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Accountability and Transparency:
LEANing on your data
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Outline
• Background• What is Lean?• Lean at MSH• Data VSA• Results of LEAN events• Questions?
Fast Facts •Community Hospital •2 sites• 1800+ staff and physicians• 700+ volunteers• 230 beds• 14972 Admissions • 68365 ER visits• 16721 Day Surgeries• 204227 Outpatient visits• Embarking on redevelopment
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What is Lean?
• Definition: Lean is a process improvement methodology based on the Toyota Production System (TPS) that identifies value added vs. non-value added activities.
• Key: Looking at healthcare through the eyes of the patient
• Goal: To more effectively and efficiently use healthcare resources to provide better patient care by eliminating non-value added activities.
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MSH Values
•• CompassionCompassion•• Leadership & Leadership &
ResponsibilityResponsibility•• CollaborationCollaboration•• Creativity & InnovationCreativity & Innovation
Lean Supports MSH Values!
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Central LHIN ISHP
Integration
Patient Centred
Accessibility
Appropriately Resourced
Effective/Efficient
Equitable
Safe
Population Based
Priorities
Integrated Health Service Plan (IHSP)2010-2013
Quality at a system level is defined as a high performing health system as described by the following performance dimension:
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Supporting the LHIN’s IHSP
• Integrated Approach» Working closely with CCAC, CCO, CIHI, MOHLTC
participating in LEAN events
• Patient Centred» Valued added for the patient» Data accurately reflect and support patient care
• Accessibility» Right information to the right person at the right time
in the right format» One-stop shopping concept
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Supporting the LHIN’s IHSP
• Appropriately Resourced» Most appropriate person performing the function» Standard work» Built in coverage
• Effective/Efficient» Accurate, timely data» Metrics for evaluating outcomes
• Safe» Key Patient Safety Indicators a LEAN event
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Lean at MSH
• Started in the Emergency Department• Engage people that do the work – ‘experts’• Uses Lean tools such as the Value Stream
Analysis (VSA) and Kaizen or Rapid Improvement Events (RIEs) to implement change
• Standardize work to improve processes and provide better patient care
• The patient defines value
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Core of Lean processes
• A large majority of the work we do is non value added in the eyes of the customer/patient
95% 5%
Value Added
Non value added!
Opportunity for Improvement!
Value added: Any activity that directly contributes to satisfying the needs of the patient
Non-value added: Any activity that consumes time/resources but does not directly add value
Patient Arrives
Patient is Discharged
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So how LEAN was our data?
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Reason for Action
• Lack of confidence in externally reported data resulting in poor decision making
• Data is becoming increasingly linked to funding and there is a general lack of accountability
• Errors in data lead to negative perceptions and tainted reputation of this hospital
• We don’t have a bigger picture understanding of what data is going out from the organization and being used to reflect our services externally
• Increasing demand from the Ministry for data transparency and accountability
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Initial State
~ 115 key external reports
identified!
Metric Baseline# of Reports available (standard + custom) 13, 669# of External Reports Run/Submitted (approx) 400# of Internal Reports run (including scheduled) 1778% of databases with process oriented data validation 20%
# of total databases 25
TAT for Ad Hoc Data Requests 5 min - 5 weeksErrors detected and corrected (DAD & NACRS)/year 600
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Initial State
•Rated and prioritized 115 key data sources
•Followed a theoretical patient through the continuum and identified data flows and key data submissions
•No method to measure data quality
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Gap Analysis
Current data systems exist in silos
Data is not error proof
Data definitions are unclear and not standardized
Lack of standard work for data extraction
Lack of communication between those collecting, reporting and accountable for metrics
Lack of clear accountability re: who is responsible for data integrity
Decreased awareness of the importance of data within the organization
Lack of standard data validation process
Lack of clear structure re: data capture
Where do you go to get information?
Registration clerks responsible for input of data, decentralized reporting structure, is this appropriate?
Very complex data management system
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Solution Approach• Streamline and error proof data collection and reporting for key metrics • Eliminate data errors at the source• Maximize functionality of current tools for data capture, presentation
and validation• Single seamless synchronized source – one stop shop for key metrics• Purge non value added reports/duplicates• Develop process/filter for new reports and data requests• Standardize registration process and accountability • Develop database of definitions, reports and accountabilities • Harmonize data systems• Automate manual data entry• Create key performance indicator dashboard that is transparent and
shared – recognize importance of electronic dashboard• Train and educate leaders and staff throughout the organization to
understand dashboard and use of existing data management tools (performance management)
• Establish Business Intelligence Group (BIG) for follow through (go BIG or go home!)
