Thinking and Acting Like One: Saskatchewan’s Lean Management

System

Maura Davies, FCCHL, President & CEO, Saskatoon Health Region Suann Laurent, President & CEO, Sunrise Health Region

Bonnie Brossart, CEO, Saskatchewan Health Quality Council

National Health Leaders Conference Banff, June 2014

Affinity Health System January 29, 2014

What we hope to leave you with:

A better understanding of the

Saskatchewan health care system’s

commitment to and early

implementation of a lean

management system

Why Lean, Why now, Why at such a scale?

Saskatchewan’s Health Care System • 12 Regional Health Authorities

• 1 Provincially and Federally funded Health Authority

• Provincial Cancer Agency

• eHealth organization

• Shared Services Organization

• Health Quality Council

• 65 hospitals

• 156 nursing homes

• Home care, public health

• Primary care

• 38000 employees, 2000 physicians

• First Nations & Inuit health services

A burning platform… • Unsafe health care

– estimates of one to two avoidable deaths per day in health system (extrapolation from Baker and Norton 2003 study)

• Long waits for services

- over 15,000 waiting more than 3 months for elective surgery in 2010

• Unrelenting expenditure growth in health care costs

– greater than 7% per annum from mid-1990s to late 2000s

a compelling vision… • “Patient First” must be

embedded as a core value in health care.

• Health care in Saskatchewan needs to function as a cohesive system.

• Frontline providers must be empowered to deliver patient- and family-centred care.

…and disquiet with the status quo.

What would Tommy Douglas think?

• Jönköping County (Jönköping, Sweden)

• Southcentral Foundation (Alaska)

• Virginia Mason Medical Center (Seattle, Washington)

• Intermountain Healthcare (Salt Lake City, Utah)

• National Health Service (England)

• Veterans Health Administration (USA)

• Kaiser Permanente (USA)

Learning from high-performing systems:

• Develop and grow leaders for change

• Commit to a consistent, rigorous, disciplined

improvement methodology

• Transparent measurement

• Engage and mobilize people

• Align processes, priorities

• Spread (replicate) innovation

Key learnings from these systems …

As well as learning from others

2012: a new partnership emerged

Patient First Review: “Keep the Best, Fix the rest”

“Fix” = Eliminate waste: waste is anything that does not add value in the eyes of the patient = LEAN

Reducing walking

Reducing waits

Reducing inventory

Eliminating defects

Making care safer and better

• Set provincial health strategy collectively (Hoshin Kanri or Strategy Deployment)

• Develop infrastructure to support and coordinate continuous improvement

• Build improvement science capability among our leaders and our entire health care workforce

• Connect learning and doing to achieve health system priorities via improvement events and daily improvement

What is Hoshin Kanri? An approach to planning that involves:

• Identifying a common vision • Setting short- and long-term goals • Executing plans to achieve those goals • Tracking progress toward them • Changing course as required

The system by which goals are determined, plans to achieve the goals are established, and measures are created to ensure progress toward these goals. Hoshin Kanri = shiny metal or compass or “Ship in a storm going in the right direction” Source: Pascal Dennis

Hoshin Kanri: Key characteristics

• Focus on a few key breakthrough improvements (or hoshins)

• Alignment of the entire organization (and health care system) around these breakthroughs

• Shared input and responsibility for plan and goals

• High participation throughout the organization

• Equal attention to end results and the methods for achieving them

SK Health system strategic intent

Hoshin Kanri: Within organizations

Front Line Staff

Manager

Director

VP

CEO

Level 5 (if applicable)

Level 4

Level 3

Level 2

Hoshin Kanri: Ongoing measurement and monitoring Visual Management is KEY! • Unit level: daily huddles

• Organizational: weekly wall walks

• Provincial Leadership Team:

quarterly wall walks

Hoshin Kanri for an entire provincial health system • Three cycles of Hoshin Kanri have been completed

(2012-13, 2013-14, 2014-15)

• 2015-16 cycle in process (aligning with provincial budget cycle)

