A LEAN Transformation Case StudyTransformation Case Study

Managing the C.I.B.M.T.R. Forms Challenge “A LEAN Transformation Case Study”A LEAN Transformation Case Study

Marita Wehde, RN, BSN, CHTC andand

Sharon Von Harz, RN, MSN .

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Siteman Cancer Center

• Objectives:Objectives:– Describe how Lean Principles were applied to

create standard workflow around the datacreate standard workflow around the datarequirements of S.C.T.O.D.

– Demonstrate how Lean Principles reduced waste and inefficiencies to improve overall pability to meet data reporting requirements

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• Rapid Improvement Event (R.I.E)Approach( ) pp

– A type of “LEAN” activity devoted to yp ycontinuous improvement

– Focus on managing processes and leading l i thpeople in the process

– An intense weeklong activityA li ‘l th h ti ’ hil h– Applies a ‘learn through action’ philosophy

• Experiment, measure and adjust in real time

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C F i l T M b hi E i l


Cross –Functional Team Membership Essential

Outside Expert WONDERFUL!

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Determining Scope

In Scope O t of ScopeIn Scope• Unique ID Assignment Form• Pre TED/ Disease Class Form

Out of Scope• Research Track Detailed Forms• Subsequent Infusion Forms

• Post TED• Infectious Disease Form• HLA typing Form

• ASBMT RFI• FACT Documentation

• Recipient Baseline Form• Infusion Form • Death Form

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Initial State: BURIED IN FORMS !

• CIBMTR team constantly switchingthrough screens and electronic systems

• No standard work

• Data to complete forms is found in multiple locations/systems within multiple BJH/WU departments / Data Capture all manual

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Initial State: BURIED IN FORMS !(continued)

• Data collection/ documentation started 2-3 weeks POST transplant

• Current time to complete manual data requirements: – Unique ID Assignment 11 min– Pre-TED Form 70 min– Infusion Form 56 min– Baseline 131 min

• Team must complete an annual update on 3085 patients

• 300+ new patients transplanted each yearp p y

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M t i B li T t A t l


Metric Baseline Target Actual

% of Pre-TEDS sent on time(Day 0)

0% 90%

% of Infusion Forms sent by Day 15 0% 90%

% of Baselines sent by Day 15 0% 90%

Quality of critical data elements within each form ( self audits ) - 100%

Unique ID form Cycle time 11 min 50%

Pre-TED form Cycle time 70 min 50%Pre TED form Cycle time 70 min 50%

Infusion form Cycle time 56 min 50%

%

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Baseline 131 min 50%


Solution Approach• Specify and Develop Flow Cells

Solution Approach

– Workup– Infusion

D l t f St d d W k• Development of Standard Work– Specify what is done, how and when

Use Rapid E periments to test and refine process• Use Rapid Experiments to test and refine process• Increase Transparency with Visuals and 5S’s

M it f th h• Monitor new process performance through– Teach Learn Coach Boards

Production Control Boards– Production Control Boards9

Flow CellSiteman Cancer Center

LowestCost:

One by One:

1-pieceFlow

StandardWork

• Best way known today• Working to Demand • Same way for all staff• Everyone sees, knows

• Batch size of one• Most direct path• Each item “flows”

through the cell Flow Work Everyone sees, knowsand understands

OnDefect

through the cell without stopping

Pull5SOnDemand:

• Work fluctuates

DefectFree:

• No asking, no searching, no clarifying

with demand• Perfect handoffs

- one way to request- one way to receive

• Can tell normal vs. abnormal at a glance

• Abnormal conditionstrigger immediate action y

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R id E i t


Rapid Experiments

• Applies a “learn from action” approachApplies a learn from action approach• “Discussion lead to action”

Q i k i t• Quick experiments measure new processes

• Provide the ability to test and adjust in real time

• Allow team to GET UP AND MOVE….