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Rapid Experiments
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Confirmed State
• 100% accuracy rate for key external reports
• Confidence in internal data collection• No loss of funding opportunities as a
result of poor data quality• Restored community confidence in MSH • 25% reduction in non-value added
custom reports• Improved transparency, access and
accountability for key performance indicators
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Completion Plan (LW)A c t io n P la n
x S tre a m lin e K e y S a fe ty In d ic a to r R e p o r t in g M a yx S tre a m lin e K e y F in a n c ia l In d ic a to r R e p o r t in g J u n ex S tre a m lin e K e y C IH I In d ic a to r R e p o r t in g J u lyx S tre a m lin e K e y W a it t im e In d ic a to r R e p o r t in g A u gx S tre a m lin e K e y E D R S In d ic a to r R e p o r t in g S e p tx N e w D a ta R e q u e s t P ro c e s s O c tx S ta n d a rd iz e R e g is tra t io n N o v
x P u rg e e x c e s s iv e / N V A re p o r ts in s y s te m L y n n T . M a y 3 1 s t
x E x p lo re & m a x im iz e u s e o f th e to o ls w e a lre a d y h a v e D ia n a & C h r is t in a J u n e 3 0 th
x A u to m a te D a ta E n try R ic k A u g 3 1 s t
x S y n c h ro n iz e d a ta b a s e fo r K e y M e tr ic s S h a ro n T . & J e a n n ie A u g 3 1 s t
x S y n c h ro n iz e d a ta b a s e fo r A ll o th e r In d ic a to rs K im O c t 3 1 s tx D e v e lo p P e r fo rm a n c e M a n a g e m e n t S y s te m D a s h b o a rd A n th o n y N o v 3 0 th
x B u ild b u s in e s s c a s e fo r C o g n o s 8 .x A n th o n y M a y 1 5 th
x E s ta b lis h B .I .G . te a m fo r fo llo w th ro u g h S h a ro n T . & R o b M a y 3 1 s t
x D e te rm in e d e f in it io n s & s o u rc e fo r K e y M e tr ic s J o a n n e , A n th o n y M a y 3 1 s t S H C N in d ic a to rs d e f in e d b e fo re 1 s t
K a ize n E v e n t
x D e v e lo p o n - lin e d a ta b a s e o f d e f in it io n s fo r k e y in d ic a to rsJ o a n n e , A n th o n y , L y n n W .
J u n e 3 0 th
x T ra in in g & E d u c a t io n fo r c a s c a d in g "s tra te g y d e p lo y m e n t" f ro m B o a rd to U n its V ic k y O c t 3 1 s t
E x te r n a l In fo r m a t io n V S A E x e c u t iv e S p o n s o r : N e i l W a lk e r D a te U p d a te d : 4 /8 /0 9
Even
t
Proj
ect
Do-
It
D e s c r ip t io n W h o D u e D a te C o m m e n ts
D e liv e r a b le s
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Data Management
Spread & Sustainability
Implementing a standard approach to request, manage, mine and report data. Targeted the main external reporting data sets.
ScheduleApril 2009: Data Management VSAMay 2009: Key Patient Safety IndicatorsJune 2009: External Data RequestsJuly 2009: Wait Time ReportingSept 2009: ERNINov 2009: ALCFeb 2010: MIS/Financial
Aim Statement:To improve data management process by ensuring that the right information gets to the right people at the right time to facilitate accurate external reporting and critical decision making.
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Key Patient Safety Indicators
• Reason for Action:• Key Patient Safety Indicators reflect
Markham Stouffville Hospital Corporation’s clinical practices and impact our funding and public reputation. Lack of standard processes for capturing, validating and submitting this data has led to confusion and decreased accuracy in reported metrics.
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Initial State
•Multiple reports going to various external organizations
•Lack of clarity around accountability for externally reported key patient safety indicators
•Multiple data locations with multiple touch points and handoffs
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One Stop Shop for KPSI
• Created a ‘Corporate Indicators’ link on the Intranet to house all key patient safety indicators
• Clearly defined accountability, definitions, frequency of reporting and targets as appropriate
• Developed standard work
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External Data Requests
• Reason for Action:• No formal process for external data
requests has sometimes resulted in submission of inaccurate data which has not been appropriately validated.
