Improving Processes Using Lean We Got This! Becky Dodge, RN, MBA, CSSBB UNC Medical Center Rehab Services

Benefits of Lean Six Sigma Provides a comprehensive tool set to solve problems and to increase the speed and effectiveness of any process Provides a consistent lens and vocabulary for all staff Increases efficiency Increases revenue Reduces costs Increases employee and customer satisfaction Develops effective people

Lean Six Sigma Purple Belt Lean Toyota Production System

Flow = The Goal of a Lean Hospital

What is A3 Thinking?

A3 Thinking: Problem Solving Process

Value Added Activities For a process step to be considered value add, it must meet the following three criteria: 1. The customer has to care about the step 2. The thing going through the process changes 3. The process step is done right the first time

The 8 wastes (DOWNTIME) are: Defects Overproduction Waiting Non-utilized Talent Transportation Inventory Motion Extra Processing

Leadership

Team Composition Who should be on a Kaizen team? Home team: members closest to the process Visiting team: those who can provide outside eyes on the process Team leader: helps manage the team, keep them on track, positive influence Sponsor: provides management oversight and support, is responsible for the success of the team and helps prepare for the Kaizen.

Falls A3 Project

Box 1. Problem Statement In calendar year 2014 the falls rate index (# falls/1000 patient days) on the UNC Inpatient Rehab Unit ranged from 0-16.43 for an average of 8.52. The National Database of Nursing Quality Indicators (NDNQI) national benchmark for Rehab units is 5.29 (based on the 50th percentile). Clearly we wanted to do better!

Falls Protocol Pre A3 Use of Red/Yellow/Green signs Bed Alarms on (?) Hourly rounding Yellow arm bands, gripper socks Post fall huddle (?)

A3 Training Team met for a total of 3 days (1 month in between) Team works through the A3 over the course of several months Why a month apart? Gives them an opportunity to do the work in between training days Gives them time to absorb the information

Box 2. Current State Words / Pictures Unsafe, poor patient satisfaction, lack of ownership in culture, complacency, lack of standardization / consistency, complex

Variables (41) Collected on Falls Patients (FY2014) N = 63 Room number Phone in reach? Time of fall Falls band on? Age of patient Urinal in reach? Sex of patient Bed/chair alarm activated? Diagnosis Gripping socks on? Isolation precautions? Environmental clutter a reported factor? Day of fall Patient taking diuretics? Previous fall in last 3 months? Patient taking sedatives? Pre fall Morse scale score Patient follows directions? Post fall Morse scale score Patient confused/cognitively impaired? Level of injury post fall Last comprehensive FIM score prior to fall Activity at time of fall Patient neutropenic? How fall occurred, ie, from bed, w/c, toilet, etc. Orthopedic diagnosis? Where fall occurred, ie, in room, bathroom, etc. Patient tethered to something? Did patient call for assistance? Patient reaching for something? Bed table in reach? Staff present? Bed low and locked? Family present? Call bell in reach? NA's fully staffed? Caution signs in place? RN's fully staffed? Light on? Number of patients RN had on day of fall Number of patients NA had on day of fall

Current State What does the data say?

What else did the data reveal? 75% of the patients were not repeat falls 52% of falls occurred while transferring or sitting 75% of falls occurred in the patient s room 66% of patients did not call for assistance 52% of the time the call bell was in reach 59% of time bed was low and locked 10% of time call bell not in reach 56% of patients followed directions 56% of patients were confused The majority of falls occurred around 4P

Who is with the patient?

We need help! Or do we?

What other information did we gather? Call bell response time AM and PM How often Care Board updated by PT and OT Room inventory chair placement, #w/c s, commode placement, assistive devices, IV poles, etc. Survey of nurse s comfort with transfers PT shadowing nursing

Box 3. Target State Where did we want to be? Reduction in falls, standard process, teamwork, commitment, communication, blame free environment, accountability, cognition and Morse scale, Staff and family education

Importance of VOC Members of our Patient and Family Advisory Board were invaluable both in terms of providing feedback on their hospital stay (both had fallen while on Rehab) and in offering suggestions for how to improve. The frankness/honesty of their answers was incredibly helpful. Things you wouldn t think of: What is mechanical soft? I didn t use the call bell because I couldn t speak and I was also embarrassed by the fact that I couldn t respond. This helped turn the team members who weren t convinced we needed a new process. As a result of what they shared, one of the team members suggested we go to another unit that was using symbols on their care boards for toileting and take a look at them. This idea was incorporated into our solutions.

