PresenterPresentation NotesFocus Boards encourage and harvest staff-generated ideas on how to improve the organization and the care it provides.

They tap into front line employee creativity and ownership to generate ideas on how to better serve patients and each other.

It is a hardwired program that promotes, tracks, implements and rewards creative problem solving.

When FOCUS Boards are supported by leadership and transparent, it can be a prime mover in pushing an organization fromgood to great.

• Purpose• Logistics• Standard Layout• Performance Measures • Defects and Action Plans• Root Cause Analysis - Asking the right

questions• Leadership Expectations• Leader Standard Work

PresenterPresentation NotesSome may be here for first time training others for review and to learn more about RCA on the Focus Boards.

Our Mission• Devoted to improving the health and

wellbeing of our family, friends and neighbors.– An environment where people can realize their

full potential – Excellence and leadership in clinical care and

service – Customer focus – Stewardship of resources

Our Vision

• To be a recognized leader in the revolutionary transformation of community healthcare.

Our Values• Integrity: We do no harm. • Service: We serve with compassion, dignity

and respect. • Loyalty: We build relationships that exceed

expectations. • Excellence: We improve performance

through learning and innovation.

Our Strategic Focus (Triple Aim)

• Enhance the patient experience

• Improve health and health outcomes

• Reduce and/or control costs

WH’s Lean Management System

Hoshin Kanri Cascade

0%

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Org Lean 2.0 Audit Rollup

Forecast Actual Goal Linear (Actual)

0%

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-14

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-14

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-15

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-15

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FOCUS Board Group A3's

Forecast Actual Goal Linear (Actual)

Level 2 Level 3

Strategic Measures Cascade

WH Measures• Safety • Quality• Satisfaction• Time/Productivity• Cost• Other In-Process Measures

How do you know if you don’t measure?

PresenterPresentation NotesMission, Vision and ValuesOur MissionDevoted to improving the health and wellbeing of our family, friends and neighbors.An environment where people can realize their full potential Excellence and leadership in clinical care and service Customer focus Stewardship of resources Our VisionTo be a recognized leader in the revolutionary transformation of community healthcare.Our ValuesIntegrity: We do no harm. Service: We serve with compassion, dignity and respect. Loyalty: We build relationships that exceed expectations. Excellence: We improve performance through learning and innovation. Our Strategic Focus (Triple Aim)Enhance the patient experience Improve health and health outcomes Reduce and/or control costs

Communication and action board in the Gemba

Focus On Customer’s Ultimate SatisfactionDo we have any safety events?

What are our customer’s saying?

PresenterPresentation NotesF O C U S - Focus on Customers Ultimate Satisfaction……… this is a our main goal – follows along with Triple AimTool for Root Cause AnalysisIncrease communication Focus on what is importantVisual to help manage our work and improve processes, etcCultivate deep thinking……

What stops FOCUS board engagement?Excuses: “I don’t have the staff…money…time.”Victim thinking: “We’ve tried it before and it didn’t work.”Blame: “No one will ever read it.”Lack of response: “I never heard anything about the idea I submitted.”Fear: “Everyone will think it’s stupid.”

• 10 minute “touch-point” meeting within the Gemba

• Every day or shift

• Facilitated by Gemba staff

• Leadership present and supportive

PresenterPresentation NotesMay be longer until standard work is established, then assign a time-keeper to keep the meeting to under 10 minutes.

Initially led by Director/Manager-then will be handed off to other staff. Leadership is mentoring-teaching.

All leadership initially leading the FOCUS board meeting needs to be trained by CSI.

All items are STANDARD, the information in each area will be different – but area cannot change the agenda

Send suggested improvement to CSI - any changes to the boards will be made organization wide

Leaders must encourage their employees to contribute, and they need to create a climate in which Focus Board ideas are welcome and “safe.”

