Strategies for Rapidly Improving Performance with Systems Thinking

Strategies for Rapidly Improving Performance with Systems Thinking Bethany Rogers, MSML, BSN, RN, LSSMBB, CPHQ, CPHRM St. Luke’s Health System Director, Performance Improvement APIC Intermountain Region 19 th Annual Educational Conference October 25, 2018

What’s Your Favorite Pixar Movie? 2

My Job as a Pixar Movie… Once upon a time… 3

Every day… 4

But one day… 5

Because of that… 6

Because of that… 7

Until finally… 8

The Imperative • Public sector organizations are increasingly compelled to transform into high-performing organizations ü What a health system produces is largely dependent upon the quality of the processes and workflows it is made of: QP 1 + QP 2 +QP 3 +…QPn = QOHS ü Poorly-designed processes will make the right thing to do inconvenient or difficult ü Well-designed processes will make the right thing to do the easy thing to do • In order to achieve our respective Missions and Visions, we must redesign our broken processes and workflows 12

Improvement Science Customer Experience A methodical change to a process that seeks to improve process outputs: outputs Production Cost Output Quality Worker Safety Product Safety Process Efficiency 13

The Industrial Revolution 1760 s to 1840 s • Transition from hand production to machine production ü Horse power Steam power ü Wood fuel Coal ü Wood machine parts Metal machine parts ü Cottage industry Factories • Sustained job growth • First meaningful increase in standard of living in centuries ü Eli Whitney – 1798 ü Henry Ford – 1913 Machine Production Increased Need for Workers Mass Production Lower Production Cost Increased Demand Increased Consumption Increased Accessibility 14

Modern Improvement Influences • General quality inspection processes (pre-1920 s) ü Responsibility of the manufacturing supervisor or foreman • Quality improvement pioneers ü Walter Shewhart ü W. Edwards Deming ü Joseph Juran • Official quality standards (1950 s to present) ü ü Military Standard (MIL-STD-105 A) International Organization for Standardization (ISO) Malcolm Baldridge National Quality Award Healthcare-specific (NIAHO, TJC, DNV, etc. ) 15

The Evolution of Improvement Science Industrial Revolution to the Present Day • PI strategies and approaches have evolved into a science over the past 150 years • Four distinct methodologies stand out ü FOCUS PDSA ü Lean Production ü Six Sigma ü Clinical Microsystems 16

What is the difference between a Process Improvement TOOL and a Process Improvement METHODOLOGY? 17

Plan-Do-Study-Act • TOOL used to TEST and IMPLEMENT changes in real work settings ü Assess real-world application of a proposed change concept • Based on the Scientific Method ü Hypothesize, Experiment, Evaluate, Replicate • PDSA Process: ü PLAN the change • what will happen, by whom, by when, for how long? ü DO the change • carry out a test and collect data ü STUDY the effect of the change • analyze data, assess practical application challenges ü ACT on the findings • as applicable, make changes to the plan or implement the change 18

Plan-Do-Study-Act • PDSA is an EXPERIMENTATION STRUCTURE: STRUCTURE 1. Test only one variable at a time - resist the urge to change more than one variable at once • Cause-and-effect will be unclear; run the risk of “analysis paralysis” 2. Conduct small tests of change • Only as many data points as are needed to learn about what parts of practical application need to be tweaked • It is NOT the goal of a PDSA cycle to get statistically significant data 3. Plan to conduct many small tests of change • Go into it intending to make small, frequent tweaks and start another test 19

The Model for Improvement • Developed by the Associates in Process Improvement (API) and adopted by the Institute for Healthcare Improvement (IHI) as its preferred PI model ü Defines three fundamental questions that must precede each PDSA cycle ü Designed to sharpen the focus of a PDSA cycle so that each cycle is purposeful and clearly articulated ü Is NOT intended to be a comprehensive improvement methodology 20

FOCUS PDSA • Designed as an answer to the shortcomings of PDSA as a comprehensive improvement methodology ü Rapid-cycle improvement with defined discovery & planning phases • FOCUS ü FIND an opportunity to improve • select the process of interest, define boundaries ü ORGANIZE the improvement effort • identify the team, agree on the aim ü CLARIFY current knowledge • flowchart the process, collect baseline data ü UNDERSTAND process variation • analyze baseline data (SPC, data subsets) ü SELECT the strategy • identify ways to reduce process variation ü …and then conduct PDSA cycles to test the change strategies 21