Box 4. Gap Analysis Getting to the Root Causes! What are the steps? 1. Brainstorm potential root causes 2. Organize (affinitize) into like groups 3. Put header cards on each section 4. Perform the 5 Whys 5. If necessary, multivote to determine focused number of causes to address 6. Perform the 5 Whys for each potential root cause

Results of the Gap Analysis # Gaps Root Cause 1 Incomplete Documentation re: fall event Lack of ownership of process 2 Inaccurate signage No accountablity 3 Lack of clarity/criteria for putting on bed alarm No accountablity 4 Lack of gait belt use Lack specific location and education re: gait belt 5 Care boards incomplete and hard to understand No accountablity 6 No cognitive assessments & action plans Lack of education 7 Lack of communication between nurses/therapy Lack process and operational definitions 8 Don't know when a fall occurs No process to communicate fall (nursing to therapy) 9 Lack of visual aides Never thought of it 10 No toileting schedule; rounding Inconsistent application of process

Box 5. Solution Approach # Solution (if we) Outcome (then we) Gap No. 1 Have a process for the purpose and use of the care boards Improve universal communication with staff, patients and families 2, 5, 7, 8, 9 2 Supplement rounding schedules to accommodate high risk falls patients/times Improved patient safety and satisfaction 10, 3 3 Create a process for interviewing patients and staff post fall Have more complete information to guide prevention strategies 8 4 Develop visual aides for the patient rooms Improve communication and increase patient safety 3, 7, 9 5 Document fall(s) in the sticky notes Therapy and other staff will be aware of when a fall occurred 8, 1

Box 6. Rapid Experiments # Experiment Anticipated Effect Actual Effect Follow-up Action SA No. 1 Standard Work for Use of the Care Boards Therapy staff will update Care Boards Daily Standard work created during Kaizen Implement standard work 1 2 Identify High Risk Patients with LEAF Identification of High Risk Pts > Dec Falls Standard work created during Kaizen for LEAF pts Implement standard work 2 3 Supplemental Rounding on High Risk Patients Decreased Falls Standard work created during Kaizen for LEAF pts Implement standard work 2 4 Document date/time of fall in the Sticky Notes Therapy staff aware of occurrence of a fall Standard work created during Kaizen for LEAF pts Implement standard work 5 5 Interview patients/family and staff post fall Improve data collection re why fall has occurred Standard work created during Kaizen for LEAF pts Implement standard work 3 6 Develop visual aids for the patient rooms/care boards Improve communication with patients, family and staff In Process 4

Identification of High Risk Patients LEAF (Phase I) This symbol is placed outside the door of LEAF patients, and a smaller LEAF magnet is placed on the Care Board for easy identification while either inside or outside the room. LEAF patients are rounded on every half hour.

Enhancing Communication (Phase I) A checklist was developed to improve communication between nursing and therapy staff; though taking care of the same patient there may be minimal contact between the disciplines during a shift. This laminated sheet hung in the room allowed for more frequent updates that all could be aware of at any given time.

