Leading Continuous Improvement - NHSGGC
Transcript of Leading Continuous Improvement - NHSGGC
Leading Continuous
Improvement
Why do we need continuous improvement in healthcare?
Instances of poor safety and quality,
Capacity constraints and queues,
Cash-flow crises,
Low levels of efficiency
Low levels of staff motivation
The above are not confined to the NHS
Other reasons?
Aim of the Programme
To provide training and real-life practice to
successfully implement an Improvement
Project.
To create a set of individuals who can
think about continuous improvement, ask
the right question at the right time and
then select the right tool to use in a
particular situation.
From : To :
Fire fighting symptoms Eliminating Root Causes
Ad Hoc improvement Controlled and disciplined approach
Unclear Priorities Data Driven Priorities
Function/Dept Focus Customer/Patient Focus
What side are you on ?
Lean
& Six
Sigma
PDSA
Project Management
Management of
Change
DMAIC
Focused Approach
for
Continuous
Improvement
Change Behaviour
Experience Results
Change Culture
Define, develop and
communicate the Quality
Improvement Approach.
Start using the good
behaviour this method
defines in key initiatives.
We can change our
behaviour quickly.
Communicate the results from
the Changes in Behaviour
resulting in the use of the
Quality Improvement
approach. Good results from
Quick wins can help
confidence and help the
rollout of good behaviour.
Longer term Culture
changes come from the
proliferation of good
practices and behaviours
throughout the company
building a Quality
approach into day to day
life.
How do we create a Culture focused on the Patient and Quality ?
Not Overnight but it starts here
Define Measure Analyse Improve Control
Create a
shared
need
Leading
Change
Set up for
success
Overcoming
resistance
Mobilising
Commitment
Making
Change
last
Process Change
People Change
CURRENT STATE TRANSITION STATE IMPROVED STATE
Approach
A single approach combining process and people change tools to help you through the transition required for
successful results.
Define Measure Analyse Improve Control
What are we trying to achieve? What’s important? What does success look like? What steps can we take? Who needs to be involved & when?
Define the goals of the improvement activity, include deliverables & benefits.
Identify the Customer (patients directly or other internal customers) and their goals.
Agree & clearly state scope of activities.
Understand the current processes and performance.
Define team involved and timelines.
Setting up for Success
Approved PID
Action Plan
Critical Customer Requirements
Process Maps
Quick Win Opportunities
Prepared Team
Activities Tools Outcomes
Team PID / Charter
Process Maps
Stakeholder Analysis
In / Out Scope Diagram
Roles & Responsibilities
Project management
Project PID
Defines (and narrows) the project’s focus
Clarify the results being sought
Confirms value to the customer & organisation
Establish boundaries & resources for the team
Communicate goals and plans
What would happen without a PID?
Project PID
1. What are we trying to accomplish? (The aims
statement)
2. How will we know a change has made an
improvement? (What does success look like? The
measures of success)
3. What steps can we take to get there? (The plan
and tests you can attempt.)
Answers the 3 Critical Questions;
In & Out of the Frame Scoping
Draw large “picture frame” on flip-chart. Use this to help team
identify what falls inside and outside the picture of their
project. This may be locations, roles, products, lines,
customers etc.
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in in
in in
in
out
out
out
Setting up for Success
Sponsor
Team Leader/Change Agent
Team Members
Stakeholder
Role of the Sponsor
Before the project Agrees, authorises and scopes the project Helps complete the PID Identifies and releases resources needed Selects team leader/helps recruit team members
During the project Meets regularly with team leader to review progress When necessary assists with issues and links to the organisation
After the project Ensures changes made by the team are monitored, Implements changes the team is not authorised to make Recommends implementation in other areas
Being an Effective Leader of Change
Strong technical/functional knowledge
Strong change management skills
Strong interpersonal and team skills
Commitment and drive
Political awareness and influencing skills
Trust and credibility with the sponsor and stakeholders
Team Members
Accepts and works towards the goal of the team
Considers the project team to be real work and not an intrusion on their real jobs
Attends and fully participates in meetings
Fulfils responsibilities and assigned tasks outside meetings
Listens to others and be open to their ideas
Are you setup for success?
Stakeholder Analysis
Who is a stakeholder?
A person who has
a vested interest
in the outcome of
your project
Change
Targets
Change
Leaders
Change
Advocates
The people who will need to change
The people with the authority and
position to make the change happen
The people who can influence
the change
Change
Agents
The people who will help
implement the change
Stakeholders
Who are the stakeholders?
Stakeholder Analysis
To identify those individuals and groups who have a vested interest in the project
To anticipate forces which will act upon the project
To agree upon pro-active measures to make sure all major "forces" are supporting the project
To use the analysis during the project to keep the stakeholders in the picture
Major Stakeholders Criteria
1. Interest in the project (indicate also + or - )? 5. Highly 4. A lot 3. Medium 2. Little 1. No
2. How much are they involved?
5. Extremely involved
4. Highly involved
3. Regularly involved
2. Little involved
1. No involvement 3. Influence on the project?
5. Very high influence
4. A lot of influence
3. Something to say
2. Can speak up for themselves
1. No influence
Stakeholder Analysis Template
Sta
ke
ho
lde
r
Inte
res
t
Invo
lvem
en
t
Influ
en
ce
Co
nc
ern
s
Role/Name of
Stakeholder
Enter
Current
Value
Enter
Current
Value
Enter
Current
Value
Indicate if the
stakeholder scores
need to change to
assist your project
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Stakeholder Analysis
High interest + high involvement + low influence Do we need to increase their influence? High interest + low involvement Is it useful to increase their involvement? If yes, how? If yes, is their influence high enough? Low interest + high involvement Do we increase interest or reduce involvement? What if influence is high and involvement remains as it is?