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Rapid E periments Create Work p Flo Cell


Rapid Experiments: Create Work up Flow Cell• Problem 1: Information required to complete Unique ID Form was

found in 7 different locations (systems)found in 7 different locations (systems)– Impedes flow, impairs standard work– Creates cycle time of >11 minutes

• Solution: Use existing BMT Intake Sheet – Revise to include all Mother’s Maiden Name, Location of birth,

History of prior transplant

• Impact: Information to complete the Unique ID Form is found in 2Impact: Information to complete the Unique ID Form is found in 2locations, Data collection begins at initial referral – Enables a cycle time of <5 minutes to complete

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Rapid Experiments: Create Work up Flow Cell


Rapid Experiments: Create Work up Flow Cell• Problem 2: Information necessary to complete the Pre-TED form was

located in 10 different locations (or systems)C cle time to complete as 70 min tes per form– Cycle time to complete was 70 minutes per form

• Solution: Use existing Nurse Coordinator checklist– Revise to include all information needed to complete Pre-TED, including

Co-Morbidity data and Date of Initial Diagnosis

• Problem 3: Disease classification often incorrect causing rework and extending cycle time– Multiple myeloma and lymphoma most common problem areasp y y p p

• Solution: Include CIBMTR criteria for multiple myeloma and lymphoma disease classification to ensure information on Nurse Coordinator checklist is correct

• Impact:p– One source of information for Pre-TED form– Cycle time reduced to 20 min– Created ability to synchronize flow for Unique ID and Pre-TED

Work up Flow Cell Possible!13

Rapid Experiments: Create Infusion Flow Cell


Rapid Experiments: Create Infusion Flow Cell

• Problem 4: Nurse required to retrieve information multiple times from over 7 systems in order to complete an Infusion Formover 7 systems in order to complete an Infusion Form

• Solution: Use existing information and synchronize flow into cell– Updated Nurse Coordinator checklistUpdated Nurse Coordinator checklist– Cryo-preservation Sheet– Pheresis documentation– Develop standard work to ensure each of the above sources of

information is accessed onceinformation is accessed once

• Impact:– Reduce the number of locations in which information is found– Reduce Infusion form cycle time by 50%

Infusion Flow Cell Possible!Infusion Flow Cell Possible!14

Rapid E periments First Prioriti e Work


Rapid Experiments: First, Prioritize Work

• Problem 5: “Forms Due” tool did not sufficiently allow ystaff the ability to prioritize workload and meet compliance standards, Work Batched, No standard work approachapproach

• Solution: Create a Workload Schedule that identifies theSolution: Create a Workload Schedule that identifies theforms to be completed, by whom, at a given time/date

• Impact: Standardized workflow to prioritize form requirements/completion to ensure we meet CIBMTR compliance standardscompliance standards

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Standard Work: Create Workflow Rotation


Standard Work: Create Workflow RotationROTATION I ROTATION II ROTATION IIII ROTATION IV

Pre- TED Infusion 6 month TED Supporte us o 6 o t Suppo t

HLA Disease Insert Annual TED/ CRF Runner

IDM 100day TED/CRF Baseline Friday SET UP

Annual TED/ CRF

Friday SET UP

WEEK ONE SHARON THERESA JEANNE CHRIS

WEEK TWO CHRIS SHARON THERESA JEANNE

WEEK THREE JEANNE CHRIS SHARON THERESA

WEEK FOUR THERESA JEANNE CHRIS SHARON

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Rapid Experiments: Eliminate Motion & Wait Waste


Rapid Experiments: Eliminate Motion & Wait Waste• Problem 6: Nurses need to

view info and complete form. With one screen, must switch back and forth…constantly

• Solution: Split screen monitorForms NetData Source

• Impact:– Streamlined process for

retrieving data and ginputting information into the CIBMTR forms

– Minimize potential for data perrors

– Reduce cycle time

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Rapid Experiment: Create Transparency with Visual


Rapid Experiment: Create Transparency with VisualManagement

Problem 7: No defined flow of formsSolution: Create home with color coding “Blue and Yellow make Green”