Post Fall Interview Patient (Phase I)

Post Fall Interview - Staff (Phase I)

Post Fall Survey (Phase I)

Box 7. Completion Plan # Action Owner Due Status 1 Care Board Pilot - 5 rooms Tim In Process 2 Staff Education/Inservice Start: In Process 3 Falls notebooks on both A and B sides 09/09/15 4 LEAF Pilot Lia 09/10/15 5 Staff Education Start: 09/09/15 6 Document Fall in Sticky Notes Lia 09/09/15 7 Supplemental Rounding Krishna 09/10/15 8 Education on New Process for Falls Lia 09/09/15 9 Sean 09/09/15 10 Process for auditing Care Boards Sean 09/09/15 11 Gait Belts Carty In Process

# Metric Unit Current Target Kaizen 30-Day 60-Day 90-Day 120 1 Staff educated on new falls process 0 0 100 2 Sticky Note in chart % % 0.1 100 3 Staff/Patient Interview done % % 0 100 4 % Supp. Rounding Completed % 0 100 100% 57 66 N/A 50 100 66 N/A 100 100 92 90 100 5 LEAF outside room for LEAF pts % 0 100 93 95 100 100 6 Magnet Up in Room for LEAF pts % 0 100 89 90 96 80 7 % Intervention sheets updated % 0 100 8 Falls Rate (Goal = 5.29) 0 5.29 0 96 93 92 100 7.08 4.42 1.68 4.61

Box 9. Insights

Gait Belts (Phase II) In the fall of 2015 a grant was written to our Volunteer Services department to obtain a grant for funds to purchase washable gait belts for all 30 beds. Belts were spray painted with UNC Rehab and the room number (labor intensive). In January of 2016, therapy staff began inservicing nursing staff on the use of the gait belts. This should assist in the transferring of patients to/from the bed (identified as the chief reason for falls).

Standard Work

Care Board Changes (Phase III)

Sustaining the Change The Falls Prevention Team was formed to meet monthly and review any/all falls, identify root causes and consider any opportunities for improvement. Members include PT, PTA, RN, CNA, Health Unit Coordinator and former HUC, and coach. Recent changes include the development of an algorithm for deciding when to take a patient off of LEAF. Staff are collecting data from recent falls and analyzing it to determine if any new root causes are evident.

Thinking about Discontinuing LEAF Protocol? Has patient been alert and oriented x3 with no cognitive deficits for at least 24 hours? NO YES Does patient use call bell appropriately without activating bed alarm? NO YES Continue LEAF protocol for an additional 24 hours (minimum), then reassess YES Has patient exhibited impulsivity within the last 24 hours? NO Additional Notes: Once LEAF protocol is discontinued, leave bed alarm on for 24 hours RN will assess Q shift and communicate LEAF status in report Communicate LEAF status daily with primary therapist Put LEAF status in "sticky notes" (ex: Date & time of fall, assisted/unassisted fall, LEAF status) Orange "Falls Intervention Checklist" Write the Date & Time LEAF protocol was discontinued Discontinue LEAF protocol [ ] Remove LEAF from assignment considerations in E-Kardex [ ] Remove LEAF from the patient s room door and care board

EPIC Changes

So What does the data say? Average monthly falls rate index: Oct 2015 Dec 2016 = 4.84 (Range 1.46 9.9) Jan 2017 Jan 2018 = 5.8 (Range 0 12.2) Our original goal was to be < 5.29 (50 th percentile NDNQI) We have reduced our falls by over 50%! Gait belt expenditures dropped (from over $3000/year to $386.35/1.5 years!)

Helpful Tips Team selection is critical ensure everyone involved in the process is included Involve patients and their representatives- their point of view is invaluable! Carefully decide the plan of action/implementation Measure sustainment to ensure success Continue to improve!

Improving Care Access in Outpatient Therapy Clinics

Box 1. Problem Statement Therapy and ORCM (front desk) staff in the Outpatient Therapy clinics were frustrated; it was difficult to get patients in for appointments, but there were also a significant number of no shows, so utilization rates were lower than expected. Use of the wait list was variable, and communication was fragmented.

Scheduling Status Pre A3 Patients are contacted and scheduled (ideally) within 48 hours of a physician referral and, once the patient is seen, getting return appointments scheduled in a timely manner. Work queues averaged from a low of 80 to 250, the wait list was used inconsistently, and processes varied depending on provider. Rehab Services and ORCM need to work collaboratively to provide appointments in a timely manner. Utilization rates were approximately 65%, compared to the expectation of 75%.