Stakeholder Analysis
Low interest + low involvement + high influence How do we make sure that influence is used in a proper and positive way? High negative interest + high influence Can we make interest more positive and how? Do we need to reduce the influence and how? High negative interest + low influence How can we prevent that their influence becomes higher? Low negative interest + high influence How can we prevent that interest becomes even more negative?
Identifying Problem Areas
Stakeholder Engagement
Stakeholder Analysis
Communication Strategy
Engagement Strategy
Continuous Assessment
Communication Plan
Project Title:Status Key :
Blue = Action agreed by team as Completed
Communications Plan Amber = Action Pending - Not started yet, requires attention.
Green = Action in Progress and on Plan.
Red = Roadblock or Showstopper , requires immediate escalation.
Comms Title Audience Objectives Message How By Who When Where Content Status Comments
1
Give the Comms a title easy to
understand and refer to that
distinguishes it from other
comms.
Who are the
primiary
recipients of the
comms
What are the key objectives
of the comms, prioritise. Too
many will mean a long
complex comms.
Define the key messages
people need to appreciate
and take from the comms.
Which medium is
to be used? Not
always email;
posters, leaflets in
canteen, face to
face, presentations
etc..
The person
responsible
for delivery.
Timing as
per your
plan.
Site,
region,
floor,
group,
event
location
etc..
Summary of the content
sourcesand structure.
As per
the RAG
status
above.
Latest updates on progress.
2
3
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Communication Strategy
Stakeholder Engagement
When are you motivated to participate in a project?
What does the project leader or others have to do/not
do?
When are you absolutely not motivated to participate in
a project?
What did the project leader or others do/not do?
Your examples?
Stakeholders will support the project
Commitment to
change
To be rewarded
To know what it’s all about
(be informed)
To find it meaningful
To be asked to play a role in it (participation)
To feel supported in my role
To see results and progress
1
2
3 4
5
6 • positive pressure • recognition
• information • feedback
• information • resources • coaching • learn from mistakes
• “we need your skills”
• own input • linked to goals
• information • training • knowledge
Strategies
• Information
• Presentation
• Informal
gatherings
• Challenge/
validation
sessions
• Redesign
workshop
• Interviews
• Give responsibility
to inform and
consult others
• Joint planning and
decision-making
• Involve in testing,
validation
• Roll out reviews
Key Mechanisms
Main Purpose
CONSULT COLLABORATE INFORM
Strategies & Focus
Communication
Strategies
Engagement
Strategies
Enrolling Stakeholders
Inform
Consult
Collaborate
What strategies can you use to engage
your stakeholders?
Add them to your Stakeholder Analysis.
Stakeholders Summary
You perform a stakeholder analysis to be able to
determine your communication and engagement
strategies towards your stakeholder
Commitment grows through dialogue (communication
and listening), not out of one-way communication
Enrolling stakeholders does not mean you need to
achieve consensus
You offer an opportunity to join the journey once the
direction is set
Early in the process, start building a critical mass of
people who can move the change through the
organisation
Stakeholder Summary There is something like ‘involving stakeholders too much
or too early’
Thinking about engagement is something you do
immediately when starting up the project – however this
does not mean that you involve everybody immediately
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Understanding your Process through Mapping
Why use it
When to use it
Symbols used in it
Steps to create it
Examples
Outcomes
Why Processing Mapping
The purpose of Process Maps is to:
– Identify the complexity of the process
– Communicate the focus for problem solving
– Provide a big picture context to all those involved
– Consensus
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Process Maps are living documents and must be
changed as the process is changed
– They represent what is currently happening, not what
you think is happening or what you would like to happen.
– They should be created with the people who are closest
to the process, the “Process Experts”.
1. When Defining the current process problem
2. When Analysing a process problem
3. When Implementing your process
improvement/change.
4. When Sustaining your new way of working.
When to use a Process Map?
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Process Map Symbols Standard symbols for process mapping (available in Microsoft
Office™ PowerPoint & Visio™)
A RECTANGLE indicates
an activity/task.
Statements within the
rectangle should begin
with a verb A DIAMOND signifies a
decision point. Only two
paths emerge from a
decision point: No and Yes,
Pass or Fail etc..
An ELLIPSE shows the
start and end of the
process
An ARROW shows the
connection and
direction of flow
Step 1 Start Check
? Step 2 Step 3 End
Pass
Fail
Process Map
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1. Identify
Process
needing
Mapped
Available
?
2. Identify
Process
Experts
3. Get
everyone
in a room
4. Agree
Start &
End points
first
Re-arrange
until all
available
No
Yes
Process Mapping Steps
5. Capture
all steps &
decisions.
(Warts & All)
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Process Mapping Examples Blood Donor Flowchart example
2. Donor is
interviewe
d and fills
out form
1.
Donor
Arrives
4.
Veins
OK?
3. Donor’s
veins are
checked in
waiting
room
5.
Doctor’s
evaluation
10. Blood
drawn
from
Donor. No Yes
Donor
Rejected
6.
Health
OK?
