Let’ Get Real!!!!

Diane Frndak, PhD, MBA, PA-C; Vice President of Organizational Excellence

West Penn Allegheny Health SystemMay 13, 2010

Objectives:

• Identify techniques to utilize front-line staff to solve real-time problems

• Explain the theory and practical implementation of second order problem solving using lean management and six sigma

100%100%

4%4%

9%9%

74%74%

Problems Problems known to top known to top managersmanagers

Problems known to Problems known to middle managersmiddle managers

Problems known to Problems known to supervisorssupervisors

Problems known to Problems known to front line workersfront line workers

The Iceberg of Ignorance

This internationally acclaimed study conducted by Sidney Yoshida, was initially presented at the International Quality Symposium, Mexico city, 1989. It indicated how management's failure to understand its processes and practices from the perspective of its customers, suppressed the company's profits by as much as 40%.

Problem Solving to Create Organizational Learning

• First Order Problem Solving---– Do what it takes to continue to care for the patient

• Second Order problem Solving---– Diagnosing and altering underlying causes to

prevent recurrence

Water line

Systems: Activities, Connections, PathwaysStuff happens

Trends/patterns“The way we do things”

Reports

Sentinel Events

MistakesDelaysService Issues

Problems

Results/Occurrences

Events

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First orderNotifying someoneTrue problem solving

Blister analogy

• Organizational problems are like poorly fitting shoes on a foot

• First a red spot occurs with pain—if no response– A blister—sterile inflammatory

response– If no response (numbness to the

pain)

• Ulcer–Amputation

4 hours RN Observation= 60% non-value added36 potential patient safety problems.

Solid=movementDashed=information

The Hairball

Front lines taking care of the patient

CEO

Vice President

Director

Manager

Supervisor

Human Resources

Finance

Organizational Chart

• Connecting the silos

The patient is the focus of everything we do!

From Functional Silos

Front lines taking care of the patient where thevalue exchange occurs

CEO

VP

Director

Manager

Supervisor Human Resources

Finance

The Patient is the Focus of Everything We Do

Previous Condition

• No standardization• Silos which were independent of each other• No accountability/responsibility• No one understanding the “whole picture”• Blame of everyone• Trying to find the problem/solution under the

moving coconut—the shell game

Dysfunctional Normal State:

• Input disconnected from Output• Starving the process for resources so

cannot achieve the quality service or efficiency—may seem to make sense in the short term

• Optimizes one department’s goals over the system goals (i.e. make more money in this department)

• Fully utilizes a shared resource with one type of demand and sub-optimizes other demands

• Becomes disconnected from the purpose

Dysfunctional Normal State:

• Focuses on interpersonal conflict or friendships to solve problems rather than alignment and contribution to ultimate purpose

• Fragmented or designed delays, waits, waste

• No tension to better towards the ideal• Does not learn or experiences decay

over time• System becomes desensitized to what

normal means and thinks and behaves as if dysfunctional normal is really normal

• Rarely in true normal state

Normal State: • Involves performance agreements (mutually understood standards) for what is normal ( for example, 30 minutes for this step)• “In process” visual controls or data assures the process that it is in normal state• The budget is appropriate for supporting the normal state—the Goldilocks approach• The organization stays in normal state at least 80% of the time or the normal state is refined

Normal State: • Input ~= Output• A designed process with a whole system understanding• Streamlined positive experience for patients and staff—designed consistent with the purpose• Designed with high quality, service and efficiency—normal state should work• Normal state should be informed by contingencies and creative states• If process does not work the way it is designed, there is a way to pull management attention to the “abnormal state”

http://www.baddesigns.com/path.html

The Path of Least Resistance

Green Status

• Our unit is operating well right now

• We can take additional patients• We can help others if needed

• We have reserve resources• We are ≤80% capacity

• We are achieving expected metrics +/- 50%

Green teams are available to help others as long at is does not convert them into red.

