Changing the Culture:
GME-Streamlining and
Standardizing for Cost
Savings and Efficiencies
Ann M. Dohn, M.A.
Stanford DIO
Nancy A. Piro, Ph.D.
Program Manager/
Education Specialist
Disclaimer

No Conflicts of Interest to Report
Session Core
Competency Focus

This presentation addresses
the GME Leader Core
Competencies of:
–
–
Developing and Supporting
Residency Program Directors &
Coordinators
Managing the Institution’s GME
Operations.
Three Key Session
Objectives
1.
2.
3.
Provide a foundation for the
understanding and application of
lean philosophies and practices to
GME.
Describe specific process
improvement measures that can
result in increased efficiency and
cost savings in a graduate
medical education (GME) setting.
Provide a Toolkit



Forms
Templates
Examples to streamline and standardize
GME processes at their respective
institutions.
Thinking Out of the Box?
Thinking Outside the Box
– Looking to Industry
and Corporations

What does industry have that we
can use?
–
Conveyor belt to move patients in
and out of OR’s?
No….

But they do use a “Lean
Philosophy”
–
–

Respect for People
Total Elimination of Waste
And they use “Lean Tools” such as
–
–
–
Kaizen
5S’s
3 M’s
Lean – Toyota
Production System (TPS)

TPS system managed to get by
with “half of everything”!
–
–
–
–
Physical space
Personnel
Capital Investment
Inventory

Resulted in far fewer than half the
defects and safety incidents
NUMMI
Lean Culture Shift



Make problems visible – not hide
them or “not talk about
mistakes/problems”
Fix problems permanently – get
to the “root cause” and eliminate
it.
Focus on the value and respect
for people.
Lean Tools --- A Sample



Kaizen
Elimination of WASTE - 3Ms
Problem Solving
–
–
–
5 Whys
Fishbone Diagrams (Ishikawa
Charts) 4 Ms
4 Ps
Lean Tools: Kaizen
What is ‘Kaizen’?
 Gradual, unending continuous
improvement of processes
 Processes must be improved to
get improved results
 By improving and standardizing
activities and processes, Kaizen
aims to eliminate waste
Kaizen Basics


Focus is on small, incremental
change (not necessarily huge
leaps, innovation)
Quality Control = quality of
people
–

“A company that is able to build
quality into its people is halfway
to building quality outcomes”
Respect for People
–
“Only people produce
improvements”
Lean Tools: 3M’s

All about Waste- Identifying it
and Removing it
–
–
–
MUDA = Waste of using resources
without creating added value
MURI = Waste of overburdening
people or equipment/resources
MURA = Waste of unevenness,
variability in processes
Five Why’s Problem
Solving Method

Keep asking ‘Why’ until you discover
the root cause of the problem
– No magic in 5 –


might be 3, or 7, or 10
Why do we? (conduct orientation in
person, fill out multiple forms, take on
line training for non MDs)
Lean Tools: – Fishbone
Charts using the 4Ms – 4 Ps




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


Manpower/Personnel
Materials
Method(s)
Machines / Equipment
People
Process
Policy
Principles
Ishikawa Diagram of ER
Prolonged Wait Times
Materials
Methods/Process
WHY?
WHY?
WHY?
Manpower/People
WHY?
Machine\Equipment
xxx hr
wait
time in
ER
5Ss - Mnemonics
Retained





Sorting
Simplifying
Sweeping
Standardizing
Self Discipline
= Seiri
= Seiton
= Seiso
= Seiketsu
= Shitsuke
QUICK EXERCISE
5Ss in Action
19
BEFORE
ER Rooms
AFTER
Now ---How Can this be
Applied to GME?




Have read the books
Know the materials
Understand the tools
Have stolen former Toyota
Manager …
–
So what do we do
Putting Philosophy into
Practice

Flowchart the processes
–




Ask- “Why are we doing this?”
Fishbone the problem
Huddle to discuss with the team
Look for the 3Ms
Apply the 5Ss
Start with the Current
State

CURRENT CULTURE
–
Paper driven registration (forms,
forms, and more forms)
CURRENT CULTURE
–
87 programs (87 fiefdoms all doing
their own thing….but having
common requirements)
Current Culture



Lack of
standardization/inconsistencies
(MURA)
Overburden (MURI)
Waste (MUDA) of both materials
and time
–
–

Lots of files
Time to file personnel folders or
ACGME letters
Time-consuming institutional
oversight of programs (MUDA,
MURI)
Streamlining a GME
Process Example

What GME Processes would be
the best targets to streamline
and improve eliminating waste
and redundancies?
Where to start?

Low hanging fruit vs. most
impact on residents/faculty/GME
staff

Actually you can do both!!!
Drivers: Where to start?


Areas of largest number of
ACGME citations?
Questionnaire data?
–
–
–
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Program Directors’ Needs Analysis
Incoming House Staff survey data
Annual GME resident survey data
Program Coordinator requests
Where to start?

