Building a Lean Team. Using Lean Methodology to Develop a Collaborative Rounding Model. April 28 th, 2010

Transcription

1 Building a Lean Team Using Lean Methodology to Develop a Collaborative Rounding Model April 28 th, 2010

2 Faculty APD, Internal Medicine Residency Program Co-Sponsor, LEAN Improvement Team APD, Internal Medicine Residency Program Program Director, Internal Medicine Residency Program

3 Agenda Lean 101 Lean Value Exercise Measuring the Current State of rounding Development of the initial rounding model Barriers to implementation Evolution to DM collaborative rounds Link to QI Impact of DM collaborative rounds Questions

4 LEAN 101

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6 Current Healthcare Climate Decreasing reimbursement Increasing uncompensated care Increased cost of capital

7 Why SPPI? Why SPPI? Impact upon margin Reimbursement Expenses

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9 WASTE

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11 Terminology Waste Gemba Value Stream Rapid Improvement Event (RIE) Process Map PDSA Flow Cell Value

12 8 Wastes in Healthcare U-WIT-D-MOP Unused Human Potential: Untapped creativity / talent / injuries Waiting: Patients / providers/material Inventory: Stacks of work / piles of supplies Transportation: Transporting people, paperwork Defects: Wrong information / rework Motion: Finding information / double entry / searching Overproduction: Duplication / extra information Processing: Extra steps / checks / workarounds

13 Gemba

14 Heart Station Value Stream Value Stream Physical Therapy Value Stream Radiology Lab Emergency Medicine Department of Medicine

15 Rapid Improvement Event and Process Map Initial State Flow Time: 2.5 Hrs Initial State Touch Time: 1 Hr 17 Min Target State Flow Time: 68 Minutes Target State Touch Time: 47 Minutes

16 PDSA

17 Flow Cells Ideal Future State One Piece Flow Standard Work Waste Current State Transparency (6S) Tight Connections

18 Flow Cell

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21 What is Value? The customer must be willing to pay for the activity The activity must transform the product or service in some way The activity must be done correctly the first time

22 Value Added and Non-Value Added

23 Value

24 Small Group Exercise

25 Assemble Team Check-In Prioritize morning Go to first patient s room Make teaching points Probe team re: presentation and illness Review data PGY-1/MS presents patient Enter patient room Interview patient Examine patient Discuss plan with team Document in chart Make additional teaching points Exit patient room Update patient of findings and plan

26 Assemble Team Check-In Prioritize morning Go to first patient s room Make teaching points Probe team re: presentation and illness Review data PGY-1/MS presents patient Enter patient room Interview patient Examine patient Discuss plan with team Document in chart Make additional teaching points Exit patient room Update patient of findings and plan

27 Visualizing the Current State

28 Evaluating the Current State Potential benefits of collaborative rounds Improved quality and patient satisfaction Improved resident education: Systems-based practice Practice-based learning and improvement Patient care Improved workflow and utilization of hospital resources

29 Evaluating the Current State The rapid improvement event team was divided into two groups In real time, each group observed and measured a resident rounding team (at the Gemba) Attention was given to the process steps, wasted work, value and time spent on each step

30 Evaluating the Current State Special attention was dedicated to precisely measuring the directional flow of communication Was it multidisciplinary? Was it top down? Was it patient centered or resident education centered? Time spent communicating was also accurately tracked Were all disciplines allocated appropriate amounts of communication time per patient?

31 Reporting the Current State The observed data was summarized and reported out to the RIE staff Using LEAN methodology, several problems with the current rounding process were identified

32 Reporting the Current State Potential problems: No value added steps, frequent waste in steps Variable patient contact time Lack of engagement with the patient and family Required team members not always present Top down communication, not multidisciplinary Most interdisciplinary communication was through charting

33 Designing a Target State Again the RIE staff was broken into 2 independent teams Each team was given the task of creating a target state of collaborative rounds Improved patient care/patient satisfaction Improved resident education in the core competencies Improved workflow, improved utilization of hospital resources

34 Designing a Target State -PDSA - The LEAN tools in the flow cell were utilized with special attention to: Standard work Tight connections 6S (sustainability)

35 Two Ideal Models??

36 Trial of the Target State -PDSA - Each RIE team trialed portions of their target state process with the rounding teams Objective measurements were performed similar to the process when measuring the current state

37 Into the Fire The two competing target states were debated and analyzed by the RIE teams Innovations and successes were identified to jointly develop a final target state solution Was not an easy process due to: Many pros/cons of each idea. Disagreements on non-value added but necessary steps Many steps of the process had value or no value open to interpretation depending on one s point of view

38 Mapping of the Ideal State

39 Collaborative Rounds Format Patients selected day prior One team meets at 9AM, the other 9:30AM Conducted at patient s bedside Team members Attending Residents Medical students Nurse Case manager Clinical pharmacist Pharmacy resident Subspecialty attending (PRN) Ancillary services (PRN)

40 Standard Work PGY-1s: Select patients (1-3) the day prior Medical complexity, LOS, social barriers Get permission from the patients Complete Specialty Notification form Notify AP (ward clerk) of patient selection

41 Standard Work Administrative Partner (ward clerk): Lists patients/room # on whiteboard Notifies necessary staff, ancillary services, specialty consults (the day prior)

42 Standard Work Senior Resident: Gather team Introduce team Run rounds Ensures others follow standard work Complete collaborative rounds checklist

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44 Gemba Walk After rolling out the collaborative rounding process for 1-2 months, it was important to re-evaluate the system Think PDSA!!

