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%
Dec
Jan-13
39%
Feb
35%
30%
24%
March
23%
April
20%
0%
7B
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