Donor
Rejected No
7. Donor
goes to
Donor
room
Yes
8.
Phlebotomist
checks veins
9.
Veins
OK?
No
Yes
Donor
Rejected
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Process Mapping Examples Blood Donor Flowchart example
2. Donor
interview
and fills
out form
1.
Donor
Arrives
4.
Veins
OK?
3. Donor’s
veins are
checked in
waiting
room
5.
Doctor’s
evaluation
10. Blood
drawn
from
Donor. No Yes
Donor
Rejected
6.
Health
OK?
Donor
Rejected No
7. Donor
goes to
Donor
room
Yes
8.
Phlebotomist
checks veins
9.
Veins
OK?
No
Yes
Donor
Rejected
DUPLICATION
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Process Mapping Examples
Blood Donor “Improved” Process
1. Donor
Arrives
2. Donor is
interviewed
and fills
out form
3. Donor’s
evaluation
occurs &
phlebotomist
checks veins
5. Donor
goes to
donor
room
4. Health
& Veins ok? Yes No
6. Blood
Drawn from
the donor
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Donor
Rejected
Patient Receives
Appointment
Patient seen at home
Is Patient Housebound ?
Patient attends
Clinic
Patient receives 1st treatment
Patient Discharged
Outcome Details
Recorded
Is Care Package
prescribed ?
Is Care Package
Long Term ?
Patient given return
appointment
Short Term Care
Patient Transferred to
Podiatry Assistant Clinic
Long Term Care
Patient given return
appointment
Long term care
process
Details sent back to referral
source
“Podiatry Patient Treatment Flowchart”
Yes
Yes
Yes
No
No
No
Podiatry Example of a Patient Flowchart:
Process Mapping Example Flowchart
Process Mapping Swimlane Process map
When multiple departments or functional groups are involved in a complex
process it is often useful to use Cross Functional Process Maps or Swim
Lane Map. This clearly shows ownership.
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Process Mapping Examples C
linic
C
all C
en
tre
P
od
iatr
ist
Pat
ien
t G
P
2. Receive Call or
Referral
9. Treat Patient
3. Register Patient Details
on System
4. Give / Send Patient
Appointment
5. Appointment card / Letter
6. Send Details to Podiatry
Clinic
7. Receive Patient Details
8. Patient Appointment
10. Discharge Patient & Inform GP
12. GP Informed
of outcome
“Referral to Discharged” Foot care Process
1.Patient Referral
13. Update Patient Records
11. Update System Records
Swim lane Process Flowchart
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Process Mapping
Process Mapping Outcomes
1. Whole team understanding improved
2. Whole team communication improved
3. Teamwork & Customer focus
4. Quick wins identified
5. Develop a plan for improvement
6. Use the map for Analysis using
techniques in Analyse stage.
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1. Project Plan / Gantt chart
2. Action Tracker
Project Management basics
Open Actions Tracker Status Key :
Blue = Action agreed by team as Completed
Last Updated : 15/08/08 by : CA Amber = Action Pending - Not started yet, requires attention.
Green = Action in Progress and on Plan.
Red = Roadblock or Showstopper , requires immediate escalation.
# ACTION / ISSUE CATEGORY RAISED BY RAISED ON OWNER
PLANNED
COMPLETION
DATE
NEW
COMPLETION
DATE
DEPENDENCY COMMENTS / UPDATES STATUS
Project Title :
Project Plan updated on: 25-Aug
Tasks Start End Duration Owner
Phase 1 21-Jul-11 5-Sep-11 33
18-J
ul19
-Jul
20-J
ul21
-Jul
22-J
ul23
-Jul
24-J
ul25
-Jul
26-J
ul27
-Jul
28-J
ul29
-Jul
30-J
ul31
-Jul
01-A
ug02
-Aug
03-A
ug04
-Aug
05-A
ug06
-Aug
07-A
ug
1 Kick Off Meeting 21-Jul 22-Jul 2 Colin
2 Charter, Plan & Actions Development 22-Jul 23-Jul 1 Colin
3 Stakeholder Analysis 25-Jul 05-Aug 10 Colin
4 Data Collection Preparation 28-Jul 29-Jul 2 Colin
5 Live Data Collection 01-Aug 31-Aug 23 HR Admin
6 Process review kick off 29-Jul 29-Jul 1 Colin & Michelle
7 Priority Process Analysis & Gap id 01-Aug 31-Aug 23 Colin
8 KPI & Scorecard Development 01-Aug 31-Aug 23 Colin
9 Workload Prioritisation Session 30-Aug 30-Aug 1 Colin
12 Phase 1 Review 31-Aug 31-Aug 1 Jennifer
13 0
14 0
Today
3. Overall Project Update
Summary page
PM Tools used in the cycle:
DEFINE Stage Checklist
Task Who Status
1. Objectives Defined
2. Stakeholders enrolled
3. Team Selection
4. Complete Project PID, all sections
5. Review existing Process documentation
6. Define Timings & Plan
7. Define & Map current “as is” process
8. Review and redefine project scope if necessary
9. Gain approval of Sponsor before next stage
Pitfalls
Project charter developed by one person
Other team members don’t buy in
Scope too big! Don’t boil the ocean!
Goals not Customer focused
Compelling reason for change unclear
No tangible benefits identified
Sponsor not involved
Stakeholder missed, revealed later when too late
Define Measure Analyse Improve Control
How do we measures our problem? Where does the data come from? What is the performance now? How will we demonstrate before & after ?
