Achieving Effective Lean Knowledge Transfer In Healthcare

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Achieving Effective Lean Knowledge Transfer In Healthcare

  1. 1. Achieving Effective Lean KnowledgeTransfer in Healthcare PRESENTED B Y:Name: Rebekah Gregory, MBATitle: Director Transformational Care PMOLean Summit New Orleans May 12Track J 2:50-3:35pm
  2. 2. Catholic Healthcare West Catholic Healthcare West (CHW) is the eighth largest hospital system in the nationand the largest hospital provider in California with 40 acute care facilities in California, Arizona and Nevada. 55,000 employees 10,000 active physicians Further the Healing ministry of Jesus 1
  3. 3. Words MatterPRESENTED B Y:
  4. 4. 2 words about Transformational Care: Leadership Development 3
  5. 5. Topics for Discussion ▪ Introduction and TC program objectives ▪ Value drivers and standard work areas/tailoring ▪ The “TC Playbook” overview of the structure ▪ TC Team ▪ Key next steps/critical path items ▪ Okay that’s great now how do we change the culture? 4
  6. 6. Context for Transformational Care ▪ Part of “Ministry Transformation” to change the way we care for our patients, families, and communities ▪ Delivering the right care, at the right time, in the right place for all of our patients ▪ You have been chosen to participate in the Transformational Care rollout! – You have the perspective, energy, and ideas to create and sustain a better patient care model – Need your help to diagnose barriers to care, implement solutions, and lead sustainable change 5
  7. 7. Objectives of CHW Transformational Care Objectives: ▪ Improve quality of care we deliver, optimize patient flow and financial sustainability ▪ Provide our management teams and employees with new tools rooted in lean thinking ▪ Develop organizational infrastructure and capabilities to sustain improvements and successfully expand 6
  8. 8. The recent shifts highlight a few emerging lessons that will shape the future of care and how providers will need to respond Addressed by Transformational Care Emerging strategic priorities ▪ Explore innovative payor models to align incentives, manage costs and risks, gain access to greater volumes through narrow networks ▪ Drive strong physician alignment in efforts to manage costs and coordinate care, and to drive increased referrals ▪ Create new service offerings to target the uninsured ▪ Ensure timely and effective implementation of IT programs to capture value from clinical IT ▪ Ensure strong capabilities are built to enable above strategies (e.g., design value proposition to payors & physicians), and to drive continued cost control and efficienciesSOURCE: McKinsey analysis 7
  9. 9. Topics for Discussion ▪ Introduction and TC program objectives ▪ Value drivers and standard work areas/tailoring ▪ The “TC Playbook”: overview of the process ▪ TC Team ▪ Key next steps/critical path items ▪ Okay that’s great now how do we change the culture? 8
  10. 10. Several core value drivers are recommended Core initiatives5 value drivers for most hospitals Customization options ED Registration Process ▪ ED front-end ▪ ED admissions ▪ ED throughput for discharged pt Potential ▪ ED ancillary services turnaround time Medical Determination (IP/Obs) to customize ▪ Discharge turnaround times for patients entering from the ED ▪ Discharge throughput ▪ OR on-time starts ▪ OR turnaround time ED (e.g., front end or throughput) ▪ Clinical resource consumption ▪ Outpatient Imaging ▪ Cath Lab ▪ Medical determination #1- inpatient vs OR or Preadmission Process obs status assignment (e.g., on time 1st case starts) ▪ Medical determination # 2- IP only procedure list ▪ Durable medical equipment rentals Insurance denials  Core initiatives chosen based on potential for financial impact  Decision to customize should be primarily based on value tradeoffs (financial and non- financial) 9
  11. 11. Important considerations in choosing value drivers ▪ Give staff “quick wins” to build excitement -> Processes amenable to rapid change and visible improvement are best choices ▪ All value driver areas will require a strong team leader and physician/clinician input (if they are clinically facing) ▪ Each value driver requires a cross-functional team to address the issues ▪ Areas that require longer lead time to demonstrate impact can be considered (e.g., Medicare LOS, patient safety issues, Clinical Quality issues) but should be complemented with areas amenable to immediate results 10
  12. 12. Topics for Discussion ▪ Introduction and TC program objectives ▪ Value drivers and standard work areas/tailoring ▪ The “TC Playbook”: overview of the process ▪ TC Team ▪ Key next steps/critical path items ▪ Okay that’s great now how do we change the culture? 11