• Visibility Walls and regular review processes have been established in all participating organizations

Making care safer and better

Developing Infrastructure to Support and Coordinate Efforts

• Quality departments transitioned to Kaizen Promotion Offices in all RHAs, Cancer Agency, Ministry of Health, 3sHealth, eHealth

• Creation of Provincial Kaizen Promotion Office (at HQC)

• Kaizen Operations Teams (KOTS) within service lines

• Presently over 100 employees in the health system dedicated to improvement

• Aim to have 1-2% of workforce with deepened capability to lead & do continuous improvement

• Consistent, standardized approach and use of Lean tools

Building improvement capability among our leaders and health care workforce (40,000 strong)

• Over 600 leaders (CEOs, VP, Directors, physicians and improvement staff) currently in Lean Leader Certification (2017 target is 880 leaders certified)

- 83 certified to date

- Over 40 physicians in training

• Over 16,000 staff have completed Kaizen Basics course (on track to reaching all 40,000 by 2017)

Making care safer and better

Summary of Lean Leader Certification Requirements

Lean Leader Certification process takes ~80 days to complete. Aim is to complete within 24 months Includes mix of in-class and hands-on learning

Involving Physicians in Lean Transformation: New Lean Leader Track for Physicians

• 80 days 22 days • Responding to demand from community-based physicians

• Learning and applying tools and methods via various improvement events

– From January 2012 to April 2014: 300+ improvement “events” engaging thousands of staff (e.g., 214 Rapid Process Improvement Workshops (RPIWs), 15 3Ps, dozens of 5S events, 28 Kanban teams, 88 Mistake Proofing projects)

– Lean facility design of major capital projects (e.g. MJUH, Children’s Hospital, LTC facility in Cypress HR)

– Lean “design” applied to Primary Health Care sites, staff scheduling and provincial laundry services

– Patients and families participating in improvement events

Our approach to making care safer and better

RPIW Try-storming change on the Gemba • Senior Leaders, managers, point of care staff from the area , and patients come

together to test and implement improvement ideas over 5 days.

Rapid Process Improvement Workshop (RPIW)

3P (production preparation process) • Quality, safety, flow and efficiencies built into design

of facility or new program

• Engages point of care workers, patients and family members in the design

• Physical mock-ups and simulation used to test design

• Since 2011, 12 3Ps in Saskatchewan, overall Capital Cost Avoidance: approx. $63 M

RPIW Building, designing or redesigning a better future • 3P stands for Production Preparation Process and is a Lean method • Highly engaging and creative workshop to rethink what’s possible

3P Workshop

A well organized work place • Organizing and sustaining the orderliness of your workplace, to allow you to do

your best work everyday.

5S Campaign

Making care safer: Mistake proofing

Zero defects is possible. Zero defects is the only acceptable goal.

Mistake Proofing Project Example

Saskatoon Health Region Achieved 100% elimination of defects in baby name changes in NICU. Prior to project, the defect rate (i.e., where patient labels didn’t match) was 6% 4 PDSAs were tested: 1. Work Standard for Registration 2. Work Standard for NICU 3. Communication Strategy with Patient and Families 4. Overall

Non-Name Change Implementation

New process ensures safer care. Saves unit aide 393 hours of work. Annual savings in armbands & labels $10K

Mistake Proofing Project Example

Five Hills Health Region - Reduced to zero defects the process for using two patient identifiers in diagnostic imaging (to prevent the opportunity for an incorrect test). 1. Elimination of illegible handwriting by implementing

electronic requisitions. 2. Successive checks in place using CT screening tool 3. Patients aware of type of test needed - added a drawing of

a body to the requisition that can be circled to draw attention to the area of concern

4. Standard process for dealing with defective requisitions (i.e. wrong/missing patient info or wrong test ordered) - “stop the line”