Collect data on the current process.
Establish a baseline of current performance.
Establish the metrics to help monitor progress towards the goals stated in the “Define” stage.
Answer how we measure project success.
Creating a shared need
Measures/KPI Definitions
Data Collection Plans
Baseline Performance Metrics & Goals
Shared vision
Activities Tools Outcomes
Measures
Data collection
Balanced Scorecard
Stakeholder Engagement
Plenty of data but no information!
Data = Facts
Information = Answers to questions
‘Information’ includes ‘data’
‘Data’ does not necessarily include ‘information’
Generating Information
Questions
Communication Data
Analysis
Formulate precisely the questions to ask
Collect data and facts
Analyse the data to determine the factual answer to the
question
Present the data the data in a way that clearly communicates
the answer to the question
How is data currently collected? Check sheet - Form has been
designed so that results can be readily
interpreted from the form itself
Data sheet – data is recorded in tabular format
– additional processing is required.
Checklist – Contain items which are important
or relevant to a specific issue or situation.
General purpose is for guiding operations rather
than collecting data.
Any examples?
Planning for data collection
1. What questions do we need to answer?
2. Where in the process can we get this data?
3. Who in the process will give us this data?
4. How can we collect this data from these people with minimum effort and chance of error?
Why Display Data ?
A Visual display of data is the best way
to understand what the data is telling you.
Benefits:
Graphical displays easier & quicker to interpret.
Trends and important relationships can be identified.
Reasonably quick to prepare.
Provides a single easy to understand view of performance to all.
Displaying data
Tool : What it does : When to use it :
Run Chart Show how a chosen measurable varies with respect to time.
Allows trend and pattern analysis.
When Gathering data in Stages D & M. When displaying Metrics performance after Improvement activities. When ensuring continuous improvement and sustainability in Control stage.
Pareto Enables you to identify the most significant category within your data.
Focuses your team on what’s important.
When Analysing data.
When Selecting the major problem areas from multiple areas.
Displaying clearly the 20% of causes contributing to 80% of the problem.
Bar Chart Allows you to compare several
items at the same point in time
and show the frequency
distribution across several items.
Gathering & Analysing data. When assessing the capability of a process. To answer if the process meets the customer requirements.
Issues Category Pareto
0
50
100
150
200
250
300
350
400
450
500
HES
Installatio
n
Content Sat
Func
tiona
lity
Patch
Install
Inte
rnet on
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ia
Inte
rnet Lap
top
choo
se one
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ers
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ver
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dPM
SApp
1st lev
el
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stion
Double Billi
ng
Wro
ng O
p
Networ
kHU
B
Demo Sys
tem
Category
Num
ber
of e
vent
s
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Cum
mul
ativ
e %
Category Qty
Cummulative %
0
20
40
60
80
100
120
1st
Qtr
2nd
Qtr
3rd
Qtr
4th
Qtr
CPU1
CPU17
Issue R eso lu tion D is tribu tion
0
2 0
4 0
6 0
8 0
1 0 0
1 2 0
1 4 0
1 6 0
1 8 0
00 - 8
8 - 1
6
16 - 2
4
24 - 3
2
32 - 4
0
40 - 4
8
48 - 5
6
56 - 6
4
64 - 7
2
72 - 8
0
80 - 8
8
88 - 9
6
96 - 1
04
104 - 1
12
112 - 1
20
120 +
H o u rs
Qty
of
Iss
ue
s r
es
olv
ed
Q ty o f Issue s
Displaying data
Hints & Tips for Stakeholder
Interviews
Non-threatening
Explain purpose of interview and project – what will be done with the information received
Explain interview structure – roles, activities, you & others
Put interviewee at ease
Open and high level questions to start
More focused as go on to get to the details
Summarise and check understanding – reflective listening
Ask about:
Issues
Possible solutions
Positive things as well as negative
Their role in the change project
Communication preferences
Potential other stakeholders
Is there anything else? (ask at end of interview)
Explain next steps
Thank you
Stakeholder Interview Example
Effective Measures
Related to customer/patient requirements
Practical to implement
Easy to understand
Able to drive desired behaviour
Developed with input & consensus from
work groups
S
U
P
P
L
I
E
R
S
C
U
S
T
O
M
E
R
S
FINANCIAL
PEOPLE
PROCESS & OPERATIONAL
PERFORMANCE
PRODUCT / SERVICE QUALITY
A Balanced set of Measures
MEASURE Stage Checklist
Task Who Status
1. Identify critical Customer/Patient related measures
2. Define Data Collection process
3. Display the data clearly & simply
4. Identify trends & patterns
5. Develop a balanced set of measures
6. Define Goals for measures
6. Gather data from stakeholders & understand themes
Pitfalls
Too much data
All measures are short term focussed
Lack of (the right) detail
Measures can drive the wrong performance
Focus on financials rather than balanced view
across the business
Define
How does the process really work? What does our knowledge about the process say? What does the data tells us about the process? What are the root causes of our process problem?
Analyse the process to identify ways of eliminating the gap between current and desired performance.
Isolate root causes not just symptoms.
Prioritise the areas of focus and id resources required to help.
Identify any obstacles or risks to success.
