Alvin S. Calderon, MD, PhD Roger W. Bush, MD Virginia Mason Medical Center. LeeAnn Cox, MD Noelle Sinex, MD Indiana University School of Medicine

Transcription

1 How Lean Concepts can improve your Residency by addressing the competencies of PBLI and SBP APDIM Fall Meeting Workshop Session II, Workshop 209 Saturday October 22, 2011 Alvin S. Calderon, MD, PhD Roger W. Bush, MD Virginia Mason Medical Center LeeAnn Cox, MD Noelle Sinex, MD Indiana University School of Medicine Workshop Overview Introduction to LEAN Methods (15 minutes) Applying Lean to Clinical Work: One-Piece Flow (30 minutes) Practice Base Learning and Improvement at IU (20 minutes) System Based Practice at VMMC (10 minutes) Group Discussion (15 minutes) 1

2 Waste and Disruptions in GME Duty Hour Violations Work Compression Disrupted doctor-patient relationships Disrupted teams microsystems Human Error Lean Production System Philosophies and Practices Customer first Highest quality Obsession with safety Highest staff satisfaction A successful economic enterprise 2

3 Waste Wheel Taiichi Ohno s Seven Wastes Processing Unnecessary processes and operations Traditionally accepted as necessary Inventory Maintaining excessive amounts of supplies, materials, or information for any length of time. Having more on hand than what is needed and used. Time Waiting for people or services to be provided. Time when processes, people or equipment are idle. Waste Defects Waste related to costs for inspection of defects in materials and processes, customer complaints and repairs Motion Unnecessary movement or movement that does not add value. Movement that is done too quickly or slowly. Overproduction Producing what is unnecessary, when it is unnecessary, and in unnecessary amounts Transportation Conveying, transferring, picking up, setting down, piling up and otherwise moving unnecessary items. Lean View of Waste Any activity that doesn t serve the valid requirements of customer usually in seven critical areas: Overproduction, Time on Hand (waiting), Transportation, Processing, Stock on Hand (inventory), Movement, Defective Products. Muda variation in output (mistakes and defects) discovered after the process is in place and dealt with reactively Mura eliminating fluctuations in operations, especially quality and volume Muri planning stage for the next project, using learnings from Muda and Mura 3

4 Waste types There are different kinds of waste Type 1: Non-value added activities that are currently required, such as work to comply with regulations Type 2: Non-value added activities that can be stopped immediately with no detrimental effect Eliminate Type 2 as soon as possible! Womack, James P. and Jones, Daniel T. (1998), Lean Thinking Free Press The Lean View of Value Value- A capability provided to a customer at the right time, at an appropriate price, as defined in each case by the customer. Value Stream- The specific activities required to design, order, and provide a specific product, from concept to launch, order to delivery, and raw materials into the hands of the customer. Work- Any action within an operation which adds value. 4

5 Upfront Lean View of Waste Waste is those system elements (including elements of the final product) which do not bring value to the customer. Value is what the customer is willing to pay for. The Customer is the entity which monetarily pays for the final product (includes wholesalers and distributors, but not internal customers, management, or other stakeholders in the production systems). Lean Principles Continuous Flow Production (vs Batch and Queue) Pull Production 5S (Sort, Simplify, Sweep, Standardize, Self-Discipline) Visual Controls Mistake Proofing (Poka Yoke, Jidoka, Heijunka) Value Stream Management Five Whys Open Book Management 5

6 High Reliability Organizations Sensitivity to operations Reluctance to Simplify Preoccupation with failure Deference to expertise Resilience e/hroadviceexecsum.htm One Piece Flow Exercise 2011 APDIM Fall Meeting Workshop Session II, Workshop 209 Saturday October 22,

7 Wrap-up: 2011 APDIM Fall Meeting Workshop Session II, Workshop 209 Saturday October 22, 2011 Indiana University Setting 115 Categorical Residents 50 Medicine/Pediatrics 4 Teaching Hospitals 15 Ambulatory Clinic Sites October 7,

8 QI Foundation PGY2 Ambulatory block: Residents design QI proposal using PDSA Cycle - Focus is learning key concepts - Proposal Feedback from local QI expert - Implementation encouraged but optional Langley GJ, Nolan KM, Nolan TW. The foundation of improvement. Qual Prog. 1994;June:81-6. How LEAN met IU Residency Roudebush VA s systems redesign engineer - Physician/resident engagement - LEAN concepts demonstrated at a local workshop Help address problem identification, feasibility, practicality, and implementation VA-Funded Quality/Safety Chief Resident Provide a QI tool box 8