Before• Each folder a patient• Each color a phase in the process

Solution: Create home with color coding Blue and Yellow make GreenImpact: Transparency of work for staff and management

Before p p

Reorganized to accommodate visual management & tight connections18

Rapid Experiments: Tight Connections throughRapid Experiments: Tight Connections throughSeamless Handoffs

Problem 8: Unclear in cell when work can beginProblem 8: Unclear in cell when work can beginSolution: Staff handing off completed work puts up blue dotImpact: Triggers next step of process to begin

Next Action Can Begin

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Rapid Experiments: Production Control Board


Rapid Experiments: Production Control BoardProblem 9: Demand unbalanced, No transparency of work completed compared to requirementsSolution: Production Control Board completed dailyImpact: Work balanced, Transparency established during Monday huddle

Unique�IDs�/�Pre�TEDsDate Planned Actual Difference ReasonDate Planned Actual Difference Reason

Monday 10/27/08 2 0 �2 two�unique�ids�pendingTuesday 10/28/08 2 1 �1 No�pt�documents,�database�consent�pendingWednesday 10/29/08 2 2 0 database�consent�pendingThursday 10/30/08 2 4 2 no�unique�id,�database�consent�pendingFriday 10/31/08 4 3 �1 two�require�form�added�to�FormsNet

Total 12 10 �212 ADMISSIONS12�ADMISSIONS

BaselineDate Planned Actual Difference Reason

Monday 10/27/08 2 2 0Tuesday 10/28/08 2 0 �2 charts�not�availableWednesday 10/29/08 2 0 �2 charts�not�availableThursday 10/30/08 2 4 2Friday 10/31/08 0 2 2

Total 8 8 0

InfusionDate Planned Actual Difference Reason

Monday 10/27/08 0 0 0Tuesday 10/28/08 0 1 1

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Tuesday 10/28/08 0 1 1Wednesday 10/29/08 0 0 0Thursday 10/30/08 2 2 0Friday 10/31/08 1 0 �1

Total 3 3 0

Rapid Experiment: Tracking Quality


Rapid Experiment: Tracking QualityProblem 9 cont.: Quality of output unknownSolution: Create quality measurement system of weekly auditing bySolution: Create quality measurement system of weekly auditing bystaffImpact: Quality system initiated, Accurate reporting of outcome data.

U i ID F P T d Ch kliUnique�ID�Form Pre�Ted Checklist

Date�of�Birth SSN

Prior�Transplant Consents

Date�of�Transplant

Cell�source CTN

HLA�match Comorbidity Date�of�Diagnosis

Patient Name: CRID:Patient�Name:� CRID:

Bucaneer,�Bonnie 1234567 � � � � � � � � � �

Tropicana,�Thomas 7654321 � � � � � � � � � �

Sunshine Florida 1122334 � � � � � � � � � �Sunshine,�Florida 1122334 � � � � � � � � � �

Rays,�Raymond 2233445 � � � � � � � � � ��

Forms,�Theres�Always 3344556 � � � � � � � � � �

Percentage of accuracy 100% 100% 100% 100% 100% 100% 100% 100% 40% 60%

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Percentage�of�accuracy 100% 100% 100% 100% 100% 100% 100% 100% 40% 60%

Confirmed StateSiteman Cancer Center

Metric Baseline Target Actual

% of Pre-TEDS sent on time (Day 0) 0% 90% 90%

% of Infusion Forms sent by Day 15 0% 90% 90%

% of Baselines sent by Day 15 0% 90% 90%% of Baselines sent by Day 15 0% 90% 90%

Quality of critical data elements within each form ( self audits ) - 100% 100%

Unique ID form Cycle time 11 min 50% 5 min

Pre-TED form Cycle time 70 min 50% 20 min

Infusion form Cycle time 56 min 50% 20 min

B li 131 i 50% 30 iBaseline 131 min 50% 30 min

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Summary of Basic Lean Principles/ Tools Utilized in CIBMTR RIE:

– Standard Work: Identifying the “best practice” and standardizing to it, stabilizing the process (predictability)

– Flow: The continuous creation or delivery of value without interruptiony p– Pull: Working or producing to downstream demand only– Visual Management: Using visual signals for more effective

communicationcommunication– 5S: A complete system for workplace organization, including the

process for sustainmentZero Defects: Not sending product or service to downstream customer– Zero Defects: Not sending product or service to downstream customer(internal or external) without meeting all requirements

• Mistake Proofing

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Freedom from Forms!Siteman Cancer Center

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Sustaining Process Change

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Completion Plan Senior Leadership Support Critical


Senior Leadership Support CriticalWhat Who When

MOSAIQ access (TBI) Linda/ Laura in TBI October 08( )

Access to FormsNet for 3 additional BMT staff Marita September 29

U d K f k S l Di f K hi S b 29Update Karnofsky Scale on Disease forms Kathie September 29

Secure Split Screens (#5) for CIBMTR team Linda November 08

Staff Education Marita/ Linda October 08

C l t 5S f CIBMTR k Sharon, Jeanne, N b 08Complete 5S of CIBMTR work area , ,Theresa and Chris November 08

Complete TLC and PCB boards to measure Marita, Linda and September 26productivity and quality Kathie September 26

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Weekly Sustainment Tool


Weekly Sustainment ToolDescription Where to Look Unit of Measure/

Description of Activity 11/7/08 11/14/08 11/21/08 11/28/08 12/5/08 12/12/08 12/19/08

Unique ID

Update Admissions Sheet % Unique IDs that can be completed using Admission sheet and RN Checklist.(Staff only needs to look in 2 areas)

Y Y N Y Y Y YObserve completion.Talk to staff Staff's cycle time for completing Unique IDs is 5 minutes

Y N Y Y Y Y Y

NC Checklist. Talk to staff. Observe form completion. % of pts listed on admits has all required info. 80% 72% 75% 80% 100%80% 72% 75% 80% 100%

Work Area The number of backlogged and incomplete Unique IDs is available at a glance. Y Y Y Y Y Y Y

Pre-TED

NC Checklist. Talk to staff. Criteria for multiple myeloma and lymphoma disease classification on NC cklist is correct. Y Y Y Y N N (1) Y

NC Checklist. Talk to staff. Observe form completion. % of pts listed on Admit List that has all required info. N N Y N (1) N (3) Y Y

Ask staff to document start and complete time for a few Pre-TEDs. Observe process. Talk to staff. Average cycle time for Pre-TED completion is 20 min.

Y Y N (30) N N Y

Observe completion.Talk to staff.

Staff does and is able to complete a started Pre-TED without stopping and working on another task (excluding small interruptions). N N Y Y Y N Y

Infusion Form / Baseline

Work Area NC checklist provides required infoY N Y N (1) Y

Work Area Cryo sheet shows all required info and looked at only onceY Y Y Y Y

Work AreaPheresis sheet shows all required info and looked at only once Y Y Y Y Y

Work AreaProcedure note shows all needed info and looked at only once Y Y Y Y Y

Work AreaThe cycle time to complete the Infusion Form is 20 minutes Y Y Y Y N (30)

Work AreaStaff completes Infusion Form once starting (excluding small interruptions) without stopping or working on another task Y Y Y N (1) Y

Visual Management

Work Area and 5S score 5S is sustained, scored weekly and a standardized clean up checklist is used daily Y Y Y Y Y Y Y

Work Area Visuals are used to trigger work and/or to control work in processY Y Y Y Y Y Y

PCBExpected production is planned the week prior and actual performance captured daily. Reasons for differences are listed and are clear

Quality of Critical Elements

and are clear.N N Y Y Y Y Y

TLC% of critical elements accurate

N N N N Y N N

% of transcription errors in Forms NetN N N N Y N Y

Work Area Forms Due is clear and visual. Staff prioritize work using a defined system. Staff alerts mgt if work exceeds a defined level.