Lean Production • Manufacturing / business strategies developed in Japan the 1970 s, under the guidance of Dr. Deming ü “Lean” coined by MIT researchers visiting Toyota in 1988 • Improve quality (as defined by the customer) by eliminating waste ü ü ü Supply just what the customer needs, when they need it, in just the right amount, for the right price, using minimum materials, equipment, workspace, labor resource, and time 22

Lean Production • Three forms of Waste: ü Mura – unevenness in work demand or work flow; stopping and starting or variable volume (vs. smooth and constant) ü Muri – greater demand than capacity or overburdening; pushing to perform above capacity and burning out machines or people ü Muda – waste that is necessary but non-value-added (e. g. regulatory requirements); waste that is unnecessary (irrational) • Value Rules: (all three must be met for an activity to be value-added) 1. It must be something the customer is willing to pay for 2. It must transform the product or service in some way 3. It must be done right the first time • DOWNTIME: Defects, Overprocessing, Waiting, (Non)-Used Talent, Transportation, Inventory, Motion, Excess Inventory 23

Lean Production Define Value Identify the Value Stream Create Flow Create Pull Pursue Perfection 24

Lean Production Define Value Identify the Value Stream Create Flow Create Pull Pursue Perfection 25

Lean Production Define Value Identify the Value Stream Create Flow Create Pull Pursue Perfection 26

Six Sigma (6σ) • Designed by Bill Smith (Motorola) in 1986 ü Any business process can be measured, analyzed, and improved upon… then controlled • Reduce variation • Increase output • Meet the desires of the customer • Goal: Decrease variation in the process to make the outcomes more predictable 27

Six Sigma (6σ) • You cannot improve what you do not measure ü Consistent production of high quality services, products, or processes • Improved process performance • Increased customer satisfaction • Structure: Define-Measure-Analyze-Improve-Control (DMAIC) ü Define the problem, agree on the goals, listen to the Customer ü Measure key performance indicators (KPIs) ü Analyze the problem using root cause analysis and statistical analysis ü Improve by developing and deploying possible solutions (PDSA) ü Control new processes by monitoring and reacting to signal 28

Clinical Microsystems • Created by Dartmouth-Hitchcock Medical Center ü First unique improvement methodology created for healthcare rather than business • Focuses on the functionality of the “microsystem” (the place where patients, families, and caregivers meet) ü Every microsystem has a mission, vision, or purpose ü Every microsystem serves a discrete subpopulation of patients ü Every microsystem is staffed by a capable group of professionals ü Every microsystem has its own routines and processes ü Every microsystem has consistent behaviors, sentiments, and results that emerge from its patterns “ 5 Ps” 29

Clinical Microsystems • Strategy: ü It is through understanding the microsystem’s 5 Ps that it identifies its values, values its problems, problems and its solutions ü Improvements are driven by grassroots peer leadership within each microsystem ü For each problem, the microsystem identifies a Theme, Theme a Global Aim, Aim and several Specific (measurable) Aims 30

Clinical Microsystems Global Aim 3 2 1 C au D se ia & gr E am ffe s ct PDSA P D A S S D A S p am me e ov pr Im R nt Measures 5 P Assessment Fl ow Theme ts Global Aim ar Specific Aim ch Change Ideas The Dartmouth Microsystem Improvement Curriculum (DMIC) Ramp 31

Comparing Methodologies* Strategic Emphasis Strengths Weaknesses FOCUS PDSA Rapid-Cycle Improvement Simplicity Does not address sustaining gains Lean Production Waste Elimination and Efficiency Offers an abundant suite of evaluation tools and change concepts Does not have a robust measurement component Six Sigma Statistical Process Control Meaningful measurement; separating signal from noise Difficult to apply with small denominators; does not provide change concepts Clinical Microsystems Frontline Worker Engagement Created for healthcare Initial emphasis on Assessment is timeconsuming *PDSA and The Model for Improvement are not included in this comparison, as they are not independent improvement methodologies 32

Jumping to Solution Can you identify this upside-down celebrity? 33

Jumping to Solution Our minds are very powerful at assimilating information… …but not infallible. What we SEE or THINK is not always right. 34