This means that leaders track and hold every employee accountable for producing some. We are looking at a minimum of 4 JDI’s/year/employee

Control the process throughout the shift/day

Use Root Cause Analysis to address issues

Visual management – Cascades from Strategy

Standard communication in real time

Process Improvement work at the Frontline

Standard Work Tracking

PresenterPresentation NotesThis is not just data collection-we need to know why the defects are happening-thus RCA is vital for us to know why these issues are happening

If we just use the Problem and Occurrences list we are just collecting data

Leader standard work – Weekly VS Boards

Daily leadership standard work – gemba walks etc

Visual Management-In-Process MeasuresCreate action plans to resolve issues in real timeComponent of Leaders Standard Work

Why use FOCUS Boards? Because they result in…Improved clinical outcomesIncreased efficiencyIncreased satisfaction scoresIncreased retentionIncreased profitabilityPROBLEM SOLVING-USING RCA TOOLSPART OF LEAN MANAGEMENT-leaders standard work.

FOCUS Board – 52 of them!

Facilities FOCUS Board Meeting

Time Financial Satisfaction Quality

Visual Management - Focus BoardSafety

Outcome Metrics – 5ft/5sec

A3’s

Process Metrics

Reasons for

Misses

PresenterPresentation NotesLine 1: Performance measures at the top relate to your boxscore – need to understand the trend, target/goal and which direction we want to go. Does not mean you will have one for every metric!

Line 2:Reason for not hitting target – needs to match the interval above. If this is not done the A3’s will not be as targeted to metric not improving.

Line 3:The A3’s come directly from the Issues and Occurrences in Row 2. ALWAYS start with the largest issue…. A3 gets to RC.

Line 4:Process metrics help with new behaviors and std work being followed. Address every FB – may also be on scorecards and reported on at the FB. What are the issues we are seeing? What needs to be tweaked?

Focus Board Leader • Encourage ideas and creative problem solving

• Encourage employees to contribute.

• Create a climate that is welcoming and safe.

• Develop an atmosphere of respect.

• Recognition of great work

PresenterPresentation Notes

Keep the flow of the meeting at a steady pace.Utilize the questions on the Standard Work Checklist.Start the meeting on time and end on time.Stick to the standard work – don’t jump around the board.Show respect- do not criticize

What stops FOCUS board engagement?Excuses: “I don’t have the staff…money…time.”Victim thinking: “We’ve tried it before and it didn’t work.”Blame: “No one will ever read it.”Lack of response: “I never heard anything about the idea I submitted.”Fear: “Everyone will think it’s stupid.”

Agenda Item Defect Monitoring Action Plan

1. Safety Cross / Logic Manager X X2. Performance Measures (Quality,Financial, etc.)

X X3. In-Process Measures X X 5. Behavioral Standards/MVV

6. Standard Work/Training Matrix X X7. Problem A3s & Just Do It’s X X8. WH News

9. Attendance X X

PresenterPresentation NotesStandard agenda use - this with the standard work questions.

Add additional agenda items to the White Board for discussion-anyone can add to this – this needs to be for agenda items-others items should be located in the appropriate area on the FOCUS Boards. We do not want it over-flowing with post-it notes.

All topics will have a designated area to list the defects in every category. Every category will also have the reasons these issues are occurring and an action plan.

The action plan may address issues, defects, or create opportunities for improvements.

It is very important for you to remember that just talking about issues is not productive…your action in response to these issues is the key!

Focus Board Standard Work

PresenterPresentation Notes

MeasuresPurpose: Measures to help control a process

Daily cell measures • Defects or daily measures to understand and manage a

process.

Post Kaizen, 5S, CIP In-Process measures• Manage and identify defects in a new processRegulatory / CMS Measures• Inpatient protocols/pathways; may be ongoing watch

measures

Roll off Focus Board IssuesCascade from Hoshin to frontline measures/work

PresenterPresentation NotesHelps to monitor the progress-fix the issues real time

This will need daily reviewing

Delegate measures to staff and have them report daily

Discuss issues and occurrences in the processes-document them on the Issues and Occurrences sheet

When trending shows an issue-staff in the Gemba may initial a JDI or CIP……add to the JDI board

What have we learned?

