The Evolution of Lean in Healthcare:
From tools and events to coaching and daily
improvement
Kevin Bahadur Craig Wickens
Change Management Specialist Manager, Support Services
Rouge Valley Health System
About Rouge Valley
Rouge Valley Centenary (RVC) Rouge Valley Ajax and Pickering (RVAP)
2867 Ellesmere Road, Toronto 580 Harwood Avenue, Ajax
RVHS formed in 1998 as part of a provincial amalgamation of
hospitals:
• Scarborough Centenary Hospital, originally opened in 1967, now is RVC;
• Ajax & Pickering General Hospital, originally opened in 1954, now is RVAP.
Getting to Know Rouge Valley
• 2 hospital campuses serving
the communities of west
Durham and east Toronto
• $300 million annual budget
• Part of Central East Local
Health Integration Network
(CELHIN), our funder
•2,774 staff, 513 physicians
Our Burning Platform for
Transformation
10 Year Surplus/Deficit Trend
10,000
5,000
(5,000)
Dollars ( Thousands)
(10,000)
(15,000)
(20,000)
(25,000)
(30,000)
(35,000)
2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 B 2012/13 P 2013/14 P
Surplus / (Deficit) (3,014) (5,748) (2,527) (6,470) 2,419 4,406 8,938 4,500 4,677 4,750
Nothing Done (6,748) (10,280) (14,457) (19,351) (23,875) (28,090) (32,531)
Years
The Early Days of Our Journey
2007 2008 2009 2010 2011
Board Strategic Plan Strategic Plan
Appoints 2008 -11 2011-14
New CEO Approved Approved
Peer Financial
Review Sustainability
Plan Launched
Lean as our Management Philosophy
The STAR Framework
Corporately Defined Expectations for Lean Deployment and Sustainment
STANDARD ADVANCED ROLE MODEL
All of the following are in place: All of the following are in place: All of the following are in place:
• Sustainment of Standard and
• Process Control Boards • Sustainment of Standard Advanced levels
level • Internal knowledge sharing
• Performance Trending
(joint kaizen with another
Boards • Kamishibai
dept; facilitator for another
• 6S • Safety Calendar (can be dept’s Lean event; lead an
part of Kamishibai system) in-service; internal article or
• A3 poster presentation)
• Idea Board with problem-
• Rounding • External knowledge sharing
solving huddles
(e.g. joint kaizen event with
• Kaizen Participation • Department leads and external partners; conference
sustains its own kaizen presentation; published
• Leader Training article)
events (at least 2 per yr)
• Use of one or more higher-
level Lean tools (e.g.
Kanban, Andon, SMED, etc.)
From: “Assessing and Accelerating Your Lean Transformation - the Shingo Model” Jake Raymer, 2013 Lean Healthcare Transformation Summit
From: “Assessing and Accelerating Your Lean Transformation - the Shingo Model” Jake Raymer, 2013 Lean Healthcare Transformation Summit
RVHS Executive Team identified 2 key areas for corporate development:
Continuous Improvement and Capability Building
Graphic From: J. Liker, ‘The Toyota Way to Continuous Improvement’
Objective of the Lean
Management System
Our Goal:
To develop our people to solve problems
and improve performance.
Developing a Lean Management System
Visual Management Daily Stat Sheet
Department Performance Board Staff Improvement Board Kamishibai
Daily Performance Huddles
Supervisor / Manager
Daily Coaching
Department Scorecard Manager / Director
Coaching
Driver Metrics Watch Metrics
Director / VP
Coaching
Monthly Performance Reviews
VP
(Week 3)
Director
(Week 2)
Manager
(Week 1)
Developing a Status Sheet
Daily Status Sheet
Adapted From: ThedaCare Centre for Healthcare Value
The Daily Status Sheet and Lean
Practices
Objectives of Status Sheet Linkage to Lean Practices
• To proactively plan the day • Use of Standard work
• To learn and understand the • Respect for People (Develop
business our Staff to Solve Problems)
• Gain insights for future • Create visibility between
problem solving normal and abnormal
• To better understand • Developing ‘Andon’ Systems
coaching needs for staff
around problem solving • Use of PDSA thinking to
solve problems
• To develop our leaders
Structure of the Daily Status Sheet
Manager to Director Daily Status Sheet
Frequency
Manager-Charge:
Daily
Director-Manager:
Weekly
VP-Director:
Monthly
Adapted From: ThedaCare Centre for Healthcare Value
Status Sheet: Clarifying Roles
Coach for Key Messages:
First Coach
•The pattern repeats at every
level to ensure everyone has the
Coach for Second opportunity to get feedback and
‘1-Up’ Coach improve
• In the typical Manager Status
Learner for
Second Coach Sheet, the First Coach would be
Coach for First the Director with the TMO
Respondent Coach
providing additional support
during LMS training
Learner for
First Coach • In the Manager Status Sheet,
‘1-Up’ the Second Coach would be the
VP or TMO during LMS training.