  13. 13. This program will feel different from previous efforts in 4 significantways • Very “bottoms-up” approach to problem solving led by you because you know what does not work and how to improve patient care • Collaborative problem solving involving physicians, nurses, and non-clinical staff to address both clinical and non-clinical processes • We will serve as your “arms and legs” to prove your ideas and help implement your solutions • We will have a “bias toward action”, which means we will always ask, “Great idea. Why not make this change tomorrow morning?” 12
  14. 14. What to expect from the Transformational Care TeamA professional group that is committed to seeing CHW succeed, whileupholding your values and working styleTC will not “come with all of the answers,” but will always offer aperspective and work to build the right system for youThe team will always push for making real, physical changes quickly, notjust coming up with new ideasWe strongly believe in the dual mission of demonstrating sustainableimpact, as well as investing in building the capabilities of your organizationThe working team will be at the frontline with you, from Monday throughThursday, for the duration of the effort 13
  15. 15. A sustainable Transformational Care system has 3 elementsMaximize value to the patient and the healthsystem by . . . . . . installing systems to manage operating system Performance • Performance management management • Capability building infrastructure processes. . . optimizingprocesses andresources• Waste elimination Operating Mindsets,• End-to-end design system behaviors & . . . giving people clear• Focus on value capabilities direction and skills to get levers job done• Variability reduction (six sigma) • Leadership role modeling • Alignment & communication • Deep skill sets • Continuous improvement infrastructure 14
  16. 16. What TC is. . . . and what TC isn’tTC organizations do this . . . Not this . . .• Remove unnecessary work • Ask people to “just work harder”• Design systems to enable better care • Improve one department by harming the whole system• Permanently eliminate waste, variability and inflexibility • View improvement as a short term project• Build capabilities for continuous improvement • Undervalue the role of some team members• Create a culture of continuous improvement 15
  17. 17. Augmenting staff’s capabilities – Proposed 12-week curriculum to teach lean operations and management skills WeekActivity 1 2 3 4 5 6 7 8 9 10 11 122-day TC Boot CampLean training ▪ TC Intro and Aspiration Setting ▪ Root-Cause Problem Solving ▪ Lean reporting (i.e., TC-1s and TC-2s) ▪ Continuous flow ▪ Standard WorkManagement skills ▪ Feedback and coaching ▪ Influencing skills ▪ Performance management ▪ Change Management ▪ Meeting and Time Management ▪ Sustainability All modules are 90-120 minutes unless otherwise noted 16
  18. 18. We will give you a preview of the 12 week curriculum with a 2 day “Boot Camp” PRELIMINARY. . . a packed 2-day preview of Transformational Care that coversthe approach and trains on general management, problem-solving and lean tools 5-Jan 6-Jan Reflection; Recap of previous day TC-1 Reports Reflection; Opening & Intros Introduction to TC and TC Playbook (including "lessons learned") Standard Work (Including Tshirt Game) Aspiration Setting Exercise (Disc-changing game) Influencing Skills TC Director lunch panel Problem Solving Working Lunch: Solving the Change (Root Cause and Issue Trees, Management Challenge Prioritization) Feedback and Coaching Value Stream and Process Mapping Break Break Best Practice Solutions: ED throughput; Registration, Medical Determination, ORJIT One Piece Flow (with Lego Game) and Keys to Success for TC Recap and Next Steps DEPARTURE Performance Management TC Fundamentals Management/communication skills Intro/team learning/team building Approach and solutions 17
  19. 19. Transformational Care is divided into distinct phasesWhere we are today The “12 week” initial TC program “Prepare” “Diagnose” “Treat” “Sustain” Assessment Performance Continuous Prepare for Transfor- of opportunity management and improvement launch mation areas integration cycleDuration 4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks PerpetualActivities ▪ Leadership ▪ Identify ▪ Wave of ▪ Refine ▪ Sustain and alignment meeting performance operational implementation build on initial ▪ Clearing of baseline change in the ▪ Launch improvements calendars and ▪ Build 4-5 selected Performance ▪ Embark on divesting working areas Improvement improvements responsibilities teams ▪ Launch daily Committee in new areas ▪ Complete data ▪ Launch daily performance ▪ Prioritize further ▪ Monitor request performance tool performance improvements ▪ Set up working tool ▪ 5-6 training improvement in metrics and teams ▪ 2-3 training sessions ▪ 2-3 training take corrective ▪ Build sessions sessions actions, if communication needed strategy 18
