Developing a Culture of Continuous Improvement: Growing Leaders at Rochester General Health System

May 13th, 2010

Behavioral Health Network

Newark-Wayne Community Hospital

Hill Haven Nursing Home

DeMay Living Center Independent Living for Seniors

Rochester GeneralMedical Group

RGH

Rochester General Health System

Rochester General Hospital Statistics

• 528 beds• 1,200 medical and dental staff• 5,000 employees• 31,500 inpatient discharges• 87,000 emergency room visits• 20,165 surgical procedures• 1,050,000 outpatient encounters

Rochester General Health System…5th largest employer in Rochester

• Named 9 times as a Solucient Top 100 Cardiac Hospital• Money Magazine Best 25 Hospitals in the Nation for Heart Attack Care and Hip

Fractures – 2003• Only area Teaching Hospital Cancer Program accredited

by the American College of Surgeons• American College of Surgeons Outstanding Cancer Program – 2006• Department of Health and Human Services – Innovation in Prevention Award –

2006• Nurse Magnet Designation – 2004, 2009• Named 2 times as Solucient Top 100 Performance Improvement Hospital• Healthcare Association of New York State

� Pinnacle Award for Quality – 2002 and 2005� Community Health Improvement Award – 2007

• Premier Award for Quality – 2007, 2006, 2005, 2004• Designated Stroke Center by the New York State Department of Health – 2005 –

and the Joint Commission Accredited – 2007, 2004• Baby Friendly designation by the World Health Organization• Diabetes Program recognized by the Diabetes Association• Nationally recognized Hemophilia Center

RGHS Recognition

Mission, Vision, and Values

Our Mission• To improve the health of the people served by providing high quality care,

a comprehensive range of services, convenient and timely access with exceptional service and compassion.

Our Vision• Rochester General Hospital and its affiliates will be the healthcare provider

of choice for physicians and patients - delivering the healthcare we expect for our own family - recognized for:� Exceptional quality � Unparalleled service and patient experience � Great place to work and practice � Academic programs and research that support core clinical missions � Clinically integrated affiliates � Our Values

Mission, Vision, and ValuesEvery Customer - Every Encounter - Every Time

Service• To serve our community is a privilege and an obligation. We excel in our sensitivity to the

needs of those we serve. Everyday we live our mission through serving our community.Teamwork• Together we can do great things for people in need. One team, with one goal - to be one Great

Health System, Always!Attitude• We are a "can do" team. We are grateful for the opportunities that are presented each and

every day. Through positive energy we can, and we will, meet the needs of those we serve.Respect• We are here to better the lives of others and we are profoundly aware of the value of each

human being.Standards• We pledge to our community the highest standards of respect, patient safety and clinical

excellence. We will do no harm. We are extraordinary people called to do extraordinary work.

Lean-Sigma at RGHS

Background:

� Rochester Business Alliance – identify need for continuous improvement thinking in region’s health systems

� Pull expertise from local manufacturing

� Kodak – extensive training with Shingijutsu, leverage experience into local health systems for greater benefit of community

� Lean Sigma at RGH – introduced July 2006

� Small Team – 35+ years Lean-Sigma experience (manufacturing), 1 Nurse Leader with 17+ years clinical leadership experience

Our Lean-Sigma Thinking

• Everything we do must create customer value

• Everything can and should be improved

• We must pursue & destroy wastes

• Defect free service to our customers is our goal

• Eliminate Variation!

• Do More with Less

• Creativity before $$

• Less human effort, time…

• All Work is a Process

� Optimize the Flow of Our Process

� Tough on the process, not on the person

Office Purpose

• Enable the highest levels of organization effectiveness

• Directly support the transformation of our culture

• Support and accelerate the development of our leaders

• Invest in our people’s personal development

Lean-Sigma Office Operating Model

Time12 to 18 months

TRANSITION ROLES• Develop individual

contributors into future leaders

• Prepare current leaders for broader leadership responsibilities

Transition member(1/Year)

Transition Member (1)

Core Team:3 Members

Rotation ofTransition Member

CORE TEAM•Ensure continuity and efficient transfer of knowledge •Ensures training, and core competencies are continuously developed to be at the leading edge. •Helps to break barriers, resolve key issues, and serves as a strong process improvement resource (Change Agents)

Lean-Sigma at RGHS

Background Continued:� Integrated with HR in 2007

� Lean-Sigma Practitioner Program – first class 2008

� Lean-Sigma Transition Members growing into broader leadership responsibilities:

� Director, Radiology

� Manager, Organizational Development

� Nurse Manager, Anesthesiology

� Finance

� Lean-Sigma Practitioner Program – second class 2009

Transforming our Culture

• Build a foundation of highly talented, motivated, diverse and engaged employees

� Create a community of 7,000 “scientists” continuously solving problems

• Create a customer centric focus

Growing Leaders – the Toyota Way

• Toyota Expression – “we do not just build cars, we build people.”� Are you born with talent, or is it developed?

� “Give us the seeds of talent and we will plant them, tend the soil, water and nurture the seedlings, and eventually harvest the fruits of labor.”

