Lean at Rouge Valley Health System: A Strategic Choice to ...€¦ · enable us to provide even better services to residents of Saskatchewan." 9 Application of Lean at Rouge Valley

1

Lean at Rouge Valley Health System:

A Strategic Choice to Drive Quality

Improvement

Seminar on Regional Sharing of Lean Applications in Healthcare

Bangkok, Thailand

Presentation by Michele Jordan,

Vice-President, Quality Improvement and Transformation,

Rouge Valley Health System, Toronto, Canada

January 25, 2011

1

2

1. Lean in the Canadian Health Care Sector

2. Application of Lean at Rouge Valley

Health System

3. Lessons Learned

Outline

3

Lean in the Canadian

Health Care Sector

A Bit About Canada

Overview of the Canadian Health Care System

Use of Lean in Canadian Hospitals

4

5

Canada QuizTrue or False?

Canada is the second largest

country in the world in

geographic area.

The Prime Minister of Canada is:

a) Stephen Harper

b) Barack Obama

c) Gordon Lightfoot

d) Rik Ganderton.

The population of Canada is

approximately:

a)10 million

b)30 million

c)100 million

d)200 million

Canada has 2 official languages.

They are:

a)English and Spanish

b)French and English

c)English and German

The capital city of Canada is:

a) Vancouver

b) Toronto

c) Ottawa

d) New York City

True or False?

In Toronto, Canada the average

high temperature in the month

of January is 28ºF (or -2 ºC).

6

Overview of the Canadian Health Care

System

• Canada has a publicly funded health care system

• The delivery of health care is a provincial responsibility; each province

and territory has its own health care system and offers a health

insurance plan for its residents

• Most (but not all) health care services are provided free of charge

• The provincial and territorial governments fund health care services

with assistance from the federal (i.e., national) government.

• The Canada Health Act requires that provincial and territorial health

insurance plans must meet 5 criteria to receive full federal funding:

comprehensiveness, universality, portability, accessibility and public

administration

• $192 billion spent on health care in 2010 ($5614 per capita)

• Life expectancy in Canada has increased to 81 years

6

7

Lean in Canadian Hospitals

• Lean is being used in hospitals all across Canada

• Use of Lean in Canadian hospitals began around 2005

• Individual hospitals launched Lean initiatives for different reasons such

as to improve quality or to reduce costs

• Finding the funds to launch Lean programs was difficult; research

shows that those hospitals that hired consultants to help them who

were specialists in how to teach Lean had the most success

• Common areas of focus for Lean include: emergency departments,

inpatient medicine units, labs, diagnostic imaging, operating rooms

• More hospitals are starting to use Lean because:

• They have seen the success of Lean in other hospitals

• They are facing funding constraints

• Governments are endorsing Lean as a way to improve access to services,

increase patient satisfaction and cut costs

7

8

Lean in Canadian Hospitals• The Ontario government has Lean programs for

hospitals:

• The Emergency Department Process Improvement Project

(EDPIP) to help hospitals to reduce waiting times in emergency

departments

• The MRI (Magnetic Resonance Imaging) Efficiency Project to help

hospitals use Lean to reduce waiting times for MRIs

• The Auditor General of Ontario has recommended that

hospitals use visual management to improve the patient

discharge process

• After using Lean in hospitals for 1 year, the government

of the province of Saskatchewan has mandated the use

of Lean in all parts of the public service

– Direct Care Time provided by nurses was increased from 26% to

41% on the Oncology Ward of one hospital

– An equivalent of 1 FTE position was released on a Medical

Ward by improving shift handover processes alone

– 5S in the operating room added an extra 1/2 day capacity to do 9

more procedures each week

8

“As we've seen from

the Ministry of Health's

experiences, the Lean

approach is an

effective way to

streamline our

approach to service

delivery," Minister

responsible for the

Public Service

Commission June

Draude said. "I'm

confident that

incorporating Lean

across the public

service will improve

our processes and

enable us to provide

even better services to

residents of

Saskatchewan."

9

Application of Lean at

Rouge Valley Health System

About Rouge Valley

Our Catalyst for Change

Why Lean?