  20. 20. SUSTAIN PHASE: A TC Steering Committee will provide ongoingoversight beyond the initial 12 week Wave PRELIMINARY TC Steering Committee membership Principal members ▪ TC Champion ▪ TC Director ▪ Quality Director ▪ TC Analyst ▪ VPMA COO CNE Mission ▪ Governance for Transformational Care ▪ Maintain current performance on TC initiatives ▪ Drive continuous improvement 19
  21. 21. Key deliverables and activities for each phase of Transformational CareWhere we are today The “12 week” initial TC program “Prepare” “Diagnose” “Treat” “Sustain” Assessment Performance Continuous Prepare for Transfor- of opportunity management and improvement launch mation areas integration cycleDuration 4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks PerpetualActivities ▪ Leadership ▪ Identify ▪ Wave of ▪ Refine ▪ Sustain and alignment meeting performance operational implementation build on initial ▪ Clearing of baseline change in the ▪ Launch improvements calendars and ▪ Build 4-5 selected Performance ▪ Embark on divesting working areas Improvement improvements responsibilities teams ▪ Launch daily Committee in new areas ▪ Complete data ▪ Launch daily performance ▪ Prioritize further ▪ Monitor request performance tool performance improvements ▪ Set up working tool ▪ 5-6 training improvement in metrics and teams ▪ 2-3 training sessions ▪ 2-3 training take corrective ▪ Build sessions sessions actions, if communication needed strategy 20
  22. 22. After the initial 12-week roll-out, CHW will continue to provide support Description ▪ Follow-up visits by the CHW TC teamSustainability to facilities after the initial launchcheck-ups ▪ As requested, visits to provide counsel and suggest course corrections: Dedicated Corp lead for each region ▪ Refresher trainings, workshops, Web-Follow-up based trainings and other programstraining (e.g., certification program) beyond the 12-week initial training provided in each Wave ▪ Examples include TC newsletterRewards and recognizing contributors, exposure torecognition senior leadership, TC Academy and epery level trainings, Annual TC Director Summit 21
  23. 23. The end result is a measured pace of changes with graduallyincreasing scope PRELIMINARY Roll out full Roll out new Stabilize Initiate initiatives initiative in initiatives in improvements in new areas existing areas existing areasWeeks 2-4 4-6 8-12 16-20 ~6 months Moving to next phase indicates stability of all previous phases 22
  24. 24. Topics for Discussion ▪ Introduction and TC program objectives ▪ Value drivers and standard work areas/tailoring ▪ The “TC Playbook”: overview of the process ▪ TC Team ▪ Key next steps/critical path items ▪ Okay that’s great now how do we change the culture? 23
  25. 25. TC is structured initially into “working teams” that meet 2x/week EXAMPLE TC Champion TC Director TC Analyst ED registration Med Det - ED ED throughput OR Denials ▪ 1 working team ▪ 1 working team ▪ 1 working team ▪ 1 working team ▪ 1 working team leader leader leader leader leader ▪ 2-3 Registration ▪ 1 data/IT or ▪ 2-3 nurses ▪ 2-3 OR nurses ▪ 1 case manager clerks Finance Analyst ▪ 1 charge nurse – 1 Prep/pre-op ▪ 1 business office ▪ 1 triage nurse ▪ 1-2 case ▪ 1 ER physician nurse representative ▪ 1 billing analyst managers ▪ 1-2 housekeeping – 1 OR nurse ▪ 1 member from ▪ 1ED chart ▪ 1 nurse director staff ▪ 1 Anesthesiologist CBO (via phone) reviewer/analyst ▪ 1 ER staff ▪ 2-3 ancillary staff ▪ 1 Surgeon ▪ 1 nurse/case mgr member – RN or – 1 from lab ▪ 1-2 housekeeping who does appeals manager – 1 from staff ▪ 1 registration/ ▪ 1 billing/coding imaging ▪ 1 OR manager admitting rep1 analyst ▪ 1 financial ▪ 1 Physician counselor Choosing the right leaders and team members to drive the TC effort is crucial to the success of the transformation; select based on talent and not necessarily tenure1 If initial notification of admission to the payor is not done by registration, then also need to add representative from group that does initial notification 24