• Lack of process and accountability has resulted in duplication of efforts throughout the organization.
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Initial State (DG)
• ‘Spray ‘N Pray’ approach• No Standard ‘place’ requests
come to and no tracking process
• Lack of clear accountability for external data requests
• Last minute data requests challenge our ability to provide accurate data
• Lack of ownership and responsibility for data validation
• May be a number of people processing the same request and don’t know it!
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External Data Requests
Dianna / Anthony
5-Jun-09x Follow-up on auto-response from [email protected]
Bobbijo 26-Jun-09
x Present at LeadershipSharon /
Anthony / Erin17-Jun-09
x Complete validation process for sick/overtime
Lynn W / Ali / Anthony
12-Jun-09
X Follow-up with Neil re: sign-off of ALC Data Erin 8-Jun-09
X Finalize std work / tracking form
Set timelines and roll out plan for education Sharon / Bobbijo
12-Jun-09 Including upload to intranet - OD?
X
X
Complete Education plan package Sharon 12-Jun-09
Eve
nt
Pro
ject
Do
It Deliverables
What Who When Comments
CompleteComplete
CompleteComplete
CompleteComplete
CompleteComplete
MIS LEANMIS LEAN
In progressIn progress
In progressIn progress
Action Plan:
• Review the template for tracking external request
• Education and communication
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Wait Time Event
Reason for Action:Lack of standardization in the OR booking process and validation of data has created excessive rework, touches and has the potential for creating inaccurate publicly reported data (WTIS). An improved process will allow for an easier transition as hospital grows and when the new Meditech Focus system is installed.
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Initial State
• Hybrid booking approach
• Confusion on ownership/ accountability of data
• OR Scheduling Office correcting and validating data
• Frustration with online booking process in some surgeon offices
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MetricsMetric Before After
External WTIS Errors (Surgery) 19% <5%
Cases with Internal Errors 75% <5%
% surgeries requiring change (Any) 75% 10%Sr. Mgnmt Confidence in data (1-low to 5-high scale) 3 5Difficulty of current OR Booking process (1-easy to 5-difficult scale) 4 1
% of offices booking cases online 56% 100%
# of Case Carts picked incorrectly 2.5/week 1/weekIn – progress for surveys/audits to measure results
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Wait Time
Action Plan:
• Survey Physician offices
•Survey Senior Team
In ProgressSharonIdentify backup for Lynn and HeidiX
July 30Magda4pm daily volunteer run to get
packages to OR BookingX
September 15Clay, LynnNew Report for Special RequestsX
December 31Heidi, LynnSecretary Cheat Sheet rollout for
remaining Dr. OfficesX
In ProgressSharon Moore
Talk to Dr. Arnold regarding gynephysician involvement to input key dataX
End of JulySharon Moore
Talk to Dr. Whelan regarding physician involvement to input key dataX
CommentsWhenWhoWhat
Deliverables
Do ItProjectEvent
In ProgressSharonIdentify backup for Lynn and HeidiX
July 30Magda4pm daily volunteer run to get
packages to OR BookingX
September 15Clay, LynnNew Report for Special RequestsX
December 31Heidi, LynnSecretary Cheat Sheet rollout for
remaining Dr. OfficesX
In ProgressSharon Moore
Talk to Dr. Arnold regarding gynephysician involvement to input key dataX
End of JulySharon Moore
Talk to Dr. Whelan regarding physician involvement to input key dataX
CommentsWhenWhoWhat
Deliverables
Do ItProjectEvent
CompleteComplete
CompleteComplete
CompleteComplete
CompleteComplete
CompleteCompleteCompleteComplete
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ERNI Event
• Reason for Action:• MSH does not have data that is complete and
accurate at the source• With transition to ERNI, Ministry requires
current 60 day facility submission turnaround time to be reduced to 3 days
• This data is used for our funding allocations and performance metrics which will be reported publicly