How we used Lean to Transform Our Hospital

10

11

Rouge Valley Ajax and Pickering (RVAP)

580 Harwood Avenue, Ajax

Rouge Valley Centenary (RVC)

2867 Ellesmere Road, Scarborough

Rouge Valley Health System

(RVHS)

12

• 2 acute care hospital campuses

o 24,000 Inpatient weighted cases

o 100,000 Emergency Department visits

o 105,000 Ambulatory clinic visits

o 22,000 Operating Room cases

o 3,600 Births

• $270 million annual budget

• 2700 staff

• 224 general practitioners and 325 specialists

12

About Rouge Valley

13

10 years of recurring deficits reaching projected $13 million for 2008

Board appoints new Chief Executive Officer in 2007

Some new Board members also appointed

Peer Review (July-December 2007)

Major cultural and operational change required at every level

We needed to improve leadership, management and accountability

Can deliver existing services within our funding envelope

(inefficient compared to others)

New Strategic Plan

Required to develop/implement Deficit Elimination Plan immediately

Started in early 2008, 3 year plan

Same volumes with less resources (eliminate 220 positions & 54 beds)

Transformation, constant improvement

Began in mid-2008, 5-10+ year journey

13

Our Catalyst for Change

14

Why Lean?

• Provides a tool set for managers to use

• Focus is on long-term sustainability

• Comprehensive approach to change

• Drives operational efficiency and cultural change at the same time

• Looks at processes from the patient perspective and flow across

departments

• Frontline staff are involved and empowered

• Specific metrics and targets established at the outset of improvement

initiatives and tracked throughout

• Process change is rapid (days not months)

14

15

How we used Lean to transform our

hospital

• We adopted Lean Thinking as our

hospital-wide management philosophy

• Lean training and management

development gives all managers a

consistent approach for how we expect

the organization to be run

• All leaders are required to lead and

manage using the Lean Management

Philosophy

• Lean thinking helps in moving leaders

from crisis management mode to a

greater focus on improvement, innovation

and strategy

15

" In a lean environment, the expectation is

that everyone has two

responsibilities. The first is to run the

business on a day-to-day basis. The

second is to improve the business, or

contribute to improving it

continuously."

(David Mann in “Creating a Lean Culture: Tools to

Sustain Lean Conversions”)

16

Lean as a Management PhilosophyShifting from Firefighting to Continuous Improvement

Top Management

Middle Management

Line Management

Front line

Maintenance

Innovation

Traditional perception of job functions

Top Management

Middle Management

Line Management

Front line

Maintenance

Improvement

and

Innovation

World class perception of job functions

“Kaizen”, Imai, 1986

1717

Lean as a Driver of Cultural Change

Lean transforms culture through:

• Defining „value-added‟ steps from the customer (patient) perspective

• Staff empowerment and engagement

• Kaizen events

• New ways of solving problems

• Emphasis on accountability for results

• Supports critical thinking and real-time actions

Transformation is seeing, thinking, and acting differently…….

Old Habits + New Tools = Same Results

(Mark Graban)

“What makes Lean difficult is not that it is so

complicated but that it is so different from what

we’ve learned”(David Mann in „Creating a Lean Culture: Tools to Sustain Lean

Conversions‟)

Organizations don’t change – people do

18

Maria Jingco – Charge Nurse, Medicine

“At first, I was a little reluctant to participate in the kaizen events as it took me away from my daily work, however, after participating in the events, I realized that being able to have input in the improvements that effect my area is quite a privilege. I believe that transformation has definitely begun to make a difference within the organization .”

Janice Yorke – Manager, Health Information Management

“My participation in Transformation has changed some of my habits that needed changing, it has opened my eyes to another positive way of thinking, everything we touch each day is a new opportunity to improve. I choose to improve and increase my skills and improve upon processes in my department for the benefit of the patient, as our doors would not even be open if it weren't for our patients!”

