A3 Training
DGSOM BEI
HR Sphere
1
Agenda
Topic
•
•
•
Intro to Lean
Project Charter
Plan
•
•
•
•
Duration
10 min
5 min
45 min
Clarify the Problem
Analyze the Current State
Develop Goals
Analyze Root Causes
Total: 60 min
Learning Objectives
At the end of the session you should be able to:
• Broad understanding of key principles and tools
• Be able to use the DOWNTIME model to identify waste
• Develop a project charter with your team
• Explain why PDCA is an effective method for problem solving
• Understand the components of PDCA
• Document your PDCA process on an A3
Taking a Different Approach…
“I’ve got too much work to do to stop and listen to you”
“The Tools Are Available”
4
Lean Definition
•
Discuss what is lean
What is Lean?
•
A management system and culture designed as a way
we work by adding value for our patients and
eliminating waste, where every employee is
empowered to continuously improve their processes
Lean is Not:
•
•
•
The flavor of the month
Concepts that apply only to manufacturing
A collection of tools and methods
5
History of Lean
Late 1800’s
Frederick Taylor
(standard Work)
Late 1800’s
Early 1900’s
Frank & Lillian Gilbreth
(Time & Motion Study/
Process Mapping)
Early 1900’s
Early 1900’s
Henry Ford
(Flow Production)
1930’s
Kiichiro Toyoda
(Just in Time)
1930’s
1950’s
W. Edwards Deming
(PDCA)
1950’s
Taiichi Ohno
(Toyota Production
System)
1950’s
1950’s
Joseph Juran
(TQM)
2009
UCLA Operating System
2009
1950’s
Shigeo Shingo
(SMED, ZQC)
2009
Mark Graban
Shingo Research Award
Lean Hospitals
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UCLA Health Operating System
Mission - Delivering leading edge patient care, education and research
Vision
- Healing humankind one patient at a time, by improving health, alleviating suffering, and delivering acts of kindness
Values
- Compassion, Respect, Excellence, Discovery, Integrity, Teamwork
Lean Benefits
How Will Lean Help Me?
•
•
Solving problems and recognizing lasting results
Establishes an environment that has controlled process,
repeatable outcomes and delighted staff/patients
What are the Benefits of Lean?
Higher quality, safety & efficiency
• Giving patients what they want when they
want it
• Increased staff satisfaction
• More time with patients and business growth
•
1. What are some more examples? In your area?
8
How we teach lean at UCLA Health
Understand Value,
Waste, & PDCA
Current State
Analysis
SIPOC
Root Cause Analysis
Implement & Sustain
Improvements
Effective Solutions
Pareto
Process Mapping
Standard
Work
Fishbone
Time Obs.
Project Lead: Veronica Corcoran
Project Champion(s): Brad Rogers
Facilitator: William Taylor
SM Orthopaedics Clinic:
Call Center
Problem Statement:
53% of calls to the call center are for non appointment related issues
Current State:
Calls
Patients
Uses phone tree to
triage call to
scheduling
New UCLA
Pt?
Schedulers
and AAs
YES
To Pt
Check-in
Complete Forms
Register Pt
Identify Reason for
Visit
Does Pt
Have Films?
NO
NO
Verify Pt Info
YES
HMO
Insurance?
YES
Auth for
Clinic Visit?
Redirect Pt to Their
Referring MD or
Medical Group
NO
PPO
Insurance?
NO
YES
Determine Correct
MD
•Use MD protocols
•If HMO & no films
schedule with general
ortho
Schedule Appt
•Scheduling notes are
entered
Create Encounter &
Link to Appt
Provide Pt
Instructions
Create and Mail
Packet
•Parking
•X-ray
•Arrival time
•Address
•Co-pay
•Docs to bring
•Website...
