OPEx: OHSU Performance Excellence
OHSU’s Lean Journey
Future
2015
2014
2013
2012
Leaders in Healthcare
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Practice Optimization
(Lean for Ambulatory)
Joan Wellman and Associates Engagement
South OR Value Stream
Grass‐Roots & Foundation
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2010
OPEx University
Pilot DMS
Large‐scale 5S Events
Breakthrough Kaizen Events
Hematologic Malignancy Value Stream
Foundation & Consultation
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2011
Inpatient Flow
Inpatient Optimization (building from Releasing Time to Care)
Level Loading
Integrated Facility Design (CHH)
Leader Standard Work
Robust DMS
Gemba Time
A3 Problem Solving
Strategy Deployment
Cardiovascular Value Stream
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Change Acceleration Process (CAP Workshops)
Releasing time to Care (Lean for Nursing)
Project‐based Improvements
Lean Training
90‐Day Plans
Change how we work
Typically first part implemented
Most discussed
Least important part of improvement efforts
Supports the Management System and Mindset Management System
Change how we monitor and approach our work
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Structures strategy deployment
Operationalizes use of methods
Supports continuous improvement
Mindset
Change how we think about the work we do
Basics
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Methods
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Integration & Reliability
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OPEx Components
True North
To be in top 10 University HealthSystem
Consortium ranked hospitals.
Pillars
Safety
Ensuring patients receive reliably safe care
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Most important element
Most challenging component
Amplifies success Management System and Methods
Requires long‐term effort
Quality
Ensuring patients receive consistent, evidence‐based care
Service
Excellence in patient experience and access
Affordability
Improving outcomes while managing cost
Foundation
Engagement
Leveraging and investing in human capital
Innovation
Employee‐driven improvements and cutting‐edge research
Education
Growing employees and future healthcare providers
Check out posters explaining Kaizen, Daily Management System, 5S, and Value Streams.
Value Streams
What is a Value Stream?
Value Stream Process
From the patient’s perspective, the path by
which they travel (physically or virtually) to
receive the product(s) or service(s) they need.
Timeline of a Value Stream:
Selection:
Traditional Organizations:
Launch:
Each step of a patient’s visit is operated, analyzed, and optimized in a silo
ED
ICU
IP Unit
Home
Education:
Project Work: Pharmacy
Value Stream Thinking:
All activities involved in a patient’s visit, including their return to the community, are viewed together to better consider patient progression, care coordination, and improve visibility for quality and safety opportunities
ICU
2‐3 month period clarifies the scope of the Value Stream, maps processes at a high level, and identifies areas of opportunity
Key team members participate in OPEx Leader Training sessions and study visits to other leading organizations
Lab
ED
The Value Stream is identified by the OPEx Steering Committee
IP Unit
Lab
Pharmacy
Home
18‐30 month period of Breakthrough Kaizen Events (about once a month) and other Kaizen and 5S Events
Sustainability:
Output from every event includes components of Daily Management Systems to ensure that improvements are maintained and improved further
Transformation:
It is the objective of the value stream to transform the operation’s performance as well as its methods, management system, and mindset
Why Value Streams?
• Act as a learning laboratory for the organization
• Are tested and stressed to drive the system to transform
• Accomplish breakthrough results
• Surface opportunities in connected areas and teach those areas through their Daily Management Systems
OHSU Value Streams
South OR:
• Launched December 2012
• Visibility Boards at KPV 5th Floor
Hematologic Malignancies:
• Launched Fall 2013
• Visibility Boards in CHM Clinic (MNP) and 14K
Knight Cardiovascular Institute:
• Launched Summer 2014
Inpatient Flow
• Launched Fall 2014
• https://bridge.ohsu.edu/health/opex/IFV
S/SitePages/Home.aspx)
Check out posters explaining OPEx, Kaizen, Daily Management System, 5S, & Leader Standard Work.
Hematologic Malignancies Value Stream
Cindy Grueber
Ann Raish
Peggy Appel
Executive Sponsor
Sponsor
Value Stream Manager
14K Key Improvements
CHM Key Improvements
HMVS in 2015
Scheduled Rounding
The Inpatient Rounding event focused on
including staff nurses and pharmacy on rounds,
facilitated by following a rounding “schedule.”
Also, afternoon Lightning Rounds help establish
the rounding schedule and improve discharge
planning.
Percentage of Time Nurse Is Present
When Team Rounds on Patient
Level‐Loading
CHM has made considerable progress towards
an ideal level‐loaded system. Major changes
include staggered patient arrival times for both
clinic and infusion to alleviate bottlenecks
around check‐in and patient preparation.