1919

Some of Our Lean AchievementsPercent

mm-yy Measure mm-yy Measure Improvement

RVC Coding Inpatient Coding Turn Around Time (TAT) Jan-10 43 days Aug-10 22 days 49%

RVC Coding Day Surgery Coding TAT Jan-10 43 days Aug-10 28 days 35%

RVC Coding Emergency Coding TAT Jan-10 43 days Aug-10 24 days 44%

Transcription (Corporate) Transcription Backlog Apr-10 3652 min Aug-10 353 min 90%

RVC MRI Patients scanned per week Apr-10 170 patients Aug-10 193 patients 14%

RVC MRI MRI Efficiency (scan time/available scan time) Apr-10 87% Aug-10 89% 2%

RVC Ambulance Offload Transfer of Care (TOC) Time Jan-08 93 min Sep-10 36 min 61%

RVC Ambulance Offload % Compliance with recording TOC time Jan-08 71% Sep-10 95% 34%

RVC Ambulance Offload Average minutes waiting in ER Jan-08 51 min Sep-10 39 min 24%

RVC Emergency % CTAS 4 and 5 patients seen in less than 4 hours - RVC Site Apr-09 61% Aug-10 81% 33%

RVAP Emergency % CTAS 4 and 5 patients seen in less than 4 hours - RVAP Site Apr-09 78% Aug-10 92% 18%

RVAP Medicine Time spent on Hospitalist daily patient assignment and work flow Mar-10 125 min Apr-10 35 min 72%

RVAP Ambulatory Care Unit Bronchoscopy Clinic Patient Touch Time (excluding recovery time) Jun-10 4 hr Jul-10 2 hr 50%

RVAP Ambulatory Care Unit Bronchoscopy nursing hours requirement Jun-10 8 hr Jul-10 4 hr 50%

RVAP Operating Room OR Changeover Turnaround Time Feb-10 15.6 min Mar-10 12.7 min 19%

RVAP Operating Room OR Changeover Manual Cycle Time Feb-10 53.3 min Mar-10 33 min 38%

RVAP Pre-Op Number of OR Cancellations due to patient not fit for surgery 2008/9 37 cancellations 2009/10 7 cancellations 81%

RVAP Pre-Op Pre-Operative Patient Visit- Number Patient Walking Steps/visit Jan-10 493 steps Feb-10 157steps 68%

RVAP Pre-Op Prescreening Process- Non Total Joint Network patients Feb-10 360 min Mar-10 60 min 83%

Before After

Program/Department Improvement Measure

20

Improvements in the Surgical Program

Pre-operative Screening Visit Redesign

Before:

•7.56 hours

average visit

length

•Patients

travelled to

various

departments

(Lab, ECG, DI)

•493 patient

steps

After Kaizen:

Patients stay

in one room

Visit length is

60 – 180

minutes

21

Before:

20% of patients

screened pre-

operatively

Surgery delayed due

to missing

documentation

Cancellations of

surgery because patient

not fit

After Kaizen:

90 – 100% of patients

screened pre-

operatively; some by

telephone

Surgeons‟ secretaries

book directly into pre-op

clinic schedule

95-100% of charts

complete one day prior

to surgery

100% of patients given IV

antibiotics pre-Total Joint

surgery as per national

guidelines

93% of patients ready by 30

minutes pre-booked Operating

Improvements in the Surgical Program

2222

Start of Kaizen End of Kaizen

Manual cycle time

(sum of time spent

for all staff

involved)

53.3 minutes 33 minutes

OR changeover

time

15.6 minutes 12.7 minutes

# of room exits to

clean room

12 5

# of operating

procedures

performed each

year at RVAP

6700

Reducing OR changeover time

on every procedure by only 3

minutes saves 335 hours per

year!

Operating Room Changeover Kaizen

Event

23

Hospitalist Worklife Improvement Kaizen Event

Start of

Kaizen

End of

Kaizen

Duration of

Hospitalist Meeting

(min)

35 5

Total Hospitalist

Time for Hospitalist

Assignment

(min/day)

35 10

# Process Steps 34 29

# Wastes 37 3

24

6S on Inpatient Medicine Unit - Before

24

Overall level of workplace organization and physical layout in the target areas

0%

0%

50%

42%

8%

0% 10% 20% 30% 40% 50% 60%

Excellent or

Very Good

Good

Poor

Non-existent

Number of Responses

50% of nurses

surveyed feel the level

of workplace

organization is poor

or non-existent!

