.shmula.com/wordpress/wpcontent/images/shmula-5s-fishbone.png 29 A3 Templates 30
Format A3 for Easy Uptake of Information Goal is to tell a story Strive to make the story visual Address all A3 elements 31 A3 Plan to Sustain How will these improvements be sustained? Monthly A3 Reports with Data Real Time Feedback/ Huddles Visual Management Go See Standard Work Leadership Rounds 32
Summary of Key Points The goal of an A3 is to tell a visual story and communicate our problem solving approach. The left side of the A3 represents the Plan of the Plan-Do-Study-Act methodology. The value of spending time planning is that we understand the root causes of the problem before selecting an intervention or solution. 33 VOICE OF THE CUSTOMER (VOC) 34
Objectives Define the Voice of the Customer (VOC) Identify who the customer IS for a process Describe how the needs of the customer are defined 35 What is a Customer? A customer is: Anyone who interacts with a product or service, from its design, development, transformation, and every step along the way to the end-user Anyone whose perception of the value offered can affect whether or how an organization continues to deliver those offerings (American Society for Quality) 36
Primary Customer 37 What is VOC? The voice of the customer is a process used to capture the requirements/feedback from the customer (internal or external) to provide the customers with the best in class service/product quality This process is all about being proactive and constantly innovative to capture the changing requirements of the customers with time 38
How do we obtain VOC? The stated and unstated needs of the customer can be captured in a variety of ways: o direct discussion or interviews o surveys o focus groups o customer specifications o observation o warranty data o field reports o complaint logs 39 Who are the Customers? External customers Those not employed by the organization who interact with a product or service Often the person who pays for the service Person who receives the output of the process End user Patient (sometimes called the primary customer in healthcare) Internal customers Those in the organization who participate in the development/ delivery of the product/ service People who need the output of the previous step to do their job Employees Organization/ Stakeholders The stakeholders or leaders of the organization who want the process to operate efficiently 40
Defining Customer Requirements To adequately determine customer requirements, practitioners need to conduct discussions with the customer Through these conversations, practitioners typically gather generic customer needs Practitioners must go on to translate these generic needs into specific items called critical-to-quality requirements (CTQs) 41 Transitioning from VOC to Critical to Quality To begin the translation to specific CTQs, consider the typical generic needs of the customer: Cost: How efficient is the process operating from the perspective of the business? What costs are involved for the patient? Timeliness: Delivery to customers when they want it Quality: Did the customers get the what they wanted? (e.g. well-explained, helpful, done right the first time) 42
Obtain Voice of the Customer (VOC) Identify the stakeholders in the process List all customers/receivers throughout this process Talk to people! This is the beginning of our communication strategy. Answer these questions: What are your customers saying? What needs to be improved and why? What does the process look like? What is happening in the environment? o National, regional, local, internal Can we validate the perceived need for improvement using data? 43 VOC 1) Who is the customer of this process 2) What do they say about this process, what do they need? 3) What is the key issue for improvement? Customer Voice of Customer Key Issue 44
VOC for Patients/ Family Timely Care 1) Who is the customer of this process 2) What do they say about this process, what do they need? 3) What is the key issue for improvement? Customer Voice of Customer Key Issue Patient I was stressed upon arrival but relieved when the doctor showed me pictures Patient uncertainty about process/ outcome Patient Would help to have more explanation if surgery is delayed for ½ hour or more OR case delays/ Explain delays Patient/ Family My mom didn t know why it took so long. OR case delays/ Explain delays Patient There seemed to be a lot of duplication in the questions they asked me Cumbersome Pre-op process/ Duplication Patient The nurses made sure I was comfortable Patient comfort Family More information about what is going on after a few hours. I thought my wife would be done by 3pm. OR case delays/ Explain delays 45 Example Critical to Quality : OR Cases Start On Time Customer Need (CTQ) Driver 1 Driver 2 Driver 3 Driver 4 Requirement 1 Requirement 2 Requirement 3 Requirement 4 Requirement 5 Requirement 6 46
Example Critical to Quality : OR Cases Start On Time Case Starts on Time Consistently Correct Surgery Scheduled Surgery Scheduling Guidelines Schedule Reflects Demand for Services On Time Staff Supplies in Reach When Needed Consistent Process to Clean and Set Up Flow Management Doctor has adequate information to select procedure(s) Schedule is blocked when surgeons are unavailable Duration of surgery is appropriate for case Level load schedule Separate emergent and elective case flow Patient is on time Doctor and staff are on time Everyone involved knows the plan for the day Standardized room set up Supplies replenished on pull system (kanban) Separate internal and external set up Standard work Contingency plan for increased patient demand (staff, rooms, communication) Performance management goal, visual management, threshold for action 47 Summary of Key Points Voice of the customer requires communication and current data. Customer needs must be translated into specific items called critical-to-quality (CTQ) requirements. 48