Daily Continuous Improvement Program Trey Coffey MD FAAP FRCPC Medical Safety Officer, SickKids Associate Director, University of Toronto Centre for Quality Improvement and Patient Safety Disclosures I have no conflicts of interest to disclose Lean Concepts • Origins in Toyota Production System c. 1930s • Term coined and applied to western manufacturing c. 1980s • Processes analyzed from the point of view of customer value • Focus on eliminating waste of all kinds in the system • Deference to expertise – executives on the factory floor (“Gemba”) Getting to know you Your prior experience with LEAN is best described as: A. I am not very familiar with LEAN. B. My healthcare organization is doing some LEAN things and my reaction is… “meah.” C. My healthcare organization (or other organizations I am familiar with) did some LEAN and it was an unmitigated disaster. D. My healthcare organization is completely LEAN Different Levels of Process Improvement Very few Large issues Few Medium issues Many Small issues Adapted from: “The Toyota Way Fieldbook” by Liker and Meier Objective To tell a genuinely enthusiastic firsthand account of a unique Lean Management System, which: • is new to SickKids • is not yet fully realized nor perfected • might be revolutionary… New Job Paediatric Medicine Quality Committee c. 2005 2011: Emergency Department Performance Improvement Program We used Lean to improve Door-to-Floor times! Reality sets in… Again. Feb 2012: Learning Partnership with ThedaCare Impact 32% improvement in patient satisfaction • ThedaCare group of hospitals and clinics in Appleton, Wisconsin. • Early adopter of Lean methods 8 years ago • ThedaCare Business Performance System to address sustainability and to develop a culture of daily continuous improvement 21% reduction in hospital cost per case Awaiting my invitation… •Rapid process improvement workshop? •Kaizen event? Manager Daily Status Sheet Manager Daily Status Sheet A few weeks later this appears Daily Improvement huddle: M,W,F 1:15-1:30 Daily Improvement Board Collect Improvement Cards Prioritize Issues Just do its More challenging problem solving (PDSA3) Completed Daily Improvement Huddle Board Early signs of success: Engagement of frontline nurses on 7B raised hand hygiene compliance 100.0 93.0 100.0 78.0 75.0 80.0 7B Moment 1 60.0 40.0 57.0 20.0 0.0 Apr May Jun Jul Aug 2011-2012 Sept Oct 2012-2013 actual Nov Dec Target Jan Feb Mar Daily CIP’s Goal: Develop people to solve problems and improve performance Different Levels of Process Improvement Very few Large issues Few Medium issues Large Projects Six Sigma Lean Event Many Small issues Focus of Daily CIP Adapted from: “The Toyota Way Fieldbook” by Liker and Meier Status Sheet: Manager, Director and VP Manager Status Sheet Charge Nurse DAILY Director Status Sheet Manager WEEKLY VP Status Sheet Director EVERY 2 WEEKS VP Status Sheet: Links Between Levels Manager Status Sheet Charge Nurse DAILY Director Status Sheet Manager WEEKLY Director A wise man once told me: “Behavior drives culture” From: To: • Competing priorities for improvement  Frequent review of improvement priorities • Improvement accountability with a few people  Improvement accountability at all levels • Project teams solve problems periodically  Front line staff solve problems daily • Ad-hoc use of improvement tools and approaches  Staff trained in adopting tailored toolkit and approach for problem solving 24 New and Improved Paediatric Medicine Quality Leadership Team • We still meet monthly to discuss trends in performance and to prioritize which metrics to improve upon Except now… • I had to get a much bigger room! • I am currently looking for an even bigger room! • Staff come in on their OFF DAYS! • I look forward to it instead of dreading it  Monthly Score Card: Driver and Watch indicators This scorecard dictates the unit focus for the month Falls, Entrapment, Strangulation, Entanglement documentation scores 120% 100% 97% 100% 90% 89% 83% 77% 72% 80% Sept 68% 67% 52% 50% 44% 43% 40% Oct Nov 57% 51% 60% Aug 54% 50% 48% Jan-13 39% Feb 35% 30% 24% March 23% April 20% 0% 7B Dec 7C 7D Three day Equipment Improvement Event Situation Overview Approach Impact Finding supplies is difficult 5S Sort Set-in-order Shine Standardize Sustain a place for everything everything in its place RESULTS Staff-driven problem solving: Over 65 improvement ideas identified and executed since April 2012 Median of 19% Improvement in Engagement Scores Key ingredients Self-Determination Theory 1. INTRINSIC MOTIVATION •Provide opportunity for self-leadership •Provide choices •Help members acquire skills and knowledge •Assign tasks but make connections •Coach Autonomy Relatedness Competence 2. DISCIPLINE • Simple behaviors repeated over and over Enterprise wide picture •12/22 units doing Daily CIP •20 yellow belts trained •178 green belts trained •Larger projects/value streams: Ambulatory, Surgical, Procurement, Pharmacy, Administrative. • ~20 Rapid Improvement Events completed to date How much does this cost? • “Lean Promotion Office” • Office of Process Improvement • Director, five staff, and an assistant • hired from industry and consulting firms • $1 million/year (approx) The Hand Hygiene graph continued…. 7BCD Moment 1 100.0% 80.0% 60.0% 40.0% 20.0% Apr May` Jun Jul 2012-2013 Aug Sept Oct Target Nov Dec 2011-2012 Jan Feb Mar Questions for consideration 1. Are we going to be able to tackle the big stuff? 2. How is this experience going to vary across units? 3. How are we going to substantively engage physicians? Acknowledgments SickKids nursing and operational leaders: Kate Langrish, RN, Lynn Mack, RN, Linette Margallo, RN, Dinarte Viveiros, RN SickKids Office of Process Improvement: Shiraz Bhajwa, MBA, Travis Beamish, MBA Ali Shahzada, MBA Executive sponsor: Jeff Mainland, EVP Strategy, Performance, Quality and Communication