Learner for The Second Coach is focussed
‘1-Up’
on providing feedback for the
Respondent
First Coach
Adapted From: The Toyota Kata, Mike Rother
Creating an Area Improvement
Centre
Visual
Management
Performance Board Structure
Create a single ‘lane ‘ of focus for each
dimension of corporate performance
Post current
strategic plan as
Describe goal in a reference
single statement
Post framework
of key initiatives
Chart key
and Patient
performance metric
Declaration of
over time to
Values
demonstrate
current
performance level
Post ‘top 10’
metrics & highlight
area of focus
Post A3 which
describes the key
initiatives that are
focussed on driving Post other related ‘process
The layout of the board tells the
improved metrics’ or initiative ‘improvement story’ of the
performance implementation information
(pictures ect.)
department and each initiative. The
information should flow like an A3
The ‘Bottom Up Story’ of the Performance Board
Linkage to RVHS Strategy
Lose Weight
• Want to visually demonstrate how
departmental outcomes link with RVHS Measure: Body
Weight (LBS)
objectives
Department Outcome Measure
• Tracking performance over time to see Calories In
variability and support sustainment Measure: Total
Calories Consumed
• The LMS department scorecard standardizes
the display of the outcome measure
Process Measures
• Process control supports daily management Measure: Number
of key drivers of chocolate bars
• Primary tools include process control boards, consumed per day
daily run chart, safety cross, Pareto chart and
Kamishibai cards
Ideas for Change
• Countermeasures are developed based on Eat less
root cause analysis and best practices
chocolate
• The A3 and ‘WWW’ are the primary tools to
support the team
Layout of the Idea Board
New Improvement Ideas In Progress Work & Ideas Implemented Ideas
PDSAs
PICK Chart
Impact
Just Do Its
Celebrations
Implement Challenge
Possible Kibosh
Almost Implemented Ideas Stephanie passed her AQ Exam!
Week 1 Week 2 Week 3 Week 4 Week 5
Zero department pressure ulcers!
Difficulty
Adapted From: ThedaCare Centre for Healthcare Value
New Improvement Ideas Review and record In any new Work &Start
Progress Ideas
with work in progress:
Implemented Ideas
improvement opportunities: a) Just Do Its – any barriers
-e.g., opportunities identified to moving forward?
• Briefly review each lane in your onArea
stat sheet b) PDSAs – if the status
Improvement Centre -Ask staff what barriers they indicator is green,
• acknowledge the work
PDSAs
Briefly review PDSAs associated are with
encountering in their day
lanes. If the status indicator is green, and move on; if the status
acknowledge the work and move on. If is red, ask about barriers.
the status indicator is red, ask the • Use the PICK chart to get feedback Move completed
from staffwork to the
following questions: 1) Any new about whether working on this will have highIdeas
“Improvement or
PICK Chart low impact and whether it is Implemented”
easy
defects? 2) Adequate resources? 3) • Monthly (+/- daily) tracking on a run chart or hard tosection
do
Barriers to moving forward? • If an
or opportunity falls into Kibosh, circle back
Impact
simple bar chart
• Discussion points may vary day by day. with the originator
• Improvement but doand
Tickets not PDSAs
place onget the
Just Do Its
• End on a high note – identify reasons PICK
to chart
moved over to this area once completed
celebrate and make them visual • All patient or employee safety or quality issues
• NOTE – we will learn more about theare immediately moved to be worked on Celebrations
standard Implement
work for the Area • If opportunity is related to existing PDSA,
Challenge
Improvement Centre in a later module driver, or other work in progress, move the
Possible Kibosh Improvement Opportunity form to that PDSA
Almost Implemented Ideas
to be incorporated
• AsWeek
capacity
1 Week becomes
2 Week available,
3 Weekproblems
4 Week 5can
be moved from PICK chart to work in progress
• Assign resources to new work in progress with
Difficulty owner(s), & mentor / coach
Adapted From: ThedaCare Centre for Healthcare Value
Monthly Performance Communication Diagram
Two Options: VP Monthly Performance Review 3rd week of
1) Portfolio Leadership Team the month
The VP and Directors meet to discuss progress on
department drivers as it relates to strategic • Review of Countermeasures,
deployment and ‘Top 10’ • Review strategy and
OR execution tactics
2) VP / Director Huddle • Review of other projects
The VP and Director meet at each performance board to
discuss progress on department drivers as it relates to
strategic deployment and ‘Top 10’
Director / Manager Huddle Director Monthly Performance Review
2nd Week of
Director meets with manager (+ other
members of the ELT, if desired) at their
the Month
performance board. Countermeasure • Lessons Learned
summaries are presented, and additional • Review of Countermeasures
resources are allocated if needed. Countermeasure
Summary … Repeat for each Director
Leadership Team Monthly Performance Review
Leadership Team 1st Week of
The manger meets with leadership Department Drivers the Month