Identify resistance to change
Process & Data Analysis
Validated Root Causes
Potential Solutions
Prioritised focus areas
Identifying and overcoming barriers to change
Activities Tools Outcomes
8 wastes in any process
5 whys
Cause & effect fishbone
Prioritisation VAP
Measure Analyse Improve Control
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Identifying Process Wastes
What is Valuable or Wasteful
Categories of Waste
Exercise
Outcomes
Value Added Activity Any activity that satisfies customer/patient requirements
Unnecessary Waste Any activity that does not support customer/patient needs in any way.
Necessary Waste/Value Enabling Supports the delivery of value but is not directly value add.
It’s value if your customer/patient experiences hands on treatment/help/support/assistance improving their situation or something they will pay for. So activities that add no value can be wasteful.
Protect & Increase
What’s Valuable or Wasteful?
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Attacking Waste !!
Waste > 90%
Value time < 10%
The Average Process :
Waste Reduction but the Value
remains.
Waste impacts all Processes
Cycle Time
Before
Step 1 Start Check
? Step 2 Step 3 End
Pass
Fail
All processes have their own proportions of Value and Wastes. All processes can benefit from Waste reduction.
After
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1. TRANSPORT The unnecessary movement of a materials / information from one operation to the next. Moving patients to tests, patients having to attend different depts.
2. INVENTORY Build up, queue or backlog of Work-In-Process (WIP) at any particular step in the process. Sometimes an indication of a bottleneck in the process. Patients queuing for clinic, lab samples for testing, stocks on wards, dictation awaiting typing.
3. MOVEMENT / MOTION Motion that requires extra steps to accommodate an inefficient work layout. Typically hunting and searching for. Working across multiple sites, storage of consumables in disparate places
4. WAITING Periods of inactivity in a downstream process due to the late delivery of an upstream process, lack of information or instruction, etc. Inpatients waiting in ED, patients waiting for discharge, physicians waiting for test results
The 8 Wastes in any Process
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5. OVER PROCESSING Extra work / Duplication - Rework, reprocessing, special handling & storage. Multiple bed moves, re-testing, multiple assessments.
6. OVER PRODUCTION Doing more than required. Producing ahead of demand or a process that continues after the customer requirement has been met. . Excessive reporting, unnecessary tests, Irrelevant information sent out.
7. DEFECTS Processing of any product or service that does not meet customer requirements. Needle stick injury, missing patient information, wrong information communicated
8. STAFF UNDERUTILISATION a) Using wrong staff for tasks. Mismatching skills & tasks. Medics transporting patients, not fully using skill mix of staff.
b) Untapped Human Potential (Hidden Value). Not involving staff in changes.
The 8 Wastes in any Process
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Identifying Process Wastes
1. Get the process experts together
to review wastes in the process
map from Video 1.Define stage.
2. Conduct a “waste walk” through
the process with process experts
identifying waste and possible
solutions.
Layout (Distance)
Long setup time
Incapable processes
Poor maintenance
Poor/Inconsistent work
methods
Undefined roles &
responsibilities
Inadequate training
Product/Service design
Ineffective planning &
scheduling
Equipment design and
selection
Poor workplace
organization
Supplier quality / reliability
Many More . . .
Causes of Waste
Identifying Waste Outcomes
1. Team consensus on key wastes in your
process
2. Ideas & opportunities to reduce waste
3. Physical & electronic workplaces organised
to remove waste
4. Ready to identify why those wastes occur in
your process.
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Discovering the Root Causes of Process Wastes
The 5 Why’s
Cause & Effect Diagram
Outcomes
What is it ?
Basically asking Why? A problem occurred at least 5 times.
A simple method of digging down to the root cause of a problem.
It cuts through the symptoms by not accepting the first explanation
of a cause.
Challenges beliefs and assumptions
How to use it :
In a team with the process experts present in order to validate the
root causes. Only factual answers accepted.
Do not accept answers such as: “It’s always been that way” or
“Because I said so” or favourite theories / urban myths.
You have reached the root cause when you have asked why
enough times that there will be no lower level explanation.
The 5 Why’s
Why?
Why?
Why?
5 WHY’s – How to
1. Gather the experts in the Process
2. Select one of your identified WASTES in your process.
3. On the top post it describe the Waste
4. Conduct 5 Why’s on “Why the Waste occurred.
5. Build up the logic chain until root cause reached.
Why?
Why?
Porters busy
transferring Blood
Tests manually
Patients waiting
for transfer
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5 WHY’s Example
No Porters
available
Jnr Docs not
using Automated
Blood test System
Info not in their
training
Jnr Docs
never told
Why?
Why?
Why?
Why?
Why?
ROOT CAUSE
WASTE
73
5 WHY’s
Why?
Why?
Why?
Why? Why?
ROOT
CAUSE 1
WASTE
Why?
ROOT
CAUSE 2
If your Why chain splits this means multiple Root Causes and therefore multiple solutions required to eliminate the waste.
Now use the 5 Why’s tool within a Cause & Effect Diagram.
Cause & Effect The Cause & Effect Diagram helps to:
Organise the knowledge of the group
Graphically display this knowledge
A process which allows teams to identify and display all possible causes related to a problem
Allows teams to focus on one cause at a time
Main
Cause
Categories
Issue or
Problem
Cause & Effect Diagram – How to
Patients waiting on
transfer
Process
People Systems
Equipment
1. Draw a box
3. Draw an arrow pointing to the box
2. Write the problem description inside the box
4. Add the names of the main categories
5. Add sub-causes
Why?
Why?
Why?
Why?
