Lean @ Concord Hospital ASQ Meeting – May 2013

http://www.concordhospital.org

About UsMission & Values

• Charitable Organization: we exist to meet the health needs of individuals within the communities we serve

• Leadership• Caring• Stewardship• Integrity• Continuous Improvement

Statistics

• Opened in 1891• FY12: $38 million in total

community benefits (incl. financial svcs, subsidized health svcs, education and community health svcs)

• Approximately 3300 employees • 295 Licensed beds• 17K+ admissions (fy 2012)• 40 Medical Specialties &

Subspecialties• ~67K Emergency visits / year –

busiest ED in New Hampshire

Lean Journey2010

• CH selects staff: Belmont University Lean Certification

• CH hires PRHI (Pittsburgh Regional Health Initiative) for Lean consultancy

2011 (fall)

• Hand-off to (new) Director of Lean Operations

Lean Approach & Philosophy• Lean is a management strategy, a way of thinking• Method for redesigning systems to focus on the patient • Emphasis on continuous improvement, teamwork, learn by doing,

process/systems, and elimination of waste • Ultimate goal is perfection

LONG TERM PHILOSOPHY LONG TERM PHILOSOPHY in seeking Perfection in the Patient Experience ‐

delivering 

value on demand. 

VALUEVALUE

is realized through Mutual Respect, Shared Responsibility, and developing 

people/partners; it enables higher performance.

CONTINUOUS IMPROVEMENT CONTINUOUS IMPROVEMENT drives organizational learning; mental models are changed 

through Deep Personal Experience.

RIGHT PROCESS, RIGHT RESULTS RIGHT PROCESS, RIGHT RESULTS is fortified in a Culture of Improvement ‐

Standardization affords the basis of improvement.

Current Framework• A3 Process• 8-Wastes (“DOWNTIME”, or “TIM WOODS”)

• Defects, Over-production, Waiting, Not best use of human creativity, Transportation, Inventory, Extra-processing

• 9 Basic Lean Tools• Takt time, Time Observation, Bar Chart, Spaghetti Diagram,

Communication Diagram, Pull, Standard Work, 6S, Flow

• Value Stream Analysis• FMEA (brand new concept to CH, focus: Patient Falls)• Partner with Organizational Development Department

A3 as an Improvement Strategy: Management System

CostQuality/Safety

TimeHumanDev &Satisf’n

Growth

Strategy  & Objectives Defined specific to the Value Streams identified

A3 “Plan”

for Work Priority Developed

A3 at the Tactical Level

VSAED

2PUnit

Redesign

VSADischargeReadiness

RNAssignmt

A3

ITS New 

HireA3

SpecialtyBedsA3

IV PumpHandling

A3

INPATIENT 

CAREDIAGNOSTIC 

CAREREVENUE 

CYCLE

Examples of Organizational Value Streams:

Examples of Value Stream Analysis A3’s:

Examples of Front Line A3’s:

PERI‐OPCARE

Emergent 

BloodA3

PainMgmtA3

VSAPeriOp/URO

Value Stream: Perioperative Svcs

Value Stream: Emergency Dept.

EXAMPLE: A3 WORKEmergency DepartmentEnvironmental Services Expectations

CURRENT STATE – overall “picture” or summary data

ED Cleaning Coverage v. Rooms Discharged per Hour

Peak discharge time (3pm – 2am) averages 8-11 discharge per hour

Identified Current State:• Target metrics TIED to ED Value Stream, System Level

as well as discrete metrics specific to the Environmental Services process within the ED

• Standard v. Non-Standard Work• V.O.C.:

• Patient Satisfaction (Press Ganey Standardized Survey Questionnaire, target questions)

• Staff Satisfaction (adhoc survey/targeted colleague audiences)

• Investigate adherence to Safety guidelines• Timeliness & Effectiveness Measures (Audit Data)

ED Room Turnover Process

•Main Cleaning Tasks

•Steps involved in each task

•Barriers to completion of task

Gaps in Standard Work:

Gap Analysis:Room Cleaning – Video

OBSERVATIONS:

• No Standard Room Turnover Practice

• No logical order to completing the steps

• Hygiene opportunities

• Colleague personal protection & handling safety issues

• Disinfectant dwell time opportunities (timing vs. need for room)

• Infection Control training opportunities

Developed Future State

Checklists for each Schedule

Standardized Room Cleaning

Assignment Plans

1. ED staff meetings would include Environmental Services – adhoc/as need arises

2. Effective Infection Control Training (mission/purpose… “the WHY”)

3. Staff empowerment to hold one another accountable for quality of work

4. Vocera for Staff

5. Change cleaning agent (expedite dwell)

6. Pro-active linen removal

7. Parallel process (pre-made stretchers during “busy” hours

8. Documented standardized work, laminated reference for Staff

9. Training for RN-ES Staff for efficient Communication and Visual Cues (action at-a-glance)

10. Map of assigned areas (Visual Management/6S)

Experiments/Completion Plans

RESULTSProcess Flow MetricProcess Flow Metric Current StateCurrent State Future StateFuture State

(expected results)(expected results) ChangeChange

# Steps 38 22 4545▼▼%%

Flow Time – (total time) 8-15 mins 5-10 mins 3333▼▼%%

# Gaps Identified 21 3 1818▼▼

# Computer Systems(accessed)

1 1 No ChangeNo Change

CONTRIBUTED CONTRIBUTED TO 10 MIN REDUCTION, TO 10 MIN REDUCTION,

PATIENT ARRIVALPATIENT ARRIVALROOM TIMEROOM TIME

Insights & Learnings (team)Positive

• Having nursing and ES involved together to see big picture• Mapping out discharges on an hourly basis. Helped to see the needed allocation of resources and gaps of resources.• Having a mentor to guide us through the A3 process.• Video highlighted inefficiencies with the initial process which led to infection control consult• Learned a lot about the Lean process and how to apply it to other processes

Negative• Not enough ED and ES staff involved to properly identify all the assigned task time and roles –

elongated the experiment phases

Neutral• Time it took to carry out the process

PositivePositive•• Having nursing and ES involved together to see big pictureHaving nursing and ES involved together to see big picture•• Mapping out discharges on an hourly basis. Helped to see the neMapping out discharges on an hourly basis. Helped to see the needed allocation of resources and gaps of resources.eded allocation of resources and gaps of resources.•• Having a mentor to guide us through the A3 process.Having a mentor to guide us through the A3 process.•• Video highlighted inefficiencies with the initial process which Video highlighted inefficiencies with the initial process which led to infection control consultled to infection control consult•• Learned a lot about the Lean process and how to apply it to otheLearned a lot about the Lean process and how to apply it to other processesr processes

NegativeNegative•• Not enough ED and ES staff involved to properly identify all theNot enough ED and ES staff involved to properly identify all the assigned task time and roles assigned task time and roles ––

elongated the experiment phaseselongated the experiment phases

NeutralNeutral•• Time it took to carry out the processTime it took to carry out the process

OTHER LEAN WORK1. 6S, various office/clinic2. Nursing flow3. Patient Quality focus, Core Measures4. Expedited Blood processes5. Walk-in Care patient flow6. Inventory Reduction7. New Hire process8. Revenue Cycle value stream9. Performance Improvement Data reporting10. Medication Prior Authorization process11. …many more A3’s !!!