Diane Bissenden
Director, Population and Family Health
Vancouver Coastal Health – Richmond
Dr. Brenda Wagner
Chair, Richmond Medical Advisory Committee
Clinical Associate Professor, Obstetrics & Gynaecology
University of British Columbia
Laura Sato
Coordinator, Lean Transformation Services
Vancouver Coastal Health
February 28 th , 2013

How do you engage medical staff in yet another administrative process to drive patient safety and quality improvement?
How do you ensure sustained medical staff engagement in system redesign that is based on Lean principles?

Initial State :
• Medical staff disengagement as have lived through multiple administrative change efforts
• Improvements have been
‘tried before’ and not sustainable
• Long standing issues that have not been resolved and people didn’t believe the issues could be changed
Feedback from Medical
Staff
• “There is lack of physician engagement”
• “Management should make the changes and leave us alone”
• “Everyone else around the table is paid for being here except for physicians”

Ideal State :
• Medical staff engagement in
Lean as a unique and successful change management process
• Improvements are sustainable
• Long standing issues are resolved and medical staff believe they are part of the change
Target State :
• One medical staff member from each relevant discipline will engage in the process i.e. family practice, midwifery, obstetrics, paediatrics, and anaesthesia
• Process inspires ongoing engagement

Provide quality family centred care for women and their families
Promote people first
Enhance capacity of the interdisciplinary team to use their talents to its full potential
Embed Lean thinking at all levels to fulfill objectives and to deliver quality outcomes

• Increase capacity to do Caesarean Births and recovery in the Birth Centre
• Build processes to manage surges
• Provide timely outpatient services
– Triage, assessment, non-stress tests & inductions of labour, etc.
• Standardize processes from decision to
Caesarean Birth

• Medical Staff
– Obstetricians
– Family Physicians
– Paediatricians
– Midwives
– Anaesthesiologists
• Nursing Staff
– OR/ PACU/ Birth
Centre/ NICU/ Staff
Support Coordinators
• Allied Health Staff
– Respiratory
Therapists, Social
Work, Laboratory
Services
• Support Services
– Housekeeping, Unit
Aides, Sterile
Processing Aides, Unit
Clerks, Medical Office
Assistants

• Physician co-sponsor on the team
• Funding for medical staff time spent in Lean initiatives
• Off site obstetrician & anaesthesiologist meeting on Code
Pink & Skin to Skin in Operating Room
• Ad-hoc meetings during down times with on-call medical staff (end of the day)
• Hallway conversations (1:1)
• Feedback obtained during observations (1:1)

• Arrange Working Group Meetings around medical staff schedules:
– Lunch times & end of the day
– Organize meeting agendas so physicians can attend at times when their key issues will be highlighted
• Mixture of 2 hour, full day & ½ day workshops
• Piggyback on existing medical staff meetings
• Provide ample notice for meeting invitations
• Invite medical staff in person
• Invite on-call medical staff

• Process improvements occurring in tandem with Lean
Management
– Using Lean Management approach based on
ThedaCare Model
– Three physicians attended Lean Management education
• Applying Lean principles to clinical office setting
• Organization investing in physician education in order to support improved patient care
• Physicians feel part of the team

Obstetrical emergency requiring imminent delivery of baby
Better response time
Better outcome for patient
Better team

OB (co-pilot)
-Provides direction to the team
-Verbal consent & explanation
-Primary RN gives report
-Site mark?
Anaesthesiologist
(co-pilot)
-Greets pt
-?who can get the meds the quickest
-Check equipment
-Receive report from
OB
Paediatrician
-Prep for baby resuscitation
-Double check ICC
-Primary RN gives report

Initial Mock
Noisy – lots of talking
Repeating questions multiple times
Post - Actual Code Pink
Calm & quiet
Lots of double checking
Too many people in the room
Staff know what to do
Duplicated work- # of people doing the same thing
Roles and responsibility clarity
Trusting environment

Keeping mothers and babies together after birth encouraged me to participate
Best thing was seeing the capacity we have within our frontline staff to make changes happen. This is the power I see Lean harnessing that I have never seen harnessed before.
Doctors see the satisfaction their patients and babies are kept together. This satisfaction is encouraging the doctors.
“…..If you want to show us this is different, fix the problem no one has been able to fix in 20 years emergency caesareans”. This physician now states with enthusiasm that LEAN is making a big difference and we are being successful.
Sessional payments are helpful and meaningful
I have been
“blown away” by the improvements during the past year

Indicator Baseline % Target ∆ Outcome ∆
Reduce the Birth Centre
OR Turnaround time
% of Caesarean Births done in BC OR
3:30 h
27%
↓ by 50%
↑ by 50%
Code Pink Response
Time (Decision to Baby born)
Medical Staff
Engagement
30~ minutes
4 per engagement opportunity
↑by 200%
*30 day data
1:30 h
(138%↓)
75%
(185% ↑)
18 minutes*
(↓ 40%)
400%

• Strong physician, director & manager leadership
• Strong relationship between medical staff and clinical resource nurse (over 20 yrs)
• Operational and medical staff leadership “Walk the Talk”
• Engaged and stable team (low turnover)
• Project leadership share successes
• Organizational commitment in form of individuals with expertise in lean thinking

• Setting the stage at the beginning of every session, no matter where you are in the process
• Simple is usually complex
• Don’t get discouraged when things get “messy” – trust the process
• Medical staff participation in all aspects of the Birth
Centre quality improvement initiative adds value and strengthens team relationships
• Deeper level of engagement and pride in the change, through doing together
• Continuous improvement is embedded in the culture of the Birth Centre

• Be flexible with meeting times
• Invite people personally
• Sometimes a different venue can overcome obstacles
• Projects identified by frontline staff as “unfixable” will convert the hard of heart
• Practice, Practice, Practice
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