Why?
6. Conduct 5 why’s on each sub cause.
7. Look for Common Root Causes
Porters
Nurses
Outcomes
1. Team consensus on root causes of process
wastes and issues.
2. Common Root Causes identified
3. Possible Solutions identified
4. Ready to implement those solutions to
reduce your process wastes and improve
performance.
5. Ready to use the techniques in the Improve
stage.
76
B
C
High
Low
Low High
D
Benefit (Increased Revenue,
Decreased Costs
or Cycle Times)
Effort (Resources: Time,
Money, People)
A
Zones:
A – Just Do It!
B – Plan to do?
C, D – Later…
Prioritising Opportunities Value Analysis Prioritisation Tool (VAP)
Be practical – scope what is achievable
1 2
3
4 5
6 7
8
ANALYSE Stage Checklist
Task Who Status
1. Analyse your data for patterns & trends
2. Analyse your process for wastes
3. Identify opportunities to remove the wastes
4. Prioritise the opportunities
5. Perform root cause analysis on the process issues
6. Analyse people’s behaviours in the process too
Pitfalls
Assume the solutions without validation
Ignore the data
Process experts not involved
Not digging deep enough for the root causes
Treating the symptoms only
Define
What are all the possible solutions? Which ones are best? How can we try it out? Has it worked as we expected? Which ones will we keep?
Improve the process.
Be creative in finding new ways to do things, quicker, cheaper & better.
Use structured methods to implement changes.
Collect data on measures to validate improvement/
Manage & communicate changes.
Mobilising Commitment to change.
Tried & tested Solutions
Process Maps and Documentation
Cost/Benefit Analyses
Improvement Impacts and Benefits
Pilot and Solution Results
Storyboard
Staff engagement
Activities Tools Outcomes
PDSA cycle
5S’s
Change Curve
Change Formula
Measure Improve Control Analyse
81
Making Improvements with the Plan,Do,Study,Act Model (PDSA)
1. What is it & why use it?
2. How to use it?
3. Expected Outcomes
PDSA Cycle – What & Why?
Test out change ideas on a
small scale.
Try something & assess its
impact before implementing it
widely.
Actions are clearly based on
evidence gained during small
scale tests.
It involves less Risk, less time
and less money.
Minimises resistance as people
have been involved and seen it
work on a smaller scale.
Avoids impulse actions.
Study
Act
Do
Plan
82
PDSA Cycle – What & Why?
Don’t expect to get it
perfect first time.
Try multiple small changes
Learn each cycle about
what works better
Use your learning as
evidence of the best
solution
Implement with confidence
and maximum benefit.
83
PDSA cycles form part of a framework for implementing changes leading
to improvement. The framework includes three key questions which need
to be answered before the PDSA cycle begins:
PDSA Cycle – How to.
1. What are we trying to accomplish?
(The aims statement)
2. How will we know if the change is an improvement?
(The measures of success.)
3. What changes can we make that will result in
improvement?
(The tests to try.)
Study
Act
Do
Plan
84
The PDSA Cycle - Plan
1. State objective of the cycle
2. Make predictions
3. Develop a plan to carry out
the cycle
4. Develop a plan to gather
data.
Plan
85
The PDSA Cycle - Do
1. Carry out the test as
planned
2. Document problems and
unexpected observations
3. Begin analysis of the data.
Do
86
The PDSA Cycle - Study
1. Complete analysis of the
data
2. Compare data to predictions
3. Summarize what was
learned. Study
87
The PDSA Cycle - Act
1. Did the test meet your
aims?
2. If yes then implement.
3. If no then what changes
are to be made?
4. What will be the next
cycle?
Act
Action was rationally based on what was learned 88
Outcomes
1. Tried & Tested Improvements
2. Evidence of Improvement
3. Convinced staff
4. A Successful Change.
89
What is 5S ?
A way to see and eliminate waste in your
workplace through better organisation.
Used to ensure that the workplace contains only
what is needed, when it is needed and where it
is needed.
At a glance, any abnormalities can be detected.
Minimal time is spent on non-value added
activities.
A foundation block for continuous improvement
90
What 5S does… Used to ensure that the workplace contains
only what is needed, when it is needed and
where it is needed.
Workplace organization
At a glance, any abnormalities can be
detected.
Minimal time is spent on non-value added
activities.
A critical part of continuous improvement
process
A way to see and eliminate waste.
SA
FE
TY
– IN
EV
ER
YT
HIN
G
Eliminate all unnecessary and seldom used items & equipment from the workplace. 1. Sort
Organise the way that necessary items are kept, making it easier to find, use and return to the proper location.
2. Set in Order
Maintain a Clean and Tidy work area for the already sorted and set-in-order items 3. Shine
Establish Standards to ensure sort, set-in-order, and shine are consistently followed by all users all the time.
4. Standardise
Create an environment to maintain and improve the first Four S’s and make it a natural everyday way of working.
5. Sustain
“A place for everything and everything in its place” 5S
Stop slips & trips, reduce wasted time searching, improve
efficiency and productivity, better quality, better environment to
work in, feel pride in the work place, impress your customers. 92
5S is a tool for Waste
Elimination
Before After
Office Example
What does yours look like?