• Every manager at Toyota is a teacher

• Add value to the organization by developing your people

• Developing exceptional people - #1 priority

• Must become embedded as a cultural value throughout the company

Growing Leaders – the Toyota Way

• Principle 9 - “Grow leaders who thoroughly understand the work, live the philosophy, and teach it to others.”� Teaching is the most highly valued skill of leaders – must deeply

understand the work to coach

• Principle 10 – “Develop exceptional people and teams who follow your company’s philosophy.”� Teams depend on well-trained people and part of individual

development is learning to work in teams

RGHS Lean-Sigma Practitioner Program

• “Give a man a fish and he’ll eat for a day. Teach him how to fish, and he’ll eat forever.”

• Practitioners develop “eyes for waste”� Understand the philosophy, principles, and tools

• Most importantly - gain confidence to teach principles to team members

• Create a culture of continuous improvement

RGHS Lean-Sigma Practitioner Program

Must demonstrate ability to:1. Understand2. Practice3. Teach

Key Outcomes:� Develop internal expertise and capabilities to lead process

improvement initiatives� Increase team member engagement and commitment to the

organization� Develop and leverage best practices� Opportunity for personal growth and development� Foster culture of continuous improvement

Development of course

12 month certification program

Allow information to be digested� Go to gemba� Practice� Fail� Teach to others� Personal guidance from lean-sigma coach throughout the course

• Without constant attention, the principles will fade. • Must be engrained in the way one thinks• Maintain a learning organization

Structure

• Lecture – every 2-3 weeks• Practitioner / L-S Coach One-on-One sessions every 2 weeks• Case Studies – White paper readings• Activities

� Walk the flow – see other practitioner’s areas� Hands-on exercises� Table top simulation – demonstrate pull� Establish visual controls� See standard work in action

• Capstone project – lead a kaizen team� Teach the team � Establish standard work� Round for sustainability

Practitioner Key Responsibilities

• Champion of change

• Lead process improvement activities & follow up

• Develop a measurement and tracking process

• Deliver Lean-Sigma training to their departments

• Coach leaders and team members to adopt Lean-Sigma principles & practices

• Lead a ‘Capstone Project’

System Support

• Executive Support� Senior leaders to sponsor participants

� Course kick-off with CEO, VPs

• Responsibilities of the Sponsor� Communicate certification initiative, and practitioner’s role

to home department� Facilitate monthly review sessions with practitioner� Review work plans; confirm priorities; provide needed

resources; confirm progress� Aid with breaking through barriers to success

Course Outline

1. History – Toyota / Motorola

2. Introduction / Understanding of the Value Stream

3. Elements of Project Management

4. 5S and visual controls

5. Key components of standard work

6. Takt time, cycle time

Course Outline

7. Kaizen circle and process

8. Importance of Capstone

9. Six Sigma tools and methodology

10. Statistical Analysis – Basics

11. Statistical Tools for problem solving

12. Review of Capstone

Course Outline

13. Leaders role in Lean-Sigma culture / Tips for training

14. 3P and Design for Flow

15. Setup and Changeover Optimization

16. Poke Yoke – HC applications

17. Success / Challenges with Capstone

18. Celebration - Certification

Competency Certification LevelsL1

L2

L3

L4

Trained

Trained; able to practice with Guidance

Trained; able to practice with out Guidance, & can teach w/ support

Master Practitioner;Fully Proficient;Master Trainer

TargetedLevel

Selecting participants

• Class of 10-15 participants

• Leaders

• Change Agents

• Live the values

• Encourage team member engagement

• Show interest in process improvement

• Multidisciplinary / Affiliate locations

• Vocal senior-level sponsorship

Multidisciplinary Focus

Practitioners exposed to other applications and affiliate locations

• Labs

• Medical Groups

• Foundation

• HR

• Support Services

• Patient Financial Services

• Volunteer Services

• Environmental Services

• Information Technology

• Radiology…

Class #1 – 200814 Practitioners

• Program Manager• Manager of HIM Operations• Billing Manager• Director of Adult Day Health Care• Program Manager• Nurse Manager• Director, Non-Clinical Operations• Operations Manager• Director of Patient Access• Educator/Clinical Nurse Specialist• Practice Manager• Quality Improvement Coordinator• Recruiter• Director of Admissions & Social Work Services