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1

79%

TBD

TBD

77%

68%

59%

Post-6S

35%

TBD

TBD

5%

18%

11%

Pre-6S

81%2W Audit Score – Clean Utility

Room

73%2W Audit Score – Medication Room

TBDAvg Monthly Medication Cost

TBDAvg Monthly Medical Supplies Cost

93%2W Audit Score - Hallways

44%Staff Satisfaction (n=12)

% ChangeMetrics

79%

77%

68%

59%

Post-6S

35%

5%

18%

11%

Pre-6S

81%2W Audit Score – Clean Utility Room



44%Staff Satisfaction

% ChangeMetrics

79%

TBD

TBD

77%

68%

59%

Post-6S

35%

TBD

TBD

5%

18%

11%

Pre-6S

81%2W Audit Score – Clean Utility

Room


TBDAvg Monthly Medication Cost

TBDAvg Monthly Medical Supplies Cost


44%Staff Satisfaction (n=12)

% ChangeMetrics

79%

77%

68%

59%

Post-6S

35%

5%

18%

11%

Pre-6S

81%2W Audit Score – Clean Utility Room



44%Staff Satisfaction

% ChangeMetrics

26

Reducing Time that Ambulance Crews Spend At

Our Hospital

Email dated December 4, 2009:

“Here is a graph showing average in-hospital [ambulance offload] times at Centenary for the period January 2006 through November 2009. The system wide average (which includes RVC) is also on the graph. As you will see, you average time have plummeted, and are now substantially below the system average. Great numbers that show the work you have put in and the commitment of the hospital to work on the problem.

Thanks for all you help.”

Peter

Manager, Hospital Offload Delay Program, Toronto EMS

Average In-Hospital Time (Minutes)

30

35

40

45

50

55

60

65

70

75

80

Jan-

06

Mar

-06

May

-06

Jul-0

6

Sep

-06

Nov

-06

Jan-

07

Mar

-07

May

-07

Jul-0

7

Sep

-07

Nov

-07

Jan-

08

Mar

-08

May

-08

Jul-0

8

Sep

-08

Nov

-08

Jan-

09

Mar

-09

May

-09

Jul-0

9

Sep

-09

Nov

-09

RV Centenary System Average

Kaizen Event

27

Key Success Factors for Sustainability

of Lean Transformation

27

Clear Strategy and Expectations

Invest in Building Internal Capacity

Leadership Attention

Performance Measurement

28

Clear Strategy: Our Lean Transformation Model (4x4x4)

4 Transformation

Themes

4 Lean Strategies

Access to Care

•Length of Stay in

Emergency

Department

•Wait Times for MRI

and Surgery

Service

Excellence

•Mortality Rate

•Infection Rates

•Patient

Satisfaction

Team

Engagement

•Employee Sick

Time

•Participation in

Lean activities

Fiscal

Responsibility

•Operating Margin

•Cost per Case

•Working Capital

Access to Care

•Length of Stay in

Emergency

Department

•Wait Times for MRI

and Surgery

Service

Excellence

•Mortality Rate

•Infection Rates

•Patient

Satisfaction

Team

Engagement

•Employee Sick

Time

•Participation in

Lean activities

Fiscal

Responsibility

•Operating Margin

•Cost per Case

•Working Capital

4 Dimensions to

Measure Our Success

Patients First

One Team Inspired & Involved

No Waste

Earn Our Reputation as the Best Every Day

Engagement

Sustainment

Spread

Improvement

2929

Clear Strategy: Our House of Rouge

30

Clear ExpectationsSTAR: A framework to promote the continuous evolution of Lean

STANDARDAll of the following are in place:

• Process Control Boards

• Performance Trending

Boards

• 6S

• A3

• Rounding

• Kaizen Participation

• Leader Training

ADVANCEDAll of the following are in place:

• Sustainment of Standard

level

• Kamishibai

• Safety Calendar (could be

part of kamishibai system)

• Idea Board with problem-

solving huddles

• Department leads and

sustains its own kaizen

events (at least 2 per yr)

ROLE MODELAll of the following are in place:

• Sustainment of Standard and

Advanced levels

• Internal knowledge sharing(joint kaizen with another dept;

facilitator for another dept‟s Lean

event; lead an in-service; internal

article or poster presentation)

• External knowledge sharing(e.g. joint kaizen event with

external partners; conference

presentation; published article)

• Use of one or more higher-

level Lean tools (e.g. Kanban,

Andon, SMED/changeover, etc.)