After > No clutter – ease of access Only necessary items stored &
clearly labelled Items easily accessible with
minimum movement More space & time to do the job Clean and tidy area
<Before X Corridors cluttered impeding access X Unnecessary equipment stored in corridors X Undefined layout of space X Searching for equipment
5S Examples
95
After > Only necessary items stored &
clearly labelled Items easily accessible with
minimum movement More space & time to do the job Clean and tidy area Item maps visible
<Before X Storage disorganised with unnecessary
items mixed with the vital items X Unclear labelling and layout, floor being
used impeding access. X Searching for items time consuming X Lack of space because its not used
correctly
5S Examples
96
After > Space cleared for utilisation as
training/study room Only necessary equipment in
place for training & study. Access controlled Library area designated Improved staff morale
<Before X No staff training/study room available X Rooms used as dumping grounds X Space available but not utilised X Staff demoralisation
5S Examples
97
Remove anything which isn’t needed
for current work
Key: Leave only the bare essentials
Ask Yourself:
–What do we need?
–What do we not need?
–What can we remove?
–What can we throw away?
–What can I reorganize?
Distinguish the necessary
from the Unnecessary
Step 1 - Sort
Arrange items so they are:
easy to find
easy to use
easy to put away
5S Map
Visual controls
Signboards
Floor painting and taping
Outlining
Colour coding
Labelling
Methods:
A Place for Everything and Everything in its Place
Step 2 – Set in Order (Simplify)
Housekeeping
Inspection
5 minute shine
Everything is ready to use
5S Schedule
Five minute shine every day
Cleaning and inspection checklists
Checklist for Needed Maintenance
Methods
Clean and Ready to Use As Is
Step 3 – Shine
Standard Systems need to be put in place:
To readily identify abnormal conditions
To Prevent Setbacks in the First Three Stages
of 5 S
To control what happens, when it happens and
how it happens
To Focus on prevention so it won’t happen
again – SOPs , training, audits etc..
o Can I tell are there too many, too few?
o Can I easily recognize that an item is missing?
o Can I easily recognize an undesignated item?
Step 4 - Standardise
Awareness & focus
Rewards & recognition
Satisfaction & enthusiasm
5S Posters
5S Photo Exhibits
and Storyboards
5S Newsletters
Tools: 5S Pocket Manuals
5S Department Tours
5S every day
Self Discipline and Motivation
Step 5 - Sustain
Management at all levels must be committed to establishing and maintaining the 5S process.
Management must lead by example Walk the Talk !
LEADERSHIP RESPONSIBILITY
“We are what we repeatedly do: Excellence then, is not an act, but a habit”
5. Sustain
5S Guide on share drive
MS Word
Desired State
Current State
The Changing Environment
Transition State
Low stability Perceived high levels of inconsistency in the environment High emotional stress Control becomes a major issue Past patterns of behaviour become highly valued Conflict increases
Unfreezing occurs
Refreezing occurs
Leading Change
Unfreezing Techniques
Burning platform
Challenge
Evidence
Restructuring
Training & education
Visioning
Refreezing Techniques
Burning Bridges
Evidence Stream
Institutionalisation
Reward Alignment
Stages and Speed of Change
People adapt to change in 3 levels
Physical This is the time it takes for a person to
comply with the behavioral requirement of the change. This is the fastest acceptance of change.
Intellectual This is the time it takes for a person to comprehend why a change has taken place or is necessary.
Emotional This is the time it takes for a person to feel comfortable with the results of the change, the new state.
Change Curve
Stage 1
Stage 2
Stage 3
Stage 4
Recognising and Supporting
Key Reactions to Change
Shock/Denial/Anger Resistance
Exploration Acceptance
Divide categories among groups and go to exercise
Managing Change Step One : Brainstorm what behaviours you have seen
or would be demonstrated during this reaction on the
change curve
Step Two : If faced with someone demonstrating these
behaviours what would / could you do as an individual to
move the employee forward
Step Three : Go to the other completed flipcharts – do
you agree with the responses ? Add any additional input
as required.
Return to your original
flipchart.
Supporting people through the Change Curve
Reaction
Employee & Team Needs
Caution
Provide facts and continually articulate the reality of change. Create a safe place to vent anger. Recognize the feelings and help get the emotions out Help focus the individual on the priorities
Shock, Denial, Anger
Clues Expressed anger, constant complaining, withdrawing and refusing to accept changes
Avoid taking personal responsibility for the individual’s reactions
Supporting people through the Change Curve
Reaction
Employee & Team Needs
Caution
Continue to articulate the reality of the change Listen actively Assist the person to reconcile personal frame of reference to the new reality
Resistance
Clues
Performance drops, errors, refusing assignments related to the change, negative, complaining, withdrawing
Understand that you will have questions as well Do not speculate or ‘make-up’ reality as you go along
Supporting people through the Change Curve
Reaction
Employee & Team Needs
Caution
Provide resources, time and support to help individuals try new and realistic alternatives Give appropriate recognition, appreciation and feedback on new ideas
Exploration
Clues Ready to change, confused about what to do, loss of confidence in skills and asking others what to do
Be sure to discuss realistic options for the future Do not mistake ‘searching’ for liking the change
Supporting people through the Change Curve
Reaction
Employee & Team Needs
Caution
Reward the team and individual for focusing on implementing the change. Encourage risk taking that supports change. Stay involved, look ahead
Acceptance
Clues Initiates problem solving on his/her own. Positive about what needs to happen, suggests ideas, supports the change
Be sure to discuss realistic options for the future
Gleicher’s Change Formula Change will occur when:-
D x V x F > R
D = dissatisfaction with status quo
V = desirable vision of future
F = first small practical steps towards the vision
R = resistance to change
Dissatisfaction
It is plain we cannot carry on as we are
The external environment makes it inevitable that we should change
It is evident from our performance in recent months that we should change
The pace of change in our environment has rather left us standing
Our systems have clearly outlasted their useful lives
D x V x F > R
Vision
All staff have bought into the vision /goal of the
change
The aspirations expressed in our change vision
are seen as achievable, if challenging
Staff can make a clear connection between our
change goals and their own jobs
D x V x F > R
First Steps
The change process is clear
The changes required in our systems and
processes have been well planned
High quality, timely communications has been a
key aspect of the change process to date
The timescale of change is demanding but
achievable
D x V x F > R
Resistance/Costs
There is a significant risk that the staff/patients will experience difficulties during this change
Major investment will be required
A number of people will have to make major changes in their approach
A number of staff will need to be retrained
D x V x F > R
Use the change equation to analyse a change
that you are;
currently dealing with or have experienced in
the past
D x V x F > R
Details/Actions What has been done?