Yellow Status

• Our unit is operating okay

• We cannot take additional patients• We cannot help others

• We have limited reserve resources• We are between 80-100% capacity

• We are able to achieve expected metrics +/-50-100%

Yellow teams self correct if possible to stay out of red status

Red Status

• Our unit is operating not well right now

• We cannot take additional patients• We need help others

• We have no reserve resources• We are >100% capacity

• We are not achieving expected metrics +/- 100%

Leaders and other team members help anyone in red statu s—goal for everyone is to get out of red as soon as possibl e

Leadership Response

• Every 2 hours charge nurse establishes status, reports every 4 hours

• Each unit defines status parameters—tracks and updates

• Addresses “constant red” syndrome• If converts to red, designed leadership

responds immediately• Contingencies implemented—depending on the

situation

“Real-time is the best time”

- immediate problem identification - real-time data - real-time response

• Patient safety issues? Missed orders, bedded patients in unsafe areas, hallway patients, challenges in getting MD approval

• Were there any less than satisfied customers? Families upset?

• Were there any defects in the transfer of patients? Batching? Missing documentation? Lack of communication (not impacting patient safety)

• Are there any disagreements between employees? Any disrespectful communication? Any misinformation provided?

• Were there any units on red status? • Were there any contingencies tested that did not work? • Are there any anticipated bottlenecks for flow today?

Daily Problems--examples

Forbes Regional Campus Condition Red Hours

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Extreme Team

Condition Red/Treatment Delay Advisories 2008-2009

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Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apri May June

Contingency State:

• Look at the process to identify potentially variability or vulnerability• Designed contingencies at each step of the process and they should be activated for specific situations• Someone with human intelligence needs to analyze the situation and activates the contingency• Contingencies are constantly learning

Contingency State:

• Contingencies are understood by many and activated on the front line as appropriate without management approval for each instance• Input > Output or Input < Output• Contingencies should be used occasionally (<20% of the time)

Creative State:

• Also called “crisis mode”• Sense of urgency and “on the fly”solutions• Going into creative state should be a rare (<5% of the time) and thus an event that gets attention• Try completely unusual solutions• Use when contingencies fail or are likely to fail• Not pre-designed so may require “breaking the rules” to meet the purpose of the process• Provides the agility of the organization in extreme situations

Alignment of the Goals

Hospital Redesign on a Dime

Here is Edward Bear, coming downstairs now, bump,bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it.

A A Milne

• Units submit a creative application and “win” the Makeover• We seek to live the words, “the patient is the focus of

everything we do ”.

What is it?

• DISCOVER--First, Focus on the Current Condition– “Walk in the Shoes of the Patients and the Staff ”

• Good-Little-Insights-That-Can-Help-Everyone Succeed (G-L-I-T-C-HE-S) Gathering

• Process mapping

What is it?

• DREAM and DESIGN --Second, Fix the Glitches– Visioning– Idea generation– Try mini experiments– Learn design principles– Track data

What is it?

• DELIVER Results--Third, Sustain the Change

You can’t reverse a makeover!!!

What is it?

Capacity Building Opportunities

• Healthcare Hero Challenges– Quick lessons for front-line workers, offered in

the Dream Room• Excellence Makeover Thinkers (EMTs)

– More in-depth sessions, offered in the Patient Care Innovation Center and through Power Ups

• Incentive System for attendance and participation

• Teach ideas from Toyota Production Systems/Lean, Theory of Constraints, Systems Thinking, Clinical Microsystems, Complex Adaptive Systems, National Health Service … what ever works!!!!

–Don’ t Make Defects–Don’ t Pass-On Defects–Don’ t Accept Defects

The Beautiful Systems Design Principles

1. Define and simplify every pathway and streamline flow

2. Clearly connect customers and suppliers

3. Specify every activity4. Improve with each glitch to move closer to

the ideal

Adapted from the Rules in Use in “Decoding the DNA of the Toyota Production System”by Steve Spear and H. Kent Bowen, HBR, 1999

Glow

Flow

Friction

Frustration

&Normal State

Flow: feeling of energized focus, full involvement, and success in the process of the activity

Friction: the resistive forces that tend to oppose and damp out motion

Glow

Flow

Friction

Frustration

Anger

Despair

Hopelessness

Apathy

&Normal State

Glow

Flow

Friction

Frustration

Perseverance

Character

Hope

Action

&Normal State

Learning

Persevere: maintain a purpose in spite of difficulty, obstacles, or discouragement; continue steadfastly.

Glow

Flow

Friction

Frustration

Anger Perseverance

Character

Hope

Action

Despair

Hopelessness

Apathy

&Normal State

APATHY CASCADE

LEADERSHIPCASCADE

Questions??

dfrndak@wpahs.org(412) 330-2425