Cell measures from the linkage chart and improvement projects

In-process measures track the performance of a process as it is unfolding, providing real-time feedback that can be acted upon without waiting for the process to end, at which point end-of-process or outcome measures tell you the results of that process. In a perfect world, in-process measures align with end-of-process measures.

Metrics – Actual Results/Trends/Goals

CGCAHPS Nov Dec Jan. Feb. Mar. Apr. May June July August Sept FINALOctAll Clinics Combined

Actual79.95

% 80.60% 81.80% 82.80% 81.70% 81.20% 81.30% 81.00% 79.50%

Primary Forecast

78.96 79.33% 79.70% 80.07% 80.44% 80.83% 81.18% 81.55% 81.95% 82.32% 82.69% 83.08% 83.08%

Actual78.20

% 80.40% 82.00% 84.40% 80.50% 83.00% 82.30% 83.90% 81.50%

Specialty Forecast

78.16% 78.52% 78.90% 79.28% 79.66% 80.03% 80.41% 80,79% 81.15% 81.53% 81.90% 82.28% 82.28%

Actual80.90

% 82.70% 84.80% 84.40% 83.70% 79.20% 77.80% 79.60% 78.00%

Chart1

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Goal

ED/UC Patient Satisfaction Forecast

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ED/UC Patient Satisfaction Goal

Medication Explanation

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ED/UC Patient Satisfaction Forecast

ED/UC Patient Satisfaction Actual

ED/UC Patient Satisfaction Goal

Medication Explanation

Excel charts and graphs

Why did we not meet goal?

Why not hitting target/goal? Problem List & Frequency of Occurrence Location:

Dates of Occurrence per Identified Problems/Obstacles to Efficient FlowProblem/Obstacle Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date

Waiting for orders x xWaiting for meds x xWaiting for ride x x x x x x x x

Chart1

0Cause 5

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1. Add Reasons / Types / Causes in Column A & Number of Occurences in Column B2. Enter Chart Title in cell C3

3. Select Ctrl-P to generate Pareto Chart

ReasonsQuantityChart Title

Cause 187

Cause 2230

Cause 340

Cause 4333

Cause 5400

Cause 610

Cause 7211

Pareto Chart

Cause 5Cause 5

Cause 4Cause 4

Cause 2Cause 2

Cause 7Cause 7

Cause 1Cause 1

Cause 30.9923722349

Cause 61

Quantity

Cumulative

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400

0.3051106026

333

0.5591151793

230

0.7345537757

211

0.8954996186

87

0.9618611747

40

10

DO NOT MODIFY

ReasonsQuantityCumulativePercent

Cause 540030.5%30.5%

Cause 433355.9%25.4%

Cause 223073.5%17.5%

Cause 721189.5%16.1%

Cause 18796.2%6.6%

Cause 34099.2%3.1%

Cause 610100.0%0.8%

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71311

Contact Info

Karen Martin, President 858.677.6799

www.ksmartin.com

www.ksmartin.com

Problems & Occurrence• Defects

– Interrupt a process– Prevent or alter standard work– Result in patient/customer dissatisfaction– Result in any safety events or near misses

PresenterPresentation NotesWe use the Problem and Occurrences Form to track how often defects are occurring by their type.

This form automatically builds a bar graph and can be easily used by staff in the Gemba to create the action plan to improve the process.

Some root causes are obvious but others you may need to ask 5-Why’s, etc.

Root Cause• Review most common issue(s) on Problems

and occurrence list• Use a Root Cause Analysis tool (i.e. 5 Whys) to

determine the real causeThe Sterile Drapes weren’t available in exam room Why?

The supply room was out and the exam rooms couldn’t be filled to par. Why?

The supply room par level wasn’t large enough. Why?

When the supply room par was established, the exam rooms were not full.

PresenterPresentation NotesPick the issue that is the most problematic-based on the issues and occurrences list and then list the most common reasons that cause that issue.