Box 2. Current State Words / Pictures

Voice of the Customer Patients overall were satisfied other than some dissatisfaction with being able to see the same therapist. Staff were dissatisfied with the timeliness of care and patients being scheduled properly. Front desk staff and therapy staff lacked unity.

What other information did we gather?

Box 3. Target State Where did we want to be?

What were we aiming for?

Results of the Gap Analysis

Box 5. Solution Approach

Box 6. Rapid Experiments Creating Standard Work

The new process map is much more efficient: a decrease of 5 non-value added steps, 6 decision points and 4 rework loops to schedule an evaluation!

Before After

Box 7. Completion Plan # Action Owner Due Status 1 Develop front office notebook for each desk (15) ORCM 07/29/15 2 Office staff education (MM, CRC, Supervisors) ORCM 07/31/15 3 Office staff education (Spine, ACC, Cary, CC, CP II, Hosp) ORCM 08/07/15 4 % Confirmed Calls Made for New Evals Tammy 07/31/15 5 Weekly no show eval metrics Brendan Weekly 6 Therapy Inservice Project & Process @ CRC 8-9am Keith/Elizabeth 08/12/15 7 Therapy Staff Training K, B, E 07/31/15 8 Metric Reporting Brendan/Tammy Weekly 9 Therapist compliance with NS doc Keith Weekly

Box 8. Confirmed State # Metric Unit Current Target Kaizen 9 / 2 6-11/ 7/ 1 1 New evaluation no show rate % 2 3 4 Provider capacity/utilization (Provider Based Clinics) Provider capacity/utilization (Hospital Based Clinics) Time to 3rd available evaluation appointment HB:25% PB:10-15% <5 % 0.85 0.85 % 0.65 0.75 day s HB: 30+ PB: 9 HB: < 14 PB: < 7 5 % Reminder calls made % 0 100% 6 Staff educated on new eval sched process 7 Referrals scheduled % 8 9 True North Metrics Staff educated in wait list process % therapist compliance w/ std doc process for NS % 0 100% HB: UNK PB: UNK 0.75 % 10-20% 1 % 0 100 Std Work Std Work Std Work Std Work Std Work Std Work Std Work Std Work Std Work HB-16 PB -8 11/ 2 1-1/ 2 / 1 HB-17 PB-9 1/ 16-2 / 2 7/ HB-19 PB-12 3 / 12-4 / 2 3 / HB-17 PB-13 81.8% 82.3% 76.3% 83.3% 71.0% 73.7% 69.3% 73.8% HB-25 PB -15 HB-32 PB -11 HB-32 PB -16 HB-43 PB -26 38% 68% 77% 82% 100% 100% 100% 100% HB - 40 PB - 50 HB - 42 PB - 46 HB - 40 PB - 40 HB - 39 PB - 45 100% 100% 100% 100% 85% 91% 93% NA

Box 9. Insights

War Room

Sustaining the Change Audits were done to determine understanding/compliance with standard work Therapy and ORCM Leadership met weekly for 2 years to review data and continuously improve processes, now meet bi-weekly Therapy and ORCM staff now meet quarterly in a joint meeting Morale is UP! Repeat repeat repeat

So What does the data say?

Post Kaizen To-do List: Where do we begin? Standard Work review and updates Education of clinical and non-clinical staff Voice of customer/ feedback Metric definitions/identification Best way to collect/ obtain data Project out of scope list! (huge )

Standard Work New Evaluation Scheduling New Evaluation Reminder Calls Check in and out procedures Standardized scheduling slip Use of waitlist No show policy enforcement No show documentation Dismissing the non-compliant patient

Standard Work - Example Standardized use of scheduling slip with complexity to indicate priority for wait list

Standard Work These three aspects of standard work and education proved very important to the goal of decreasing our noshow rates: No show policy enforcement No show documentation Dismissing the non-compliant patient

Staff Education Each area of standard work was rolled out to the clinical and non-clinical staff in a variety of ways Lots of updates, revisions and re-education needed Small team meetings Larger staff meetings Email updates Kaizen Newsletter Standard work notebooks

Importance of VOC The action plan was implemented, but Feedback from staff indicated there was a lack of understanding of the standard work Further education to clinical staff of standard work of front desk staff (Who is taking care of what?)