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46 What Worked Well?? Increased patient interview time (Value added) Increased bedside exam time (Value added) Barriers to care (and discharge) readily identified and fixed in real time (Value added) Patient more fully aware of plan (Value added) Improved communication among Care Team Less tracking down of team members Consistent message to all Improved role-modeling for learners

47 What Did Not Work So Well Required constant pressure Frequent transition of team members made standard work compliance difficult Constant struggle for consistency Standard work conflicts w/ standard practice Unable to have necessary staff present at times Time-intensive qualitative measures Few trackable quantitative measures Some residents have difficulty leading rounds Residents: What s the point?

48 Pulling the Andon Cord Important to be able to stop a process that isn t working as expected Must have the ability to re-evaluate a system and evolve it as part of the standard work Consider another mini-rie to refine a complex system put into practice

49 Pulling the Andon Cord Undervalued the resident perspective when assigning value to steps of the process Residents were as much of a customer as the patient in sustaining the process

50 What Is Not So Lean?? 6S (Sort out, Straighten, Scrub, Safety, Standardize, Sustain) Standard Work Tight Connections Value

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52 Reapplying the Lean Tools Future reality diagramming Revisualize the end product you want to achieve via process redesign Improved quality patient care/patient satisfaction Improved resident education in the core competencies: Patient Care, SBP and PBLI Improved workflow, improved utilization of hospital resources

53 Reapplying the Lean Tools 6S: Improve sustainability, transparency Transparent resident education Low hanging fruit, quantifiable outcomes Simplify the standard work Tight Connections Improving the trigger Less inertia as resident teams rotate Expectations of the standard work are clear Value Added / Non-Value Added Value from patient s and resident s perspective Re-evaluate each step of the process for value Realized it was important to evaluate each step for value to the patient as well as the participants to improve buy-in

54 Diabetes Collaborative Rounds Initial poor baseline outcomes Low hanging fruit Need for multidisciplinary education/didactics Value added at the healthcare worker level Realized knowledge deficit among providers/staff Transparent need

55 Diabetes Collaborative Rounds Prevalent disease, institutional cost Transparent need Concrete measures Transparent outcomes Quantifiable outcomes Knowledge (Pre / Post Test) EMR - Glucose tracking (EBM Guidelines) Patient satisfaction surveys Resident chart scorecards on diabetic management LOS data

56 Diabetes Collaborative Rounds Residents could link medical knowledge with systems based practice Willing Champions: Endocrinologist and DM nurse educator Real time outcomes dashboard Transparency of education Value added education Tight connections of ownership Sustainability Tight connections Timely transparent results Transparent value added

57 Diabetes Collaborative Rounds Easier selection of patients Decrease frequency of didactics and collaborative rounds to once weekly Simplify standard work with clearer resident expectations Tight connections Sustainable trigger Sustainability Sustainability Transparency

58 Collaborative Rounds New Current State Multidisciplinary weekly didactics led by a medicine attending, endocrinologist and diabetes nurse educator Attendings Residents Nursing staff / students Students Pharmacy

59 Collaborative Rounds New Current State Weekly diabetes collaborative rounds with a multidisciplinary team Endocrinologist Medicine attending Diabetes nurse educator Residents Nurses Students Pharmacy staff Case management Other potential important caregivers

60 Collaborative Rounds New Current State Daily collaborative huddle at 1pm between senior residents, case management, nursing and the unit secretary to discuss discharges, utilization of floor resources Open for discussion on all resident covered patients independent of diagnosis

61 Collaborative Rounds New Current State Real time feedback Visibility Walls with quantitative endpoints LOS, diabetic control, discharge time Pre-test and post-test of diabetic knowledge Quality of care scorecards Reviewed by endocrinologist and returned to senior residents Compare patient care data by resident teams. Track Press-Ganey data Compare collaborative patient outcomes to control services

62 Final Take Home Points st Q 09 2nd Q 09 3rd Q 09 4th Q 09 1st Q 10 2nd Q 10 3rd Q 10

63 Final Take Home Points Successes of change Less complicated standard work Less disruption of normal practice Better trigger for patients likely to benefit Transparent benefit from an institutional level to a student level Motivated champions ensure ownership and sustainability Identifying right customer or customers Quantifiable measures of change Change (PDSA) must be part of the standard work!

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