Huddle-need team involvement
–
–
Respect for people
Respect can lead to elimination of
unnecessary work
Real Time Examples of
What We Standardizing
We Have Done


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
Project One: Program evaluation
standardization
Project Two: Orientation
standardization/streamlining
Project Three: Policy
standardization
Project Four: Summative
evaluation standardization
Project Five: Paperless
Office/Registration
Project One: Standardize
Program Evaluations

Factors driving decision to
standardize:
–
–
–
–
Largest number of program citations
from ACGME
Lack of consistent data on program
evaluation for APRs (MURA)
Huge amount of paper generated to
produce suboptimal evaluations
(MUDA)
Burden of work on the coordinators
(MURI)
Standardized Program
Evaluations
What did we do?
 Developed standardized
comprehensive core
competency-based Program
Evaluations – by Faculty and
Trainees
 Presented the draft templates to
the Program Directors who
edited and approved them.
Standardized Program
Evaluations – Process
Implementation

Annually the GME office:
–
–
–
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Delivers --via our Residency
Management System (RMS)--176+
evaluations
Aggregates each program’s data after
the evals have been completed
‘Prints’ (electronically to pdfs) their
aggregate Program evaluation reports
Posts the Program Eval Reports
(pdfs) on their APR site (in the RMS)
Program Evaluation
Standardization “Toolkit”
Example
Standardization of
Program Evaluations

Benefits
–
–
–
–
Fewer citations
Can be input to our Institutional
Report Card
Easy oversight by DIO/GMEC
Early warning system
Results of Project One

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Less paper wasted (none used)
Program evaluations sent out
centrally by GME using standard
evaluation forms
Compliance with program
evaluation can be easily
monitored by GME
Reduction in ACGME citations
Less concern about
confidentiality from house staff
Project Two: Orientation
Standardization/Streamlining

360+ incoming residents/fellows
attending one day orientation
sessions
–
–

Completion of various mandated
training
Issuance of computer codes,
pagers, ID badges, parking permits,
etc.
How do we cope with residents
unable to attend orientation?
CURRENT CULTURE
–
Face to face orientation


great to know what we look like but big
differential in quality of some
presentations
inability to really control content of
each presentation and test knowledge
of materials
Project Two: Orientation
Standardization/Streamlining

Wasted both incoming trainee time
and staff time - MUDA
–




20+ speakers
Long lines waiting for such stations
as photo ID - MURI
Lack of standardization of
presentations - MURA
Loss of the one auditorium large
enough to hold group
Difficulty in keeping the attention of
the trainees (material overload vs.
shopping at Nordstrom's) - MURI
Project Two: Web-based
Orientation

Based on the input from resident
orientation questionnaires:
–
All mandatory modules became Webbased




Offered in advance of orientation
Many have post tests
Can verify completion of training
Can be done from home/Starbucks
Unintended Outcome

Have we gone too far?
Project Three:
Standardization of
Policies

Design a policy template for
common program requirement
policies to reduce redundancies
(MURA, MURI, and MUDA)
–
–
–
–
–
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Supervision
Moonlighting
PLAs
Recruiting
Duty Hours
Work Environment
Beyond Duty Hours
etc.
Policy Development
Teaching the Use of
Policy Templates


Program director noon
conferences
Policy writing workshop
Monitoring
Implementation of the
Policies

Verify in our residency
management database (system
which cannot be named)
Easy Online Policy
Verification for each
program - Example
Project Four: Summative
Evaluations – The
Drivers

ACGME Citations
–



Incoming and Outgoing!!
Multiple / variable forms (MURA)
Redundant wasted paper (MUDA)
Overburden PCs and PDs (MURI)
How Do We Do This
Efficiently and Effectively?
Fill in the blank?
Multiple Choice??
Can my coordinator
help me out here?
Project Four: Summative
Evaluations – What did
we do?

Developed Standard Evaluation
Template for Summative
Evaluations
Comprehensive over program
training years
Core-competency based
User friendly word document

Held Program Director and
Program Coordinator Teaching
Sessions / Workshops
Taught the use of the template and
how to pair it with aggregated
evaluation data from our RMS
Use of Resident
Evaluations from RMS:

Programs could select the
evaluations to use –
–
We recommended:




Evaluations Competencies by Resident
Resident/Faculty Ranking Report
(aggregate)
Aggregate Comments Report
Evaluation Competencies Report
Coordinate with
Aggregated Evaluation
Data
Summative Evaluation
Template
Macro-enabled Word Doc
Additional
Considerations

Special Cases
–
At the end of a preliminary year
(internship)

Need to list Rotations
Final Points


Review report with trainee
Place a copy of the summative
evaluation in the Trainee’s
permanent file and upload to our
residency management system
Project Five: The Paperless
GME Department




Files
Program reviews
Registration
PIF reviews
Project Five: The
Paperless GME
Department

Load all forms into the residency
management system (RMS)
–
–
–
Scan
Upload
Direct enter
Project Five: The
Paperless GME
Department

Program reviews
–
Review on line




Duty hours
Policies
Annual program review documentation
Evaluations
–
–
–
–
–
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% complete
Ranking status
360’s
Surveys
Board pass rates
etc…
Project Five: The
Paperless GME
Department

PIF Reviews
–
shared document review on line
Project Five: The
Paperless GME
Department
Incoming House Staff
–
Learning modules web-based




–
Standardized content
Post tests
Tracking that all modules complete
Annual review of module content
Registration



Summative Evaluation Acquisition
Access to RMS system to enter data
Upload forms/documents
Project Five: The
Paperless GME
Department - Results

500 fewer pages of paper per
Internal Review x times 2 drafts and
an average of 20 Internal Reviews
per year =
–
Savings of 40 reams of paper =


Two entire trees saved (17 reams of paper
= one tree)
Time Saved (walking, waiting,
mailing eliminated)
Questions?
Contact Information:

Ann Dohn, DIO
–

adohn@stanford.edu
Nancy Piro, Program Manager
–
npiro@stanford.edu