Importance of VOC Restart of Implementation Audits of processes revealed inconsistencies Not everyone understood or was following the script Notebooks were not in color and important aspects were not clear/ highlighted Updates to standard work were not getting replaced in the notebooks

Metrics: What data was important to track? % No shows % No show New Evaluations % schedule utilization Time to 3 rd next New Evaluation slot Referral Work queue Totals % Therapist No show documentation Collections

Metric definitions: Work Queue Total The number of referrals waiting in the Epic work queue to get scheduled. This is a general indicator of access. Larger work queue volumes indicate longer lines of patients waiting to be seen, which leads to longer wait times to get patients in for an evaluation.

Metric definitions: % Therapist Use of No-show Documentation How many times the no-show documentation is completed in the chart compared to the overall number of no-shows. This helps track that physicians are being notified of patient noncompliance, and helps therapists spot patterns of noncompliance in the medical record. This also helps track need for dismissal from therapy and improved access for more compliant patients.

Initial Metric Tracking Display Each clinic had a display updated weekly for all staff to see real time results Eventually transitioned to an electronic version with periodic updates sent to staff.

Current Data Collection The Epic Appointment statistic report is run weekly for the previous week. The total visits, new and return appointments, no shows are filled into an Excel spreadsheet Time worked is added Formulas compute schedule utilization and no show percentages.

Current Data Collection WQ totals and time to 3 rd are also collected Each therapist data sheet is linked into a clinic roll- up Each clinic is linked to an on-going dashboard Working with programmers for an automated report and eventually an automated clinic dashboard

Data Collection- Sample Dashboard

Additional Problem Areas Tackled Referral Inconsistencies Single flow vs batching Inappropriate referrals or insufficient info Back and forth to correct and delay in care

Additional Problem Areas to Tackle Clinic Information Accurate clinic information needed for automated calls and printed appointments Easily accessible clinic information with maps and directions for patients Website overhaul for easily accessible, accurate and valuable information

Where are we now?

More Than The Numbers! Patient access, improved schedule utilization and reduced no-shows were the main initial drivers of this project Additional bonuses: Greatly improved relationship between clinical and nonclinical staff Greatly improved communication Better understanding of each area of responsibility and challenges Improved staff and patient satisfaction

I went through some helpless experiences trying to make an appointment at UNC Healthcare, including being on hold for literally hours with the Spine Center. When I finally reached them, their first opening was for two months later. However, after the first of this year things became much better and I am grateful that both of you were able to help me. Please tell whomever was responsible for fixing things, that his/her efforts have worked and I am extremely grateful for them. -Spine Center Patient The wait list function has been working exceptionally well and has been critical to maintaining a high utilization rate...the reminder calls for new evaluations have also been well received - post-project feedback from therapist staff member

Lessons Learned Our process was inconsistent and undefined Consistency is the key We have good people working hard to help patients get in for care but the process needed to support them Voice of the customer! Don t stop after the initial rollout: keep re-introducing and refining the process Better access = satisfied patients and staff Project and follow up was hard work but well worth it!

What is 5S? Sort Red tagging, eliminating supplies/ stuff Set Organize remaining items Shine Clean and maintain Standardize Standard work (labeling, pictures, videos, flowcharts, etc.) Sustain Audits and accountability

5S Wakebrook Before

5S Wakebrook After

Wakebrook Before

Wakebrook After

OT Psych Red Tag

OT Psych Before

OT Psych After

OT Psych Before

OT Psych After

OT Psych Additional Features

Equipment Room Before

Equipment Room After

Standard Work / Visual Management

Start small Build buy in Have successes Helpful Hints Proceed to larger projects Build leadership in your staff Create pull (vs push) how much change at one time? Drive quality through local area councils and Keep improving! You got this!

Thank you for the privilege of your time! Becky.Dodge@unchealth.unc.edu