Root Cause Example

Causes of the Late Report Outs:1. CSI staff didn’t follow standard work, was not put on calendar2. Team Leader did not respond to emails3. Reschedule, Team Lead ill4. Team Leader not scheduled on report out date

Root Cause Determines Actions

Actions should address root cause

Connecting Defects and Actions

0246

Category 1 Category 2 Category 3 Category 4

Series 1Series 2Series 30

246

Backorder Par Level Demand ⇧

Root Causes

Issues

Actions

PresenterPresentation NotesThe action plans link improvement to the items in the Problem and Occurrences list.

What needs an action plan? Is it every item that we fix? Or is it more detailed fixes? What is the value to entering every action taken?

Action Plan• Empower staff to problem solve in real-time• Eliminates the root cause of the defects• Document actions on Improvement Tracking form

PresenterPresentation NotesThese action plans are created by staff in the process as a way to empower gemba staff to problem solve and support the value stream goals in a productive way. It is based on data.

Group FOCUS Board A3

Just Do-It (JDI)Purpose: To empower people in the Gemba, who do the work, to make quick and

easy improvements. This is about daily problem solving.

•Write ideas on white board for approval or JDI form at the focus board•Once approved document on the Improvement Tracking form•Completed JDIs are submitted to the Pulse

PresenterPresentation NotesWe all have ideas to improve the work around us – use this tool to do that

Show boardProcess:Write idea for improvementDiscussed at the daily meeting-many ways to solve each problem-find the bestAssigned Due date-make sure that you follow up on the items that are DUEReport back on due dateFill out JDI log on the FOCUS board

These will be trended and shared through out the organization-we will only be counting the JDI that are finished on the form.

Need to pull ideas out-leadership may need to start the first example

Defects may include: JDI’s not being completed timely, and the action plan may address when and how the approval process occurs within the department

Action plans may also qualify as a JDI and should be written up as such.

Safety CrossSafety is Non-Negotiable

Description:• Cross shaped document indicating the of safety

events in a month. • Also it gives a glance at the monthly events

throughout the year.

Purpose:• Brings awareness to all safety incidents/near misses• Correct issues immediately• Encourage reporting – best is 3/yr./employee• Visual management tool in the Gemba.

PresenterPresentation NotesSafety is one area where there is no “do over” when mistakes happen and for this reason we need to be vigilant year-around.

Shaped like a cross because to is a universal sign of safety

It demonstrates the talk of action on respect for people.The safety issues should be the top priorities from Press Ganey, Safety Surveillor or other feedback. The Focus of the week or month should be discussed daily and needs to be entered into safety Surveillor-how did we improve this-what was the Root cause(s) and the action plans need to be sustained.

Safety CrossTo document

any safety incidents

regarding

STAFF,

PATIENTS, or

VISITORS

in the department

or cell. These also

need to be

documented in

Safety Surveillor

MONTH# OF

INCIDENTS

# APPARENT

CAUSE

Safety Calendar 1 2 MonthJAN

3 4FEB

5 6MAR

7 9 11 13 15 17 19 21APRIL

8 10 12 14 16 18 20 22MAY

23 24JUNE

No Incident25 26

JULY

Reportable Incident include near miss 27 28

AUG

29 30SEPT

31OCT

Safety Focus for the month

NOV

DEC

FEB17

Patient call lights within reach.

PresenterPresentation NotesInstructions: Fill in the day on the cross with Red-if issues or near misses or Green if there are not any.

Review using the standard questions.

This is deeper than a surface conversation.

There needs to be meaningful dialog and employees need to feel safe to share their observations and concerns.

This is about PATIENTS, VISITORS AND STAFF

The issues and occurrences list needs to match the safety Surveillor.

THIS IS VISUAL-safety Surveillor is in the computer-hidden from view.

Move the total incidents/month to the side in the appropriate month

Apparent Cause- Can be indicated on the right side of the cross and results shared with the staff.

Think deeply

We miss many safety issues right in front of our eyes

Defects need to tracked on the issues and occurrences log and placed on a pareto chart. Defects might include falls, medication errors, or needle stick injuries. Action plans around safety may include changing to needles equipment, using single dose vials, etc.

What is the RCA-ask 5 Why’s

What have we learned?