Jumping to Solution • The easiest solutions to jump to are Person-Oriented solutions intended to make people less fallible: fallible ü telling people to do it right / better / faster / more carefully, ü sending an e-mail, ü sending out a Single-Point Lesson / Tip Sheet, ü creating a new form, ü holding a staff meeting, ü providing more training / classes, ü writing or revising a policy, etc. Plan Workaround 35

The PI Advantage What We Have Right Now • A general idea of what the problem is • A general idea of what we’re here to do What We May or May Not Have Right Now • Thoughts on what is contributing to or creating the problem • Ideas on how to fix it What We Don’t Have Right Now That We Need • Assurance that our assumptions are right • Evidence that our solutions will work • Confidence that our solutions will stick Bridge this gap using improvement science 36

The PI Advantage • In contrast, System-Oriented strategies attempt to safeguard against the impact of errors or to reduce the ability of the error to occur ü Error-proofing, ü Automation, Can we eliminate human error or fully control human behavior? ü Redundancies, ü Checklists, ü Usability testing, ü Visual management, ü Alerts, No; we have to design our systems anticipating error / deviation and protect against it before and after ü Standardization, etc. 37

The PI Advantage • Two Schools ü School A: Private College in Intermountain West ü School B: Private University in New England • Same Problem ü New grass in Quad being damaged by foot traffic • Different Problem-Solving Strategies ü Person-Oriented ü System-Oriented 38

School A’s Problem-Solving Strategy System-Oriented or Person-Oriented? 39

School B’s Problem-Solving Strategy System-Oriented or Person-Oriented? Making observations of the foot traffic Analyzing the data: Most-traveled paths? Natural angles created? 40

School B’s Problem-Solving Strategy 41

Rapid Cycle Improvement PLAN / DO PDSA Cycles Small Test of Change • Goal: Assess the real-world application of a proposed change concept ü Rapid – “What can we test by next Tuesday? ” • 1 Day Shrink the • 2 Nurses change • 3 Shifts ü Cycle – Expectation of repeating tests again and again ü Improvement – Changing the test each time based on worker feedback • Hands-on, active, responsive process • Make changes; test again Make Changes Get Feedback ACT STUDY 42

How Do You Get It Done Fast? Rapid Cycle Improvement • “Working meetings” ü Preparatory work between each meeting ü Produce something by the end of each meeting ü Each meeting’s tasks move you closer to Rapid Cycle Testing • • Kickoff Problem Statement, Aim Statement, Workflow Overview (SIPOC-R) Meetings 2 -3 Review data / process to identify a high-impact workflow Meeting 4 Test of Change (To. C) Plan, Specific Aim Statement Meetings 5 -8 Review To. C results, make revisions, test again Meeting 9 Final To. C Plan Meeting 10 Implementation Plan Meeting 11 Evaluation and Celebration! 43

How It All Fits Together 6σ Lean FOCUS PDSA F O C U S Clinical Microsystems Understanding the Problem and the Scope Assessing Current State Planning and Testing Possible Future States Making Short Term Gains Long Term 44

The Ball Game PDSA Practice

Teams and Roles • Break up into teams of at least 6 individuals: ü Players (4+): Perform the exercise, conduct tests of change ü Timekeeper (1): Times each test ü Recorder (1): Documents test times, change concepts tested, and learnings from each PDSA cycle • Each team needs: ü 1 ball ü 1 stopwatch (use smartphone timer function) ü DMAIC/PDSA document to record test times, change concepts tested, and learnings from each PDSA cycle 46

The Rules • • • Every Player must participate in the cycle To complete a cycle, the ball must return to the person who started with it You cannot pass the ball to the person next to you The ball must travel through the air The ball cannot be rolled across surfaces (e. g. floors, walls, tables, chairs, etc. ) The PDSA Simulation Exercise 1. Create a process for giving and receiving the ball in your group, adhering to The Rules above 2. Conduct a timed baseline test 3. Come up with change ideas to reduce your baseline time by half 4. (As time allows) Come up with change ideas to reduce your baseline time by half again Ready… Set… Go! 47

Debrief • Which team had the fastest cycle? ü How did you do it? • Would you have had the same kind of improvement if you had stayed with your original strategy and strongly encouraged people to do it the same way, but faster? faster 48

Questions?