2010/11

2011/12

2012/13

90%

100%

10%

100%

0%

10%40%

67% 33%

31

System of Daily Audit

Checks Completed by

Staff

Note: Check the items listed on this card to

assess compliance. If good, insert the card

into the slot with “green” side showing. If

issues are found, please place card in slot

with “red” showing and document corrective

actions on board.




issues are found, please place card in slot with

“red” showing and document corrective actions

on board.

Please check for all of

following:

1 Ultrasound machine in

Resus

1 Glucometer in Resus

2 Thermometers in Triage,

1 Thermometer in Resus

1 EKG in Triage 1,

1 EKG in Resus

3 Vital Sign towers in Triage

2 Portable Monitors

1 IV/Lab tray in Triage,

1 IV/lab tray in Resus

Fail Criteria:

Equipment is not being used

and is not in designated area.

(Please return found

equipment to designated

areas and document issues

and corrective actions on

board.)


following:


Resus




1 EKG in Triage 1,

1 EKG in Resus


2 Portable Monitors



Pass Criteria:

All equipment is in designated

area(if not in use).

Area: Triage and ResusArea: Triage and Resus

Card: #4A

Equipment

Card: #4A

Equipment




issues are found, please place card in slot

with “red” showing and document corrective

actions on board.




issues are found, please place card in slot with

“red” showing and document corrective actions

on board.


following:


Resus




1 EKG in Triage 1,

1 EKG in Resus


2 Portable Monitors



Fail Criteria:

Equipment is not being used

and is not in designated area.

(Please return found

equipment to designated

areas and document issues

and corrective actions on

board.)


following:


Resus




1 EKG in Triage 1,

1 EKG in Resus


2 Portable Monitors



Pass Criteria:

All equipment is in designated

area(if not in use).

Area: Triage and ResusArea: Triage and Resus

Card: #4A

Equipment

Card: #4A

Equipment

Advanced Level Lean Tools:

Kamishibai

32

Advanced Level Lean Tools:

Safety Calendar

GYR

7 8 9 1 0

1 3 1 4 1 5 1 6

1 9 2 0 2 1 2 2

2 5 2 6

2 7 2 8

2 93 0

M o n th /Y e a r:

N o In c id e n ts

N e a r M is s

6

3

1 7

2 3

1 2

1 8

2 4

1 1

P A T IE N T S A F E T Y C R O S S

1 2

P a tie n t In ju ry

4

5

3 1

33

Advanced Level Tools: Idea Board

34

Invest in Building Internal Capacity

1. Transformation Management Office (TMO)

2. External Expertise (Sensei)

3. Training and Coaching

35

35

Michele Jordan,

VP Quality Improvement

and Transformation

Julie Goldstein

Director, Transformation

Vivian Chan,

Change Management

Specialist

Rita Frost

Project Coordinator

Fred Koeman

Change Management

Specialist

Catherine McConnachie

Change Management

Specialist

Transformation Management OfficeROLE OF THE TMO

Support program and

department leaders in

making successful

transformational change in

their areas including:

Facilitate improvements in

quality and processes;

provide a “safety net” for

Deficit Elimination Plan

resource reductions

Build capacity in the

organization to ensure

sustained excellence with

strengthened leadership

and a renewed culture

36

• Teaching through questions

• Challenging paradigms

• Keeping you from making big mistakes

• Guiding from experience

• Helping you learn from little mistakes

• Encouraging learning-by-doing

• Leading the team from the back

• Leadership by example

Role of A Sensei:

External Expert Resources - Reduced

Reliance on External Resources Over Time

37


38

Personal Business Commitments (PBCs) Provide

a Leadership Accountability Framework for

Transformation

Extract from 2010/11 Chief Executive Officer PBCs:

Dimension SERVICE EXCELLENCE

1 a) Lead the continued rollout of Lean as our enterprise-wide management

philosophy to support the transformation of RVHS culture and sustained

improvement of RVHS processes.

