Understanding Processes and Improving with PDCA Collaborative Webinar

Today’s Agenda n Quick Review n Tools to Understand Ø Fishbones Ø Swimlanes Ø Smart Data n Continuous Improvement with PDCA Experiments n SMART Huddle Boards to Engage all Staff n Case Study www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Key Review Ideas q Start with Why (Emotionally Connect the Team!) n Teams will Move Mountains with Big Goals, Belief, and New Skills! q Team Trust Will Open Up Communication n It’s the Process Not the People! n Everything on the Table…Problems are Good! n Everyone Has a Say…each team member’s input important q Prioritize Your Work Using Team and Provider Input and the Pareto Principle n Difficult to Drive Improvement with Low Numbers n Staff Know Issues that Cause them Frustration & Stress Ø Will lead you to issues that impact quality of care and satisfaction www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Twin Pillars of Lean… q Respect for People Ø “Investing in People is the Only Way to Succeed!” Ø Challenge them to Grow! Ø Employees and Customers q Continuous Improvement Ø Pursuit of Excellence Ø Structured, Coached Ø Learning Organization “The Toyota Way 2001”, Choi www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Step 3… To Improve you Must Understand (not guess!) © Sigma. Med Solutions 2017

To Improve you Must Understand q Understanding the Current Situation is 90% of the Battle! q When you do, the right solution becomes obvious! q If the solution isn’t obvious, we don’t understand the situation well enough q We Understand through Asking, Observing and Experimenting n Data is NOT a Substitute for What we can Observe! www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Work is Flow thru Subprocesses Admissions Process Inpatient Intake Process Inpatient Care Process Medication Administra -tion Process Discharge Process Primary Care Follow Up Process Patients Flow Through the Departments/Functions q The Patient Doesn’t Care What Department they are in q Process Problems Become Visible in Hand-off Between Departments www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Create a High Level Process Map q Start Here to Establish Bounds and Visualize Subprocess Chunks Patient In Scheduling PACU Pre Admission Testing Inpatient Stay Discharge www. sigmamed-it. com (303)666 -6776 main Pre. Op Surgery Patient Out © Sigma. Med Solutions 2017 all rights reserved

Choose Simple or Common Path… q Can’t Map Them All at the Same Time q Simpler to Pick a “Patient Type” or “Patient Class” Most Interesting or Important…Map This One First Over 65 Patient Admitted Patient Eligible for Vaccine Smoker Patient Admitted Patient Eligible for Vaccine Under 18 Patient Admitted Patient NOT Eligible } www. sigmamed-it. com (303)666 -6776 main Treat these as “special cases” Map only after you understand the “Over 65” type © Sigma. Med Solutions 2017 all rights reserved

Swimlane to Detail the Work Flow… q Trace Patient Flow thru Interactions Who = “Lanes” Does What www. sigmamed-it. com (303)666 -6776 main Where Message = To 1) All info to do Whom things OTIFNE 2) When to start © Sigma. Med Solutions 2017 all rights reserved

Drill Into Suspect Subprocesses… Patient In Scheduling PACU Pre Admission Testing Inpatient Stay Discharge www. sigmamed-it. com (303)666 -6776 main Pre. Op Surgery Patient Out © Sigma. Med Solutions 2017 all rights reserved

Fishbone for Root Cause Surroundings Nurses often interrupted Can’t find right EMR screen Systems Stuff Paper forms missing Vaccination data not entered OTIFNE into EMR We don’t know How to do that Skills We can also use this with Time -- OR room turnover time is 39 minutes vs. a target of 28 min www. sigmamed-it. com (303)666 -6776 main Current Defect Rate 500/1000. Target Rate 5/1000 © Sigma. Med Solutions 2017 all rights reserved

Remember Pareto (80 -20 Rule) Start with the 20% of the Causes that Lead to 80% of Errors (Problems) Top 2 Causes Give > 80% Of Defects Don’t put ANY effort on fixing this www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Team Pareto Votes to Prioritize Surroundings Nurses often interrupted Can’t find right EMR screen Systems Fishbone the top 2 or 3 to Learn More Stuff Paper forms missing Vaccination data not entered OTIFNE into EMR We don’t know How to do that Skills Current Defect Rate 500/1000. Target Rate 5/1000 www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

The “ 5 Whys” (sometimes 4 or 3) Nurse must restock room Why? Out of supplies Team highly annoyed at this stage Why? Used them all Why? www. sigmamed-it. com (303)666 -6776 main Didn’t restock room in AM © Sigma. Med Solutions 2017 all rights reserved