  26. 26. The working teams will be the vehicle for transforming the areaand instilling the continuous improvement mindset ▪ Performance Begins with a broad monitored daily on evaluation of “the 1 an ongoing basis problem” and quickly Track progress and ▪ “Course correct” refine initiatives as Assess narrowing down on as necessary current access the most critical, part of a and flow highest impact areas continuous improvement metrics process Increasing our patients’ access and flow to care is critical to serving 3 our patients and community Prioritize and launch 2 completely a portfolio “Bias towards of initiatives to improve action”, strive to performance achieve immediate, measurable impact Maintaining this cycle is the most crucial component of preserving the momentum which the transformation effort seeks to instill 25
  27. 27. . . . in supporting your teams through a standard “TC” approach Key activities Timing ▪ Discuss areas of responsibility for working team Weeks 1-2Agree on opportunity ▪ Understand baseline data and metricsareas ▪ Uncover bottlenecks and agree to collecting meaningful sub- metrics to diagnose barriers ▪ Review metrics and new sub-metrics for our area of Weeks 2-4Create and launch responsibilityportfolio of initiatives ▪ Collectively brainstorm improvement initiatives ▪ Communicate with key stakeholders (staff and physicians) in our areas (e.g., ED, nursing units) ▪ Launch pilot initiativesTrack performance ▪ Communicate successes from initiative launches Weeks 5-10and continuously ▪ Implement full initiativesimprove ▪ Review daily metrics and discuss with key stakeholders ▪ Refine initiatives as necessarySustain performance ▪ Transition refinement leadership to key stakeholders Weeks 10-12and continuously ▪ Work with front-line staff and key stakeholders to ensureimprove culture of responsibility for continuous improvement It is the responsibility of the working teams to improve the metrics in their area 26
  28. 28. After the initial 12 week roll-out of TC, CHW’s TC Team will support you and provide a network-wide foundation for TC over timeSupport of TC efforts for Foundation for TC across theindividual sites networkObjective Objective▪ Support individual sites through ▪ Build a consistent and launch and sustainability of continuously improving Transformational Care foundation for TC across the networkActivities▪ Participate in pre-launch Activities session with leadership CHW ▪ Compile compendium of best▪ Participate in 2-day TC Training TC Team practices for different processes▪ Lead one of the TC teams on- ▪ Provide support in definition of a site during the 12-week roll out common set of metrics across▪ Provide coaching/feedback for all facilities TC Director on an ongoing basis ▪ Update and share TC Playbook▪ Provide onoging education and as continuously improved with training roll-out to new facilities ▪ Convene TC meetings for sharing of best practices 27
  29. 29. Topics for Discussion ▪ Introduction and TC program objectives ▪ Value drivers and standard work areas/tailoring ▪ The “TC Playbook”: overview of the process ▪ TC Team ▪ Key next steps/critical path items ▪ Okay that’s great now how do we change the culture? 28
  30. 30. Questions you may have…..So, is it really working?Is it worth the trip?What happens next? 29
  31. 31. What We’ve Been Able To Achieve – step change, not incrementalimprovements Value Stream Metric Measure Baseline May Improvement Emergency ED Discharged Minutes 311 223 25% Department LOS Emergency ED Admitted Hours 9.0 6.9 25% Department LOS Pressure ulcers HAPU # of occurrences 4.1 1.4 66% occurrences per 1000 pt hours Emergency Co-pay collected Rate 5.5% 6.8% 25% registration Emergency Left without Rate 15.8% 2.8% 80% registration being registered Emergency Left without Rates 2.0% 0.4% 80% Department being registered 30
  32. 32. Each Site has seen 2 ½ X return on investment Implementation of TC in 29 facilities so far FY 11 annualized 64 million to the bottom line (18months) More than 1500 people trained Integration with quality, risk, finance 31
  33. 33. Are mindsets and behaviors changing?“I really like the new process because it makesall of the staff focus on moving patients inand out of the ED in a timely manner.” ED Physician “I always know what is next for my patients at any given moment. The way things are organized just makes it feel as if things are running smoothly.” - ED Nurse“Before, I would go to the ED 2 or 3 times forthe same patient. Now, I know when the patientis ready for me and I don’t have to waste timemaking unnecessary trips.”- Imaging Technician “Things are working with the new changes because we can see it in the data and it just feels like we are less busy even though we have the same number of patients.” - Charge Nurse 32
  34. 34. Presentations of team work shared at each site 33