– Metric: 90% of all departments achieving minimum standard for Lean at RVHS

by March 31, 2011.

– Metric: 70% of Kaizen improvement metrics to show they are meeting targets or

an upward trend in performance within 90 days of the completion of the event.

38

39

Other Strategies we use to Channel


• Transformation Rounds (twice per month by entire

senior team)

• Regular Senior team walkabouts with the CEO

• Transformation Updates in monthly Leadership Forum,

Town Halls and President‟s Blog

• Transformation Update standing agenda item in key

meetings such as Medical Advisory Committee; part of

President‟s Report to the Board

• Presentation on Transformation at every orientation

session for new staff

• Senior leaders deliver workshops on Lean topics

• Lean Leadership Culture Survey conducted every 6

months

Visibility

Communication

Role Models

Self-Reflection

4040

Performance MeasurementSome of the Lean Performance Indicators Tracked

40

Cumulative number of staff involved in at least one lean activity

Cumulative number of physicians involved in at least one lean

activity

% of kaizen metrics meeting target or on an upward trend 90 days

after the kaizen event

Average Score on kaizen event evaluation forms

% of departments meeting all standard level requirements in the

STAR framework

Annualized potential hours saved through kaizen events

41

The Patient Perspective on Lean

Email dated February 26, 2010:

“THANK YOU for inviting a „consumer/resident/volunteer/patient‟ to participate in this event. It is so refreshing to work with front line workers who really know the system and can make a difference for the patient and family. I have confidence that you will make progress in the future processes and touches with the patient and commit to advocating for many of the changes you have outlined to the various levels of government and agencies responsible for health care.

I am a believer in the lean process and hope to participate again with more agencies involved in the continuum of health care and in particular, in driving a “senior friendly environment” into our hospitals.

Again, thanks!”

Randy

Randy

4242

In Summary

Almost all areas of the hospital have made some form of Lean improvement

Financial and operational stability have occurred at the same time as we have preserved or enhanced the quality of care

We are building internal capacity to deploy and sustain Lean over the long-term consistent with LHIN and Ministry directions

Cultural Change is happening (greater trust, transparency and accountability; Lean terminology is widely used; high use of A3 thinking)

Voluntary turnover is down and 2010 staff survey results indicate that trust, involvement in decision-making and satisfaction with the organization have increased since 2008

Physician leaders are engaged

Lean used to support corporate priorities including accreditation, enterprise risk management, redevelopment, pandemic planning

Positive change in our reputation with our community partners (e.g. LHIN, CCAC, EMS, TSH); joint kaizen events with other health care organizations

Growing external recognition for our achievements

43

Lessons Learned

Challenges

Lessons Learned

44

Challenges

• Competing priorities

• Organizational fatigue

• Unionized staff

• Skepticism

• Negative perceptions of the term „Lean‟

• Staff concerns about job security

• Resistance to change

45

Lessons Learned

1. Strong, ongoing, united leadership commitment is ESSENTIAL

2. Lean is harder for leaders than for frontline staff

• They must learn to lead differently

• They must be visible in the „gemba‟

• They must empower staff to find solutions

3. Lean is 80% culture and 20% tools

4. Don‟t use Lean as a cost reduction mechanism – use it to drive quality

improvement and team engagement (good quality costs less!)

5. Lean must be embedded into the organizational strategy and

management approach – not an extracurricular activity

6. Lean is not a project – it is a journey

7. Physician involvement is critical – but be strategic about it

8. Communicate, Communicate, Communicate

45

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Documents

Lean at Rouge Valley Health System: A Strategic Choice to ...€¦ · enable us to provide even better services to residents of Saskatchewan." 9 Application of Lean at Rouge Valley