•Confirmation letter
•Map of location
•MD questionnaire
•Consent for treatment
Verify Correct
Scheduling &
Authorizations
Print MD
Schedule
AAs
YES
Front Desk
Print MD
Schedule (if charts
are in clinic)
MAs
Pull Existing Charts
or Create New Chart
Submit Radiology
Orders if Needed
•Write Pt name on chart
•Include tabs, films, &
auths
•Sometimes new Pt
questionnaire
•Fax hardcopy or
submit in IDX
Send Charts to Clinic
if Needed
Print Encounter
Sheet
Add Encounter Sheet
to Chart
Print MD Schedule
•Demographics
•Labels
•Charge Doc
Pull Existing Charts
or Create New Chart
•Too much time spent on non-appointment issues
•Time wasted looking for authorizations
• Lack of trauma appt escalation process leads to 15+ minute phone calls for
needs
• Call abandonment rate: 8.6% (4Q-FY11)
• Mothly call volume: 8,000+
Action Plan:
Day Main Menu
Option "3"
Billing Inquiries
Option
"3"
Return to
Main
Menu
Option "1"
Physician Bill
Inquiries
Option "2"
Santa
Monica
Clinic
Task
Spine Phone Tree
Edit script & send to Debbie
Reduce the number of non-appointment incoming calls by 50% by
December 2011.
Spine Phone Tree
Program new script
PDCA / A3
Methodology
Spine Phone Tree
Record script
Spine Phone Tree
Go live
UCLA Orthopaedic Day Menu
•Phone options tree out of
order
•Callers automatically sent to
appt line if they wait more
than
4 seconds to make choice
•Lack of consistent discharge
process
•Unable to reach AA
•AA voicemail directions
unclear
•Clienttell may be confusing
FPG
Option "4"
Orthopaedic
Pediatric Clinic
Option "5"
Appointment
Scheduling
Pediatric
Appointment Line
Call Center
Option "2"
Ronald Reagan
UCLA Medical
Center Hospital
Option "3"
Santa Monica UCLA
Medical Center and
Orthopaedic Hospital
Ronald Reagan
Billing
Santa Monica Billing
Option "6"
Physician Directory
Physician Directory Attached
Option "4"
Return to Main
Menu
Call 310-319-1234
Do
Option "1": Repeat
Option "2": Return to Main Menu
Act
Solution/Initiative
Daily Huddles
Call 310-319-1234
Option "2"
Medical Records
Medical Records
Westwood
Clinic
Goals and Dashboard Metrics:
Analysis:
Date: 12/2/11
UCLA Orthopaedic Day Menu
Option "1"
Address and
Directions
Option "1"
Plan
NO
Are Charts
Located in
Project Team: Karen Meyers, Tina
Nguyen, Stephanie Ngo, Kelley WestGrant
Potential Solutions:
•Redesign options on phone tree
•Repeat main menu
•Include physician directory on
tree
•Standardize AA voicemails across
dept to include more information
•Set expectation for same
business day voicemail return
(before 3pm)
•Update Clienttell message to
include x-ray info
Active Daily
Management
Check
Who
Start
ECD
Done
Stephanie
11/18/2011
11/21/2011
100%
Debbie
11/18/2011
11/29/2011
100%
Veronica
TBD
12/9/2011
TBD
12/12/2011
11/18/2011
11/30/2011
Debbie
Spaghetti
Diagram
5 Why
Operational
Planning
Day Main Menu
Option "1"
Appointments
Option "2"
Hospital, MD office,
referring MD
Option "3"
Address & Directions
Option "4"
Orthopaedic
Pediatric Clinic
AA Same Day Callback
New voicemail script
Stephanie
AA Same Day Callback
Email instructions to AA
Tina
11/18/2011
12/1/2011
AA Same Day Callback
Record new voicemails
AA's
12/1/2011
12/6/2011
Call Center
Option "1"
Westwood
Clinic
Option "2"
Option "1"
Physician
Bill
Santa Monica Clinic
FPG
Option "2"
Ronald Reagan
UCLA Medical
Center Hospital
Option "3"
Santa Monica UCLA Medical
Center and Orthopaedic
Hospital Billing Inquiries
Ronald Reagan
Billing
Santa Monica Billing
Dashboard Metrics
% of non appointment related calls
Abandonment Rate
Baseline
53%
8%
Sustain the Results and Next Steps:
Target
26.5%
6%
Current
30%
5.8%
•Daily monitoring of metrics during huddle
•CICARE rounding
•Identify new phone system that would allow manager to interject in calls whne the call needs to be
escalated
•Evaluate phone tree monthly for glitches or new suggestions
Change Mgmt
Seeing With New Eyes
10
Seeing with new eyes requires an understanding that
activities either add value or waste…
Why?
