Daily Continuous Improvement Program

Trey Coffey MD FAAP FRCPC

Medical Safety Officer, SickKidsAssociate Director, University of Toronto Centre for

Quality Improvement and Patient Safety

Disclosures

I have no conflicts of interest to disclose

Lean Concepts

• Origins in Toyota Production System c. 1930s

• Term coined and applied to western manufacturing c. 1980s

• Processes analyzed from the point of view of customer value

• Focus on eliminating waste of all kinds in the system

• Deference to expertise – executives on the factory floor (“Gemba”)

Getting to know you

Your prior experience with LEAN is best described as:

A. I am not very familiar with LEAN.

B. My healthcare organization is doing some LEAN things and my reaction is… “meah.”

C. My healthcare organization (or other organizations I am familiar with) did some LEAN and it was an unmitigated disaster.

D. My healthcare organization is completely LEAN

Different Levels of Process Improvement

Adapted from: “The Toyota Way Fieldbook” by Liker and Meier

Very fewLarge issues

FewMedium issues

ManySmall issues

Objective

To tell a genuinely enthusiastic firsthand account

of a unique Lean Management System, which:

• is new to SickKids

• is not yet fully realized nor perfected

• might be revolutionary…

New Job

Paediatric Medicine Quality Committee c. 2005

2011: Emergency Department Performance Improvement Program

We used Lean to improve

Door-to-Floor times!

Reality sets in… Again.

• ThedaCare group of hospitals and clinics in Appleton, Wisconsin.

• Early adopter of Lean methods 8 years ago

• ThedaCare Business Performance System to address sustainability and to develop a culture of daily continuous improvement

Impact

32% improvement in patient

satisfaction

21% reduction in hospital cost per

case

Feb 2012: Learning Partnership with ThedaCare

Awaiting my invitation…

• Rapid process improvement workshop?

• Kaizen event?

Manager Daily Status Sheet

Manager Daily Status Sheet

A few weeks later this appears

Daily Improvement huddle: M,W,F 1:15-1:30

Daily Improvement Board

Just do its

More challenging

problem solving (PDSA3)

Collect Improvement

Cards

Prioritize Issues

Completed

Daily Improvement Huddle Board

Early signs of success: Engagement of frontline nurses on 7B raised hand hygiene compliance

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar0.0

20.0

40.0

60.0

80.0

100.0

57.0

75.0

93.0

78.0

100.07B Moment 1

2011-2012 2012-2013 actual Target

Daily CIP’s Goal:Develop people to solve problems and improve

performance

Different Levels of Process Improvement

Adapted from: “The Toyota Way Fieldbook” by Liker and Meier

Very fewLarge issues

FewMedium issues

ManySmall issues

LargeProjects

LeanEvent

Focus of Daily CIP

Six Sigma

Status Sheet: Manager, Director and VP

DAILY

ManagerStatus Sheet

WEEKLY

DirectorStatus Sheet

EVERY 2 WEEKS

VPStatus Sheet

ManagerCharge Nurse Director VP

Status Sheet: Links Between Levels

DAILY

ManagerStatus Sheet

WEEKLY

DirectorStatus Sheet

ManagerCharge Nurse Director

A wise man once told me: “Behavior drives culture”

24

• Competing priorities for improvement

• Improvement accountability with a few people

• Project teams solve problems periodically

• Ad-hoc use of improvement tools and approaches

Frequent review of improvement priorities

Improvement accountability at all levels

Front line staff solve problems daily

Staff trained in adopting tailored toolkit and approach for problem solving

From: To:

New and Improved Paediatric Medicine Quality Leadership Team

• We still meet monthly to discuss trends in performance and to prioritize which metrics to improve upon

Except now…• I had to get a much bigger room!• I am currently looking for an even bigger room!• Staff come in on their OFF DAYS!• I look forward to it instead of dreading it

Monthly Score Card: Driver and Watch indicatorsThis scorecard dictates the unit focus for the month

Falls, Entrapment, Strangulation, Entanglement documentation scores

7B 7C 7D0%

20%

40%

60%

80%

100%

120%

24%

44%

23%

35%

43%

30%

51%

39%

50%

57%

50%54%

0.670000000000002 0.680000000000001

52%48%

97%100%

72%

83%89%

77%

90%

Aug

Sept

Oct

Nov

Dec

Jan-13

Feb

March

April

Three day Equipment Improvement EventSituation Overview

Finding supplies is difficult

Approach Impact

a place for everything everything in its place

SortSet-in-orderShineStandardizeSustain

5S

RESULTS

Staff-driven problem solving: Over 65 improvement ideas identified and executed since April 2012

Median of 19% Improvement in Engagement Scores

Key ingredients

1. INTRINSIC MOTIVATION

•Provide opportunity for self-leadership •Provide choices •Help members acquire skills and knowledge •Assign tasks but make connections •Coach 2. DISCIPLINE• Simple behaviors repeated over and over

Autonomy

RelatednessCompetence

Self-Determination Theory

Enterprise wide picture

• 12/22 units doing Daily CIP• 20 yellow belts trained• 178 green belts trained

• Larger projects/value streams: Ambulatory, Surgical, Procurement, Pharmacy, Administrative. • ~20 Rapid Improvement Events completed to date

How much does this cost?

• “Lean Promotion Office”

• Office of Process Improvement

• Director, five staff, and an assistant • hired from industry and consulting firms• $1 million/year (approx)

The Hand Hygiene graph continued….

Apr May` Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

20.0%

40.0%

60.0%

80.0%

100.0%

7BCD Moment 1

2012-2013 Target

Linear (Target) 2011-2012

Questions for consideration

1. Are we going to be able to tackle the big stuff?

2. How is this experience going to vary across units?

3. How are we going to substantively engage physicians?

Acknowledgments

SickKids nursing and operational leaders: Kate Langrish, RN, Lynn Mack, RN, Linette Margallo, RN, Dinarte Viveiros, RN

SickKids Office of Process Improvement: Shiraz Bhajwa, MBA, Travis Beamish, MBAAli Shahzada, MBA

Executive sponsor: Jeff Mainland, EVP Strategy, Performance, Quality and Communication