Operational Excellence at Lifespan. Sharon Tripp RN, MS, CPHQ Director of Clinical Excellence

Transcription

1 Operational Excellence at Lifespan Sharon Tripp RN, MS, CPHQ Director of Clinical Excellence

2 Objectives Discuss Lifespan s approach to establishing a system-based quality structure Describe the organization s approach to applying six-sigma methodologies

3 Lifespan as a System Founded in 1994 as RI s first integrated health system Present partners: Rhode Island Hospital/Hasbro Children's Hospital, The Miriam Hospital, Bradley Hospital (Providence, RI), Newport Hospital (Newport, RI), Gateway Healthcare Mission: Delivering health with care. Multiple outpatient clinics, surgery, diagnostic and treatment centers in the state of Rhode Island

4 Lifespan Mission Delivering health with care.

5 4Ps Patients We put patients at the center of everything we do. Providers We will ensure that our caregivers have the resources to maximize professional satisfaction, collaboration, efficiency and patient outcomes. People All Lifespan employees are members of the care delivery team each with a different contribution to make. Purpose We must be financially strong to meet our academic mission and fulfill our promise of Delivering health with care.

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7 Organizational Infrastructure - System System quality, safety and patient experience strategy co-led by executive RN-MD dyad Executive VP, Nursing Affairs Executive VP, Physician Affairs Affiliate CNO-CMO dyad as site executive leads for quality, safety and patient experience Nearly all staff dedicated to quality functions serving under system quality Staff organized by core quality function led by a system Director

8 Aligning Quality Across the System Staff and department structures and core quality functions centralized to system in October 2014 Committee structures remain affiliate-based with some system structures to coordinate and align activity Transparent dashboards with system and affiliate performance available to all via Lifespan intranet

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10 Operational Excellence Operational Excellence (OpX) is Lifespan's applied philosophy towards continuous improvement, data-driven decisionmaking and the use of Six Sigma and Lean tools to drive efficiency, meet and exceed customer needs, and achieve optimal clinical and performance outcomes. It is the umbrella under which all key core quality functions and performance/process improvement functions support the organization. The division is divided into distinct departments focusing on Clinical Excellence, Patient Safety, Accreditation & Regulatory Readiness, Service Excellence, OpX Programming & Informatics, as well as a team of OpX Analysts, Senior OpX Analysts and Performance Improvement Consultants.

11 Operational Excellence (OpX) Utilizes OpX tools to address complex problems from identification to resolution/sustainability of improvement Supports key process owners in the use of the OpX tools to drive improvement Leads and facilitates process improvement projects using data driven and results-oriented methodologies (DMAIC, DMADV) Provides support for major lean workouts, Kaizen events, OpX Walk activities Enhances training programs for certification in Lean/Six Sigma and other core performance/process improvement tools

12 Operational Excellence (OpX) Staffing: Administrative Director, Operational Excellence (OpX) Senior OpX Analysts OpX Analysts Administrative Assistant Core Competency Expectations: Experienced Master Black Belt Experienced Black Belts/Green Belts (Senior OpX Analysts) Black Belt or Green Belt within 18 months (OpX Analysts) Certification in TapRooT, FMEA

13 Clinical Excellence Oversees quality measure abstraction and reporting- CMS, TJC, multiple registries Identifies improvement opportunities and leads improvement project teams Provides PPE Support Manages the compliment and complaint process

14 Clinical Excellence Staffing: Director of Clinical Excellence Manager of Clinical Excellence Clinical Quality Improvement Specialists Clinical Abstraction Specialists Clinical Excellence Assistants Supervisor of Patient Liaison Services Patient Liaison Advocates Administrative Assistant Core Competency Expectations: Certification as Lean/Six Sigma Green Belt or Black Belt within 18 months Certification in TapRooT CPHQ preferred

15 Service Excellence Executes system strategy for Service Excellence and training aligned with Lifespan brand mission, incorporating the best of the best practices from each affiliate s current Service Excellence programs Supports Patient Experience data mining, analytics and action Supports service recovery efforts Supports new manager orientation and training needs for process improvement work

16 Service Excellence Staffing: Director, Service Excellence Manager, Service Excellence OpX Training Specialists Administrative Assistant (shared) Core Competency Expectations: Certification as Lean/Six Sigma Green Belt or Black Belt within 18 months

17 Patient Safety Manages event reporting system systemwide Triages/screens all reported events Assigns appropriate event follow-up TapRoot, ACA, FMEA, Peer Review, Manager review Promotes culture of safety Facilitates improvements to reduce hospital acquired conditions Facilitates improvements to promote patient safety

18 Patient Safety Staffing: Director of Patient Safety Manager, Patient Safety Patient Safety Specialists Administrative Assistant Core Competency Expectations: Certification as Lean/Six Sigma Green Belt or Black Belt within 18 months Certification in TapRooT, FMEA CPHQ preferred

19 OpX Programming and Informatics Develops system-wide and affiliate scorecards, dashboards, quality reporting, analytics with common branding and data standards Coordinates technological aspects of internal/external reporting Defines and implements data and reporting standards Ensures access to clinical information necessary to perform quality functions/address real-time opportunities Manages and controls release of quality data

20 OpX Programming and Informatics Staffing: Director, OpX Programming and Informatics OpX Programmers OpX Informatics Specialists Administrative Assistant (shared) Core Competency Expectations: Consistent with our UHC peers in similar departments Computer systems analysis Application development