This allows you
to focus your
resources (to
eliminate waste,
increase value,
or support
value)
• Waiting in general
• Waiting for orders to be written
• Late/missing callback for tests
• Clinical or operational errors
• Unnecessary documentation
• Unnecessary approvals
Activities that are Wasteful (any can be true)
• The patient is not willing to pay for
• That do not move the care process forward
• That are not done right the first time
WASTE
VALUE
• Comforting a patient
• Examining a patient
• Diagnosing a patient
• Treating a patient
• Educating a patient
Intro
Value
Analysis
Waste
Analysis
Activities that add Value (all must be true)
• The patient is willing to pay for
• That moves the care process forward
• That are done right the first time
RCA
RCA Causes
RCA –
Pareto
RCA –
Cause &
Effect
RCA – 5
Whys
11
Value-Added & Non-Value Added Example
Value-added Actions
1
3
Pt checks
in, pays
co-pay
2
8
MA takes
vitals and
rooms pt
Pt waits in
waiting
area
4
5
MD
completes
consult
Pt waits for
MD in room
6
Pt receives
AVS and
schedules
f/u appt if
necessary
Pt waits
7 Pt waits to
nurse/MA to
checkout
come and
complete
visit
Non-Value-added Actions
12
Waste models can help you identify/find waste
For “non-value added” activities, next you find/identify waste; this is made
easier by using a model such as DOWNTIME*
Mistakes, errors, resulting rework Producing too much, too soon, or excessive setup Actual downtime (patient, service, or production) Poor use of skills and talents, knowledge loss Moving things around Too much inventory, or too little People moving around, searching, etc. Duplication, unnecessary: refinements, approvals -
•D efects
•O verproduction
•W aiting
•N ot utilizing Talent
•T ransport
•I nventory
•M otion
•E xtra Processing
*Different systems classify wastes into different amounts of categories. Most use 7 (same as above but without N) or 8 but some use up to 11!
** There are different types of waste – Type 1 and Type 2. Type 1 adds no value and can be removed easily. Type 2 adds no value but is necessary in the current
system and/or is very difficult to remove. This distinction will become more important when focusing on solutions
Intro
Value vs
Waste
Waste
Analysis
RCA
RCA Causes
RCA –
Pareto
RCA –
Cause &
Effect
RCA – 5
Whys
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Eight Wastes in Ambulatory Processes…
Defects
Overproduction
Waiting
Not Utilizing Talent
▪ Incomplete Specialty
referrals
▪ Full sheet of labels
printed when only one
is needed
▪ Pt waits in exam room
for MD
▪ Numerous ideas are
“lost” only to be
rediscovered later
▪ MD/Nurse time spent
on clerical tasks
Transport
Inventory
Motion
Extra-Processing
▪ Patients are taken
from waiting room ->
vitals intake -> waiting
room -> exam room
▪ Expired supplies
because of excess
ordering
▪ MA/Nurse spends
time looking in
multiple places for a
particular supply
▪ Patients asked the
same questions
multiple times
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Waste Waste
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A3s and A4s are used to communicate progress
A4 Problem-Solving (8.5 x 11)
A3-Problem Solving (11 x 17)
Everyday problem-solving, consensus &
communication tool used by staff
Complex problem-solving, consensus,
communication tool
Known root-causes and solutions
Unknown root-causes and solutions
Quick and easy to use
Requires Planning (PDCA) and usually data
Example: Peanut butter and jelly sandwiches in the
RR.
Example: A unit wants to improve poor patient
satisfaction scores but they do not understand why
the scores are so poor or how to improve them
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We will be working with A3s today
A4 Problem-Solving (8.5 x 11)
A3-Problem Solving (11 x 17)
Everyday problem-solving, consensus &
communication tool used by staff
Complex problem-solving, consensus,
communication tool and project management tool
Known root-causes and solutions
Unknown root-causes and solutions
Quick and easy to use
Requires Planning (PDCA) and usually data
Example: Peanut butter and jelly sandwiches in the
SMH.
Example: A unit wants to improve poor patient
satisfaction scores but they do not understand why
the scores are so poor or how to improve them
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Project Charter
Project Charter
4W UPC Assaults A3
Vision Statement
The staff on the 4 West Child/Adolescent psychiatry unit will have resources, tools, and evidence-based protocols necessary to minimize the assault rate. At a minimum, the
unit will maintain assault rates lower than the NDNQI assault and assault with injury benchmarks. This will allow staff to deliver the highest quality of care to all patients and
minimize disruptions to the milieu caused by aggressive patients. Staff will feel safe while providing care to all patients and staff, patients, and visitors on the 4 West unit will
remain free from injury related to patient assaults.