• Cannot submit data to CIHI from Meditech
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Initial State
• At least 4 data quality checks performed prior to submission
• Upon submission 6-9% of data still incorrect• Lack of ownership and accountability• 75% of patients from ER with incomplete,
incorrect, or missing data elements
"Quality @ Source" Index (at Time of Pt Disposition)
25%
75%100% Correct and TimelyErrors / Missing / Late
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ERNI
Action Plan:
• Implement standard work for audit with ER Registration
• Update the baseline measures for ERNI and monitor
Sept 25, 2009GraceCreate Standard Definitionsx
Sept 25, 2009
Sharon, Elizabeth, Sandy, Elaine
Integrate Uxbridge into new processx
Oct 2009Sharon, ElizabethER Educationx
Oct 9, 2009Cassandra, SharonTransfer sheet formalized x
Sept 25, 2009JeannieApproval and final edits for
emerg face sheetx
Sept 30, 2009Magda, MariaGet 24 hour clocksx
Sept 24, 2009Elizabeth, Heidi, Sandy
Standard work for audit report runningx
CommentsDue DateWhoTask Description
Deliverables
Do-ItProjectEvent
Sept 25, 2009GraceCreate Standard Definitionsx
Sept 25, 2009
Sharon, Elizabeth, Sandy, Elaine
Integrate Uxbridge into new processx
Oct 2009Sharon, ElizabethER Educationx
Oct 9, 2009Cassandra, SharonTransfer sheet formalized x
Sept 25, 2009JeannieApproval and final edits for
emerg face sheetx
Sept 30, 2009Magda, MariaGet 24 hour clocksx
Sept 24, 2009Elizabeth, Heidi, Sandy
Standard work for audit report runningx
CommentsDue DateWhoTask Description
Deliverables
Do-ItProjectEvent
CompleteComplete
CompleteComplete
Complete/OngoingComplete/Ongoing
CompleteComplete
CompleteComplete
CompleteComplete
CompleteComplete
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Metrics
4.85%9.7%Ambulance Transfer of Care
5%75%Error at Source(internal)
0%New Process
Rejected Records on submission to CIHI/CCO
5.4%
Current
2.7%Missing PIA
FutureIndicator
<5%<5%
15%
12-15%
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ALC Event
• Reason for Action:• Ministry mandated changes to the ALC
definition and new data reporting requires MSH to redesign its ALC data collection processes.
• MSH is contractually obligated to submit timely and accurate data, failure to do so could result in financial penalties.
• Need for new processes set for November by Ministry and CCO
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ALC External Submissions
CCO Interium Upload Tool OHA report
CCAC Daily Web Submision
CCAC Monthly Web CCAC Flo Central LHIN P4R EDRS ALC CIHI DAD
Submission
Who Collects the Data? Doc/PFC's Doc/PFC's Doc/PFC's Doc/PFC's Doc/PFC's Doc/PFC's Doc/PFC's Doctor/PFC
Who enters the data? Unit Sec/ Nurse/Pt Reg
Unit Sec/ Nurse/Pt Reg
Unit Sec/ Nurse/Pt Reg
Unit Sec/ Nurse/Pt Reg
Unit Sec/ Nurse/Pt Reg
Unit Sec/ Nurse/Pt Reg
Unit Sec/ Nurse/Pt Reg
Unit Sec/ Nurse/Pt Reg
Who Processes the data? ALC Site Lead ALC Site Lead PFC DS Analyst/ALC Site Lead Flo Manager DS Analyst DS Analyst Coders
Where does the data come from? -where is it stored/found
Meditech ADM & OE
Meditech ADM & OE
Meditech ADM & OE Meditech ADM & OE Meditech
ADM & OEMeditech ADM & WinRecs
Meditech ADM Census
Coders review the e-chart and enter the info into Winrecs abstract
- scope of ALC
All discharges with ALC days for the month; case count of open cases
Current ALC inpatients
Current ALC inpatients
2 parts - discharged ACUTE patients only; all current ALC inpatients
Current ALC inpatients - unit specific
All discharges with ALC days for the month
Current ALC inpatients
Acute inpatients only
- timeframe for data month month daily monthly/daily Tues/Thurs Monthly Monthly Monthly
Timeliness/Frequency of Reporting
7th initial submission; 15th final submission
15th of month daily 15th of month Weekly 30 days post month end
60 day post month end
30 days post month end
Who Requires the data? CCO OHA CCAC CCAC CCAC Central LHIN CCO CIHI
Who submits the report? ALC SPOC ALC Site Lead PFC ALC Site Lead Flo Manager DS Analyst DS Analyst DS Analyst
Validation/Reconcilliation ALC Missing Data Report OHA report Census report CCAC Report Census