Sometimes We Need Smart Data q Most of our Data is Worthless! n But Sometimes We Need a Little More to Understand q Collect Small Targeted Sample – audits, logs…don’t need precision q Example – Clinic Call Volume n Create a Simple Worksheet to Log Calls Ø Log enough info to understand reason for call Ø Don’t need much data – 2 -4 hours, 10 -20 data pts n Front Desk Logs Calls for 2 hrs at Various Times n You then know why people are calling q Then you can target solution www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Brainstorming Facilitation Tips q Everyone Needs a Chance to Contribute Ideas…go around the table and force the issue! Ø Saying something silly like “could it be alien abduction? ” will give them time to think. Ø It’s OK for them to “pass”, but try to get something out of them q Keep going around the table until they are really annoyed at you. Good ideas often come at the end q Write down what they said n Summarize to fit the writing space you have n But don’t try to insert your ideas or over-wordsmith. n Your role is the objective facilitator, not the subject matter expert www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Step 4… …Experiment your Way to Greatness © Sigma. Med Solutions 2017 all rights

Bad Model on How to Improve q “Big Bang” Helpful in Understanding Universe q Worst Model for Improving Anything! www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Better Model - PDCA…. Don’t just Change it, Experiment! Team Ideas Fail Safe, Fast, Cheap And Learn From It! Better Ideas Keep Experimenting until it works for Your Organization and Your Team www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

The Improvement Kata “Striving to Attain a Target Condition by Working Step-by-Step through Obstacles. ” The Improvement Kata is a Behavior Routine for how we Improve and Adapt as an Organization! www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Target Conditions q Every function must always be working toward some improved objective…a Target Condition q Target Conditions move Groups from an Implementation to an Improvement Mindset q A Target Condition is a Stretch Goal that no one knows how to reach n Otherwise it would be an implementation n Unobtainable is demotivating q SMART Goals – Specific, Measurable, Attainable, Relevant, Time-bound www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Pursuit of Perfection is the Value q Attainment of Perfection is not Expected q Lean Ideal Conditions Provide a Target n 1 -1 Flow, Leveling, Kanban, Takt Time, 8 Wastes q The Process of Moving toward Ideal Drives Improvement n Asking, “what prevents us from attaining the ideal” uncovers things you need to work on “We see that it is not actually the leveling pattern or Kanban routine that by itself generates the improvement, but the step by step pursuit of conditions required to make those techniques work as intended. It is the striving for target conditions via the routine of the improvement kata that characterizes the improvement kata. ” www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Next Step is All That Matters… q A Fundamental Power of the Improvement Kata is it’s Focus on only The Next Step q The Last Step has Likely Changed the Situation Rendering Plans Useless! q You Need to Observe the New Situation and the Next Step will be Clear…. n Either the Solution will be apparent, or you need to Understand the Situation Better q Thinking of only the Next Step takes us out of the Implementation Mode and into the Improvement Kata…and significantly reduces your stress!!! Working On Anything Other than the Next Step is a Waste! www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

The 8 Lean Wastes – “DOWNTIME” www. sigmamed-it. com (303)666 -6776 main © Sigma.

PDCA Experimentation Cycles “A Scientific Process of Acquiring Knowledge” q Plan - This is the Experiment n Define What You Will Do n What Do You Expect to Happen? n How Will You Know it Happened? q Do – Run the Experiment n Small Scale n Observe q Check – Compare Actual with Expected Outcome q Adapt – Spread and Operationalize, if it works n If it doesn’t, try another PDCA experiment www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Coaching to Support Growth Coaching is Vital to Support the Learning of Staff at all Levels… everyone needs a Sensei, even the CEO! It is Disrespectful to Expect Staff to Deliver Results without Continual Training www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

PDCA Coaching Approach q Empowering Everyone to make many little improvements q You Need to Teach Them How q Ask: n “What do you propose we try? ” (Plan) n “What do you expect to happen? ” (Do) n “How will you know it worked? What can you measure? ” (Check) n “What will you do then? ” (Adapt) q Teaches staff to think in terms of PDCA www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Spread Gently “like ripples on a pond…” www. sigmamed-it. com (303)666 -6776 main ©