Problem Statement
During the month of January, 4W recorded 38.2 assaults per 1000 patient days, and similar figures for the past two quarters (July-Sept= 58.3, Oct-Dec= 29.5), which are well
above the NDNQI of 18.6assaults/1000 patient days.
Objective Statement
Objectives
Criteria for Evaluation
1. Reduce the assault rate to 0 and maintain assault rates below the NDNQI
1. Assault rate
benchmark.
2. Documentation of protocols in CareConnect
2. Develop protocols for:
3. The number of patient groups canceled or relocated due to an aggressive patient
a. Handling aggressive patients
4. The number of times nonaggressive patients are relocated due to an aggressive
b. Staffing assignments for aggressive patients
patient
c. Lead RN rounding & Standard Work for aggressive patients
5. The number of times visitors are impacted by assaultive patients
d. Handoff consistency
6. Staff perception of safety on the unit
3. Improve staff safety on the unit as evidence by absence of staff injuries related to 7. Staff perception of lead nurse support related to care of the aggressive patient
assaultive behavior
8. Satisfaction/unit culture survey, nurse burnout
4. Improve staff moral as evidenced in the staff satisfaction/unit culture survey
9. Staff perception of interdisciplinary communication and collaboration related to
5. Improve interdisciplinary communication and collaboration related to treatment
treatment and management of aggressive patients
and management of aggressive patients
10. Information related to aggressive patients and assaults is communicated in huddles
Project Scope
Boundaries
In Scope
Out of Scope
Deliverables
Process Starts: When assignments
 CareConnect smart text
 New CareConnect build
 Evidence-based protocols for handling
are made by the off-going charge
 Leader Standard Work & Assignments
 Staffing ratios
aggressive patient, staffing assignments
nurse
 Plan of care & medications
 Relocation of the seclusion room
for aggressive patients, lead RN
 Huddles & Performance Boards
 Patient placement/admissions
standard work and rounds, handoffs
Process Ends: End of Shift handoff
 Assaultive patients room placement
 LOS: acute vs long term care
 CareConnect Smart Texts
Major Milestones
What
Fishbone Diagram Complete
Root Cause Analysis Mtg
Team:
Sponsor/Process Owner: Scott Grosz, MSN, RN
Sponsor/Physician: Mark De Antonio, MD
Team Leader: Kandace Whiting, MSN, RN-BC
Facilitators: William Taylor
Team Members: Jonathan, PhD, RN Quan Phan, BSN, RN, Joyce
Reinholdt, BSN, RN Lin, Brittany, MSN, RN Alaina Burns, MD,
Galya Rees, MD, Miranda Daniel, MSW
Other Stakeholders: Pat Matos, DNP, RN, NEA-BC
Who
Unit Staff
A3 Team
When
4/22/14
4/23/14
Team Roles:
Sponsor/Process Owner: (2-5 hr/wk) Provides leadership support; validates project objective and approach; ensures availability of
appropriate resources and support; helps to remove cross-functional barriers.
Sponsor/Physician: (min 1 hr/wk) Provide feedback on project direction and plans, build consensus with other physicians, promote
open environment for change, foster 2-way communication between all stakeholders
Facilitator: Partners with champion and team leader to manage scope, issues, and risk; works side by side with team; provides lean
coaching and consulting for project, challenges traditional thinking
Team Leader: (10-20 hr/wk) Partners with facilitator for the planning and the development of all project deliverables; responsible for
managing team members, implementation and sustaining gains Members: (5-10 hr/wk) Participate in project as requested by team
leader and facilitator – including: completing assigned work ; informing the project leader of issues, scope changes, risk and quality
concerns; communicating changes to peers
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PDCA – Continuous Improvement
• A structured guide and method for problem solving
• The way by which we should be practicing continuous
improvement in our daily work
Plan
Step 1
Step 2
Clarify the
Problem
Analyze
Current
State
Do
Step 3
Step 4
Step 5
Check
Step 6
Develop Analyze Implement Evaluate
Goals Root Cause Solutions Results
Plan
Do
Act
Check
Act
Step 7
Adjust,
Standardize
& Sustain