N N Y N Y Y YYes 6 5 16 13 16 12 18No 6 7 4 7 4 8 2% Yes 50% 42% 80% 65% 80% 60% 90%

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Weekly HuddleSiteman Cancer Center

• Held Monday morning• Held Monday morning• Team leader keeps group focused on plan• Review production (#of forms/ rotation) for

upcoming week• Identify workload of rotations to determine

areas in need of assistance. • Plan work volume (production) for week

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• What is Standard Work?

– A tool used to define and balance work– The best combination of staff tasks grouped

together to meet demandD fi d ibiliti d l l– Defined responsibilities and clear roles

– A stable team effort– Creating predictability – Documented quality inspection points

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Standard Work DocumentsSiteman Cancer Center

• Documents which outline the detailed

Standard Work: CIBMTR Regulatory RequirementsDocument Owner: Linda Laub, Nurse Manager, BMT

This instruction applies to: 14th floor, NWT - BMT Group Issue Date: 29-Oct-08

Primary Responsibility: Complete Regulatory Documentation outline the detailedsteps of a flow cell

Unique ID/ Pre-TED Work SequenceUNIQUE�ID/�PreTED�FLOWCELL�

1)On�Friday�at�1PM:

RN�Coordinator�checklist�and�Disease�Classification�Forms�delivered�by�member�of�management team BLUE DOT HUNG

• Promotes same way for all staff

management�team�BLUE�DOT�HUNG.�

2)�CIBMTR�RN�on�Rotation�4�huddles�with�Wendy�Sherman�and�individual�PreTED�patient�folders�are�initiated.��Wendy�enters�the�individual�patient�names�on�the�Xdrive�spreadsheet.��

RN�on�Rotation�4�places�the�patient�folders�within�the�PreTED�area�of�the�workcell�cabinet.��RN�documents�the�quantity�of�PreTEDS�on�the�Production�Control�Board(PCB).��(�see�standard�work�for�PCB�documentation).

3)O d i

• Everyone sees, knows and understands

3)On�Monday�morning:

Wendy�completes�the�Unique�ID�form�in�Forms�Net

Wendy�enters�the�Unique�ID�numbers�on�the�Xdrive�spreadsheet

Wendy�prints�the�Unique�ID�forms�and�files�them�in�the�PreTED�patient�folders

Wendy�hangs�the�BLUE�DOT�to�signify�that�the�unique�ID�process�is�complete�

4)CIBMTR RN in Rotation 1 see the Blue Dot and completes PreTED forms on all patients and

• Visible in work area

4)CIBMTR�RN�in�Rotation�1�see�the�Blue�Dot�and�completes�PreTED�forms�on�all�patients�and�verifies�randomization�level.�

TED�level�randomization�:��RN�files�the�patient�information�in�the�Patient�Transplant�Data�Book�alphabetically.��

CRF�level�randomization:��RN�files�the�patient�information�in�the�Recipient�Infusion/Baseline�Area.��RN�documents�randomization�level�in�Xdrive.��

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RN�in�rotation�1�documents�productivity�on�the�PCB�board�according�to�standard�work�daily�and�then�weekly�on�Friday.��When�flow�cell�is�complete�RN�delivers�the�BLUE�DOT�back�to�manager.��


Lessons Learned

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Insights


Insights• Reviewing current process and timelines helps identify where

change is needed• ALL ancillary departments were very receptive to proposed• ALL ancillary departments were very receptive to proposed

solutions• Staff willingness to think “outside of the box” is critical part of

success( new rotation schedules) • Quick “Lean” teaching opportunities help with building new process• Discussion led to ACTION!• Changes in process supported quality and efficiency

B i i i t id t id t i i ht• Bringing in outside experts provides great insight• BLUE + YELLOW = GREEN• Electronic Data Base (“Enter Once, Use Often”) • Additional RIEs:• Additional RIEs:

– Data Gathering into Work Up Flow Cell – Annual F/U forms to broaden scope Thanks,

Marie!

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