Report Winrecs report Census Report Winrecs/CCO reports
Specs for the report/submission
Data collection process
ALC Reports
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Audit of ALC Orders
• December Discharges
Number of ALC Discharges 38 8 46Number of ALC Order Forms 25 65.79% 6 75.00% 31 67.39%Number of Start Orders only 24 63.16% 6 75.00% 30 65.22%Number of Complete Orders 1 2.63% 0 0.00% 1 2.17%
MSH site Uxb site Total
March Discharges
Number of ALC DischargesNumber of ALC Order Forms 49 76.6% 5 83.3% 54 77.1%Number of Start Orders only 47 95.9% 4 66.7% 51 94.4%Number of Complete Orders 2 4.3% 0 0.0% 2 3.9%
MSH site UXB site Total64 6 70
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ALC
Nov 23-30, 09MelissaEducation on OEX
Nov 30, 09JulieAssign dedicated
Site LeadX
Dec 15, 09Sharon Tai Young
Modify reports for validation and submissionx
Dec 1, 09Julia Scott, Dave Austin
ALC Designation Role of PFC, SW,
D.Plannerx
Nov 30, 09ALC Site LeadDefinition Educationx
Dec 1, 09BarbaraGo Live on OExDec 15, 09OD
Team Building SW/PFCx
CommentsDue DateWhoTask Description
Deliverables
Do-ItProjectEvent
Nov 23-30, 09MelissaEducation on OEX
Nov 30, 09JulieAssign dedicated
Site LeadX
Dec 15, 09Sharon Tai Young
Modify reports for validation and submissionx
Dec 1, 09Julia Scott, Dave Austin
ALC Designation Role of PFC, SW,
D.Plannerx
Nov 30, 09ALC Site LeadDefinition Educationx
Dec 1, 09BarbaraGo Live on OExDec 15, 09OD
Team Building SW/PFCx
CommentsDue DateWhoTask Description
Deliverables
Do-ItProjectEvent
CompleteComplete
CompleteComplete
In progressIn progress
CompleteComplete
CompleteComplete
In progressIn progress
In progressIn progress
Action Plan:
• Ongoing Education with staff
3939
MIS LEAN
Reason for Action:• With the ministry and LHIN now
looking at MIS submitted statistical data to compare hospitals and determine funding levels, MSH needs to ensure processes of collecting data are fixed, and data reported is accurate and timely
4040
Initial State• MSH often put on the spot at ministry "data
blitzes" to explain data that appears to be erroneous
• Posting of statistical data in batches after close• Single resource chasing incomplete/incorrect data
elements• Data collected "after the fact"
Indicator Current
Missing data elements prior to Submission 62
Total Time on Submission 168 hours
# of corrections required for a successful Submission
118
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Metrics
50%3162 Missing data elements prior to Submission
80%33.6 hours
168 hoursTotal Time on Submission
50%59 hours118# of corrections required for a successful Submission
TargetCurrent % ChangeIndicator
To be evaluated after next submission – May 2010
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MIS
Agenda has been determined and will focus on roles, responsibilities and expectationsMarch 31
Jean Marie , Directors, Analysts
Role of Analysts & Team Building with DirectorsX Training presentation complete:
outcome is improved understanding of department’s business activitiesMarch 10
Jean-Marie, Keith
Education for Managers and Directors on MIS Trial
Balance and accountability of dataX
March 31Tim and Christina
Investigate integrating GL structure and mapping into
Meditech 6.0X
Result of this meeting is to assess development of indicators. If reasonable, then integrate Cognos methodology into our practice. Feb 10
Jeannie, Denis, Bobbijo
Cognos and statistical indicator developmentX
Creates standard reports for each department March 31Jean-Marie
Set clear guidelines for variance reports and develop
a standard templateX
Feb 28KeithEliminate unused Functional
Cost CentresX
If financially feasible Stats Reports will be updated/ redesigned and interim fixes will be evaluated -Week of Feb 15Christina
Initial meeting with Expert-Scope the feasibility of updating stat reportsX
CommentsDue DateWhoTask Description
Deliverables
Do-ItProjectEvent
In progressIn progress
In progressIn progressMar 15
Apr 30
todaytoday
In progressIn progress
In progressIn progressJun 30
In progressIn progressMay
Jun 30In progressIn progress
Questions?