This will be trended and we will looks for areas to improve

Includes a column for the “Apparent Cause Analysis”

We want to know of any reportable safety issues that happen to patients, staff and visitors-Learn by trending, discussing daily-Manager/Leader may need to engage staff-may need to add something observed

Visual so that anyone can see the progress-red and green

Reviewed daily

Gemba walkers can add to the list-or anyone else

Column added for # of Apparent Cause Analysis Completed

What will be your safety focus of the month???

Review Safety questions-standard work

• Safety Cross-patients, visitors and staff• Has there been any safety issues’, including near misses involving

patients, residents, visitors or staff since the last meeting?•

SEEKING DEFECTSHave there been any safety issues or near misses identified since the last meeting?

DIGGING FOR ROOT CAUSEWhy is this safety issue occurring?

Who might be impacted?

DETERMINING ACTIONSHow can we take action to prevent reoccurrence?

Do we need to involve other departments/staff?

Log ALL near misses and

actual events in Logic

Manager

PresenterPresentation NotesThis is “Improving Health and Outcomes” in the Triple Aim.

Safety Standards

Standard WorkPurpose: To reduce variation in a process and minimize

errors.

• Outcome from A3s, Kaizens, 5S or CIPs• Monitor adherence issues• Keep it up to date• Always available for staff to refer to

PresenterPresentation NotesDefects here will often revolve around standard work implemented by a Kaizen or CIP event.

If a new process asked that staff use a wheelchair to transport patients from the clinic to radiology, a defect would be any time the w/c was not used. The defect would be listed by typew/c unavailable patient refused

New standard work from a kaizen should be on the In-Process board under the Kaizen/CIP in-process measures-once the kaizen is closed the standard work can be moved over to the “Standard Work” area.

Action plans may be to relocate the wheelchairs or bring radiology to the patient when refusals occur

Behavioral Standards• Description: A set of behavioral expectations

for Winona Health Employees

• Purpose: Assist employees to live these behaviors by:• Focusing on the behaviors daily• Links the standards to our daily work• Engage all staff in improvements which

support the behavioral standards

PresenterPresentation NotesSchedule:Monthly:  ‘Behavioral Standards of the Month’ will be sent to post.Weekly:   The weekly standard will be featured on a Pulse banner.  The weekly standard will be reviewed on the Pulse, including patient/resident survey comments on what this could mean from the customer perspective. Feedback:  Who is your weekly behavioral standards champion?  Send Betsy or Hayley the name of the staff member who best exemplifies the standard.  Why were they chosen?  These individuals will be recognized in next week’s Pulse announcement and will be asked to suggest a staff member that exemplifies the next standard…and so on …  Forward any other helpful suggestions or comments to both Betsy and Hayley. 

Behavioral StandardsIt is the expectation that the ‘behavioral standard of the week’ are discussed every week.

Training Matrix

Pediatrics Training Matrix

LEGEND0 Not trained1 Trained5 Competent9 TrainerX Not applicable

SERVICE EXCELLENCEBehavioral Standards 1 0 0 0 0 0 0 0

CSI TRAININGKaizen Training Event #1 5 0 0 0 0 0 0 0Kaizen Training Event #2 9 0 0 0 0 0 0 0Kaizen Training Event #3 0 0 0 0 0 0 0 0Team Lead Training 0 0 0 0 0 0 0 0Co-Lead-Team Leader Training 0 0 0 0 0 0 0 0Team Leader 0 0 0 0 0 0 0 0Data Collection 0 0 0 0 0 0 0 05S Training 0 0 0 0 0 0 0 05S Event 0 0 0 0 0 0 0 0Mapping 0 0 0 0 0 0 0 0JDI 0 0 0 0 0 0 0 0FOCUS/Daily Meeting Leader 0 0 0 0 0 0 0 0

PresenterPresentation NotesTraining Matrix can be used for: New proceduresNew standard work from an improvement projectNew equipment trainingSoftware upgrade training

Cross Training Matrix will be on the Weekly VS Board utilized more for:Flexible capacityGrowing staffPrevention of overtimeCross training to prevent issues with flow

Do not want all your eggs in one basket-what happens if that person gets ill, leaves, etc?