What needs to be done
Dissatisfaction with status quo
Clarifying and communicating the future vision
Identifying and communicating the first steps/plan
What will be the impact of the change? What resistance do you anticipate?
Applying Gleicher’s Change Formula D x V x F > R
35
IMPROVE Stage Checklist
Task Who Status
1. Plan your changes – start with PDSA
2. Perform pilot change small scale first
3. Assess pilot results
4. Re run pilot if necessary
5. Develop implementation plan
Pitfalls
Poorly communicated changes
Big bang approach instead of smaller pilots
Failed to convince others of need for change
Lack of evidence of improvement
Define
How do we makes our changes normal operation? How can we sustain our improvements & benefits? How will we measure in future? Have we met the goals we set and can we close the project?
Control the new processes.
Embed the changes into everyday routines and systems.
Maintain monitoring reports.
Demonstrate and Sustain the benefits.
Making Change Last
Sustaining Benefits
Standards and Procedures
Standardization
Trained staff & training Plans
Project & Team Review
Success Stories
Replication opportunities
Activities Tools Outcomes
Sustain/Control plan
Training Plan
Communications
Stakeholder Mgmt.
Role & Responsibility RACI matrix
Document plan
Lessons Learned
Closure Report
Measure Control Analyse Improve
Control
What steps can you take to control and ensure the sustainability of your project?
Use the Control Plan.
Control 1. Training What training is required for staff to implement new or revised processes and procedures? Think about both existing and new starts, Who will write the training material? What will the training comprise
2. Communications Review your Comms plan from the Define stage as there may be new requirements at this stage.
3. Stakeholders Revise your Stakeholder Analysis at this stage also as new Stakeholders may be involved since the changes have been implemented and their impact has spread.
4. New Roles & Responsibilities Carefully define the new Roles & Responsibilities within the new or improved process. Clarity at this stage is critical to the process being sustained. Use the RACI Chart to Identify who will be Accountable for the process tasks being carried out, who is Responsible for performing the tasks, who will need to be Consulted and when and also who will need to be informed at what point within the new process.
Control 5. Documentation Documentation is necessary to ensure that what has been learned from the project is shared and institutionalized: Used to aid implementation of solutions, Used for on-going training. Documents need to be kept current to be useful with help from the Documentation Plan.
6. Align Policies & Recognition Allowing people to change their behaviours permanently means implementing goals, measures, job descriptions, incentives etc.. Which align with the new process approach and will motivate them to sustain the changes & benefits.
7. Lessons learned Lessons Learned can be started from the beginning of the project and maintained throughout making this step at the end a summarising activity.
The main question to be addressed here is “What could we have done better and how?” using the Lessons learned matrix.
8. Capture, Document & share Success Single page overview of the improvement project to Share Learning's, Document Case Study, Communicate Success, Evidence of Improvement & Convince others to try
CONTROL Stage Checklist
Task Who Status
1. Complete Control Plan for changes made
2. Define Control measures/metrics
3. Rollout improved processes/changes
4. Monitor Progress using measures
5. Conduct training on new processes
6. Document new processes
7. Define ownership of new processes
8. Complete Summary report & Lessons Learned
Pitfalls:
Teams can potentially derail when they:
Fail to engage in leadership behaviors necessary for change.
Are transferred too quickly before change has occurred.
Try to do it all alone without involving others.
Shift to other goals before completing the change. (“Flavour of the Month”)
Fail to establish and clarify the key change roles.
Allow the change process to be diluted by other priorities.
Fail to integrate the change into the “real work” of the business.
Define Measure Analyse Improve Control
Create a
shared
need
Leading
Change
Set up for
success
Overcoming
resistance
Mobilising
Commitment
Making
Change
last
Process Change
People Change
CURRENT STATE TRANSITION STATE IMPROVED STATE
1. Stakeholder
Analysis & Q’s
2. SIPOC
3. Flowcharts
4. Gantt Chart
5. Actions tracker
TEM
PLA
TES
6. Comms Plan
7. Run chart
8. Pareto chart
9. Bar chart
10. 8 Wastes
11. Fishbone
12. PDSA
13. 5S Audit
14. Progress
Update
15. Gleicher
formula
16. Control Plan
17. Training Plan
18. Docs Plan
19. RACI Chart
20. Lessons
Learned
21. Closure Report
33