9 What Does LEAN Look Like? Rapid Process Improvement Event LEAN Based Advance QI Curriculum PGY3/4 Immersion Week - Adapted from RPIW - One-week project in continuity clinic site - Mixed format Didactic sessions Clinic process observation Multidisciplinary consultation 9

10 Day 1: Didactic Session Brief intro to LEAN concepts and tools Voice of the Customer Learning activity Introduce Process Mapping Create a project charter Day 2: Clinic Process Observation Observe process Talk to customers Key QI faculty on site or available by pager Develop project charter October 7,

11 Day 3: Didactic Session Review concepts and cools Learning activity Consultation/feedback with QI faculty - Process mapping - Planned Test(s) of change Day 4 & 5: Clinic Process Observation Data gathering Small tests of change Study after-effects Talk to customers (part 2) Implementation? 11

12 Day 6: Presentation & Feedback There is no organized, efficient process for distributing patient handouts in clinic. The handouts which are available are disorganized, often outdated, and often are not available in both English and Spanish despite our large population of Spanishspeaking patients. Many physicians express a desire to have an efficient way of accessing educational handouts in clinic. Place Picture of Current State Process Map Here Involved in Current Proces and Revision: Staff and Resident physicians RNs in charge of patient check-out Site director Place picture of future state here Day 6: Presentation & Feedback October 7,

13 Resident Improvement Projects Improved utilization of POC testing - Flow of charts - EBM in ambulatory clinic - Patient flow - Patient Education Material - Medication Reconciliation/Med List - Diabetic screenings - Testing result follow-up - New patient appointments - Routine Screening - 18-month screening - Continuity - Ambulatory glucose monitoring - Oximetry measurement Medication Reconciliation - Cardiac Rehab Referral - Developmental Screening - Smoking Cessation - No-Shows - Diabetic screenings - Medication refills - PT referrals/scheduling - Vaccinations updates/flu shots - Patient information/data Collection - Urine testing - Documentation (ROS, BMI) - Work environment - Electron prescribing - Blood pressure measurement Results: Resident Feedback 5 Curriculum Evaluation Curriculum Activities Comfort in Multidiciplinary Teams Team Leadership Utilization in Future 13

14 Results: Resident Feedback Curriculum Evaluation - 100% of respondents felt experience worthwhile - Most useful aspects: talking/working with clinic staff/personnel to implement a project learning how to break down and analyze a potential area for process change learning activities encouraged innovative ideas to solve problems seeing other clinics problems Results: Resident Learning QIKAT - Assessment of general QI knowledge - Significant difference between pre/post test (P<0.001) 12 QIKAT Scores Pre-Test Post-Test Morrison LJ, et al. The quality improvement knowledge assessment tool (QIKAT): an instrument to assess knowledge application in practice-based learning and improvement. J Gen Intern Med 2003;18:

15 Results: 3 Month Follow-up Implementation 40% achieved % immediate implementation 19% indicated further implementation of the interventions after 3 months 33% no change in implementation 1 project noted decline due to partial sustainability Results: Summative Clinic Staff Evaluations Clinic administration unanimously agreed - The process did not interfere with work flow - Projects were potentially beneficial to flow - They were comfortable with residents as QI Leaders 87% of respondents indicated effective promotion & advancement of clinic QI goals. 15

16 Lessons Learned Alignment of resident/clinic goals difficult - Some clinic sites have split administration - Goals from clinic systems vague or outdated Do all residents get it? Identifying presumptive solutions before process observed & understood Some solutions rely on people doing it better rather than improving system Lessons Learned LEAN provides practical improvement tools Alignment with clinic/admin goals is critical - Residents like to optimize their micro-system - Leadership can effect residents focus Balance resident enthusiasm vs clinic buy-in Appropriate Scope is key Residents like exposure to peer projects 16

17 Moving Forward Realign Resident Projects with clinic and organizational goals Recurrent/on-going projects Improve communication of findings back to clinic leadership Comments and Questions 17

18 Virginia Mason Medical Center Environment Founded in 1920 An integrated healthcare system 501(c)3 Not for Profit 336 bed hospital 9 clinic locations 440+ physicians 5000 employees 17,000 admissions 32 bed adult ICU Virginia Mason Medical Center Environment ACGME accredited training programs (6). Residents (112) in: Anesthesia Internal Medicine Surgery Radiology Transitional Pain Fellowship 18

19 System-Based Practice Work effectively with other care providers and settings Improving health care delivery Cost-effective care for patients and populations The SBP Question: How can I improve the system of care? * *Johnson 2005 AHRQ. VMPS Lean is the system of improvement by which we improve our system. It s how we work on our work. 19