Example – PDCA Spread Process Improvement: Change the Way Vaccination Data is Recorded in the EMR q First PDCA Cycle n Plan q One Nurse – Not on the Team q One Patient – Not critically ill q One Shift – Not Monday or Friday… n Do q Let the Nurse Run it Once Without your Help www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Example – PDCA Spread (cont’d) q Check n Let the Nurse tell you what it was like to use the Process q Adapt n Revise the Process & Job aids if needed to make it easier to do right/ harder to do wrong q Plan a New Cycle Immediately Note: Don’t confuse a little planning and experimentation with slowness. § With a one Nurse, one Patient “test environment”, you can make several PDCA cycles in an afternoon. § Don’t wait for your weekly meetings! www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Why this works… q You learn from your mistakes without having to show them to the whole organization q When you do Process “tuning”, you don’t have to go back and retrain the whole staff q You’re continuously getting feedback on the Process from the people who use it www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Agile Sprints Improve Fast, Learn, Accelerate! q Improvement Organized into 1 -2 week Sprint Cycles n Get as much done as possible in Sprint Cycle Ø Maintain a work “Backlog” to pull from n Daily “Stand-up” meetings to discuss progress Ø 15 minutes at the most n At End of Cycles Discuss Obstacles to Faster Progress Ø Team works together to get rid of obstacles and improve faster q No Blame, Scientific Approach to Process Work Better and Better Together www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

SMART Huddle Boards q Create positive energy and teamwork to address the challenges of the day with a focus on continuous learning through shared decisions, ideas and recognition q Develop Staff by Coaching them in PDCA Behavior Patterns and Challenging them to Learn Engagement = Owners not Renters www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Huddle Visual Management Board Engage Staff and Teach PDCA www. sigmamed-it. com (303)666 -6776

Purpose of Huddle Boards q To bring continuous improvement front and center in dept. management! q To help start the day well q To reinforce focus on the right things q To reinforce the sense of team q To communicate what is going on q To acknowledge successes www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Staff Suggestions www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all

Prioritizing Suggestions www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all

Delta Family Huddle Board www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions

Summary of Improve q Develop PDCA Intervention Plans for Top 2 -3 Issues n Who? n What? n By When? q Create Backlog Chart – all remaining ideas q Rank Backlog by Complexity n Are they “Just Do It’s” or next round of “PDSA” q Assign “Just Do It’s” to Team Members q Schedule Next Meeting – 1 or 2 weeks q Run Rapid PDCA Experiment Cycles q Meet q q Share, Discuss Obstacles, Accelerate Improvement Keep it up!!! www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Primary Care Clinic Case Study Primary Care Clinic at a Hawaii CAH © Sigma.

Problem, Opportunity and Vision Problem – process problems lead to wasted time, mistakes, and incomplete work Opportunity • Clinic Longevity • Lost Revenue • Community Care • Improved Pat, Staff, Provider Satisfaction Vision – to be the best clinic on the island where patients want to come for care www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Initial Fishbone on Problem www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions

Swimlane Diagram – Existing Patient Follow-up Visit www. sigmamed-it. com (303)666 -6776 main ©

Drill Down Fishbone – EHR www. sigmamed-it. com (303)666 -6776 main © Sigma. Med

Registration PDSA - Jessica q Stop n n Scanning ins ID card Filling out/scanning KMC reg forms q Start n n n Ins verify day before only At reg tell pats to change PCP or appt may be cancelled Can offer con call at reg to change PCP q Actions n n n Write phone script for reg call Time check-in process steps Document new process and train when working www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Triage PDSA – Annette q Plan n n In-room Triage Blood Draws Moved to Outside Lab Begin Previsit Lab Testing Work with Jessica to ensure paperwork is completed, received, entered before appointment Time the Process www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Next Steps q Implement Intervention Experiments q Observe, Refine, Implement, Observe, etc…. q Improvement Team Meeting every 2 weeks n n n Discuss Results of Experiments, Changes Needed, and possible Unintended Consequences Agree to Roll-out and Training Plans Develop a new set of Intervention Experiments and Accountability for Next Priority Issues Ø Observe-Refine-Observe-Train (or Refine, etc) q Continue PDSA Cycles until Issues Resolved q Determine new work assignments to make use of extra time created for creating patient value q Fishbone and Swimlane Diagrams to Assess new process and Discover New Obstacles www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Summary The KMC Clinic team functioned well and isolated many process issues that will very likely improve clinic productivity, operations, patient care o Expected Time/Financial Benefits n Registration – significant time savings on registration – ~ 1000 mins/month - enable front desk to call pats and perform higher value tasks related to advanced care models, i. e. scheduling patient visits thus increasing revenue and quality of care n Triage – flow improvements enable MA’s to quickly room patients with paperwork and vitals complete on time for provider visits; will reduce total time in clinic, improve patient perception, and increase provider time with patient www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved

Our Tools Available to You q Rapid Improvement Training Project Planner q Project Charter Template q Guide to Using Fishbone Diagram q Guide to Using Swimlane Value Stream Maps -> Available from Angie www. sigmamed-it. com (303)666 -6776 main © Sigma. Med Solutions 2017 all rights reserved