21 Accreditation & Regulatory Readiness Coordinates continuous survey readiness TJC, CMS, others Centralizes mechanisms to ensure standards compliance Manages Command Center activity and onsite survey management processes Formalizes mechanisms to identify potential vulnerabilities and disseminates across system Incorporates required maintenance/readiness systems into daily work

22 Accreditation & Regulatory Readiness Staffing: Director of Accreditation and Regulatory Readiness Accreditation & Regulatory Readiness Specialists Administrative Assistant (shared) Core Competency Expectations: Certification as Lean/Six Sigma Green Belt or Black Belt within 18 months CPHQ preferred

23 Core Competencies For most certified Six Sigma green belt within 18 months of entry to position Ability to lead and facilitate meetings and project teams independently Knowledge of process improvement methods and standards Knowledge of practice methods and tools related to measuring and driving performance improvement TapRooT / Apparent Cause Analysis Training Strong verbal and written communication skills Proficiency with data analysis and use of Microsoft and other applications Word, Excel, PowerPoint, Visio MiniTab

24 Characteristics of a Six Sigma Organization Customer Focused (What customers expect) Process Focused (Our capability to deliver) Causal Thinking (What makes this happen) Accountability Driven (Ownership) Fact-Based Statistical Thinking (Data Driven) Stretch Goals (More than continuous improvement) Standardized Approach to Improvement Partnership (Employees working together) Open Communications

25 Six Sigma Defined The Six Sigma term refers to a Management Philosophy Executive Leadership Driven Strategic Alignment with Operations and People Impact of the Voice of the Customer Established Customer/Supplier Partnerships Focused and Dedicated Resources Staff Accountability Competitive Business Results Open Communications

26 Six Sigma Defined The Six Sigma term refers to Methodology (DMAIC) D M A I C - Define in numerical terms problems or opportunities - Measure the current levels of performance - Analyze and determine the root cause of the problem - Improve the situation - Control the new process to ensure continued better performance

27 Lifespan Rapid Cycle Methodology D M A I C Define Measure Analyze Improve Control Rapid Cycle Testing 30 Day 60 Day 90 Day Project Closure Using Lean Concepts Hardwiring using Control Plans

28 OpX/Quality - Organizational Commitment Optimizing internal competency for robust process improvement: Currently, under the OpX/Quality umbrella: 1 Master Black Belt 5 Black Belts 2 Black Belts in training 14 Green Belts 9 Green Belts in training 11 Green Belts to be trained (staff in roles with GB expectations) Across System outside the OpX/Quality Department 19 Green Belts and 1 Black Belt 1 BB in training

29 Six Sigma Roles Executive /Senior Team Sponsor/Champion Master Black Belt Black Belt/Green Belt Team Member Process Owner

30 Commonly Used Tools Charter SIPOC Flowcharting Brainstorming Fishbone Diagram C&E Matrix FMEA Stakeholder Analysis Run charts Affinity Diagrams Multi-voting Scatter Diagrams Control Charts Pareto Charts Process Capability Descriptive Statistics

31 Project Requests Any Lifespan employee may submit a project request for consideration Requests can be submitted verbally, via , or via the Lifespan Intranet

32 OpX Steering Committee This executive leadership committee guides and provides general oversight for OpX programming, activities and projects with the goal of driving improved outcomes and performance across key clinical and service processes. The committee aligns OpX support with the pursuit of Lifespan s annual goals, and strategic objectives. The committee reviews all project requests, utilizes a decision matrix for project prioritization and selection, and charters and supports selected projects

33 OpX Check-Ins Open to executive leadership, board members, and all Lifespan employees Held quarterly-teleconferenced to all affiliates Projects shared by Belts and Process Owners New projects Project Updates

34 TapRooT

35 What is TapRooT? TapRooT is a root cause analysis system and training program that helps solve problems both reactively and proactively. Identifies root causes without finger pointing and blame. Used internationally in many industries JC Sentinel Event Division has been trained in the TapRooT methodology

36 TapRooT Basic Steps 1. SnapCharT the Event Chronologically 2. Identify Failure modes 3. Identify the Causal Factors (contributing factors) 4. Obtain Audits/Observations (Data) and Evidence 5. Determine the Root Causes 6. Design Corrective Actions 7. Implement Corrective Actions 8. Monitor Redesigned Process

37 TapRooT Roles & Responsibilities Executive Sponsor Facilitator Process Owner Team Members

38 Team Member Role / Responsibilities Participates in the development of the content of the SnapChart. May be asked to complete an assignment between meetings. Can assist to brainstorm improvements for the corrective action plan. Makes every effort to complete the investigation within 30 days of the TapRooT request.

39 SnapCharT Diagram Visual tool to explain what happened Display in chronological order (for retroactive analyses) Show all process steps and conditions Identifies points of failure/possible failure Audited and validated prior to completion of analysis by team

40 Corrective Action Planning All root causes must be addressed in a corrective action plan. Elements of the action plan must include: Action Responsible Party Date for Completion MOS

41 Contact Information Nidia Williams, PhD, CCC-SLP, CPHQ Administrative Director, Operational Excellence Master Black Belt (401) Sharon Tripp, RN, MS, CPHQ Director of Clinical Excellence Black Belt (401)

42 Questions?