Class #1 Projects and Results

Decrease access time to services at BHN

Improve admissions

Streamline processes to allow for 32% volume growth in endoscopy

Streamline processes at registration to allow for 4% volume growth in radiology

Streamline workflow for follow up on insurance claims

Increase accuracy of deficiency

Workload rebalance of access associates

- Increased # of intakes- Revenue

Behavioral Health Network

Newark-Wayne Community Hospital

25% volume growth50% reduction in patients

rescheduled

Wayne County Rural Health Network

6% volume growthDeMay Living Center

5% increase in accounts worked per dayCentral Business Office

- Expected: 75% Improve accuracy

Behavioral Health Network

Average Denial Turnaround time reduction of > 75%

VMG Medical Groups

Affiliate /Dept Capstone Project Demonstrated Results

Class #1 Projects and Results

-Reduced from 7 stops to 2 stops-Employee Retention

Improve on-boarding Process for new employees

Human Resources

Decrease time from patient presentation in ED to EKG

Rebalance Workload of Access Associates to improve access to registration

Being Decided after Magnet accreditation

Eliminate Discharge Delays in Rehab. Unit due to Facility Errors

Redesign work processes to enable electronic scheduling

Develop work processes to accompany Lithotripsy service

-Revenue-Patient Satisfaction

Patient Access

Expected 50% reduction in Turnaround time

RGH Quality Improvement

Expected: -Patient Satisfaction

Women’s Center & Genesee OB / Gyn

Medicine-Surgery Nursing

-0 delays > 24 hours-Patient Satisfaction-Revenue

Hill Haven

Expected: - 10 additional cases per day

RGH Department of Diagnostic Imaging,

Affiliate / Dept Capstone Project Demonstrated Results

Class #1 – 2010 Status

• Continued communication/collaboration with coaches

• Move into larger system roles

• System Recognition – Axe Award

• Mentors to current practitioners

• Extension of Lean-Sigma office� Requests for coaching � Manage process improvement initiatives at affiliates

• ILS, Medical Groups

Class of 2009• 11 Practitioners

� Writer/Director, Donor Stewardship� Manager, Laboratory Services� Manager, Patient Access� Practice Manager� Volunteer Services� Manager, Environmental Health and Safety� Compensation Analyst� Manager, Environmental Services� Senior Manager, Laboratory Services� Call Center System Specialist � Student (Industrial and Systems Engineering), RIT

Class #2 – Projects

Reduce Rework and Patient Wait Time for Direct Admissions

5S Specimen Courier Drop-off

Charge Capture Standards for Physicians

- Standard work for Special Events- Mailing Data Analysis

On-Call Physician System Roll-out and Standards

Cytology Work Redesign

Improve Bed Turn-Around

Reduce internal waiting by 25%Patient Financial Services

25% reduction WIPLaboratory Services

5% Revenue IncreaseMedical Groups

- Reduction in expedited costs- Identify effectiveness of mailing

strategies – Increase donations

Foundation

Improve Physician SatisfactionInformation Technology

3% Productivity ImprovementLaboratory Services

95% of Dirty Bed triggers within 10 minutes of patient discharge

Environmental Services

Affiliate /Dept Capstone Project Targeted Results

Organizational Fit – Ideation

• DO-IT Groups a.k.a. DIGs� Four, one hour meetings

� 1) Define the Problem

� 2) Outline Causes and Identify Solutions

� 3) Implementation Plan (Action Plan)

� 4) Test Changes / Track Results

• Just DO-ITs a.k.a JDIs� Ideas immediately implemented

• All ideas go triaged to appropriate leader

Organizational Fit – Ideation

• Ideation - DIGs, JDIs• Team member engagement• Culture shift – ‘authority to act’• Lean-Sigma leaders and practitioners

� Sensei � Coach on waste identification� 5 Whys� Guide groups on system implications� Focus on the customer� PDCA cycle – round for sustainability

Culture Shift

• Language changing� “We need to map the value stream”� Lean terms becoming commonplace� Individuals bringing kaizen experience to DIGs

• Focus on the process� Two major health system initiatives

• Patient Flow� Process Focus and Standards from Admission to Discharge… and beyond

• Patient Safety� Patient Safety Summit – “Focus on the process, not the person.”

� Guidance from Lean-Sigma office and practitioners

• Waiting list for next practitioner course

Sustaining the Gains

• Roles of Practitioner� Leaders that “get it”

� Drive sustainability of improvements

� Understand importance of adherence to standard work

� Support standard work as a living document

� Track metrics to identify process shifts, changes in variability

� Encourage team member ideation• Identify wastes

• 5 Whys

• Establish a process

• Focus on the customer

• Tie back to values

Challenges• Time Commitment

� ~ 6 hours per month

• Need strong senior level sponsorship

• Establishing metrics

• Statistics / Excel

• Making data driven decisions

• Confronting silo mentalities

• Transition from “manager” to “teacher”

• Perseverance to break through common set-backs

RGHS / RIT Alliance

• Strategic Alliance - 2009� Advances in research, education, technology

� Biomedicine and Health Sciences• Health Sciences Engineering, Patient Safety / Quality, etc.

• IOM Call

• Tomorrow’s health care leaders� Process Thinking

� Change Management

� High Reliability Organizations

� Complex Systems Theory

Path Forward

• Integrate past and current practitioners in patient safety and flow initiatives

• Rounding with leaders to encourage:� Problem Solving� Use of Standard Work� Focus on Process� Teaching Others

• Plant new seeds – Practitioner Class #3

• Continue to build culture of continuous improvement

Contact Info:

Roop Hazarie (585) 922-2988

� Roop.Hazarie@rochestergeneral.org

Robert Agness (585) 922-4245

� Robert.Agness@rochestergeneral.org

Sarah Bonzo (585) 922-4378

� Sarah.Bonzo@rochestergeneral.org

Questions?