20 VMPS and GME Every resident required to participate in an improvement activity. Rapid Progress Improvement Workshop, Kaizen Event, or System Based-Practice Elective. Lean Journey since Over 500 RPIWs. Decreased total staff walking by 60 miles per day. Saved $1 million in inventory (2009). 18% 16% 14% 12% 10% Medicine Interns : < 10 Hour Break Between Shifts % 6% 4% 2% 0% Rotation

21 Flow mapping an intern s day Waste in Intern Work Time (18) Waiting for morning labs Delay in contacting consultants Waiting for consultants to call back Time spent finding RN for rounds Overproduction (13) Too much in progress notes Checking orders multiple times Multiple plans of care Defects (32) Lack of standard processes Lack role expectations Rounds going past noon Difficult for RNs to contact correct intern Overprocessing (10) Learning curve for interns accepted All labs imported into progress note Too much information in presentations Waste (75) Motion (2) Up and down stairs for rounds Walking to find RN for rounds Inventory Excessive supplies, material, information. More on hand than what is needed. Transportation Conveying, transferring, picking up, setting down, piling up and otherwise moving unnecessary items. 21

22 Average Breaks per Month less than 10 hours for Interns on Wards Once a Week Twice a Month Once a Month Rotation Average Breaks per Month less than 10 hours for Interns on Wards Twice a Month Once a Month Rotation 22

23 Project Resident Handoffs Elective Knowand-Go Problem Description No standard for handoffs No standard day one info SBP and Lean Multidisciplinary Participants Medicine Surgery Residents, Info Systems Medicine, GME Staff Method PDSA, Faculty Champion, Institutional Alignment PDSA, SBP Rotation Result System wide handoff in Medical Record Standardized day one info Eastgate Clinic Project Non-standard exam rooms MD, RN, support staff SBP month time with patients. MD stays in room. Cardiac device RPIW Batching device checking MD, Cardiac Device RN RPIW Resident input saves $25,000 travel Teaching RPIW Variation in clinic teaching MD, RN, support staff RPIW ITE scores evaluations IMC RPIW Morning rounds MD, RN, Nurse leaders RPIW autonomy communication SBP Elective Clinical Information Systems: Purpose: Study system design and performance improvement through the focused study of the flow of information. Patient Safety Alert System Purpose: Study system design and performance improvement through the Patient Safety Alert System. 23

24 SBP Elective Center for Healthcare Solutions: Evidence-based medicine 100 percent patient satisfaction Same-day access to care Rapid return to work or usual function Affordable price for employer and provider SBP Elective Patient Relations and Service Purpose: Understand how patient perspective can inform process improvement through focused study of patient feedback. 24

25 Variation Standardization Improvement ACT ACT PLAN PLAN Observation & Develop a New Vision DO DO ACT ACT PLAN PLAN Observation & Develop a New Vision DO DO CHECK STUDY CHECK STUDY SBP and Lean Start with a need: What do residents see as their main obstacles to caring for patients. Teach residents to improve systems. Coach the residents on how to work on their work. Small success or big failure? 25

26 Discussion: 2011 APDIM Fall Meeting Workshop Session II, Workshop 209 Saturday October 22, 2011 References Bush RW, Philibert I. Making Sense: Duty hours, work flow, and waste in graduate medical education. JGME 2009;1(2): Bush RW. Reducing Waste in US Health Care Systems. JAMA 2007;297: Kim C, Lukela M, Parekh V, Mangrulkar R, Del Valle J, Spahlinger D, Billi J. Teaching Internal Medicine Residents Quality Improvement and Patient Safety A Lean Thinking Approach. Am J Quality 2010: 25(3): Flanders SA, Kaufman SR, Saint S, Parekh VI. Hospitalists as emerging leaders in patient safety: lessons learned and future directions. J Patient Saf. 2009;5(1):1-6. Gosbee JW, Williams L, Dunn E. Teaching the teachers of patient safety: A progress report. ACGME Bulletin. Sept 2006; pdf. Accessed September 1, Lypson ML, Frohna JG, Gruppen LD, Wolliscroft JO. Assessing residents competencies at baseline: identifying the gaps. Acad Med. 2004;79(6): Johnson, JK, Miller SH, Horowitz SD. System-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work. Advances in Patient Safety: New Directions and Alternative Approaches. Volume 2. AHRQ Womack, James P. and Daniel T. Jones (2003). Lean Thinking: Banish Waste and Create Wealth in your Corporation. New York: Free Press. 26

27 Intern Manual