  35. 35. Mindset and behaviors ARE Changing… “I notice the nurses asking each other ahead of time for help with the assessment when they are getting an admission.” -Charge nurse It is amazing to see people with different roles all meet together to discuss a plan for the day. -OR Nurse “Transformational Care gave us the ability to fix problems instead of blaming each other” - ED registration clerk 34
  36. 36. Specific keys to Success for staffPerformance Management ToolDaily Performance HuddlesStandard Work-PO ownershipExecutive GEMBA walksRewards & Recognition 35
  37. 37. Common features of successful implementations are clear▪ Strong champion at the senior leadership level▪ A credible facility TC Director▪ Engagement at the staff level▪ Physician involvement▪ Picking the right process areas▪ Time for team leads to do the work▪ Participation by all managers in the TC training sessions▪ Appropriate participation by department managers in implementing the solutions for the teams▪ Communication and celebration▪ Timely IT support to develop the performance management tool and system 36
  38. 38. Address the mindsets and behaviorsSuccess = Total transparency▪ Tell the stories▪ Celebrate the successes▪ Share the mishaps and lessons learned▪ We learn from each roll out and we change and become more sophisticated: PDCA▪ Say…. “that’s a good idea try it tomorrow”▪ Practice exactly what you preach▪ Be Present: all levels must go to the GEMBA▪ Respond to daily metrics▪ Support don’t interfere: Remove barriers 37
  39. 39. Topics for Discussion ▪ Introduction and TC program objectives ▪ Value drivers and standard work areas/tailoring ▪ The “TC Playbook” overview of the structure ▪ TC Team ▪ Key next steps/critical path items ▪ Okay that’s great now how do we change the culture? 38
  40. 40. What are we doing?•The pressures to change farout way the risk of standingstill, healthcare reform; 2trillionin Medicare cuts, need I saymore?•Quality, we are still killingpeople and spending a fortuneon professional liability.Healthcare, we have a burningplatformSo…in the tradition ofhealthcare let’s write a policyand educate! NO STOP THEMADNESS 39
  41. 41. That’s all Great but how?We have a burning platformWe have tools and methodologies but we still have questions…Q▪ How do we integrate this into the way we work?▪ How do we excite the front line staff?▪ How do we teach front line staff?▪ How do we ask managers to be involved and support but not sit on the working teams?▪ How do we ensure leadership is committed?A▪ The answer is “culture change” and this happens one story and experience at a time▪ Let’s talk about what “won’t work” – LEAN everything – Pure Replication-EDICS – Education – Green, yellow, red bop it on the head 40
  42. 42. Let me tell you a story about the Emergency Department We had an unfortunate event: A young girl died after waiting 5 hours in the ED-You may have seen it on Nancy Grace 41
  43. 43. Guess which one was successful and which one failed • Perform RCA-leadership • Root cause: no one watching patients in waiting Traditional room • Solution: Put RN in waiting room • Call them waiting room liaison method • This is a “quick fix or work around” • Put a team of ED staff together: owner • Determine the RCA and the GAP TC • Determine a new process to eliminate the GAP • Create standard work for the new role (people performing the standard work) method • Test; re-do; training plan; implementation plan • Repeat 42
  44. 44. Change the cultureWe love to say this, but whatdoes it mean?David Mann says “Culture isan idea, it is the result of aorganizations managementsystem”What do you reward? Workarounds?What do you do when the newprocess isn’t followed?Nothing? When the data isn’tmoving? Nothing? 43
  45. 45. Culture change todayCan we change the culture today, Tomorrow?How do we change a culture?▪ One step at a time, one person at a time, one project at a time, one patient at a time, one story at a time, one experience at at time.▪ It all adds up to a new efficient effective Culture 44
  46. 46. How do you change a culture? Targets you Specific can see, expectations visual controls Tools, Routine Leaders practices behavior In 2 words “Management System” 45
  47. 47. They are watching you!As a leader in lean every decision is watchedAre you walking the walk or just talking the talkCase Study;You are the Process Owner of the ED throughput teamYour daily metrics are showing an increasedLength of stay.What do you do? 46
  48. 48. To answer your questions… So, It is really working and It is worth the trip 47

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