Safety Alert/Stop the Line System

• Zero harm to patients or staff

• SHR (St. Paul’s Hosp.) is Model Line

• 24 hour call centre

• 2014/15 replication to +2 SHR sites and 1 other region

• Eventual province-wide replication

• This is a game changer

SAS/Stop the Line: Key Elements

• Reporting (by anyone), Call 1600

• Classification (4 levels)

• Response

• Mitigation and mistake proofing

• Building capacity through the process

• Increased Senior Leadership involvement

• Oversight

Province-wide learning & sharing: KaizenTracker.ca

BetterHealthCare.ca

Achieving Results

• Monthly Summary of Impact Report to Ministry • Recent improvement event vignettes

• Aggregated Roll Up of RPIW activity

• Aggregated cost savings / cost avoidance

Highlights of RPIW Results to date (March 1/12 0- April 30/14)

Metric Cumulative

Baseline Change % Change

Space (sq ft) 65,829 21,627 33%

Inventory (items) 187,461 97,345 52%

Walking Distance (ft) 344,153 168,049 49%

Part Travel Distance (ft) 703,100 533,677 76%

Lead Time (hours) 84,089 35,045 42%

Quality Defects (#) 5,337 3,775 71%

Set-Up Time (hours) 7,060 5,475 78%

Cycle Time (hours) 21,857 14,076 64%

Total Number of RPIWS: 217

Early Results – Quality, Delivery, Productivity Hospital/Area Objective Before After Improve

-ment

Saskatoon Health

Region

Optimize home care demand

/ supply (reduce travel;

increase direct care, reduce #

of different providers)

45%

Direct care

time

30 diff

providers

68%

6-8

23%

73-80%

Sunrise Health

Region

Reduce lead time from when a

CTAS 4/5 patient is triaged to

when they are discharged

0:97 min 0:43 min 56%

Five Hills Health

Region (Moose

Jaw SK)

Wait time for mental health

services (access to a

psychiatrist)

44 days

26% no

show rate

18 days

13% no

show

rate

60%

50%

Regina Qu’Appelle

Health Region

Reduce / eliminate cancelled MRIs 12 per

week

1 per

week

92%

+650/yr

Saskatchewan’s Implementation of Lean

• Our health system is complex

• Fixing it is complex

• Lean management is far more than lean projects

Saskatchewan’s Implementation of Lean

• Requires strong leadership, commitment and perseverance

• Engagement of care providers and patients is essential

• Incredible benefit to systemic AND systematic learning

• Ambitions are huge; work is hard

• Replication is key but again isn’t easy

• You’re never done…and that’s ok!

Additional lessons learned so far

“When it comes to Lean, Saskatchewan hasn’t even hit kindergarten.”

And probably the most important one: Humility

Staff’s Experiences with Lean

“That RPIW really proved what lean was all about; making small incremental improvements…When something doesn’t work, you try a different approach and get expertise from the people at the point of

care and service. I love seeing the shared education that happens when we cross pollinate on rapid process improvement workshop

teams.” Lisa White, Kaizen Promotion Office, Saskatoon Health Region

“Each potential and true injury is treated and addressed as an opportunity for learning and prevention with frequent team

huddles and transferring/lifting/repositioning (TLR) audits…This has been effective and inspired everyone to be more aware. Marie Legault Lalonde, Unit 3-2 Manager, Wascana Rehabilitation Centre

Patients’ Experiences with Lean “This experience was very empowering. I am confident patients

are being listened to. This is a game-changer for patients.” Louise Frederick, patient team member who participated on a RPIW focused on ensuring all cancer patients receive consistent assessment and screening for pain and

symptoms, every patient, every time.

“I am now a believer in these processes our hospitals are using to make things better for patients and families. I trust that they have

me in mind, as a regular user of the health care system…it will renew your faith in our health care system. It certainly did for me.”

Heather Thiessen, patient who has participated in Rapid Process Improvement Workshops and a 3P event. Heather has been in and out of the health system for the past 15 years to receive care for two chronic conditions: MS and Myasthenia Gravis.

“In their own words” video

Questions, Comments, Discussion?