team following defined Standard Work • Lessons Learned Shared,
around scorecard. When areas are not • Stratification of Red Metrics
meeting goal-countermeasures are • Develop Countermeasure
developed and summarized. Summaries
Manager … Repeat for each Manager
21
Adapted From: ThedaCare Centre for Healthcare Value
ay things really are 7.0
4.7
Wave 1 Staff Feedback (All Model Cells)
rt of our daily work
ent and/or hospital
1. I understand what the department goals are for the next year 7.1 7.1
5.7
2. There are regular meetings on units/departments that focus on the review of
5.1 8.0
unit/department performance metrics and result in plans to improve processes 6.2
metrics
3. Department impact theare openly displayed and reviewed with front line staff
performance metrics 8.0 6.8
on a regular basis 5.7
4. Senior Leaders are aware of front line issues and challenges (the way things really are 5.0 7.0
around here) 4.7
aring forums across 5. Learning is an important part of our daily work 8.2 6.8
7.7
provement
6. Employee and physician suggestions on how to improve department and/or hospital 4.5 7.1
performance are actively solicited 5.1
d and used
7. Employees to drive
and physicians understand how their area's performance metrics impact the
whole organization's performance 5.0
6.8 7.3
8. The organization facilitates regular knowledge/idea sharing forums across 5.1 6.8
units/departments that are related to hospital improvement 4.5
sicians
9. Visualare
displaysinvolved
of hospital performance data are regularly reviewed and used to drive
improvement 5.1
7.3
6.9
10. When changes are made in my unit/department, employees and physicians are involved 4.4 6.9
in the process 4.4
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0
0.0 1.0 2.0
POST LMS Score
3.0
PRE LMS Score
4.0 5.0 6.0 7.0
Neutral
Negative Positive
POST LMS Score PRE LMS Score Response Response
Experience of A Model Cell
Support Services: Hospitality
What is “Hospitality”?
• Patient Transport
• Daily Cleaning
• Discharge Cleaning
• Patient Meal Delivery
• Nursing Assistance
• Approx. 300 Multi Skilled Employees
What Can Be Learned
From This Model Cell?
How does the Leadership Management “System” help us
with “the problems we are trying to solve”?
First Things First…The Lean Context
After 6 years what does “Lean” mean to us?
• What is required for best patient care?
• What needs to be done to achieve that?
• What is our plan?
• Continuously improve Safety, Quality, Efficiency?
Our Approach
The plan is our foundation on which to build; our approach is…
• Have a Plan
• Visualize the Plan
• Respond to the Plan
• Improve the Plan (safety/quality/efficiency)
Our First Problem!
…and solutions so far
How do you build a Plan when ?
• Develop Standard Work
• Select/Train Master Trainers
• Train 300 Staff
• Sustain
Our Next Problem!
…solutions to follow
How do you build a Standard Plan when the day is so ?
• The day depends on who comes in the door
Our Next Problem!
… solutions so far
Maintaining flow
• 75% of the day is predictable
• 2 different tactics
• Staff and plan to 75%
• Additional staff move to multi-skilled pool
• 75% exceeded – send in reinforcements
• Problems now separated
Yet Another Problem!
…and solutions so far
Everyone is so spread out, how can we ?
• Call Centre tracking (actual vs. plan)
• Maps and door magnets
• Control boards
• Colour coded carts/equipment
Another Problem Still!
…and solutions so far
A Supervisor has 55 direct reports, how can they ?
• Leader Standard work
• Group Leaders
• Red/Yellow Pager
Introducing LMS
…congratulations you have been selected
Initial thoughts on being selected as a pilot site?
from implementing the plan
• Need not indicators (yet)
• Focus needs to be plan;
• Staff ideas will not be
• Out of sequence;
• Either way – ok, sure, we’ll do it – so we start.
Big New Problem
… in the mean time a new problem begins to emerge
“how do we maintain the base and continue to move ahead?”
Defining the Big New Problem!
… ok so it took 6 why’s!
• Why is the plan not always followed?
• Lack of front line passion for it – why?
• Leadership has not fostered passion – why?
• We may not really know how – why?
• We are still managing the old way – why?
• We are comfortable with it – why?
• We haven’t practiced anything else
Can LMS Help?
… maybe this “distraction” can help with our problem
LMS as a Solution
… a new way of thinking
• Process is performed by people
• People are the process
• Develop people to develop the process
• Not one before the other
How LMS Helps
… changing the way we manage
• Build Leadership discipline
• Develop Leaders as coaches
• Practice implementing ideas
• Build ownership/passion of process
• Build PDCA know how
“Habit is the most effective form of motivation”
LMS Purpose?
… how does LMS help solve our problem
Builds “people capacity” for:
LMS Next Steps?
… what’s next for Support Services… now that we kind of get it
• Pilot expanded
• LMS in other “plan” cell
• “Plan” and LMS together forever
• Grow future Leadership from within
Thank You!
Session Code: ThP/11
The Evolution of Lean in Healthcare
Kevin Bahadur
Rouge Valley Health System
[email protected]