Winona Health NewsPurpose: To communicate to all employees organizational events, news and announcements.• Upcoming events

• New providers & Services

• PULSE announcements

PresenterPresentation NotesDefects in this may include that clinic staff were not aware of a start date for a provider and the action plan may be to post all provider notices on the focus board.

Attendance• Should not impact meeting time

• Diversity of team is important

• Meeting times may need to be adjusted or staff rotated

• Attendance does not mean engagement

PresenterPresentation NotesAttendance doesn’t mean engagement…….take interest in this-it the same person is always out on the floor – is there an engagement issue?

Just like being a an event is not “engagement” – we as leaders must speak to the value.

Great time to communicate any updates…….communication is many times the root cause of issues that come up.

Defects may include: A provider is not available during the focus meeting time and the action may be to open up the physician schedules to accommodate this meeting. This can be challenging-especially in the clinical areas.

Maintaining your FOCUS Boards• Training on the PULSE

• Templates on the Pulse under “Tools” then “FOCUS Boards”

• New leaders will need training from CSI then it is Train the Trainer

• Requiring documentation of new issues on the boards BEFORE the meeting starts

Pulse Templates

Facilitating the Focus Board• 1. Energize ideas and thinkers

Encourage fresh ideas Create solutionsSeek observations

• 2. Encourage thoughtExplain a situation and time to think

• 3. Get it nowValue opinions and experience

• 4. Don’t say NO, dig deeperThinking outside the boxEncourage deeper conversation – Humble Inquiry

PresenterPresentation Notes“Are there systems or communication tools you’ve used or heard about that work well?”“Your comment brings up a good point—do you have any ideas on how we might improve?”“Is there anything you see that could work better?”“Your idea has recently been implemented and resulted in…. Have you seen any improvement? Do you have more ideas?”

“Our patient satisfaction has been trending down in the area of attention to personal needs. “Over the next day/week, be thinking about how to improve this situation.”

“How about Holli and Jenni brainstorming and bring back some suggestions tomorrow?”

Leadership Coaching• Foster innovative ideas

• Mentor staff to also be innovative

• Supporting ideas

• Consistency by all leaders.

Go see, Show respect, Ask why. . .

Lessons Learned• Meaningful metrics to frontline• Connection to strategic plan and waste• Control outcomes – can they fix it?• Standard content• Start with Leaders facilitating meeting• Challenging to find the right time in clinical

areas• Defects and Recognition

Results• Engaged staff• Communication improves• Problem solving by experts in the process• Line of sight connections - Leaders• Data based• Learning – CSI Learning Lab• Gemba Walks – Leadership – in touch with

staff and in the know with current state

Any questions?

Slide Number 1Learning Objectives�Tools Needed: Question Worksheet & FOCUS board exampleOur MissionOur VisionOur ValuesOur Strategic Focus (Triple Aim)�WH’s Lean Management SystemHoshin Kanri CascadeSlide Number 9WH MeasuresWhat are FOCUS Boards?Slide Number 12Slide Number 13FOCUS Board – 52 of them!Facilities FOCUS Board MeetingSlide Number 16Visual Management - Focus BoardFocus Board Leader Slide Number 19Focus Board Standard Work MeasuresMetrics – Actual Results/Trends/GoalsExcel charts and graphsWhy did we not meet goal?Why not hitting target/goal? Problems & OccurrenceRoot CauseRoot Cause ExampleRoot Cause Determines ActionsConnecting Defects and ActionsAction PlanGroup FOCUS Board A3Just Do-It (JDI)Safety Cross�Safety is Non-NegotiableSafety CrossSlide Number 36Safety StandardsStandard Work�Behavioral StandardsBehavioral StandardsTraining Matrix�Winona Health NewsAttendanceMaintaining your FOCUS BoardsPulse TemplatesFacilitating the Focus Board�Leadership CoachingLessons LearnedResultsSlide Number 50