Maximum Number of Patients Scheduled to Arrive for Check‐In at One Time (2 PAS Staff)
Hematologic Malignancies patients are cared for
as inpatients primarily on 14K and as outpatients
at the CHM Clinic/Infusion Center. However, the
average daily census for inpatients exceeds the
total capacity on 14K, leading to HM patients on
multiple other nursing units. In addition, CHM
operates beyond scheduled “capacity” on a near
daily basis. Improving the current state on 14K
and at CHM will be measured by two metrics in
2015.
<10% → >80%
Discharge Zone
The Inpatient Discharge Kaizen established a
“Discharge Zone” for patients within 2‐3 days of
expected discharge to help structure the work
required for a smooth process without delays. A
Milestone Board in the patient’s room helps
improve communication with patients and
caregivers about progression towards discharge.
Average Time from Clinically Ready for Discharge to Actual Discharge
147 min → 102 min
Epic Rounding Report
The Inpatient Provider Documentation project
identified wastes associated with collecting data
and information before and during rounds. An
Epic Rounding Report was designed to display
multiple key data elements in a single location and
reduce time spent “chart surfing.”
10 → 4
Just‐in‐Time Nurse Assignments
CHM Infusion developed a Complexity Scale to
quantify the nursing time required for a variety
of treatments. This scale is then used to assign
nurses as patients arrive and evenly distribute
workload across the staff.
Nurse Subjective Assessment of Workload
Scale of 1 (Low) to 3 (High) with a Target of 2
2.6 → 2.0
Treatment Location Committee
The Inpatient to Outpatient Shift Kaizen
developed a process to systematically analyze
treatments from clinical, social, financial, and
other perspectives to determine if the setting of
care should be shifted from inpatient to
outpatient. Four regimens have been evaluated;
two approved for pilots; and one pilot approved
for full implementation in January 2015.
Shift Setting of Care from
Inpatient to Outpatient
One strategy to reduce our number of inpatient
days is to, when possible and appropriate, shift
the setting of care for a treatment or service from
inpatient to outpatient.
Increasing CHM Capacity
To accommodate the increasing demand on
outpatient services, outpatient capacity must
improve. Through waste reduction and process
improvement, this capacity increase will be
achieved ideally with minimal cost increases.
Inpatient Flow Value Stream
Megan Boyle, Hue Chiang
Problem Statement
Areas of Opportunity
Results
Hospital capacity is not meeting patient demand, leading to boarding patients, postponed/cancelled surgeries, and patients staying in their own communities longer than providers would like them to.
Inputs: No standards around level loading, communications, patient placement prioritization
Outputs: Discharges are not prioritized and unnecessarily complex
Management systems: No standards around capacity management (Diverts, Andon, Communication)
• Work gets pushed to the evening when there is less staff
• Planning for home starts too late (no upfront mobility plans, milestone markers, education)
• No standard for interdisciplinary communication
November: The value stream improvement team mapped the value stream and identified the problems
December: The value stream improvement team prioritized and sequenced the work
January: The Inpatient Flow Value Stream bridge site and dashboard was created (https://bridge.ohsu.edu/health/opex/IFVS/Site
Pages/Home.aspx)
Discharges are batched and done late in the day when there are less resources and patients waiting to get admitted. Patients stay in the hospital longer than medically necessary.
Target State
Safety: No increase in readmissions
Quality: 80% accuracy on discharge predictions
Service: Decreased ED Boarding time and batching of discharges
Affordability: LOS from 6.1 days to 5.15 days, increased number of admissions
Improvement Projects
Next Steps
February: The first 2 events will be kicked off
Knight Cardiovascular Value Stream
Sanjiv Kaul, Chuck Kilo, Joaquin Cigarroa, Greg Lampros, Judi Workman, Miranda Fraundorfer, Kristi Hanson
Problem Statement
KCVI currently functions within 8 different subspecialties, 3 clinics, and 2 inpatient care areas that are very procedure focused. Patients come into the system through a variety of entry points, and due to a lack of standards, they receive different care, which leads to silos and fragmentation.
Target State
To operationalize a comprehensive disease state approach when caring for patients that is driven by standardized clinical pathways, and ensures transitions of care maintain a seamless flow. This will include transitions back to the community, thereby building trust and enhancing relationships with referring providers. Initial areas of focus are: • Complex Heart Valve
• Aortic
• Heart Failure
• Arrhythmia Success will be indicated by the following:
• Improve Overall Patient Satisfaction
• Increase Market Share • Increase Access
• Improve Safety and Quality of Care
• Be in the top 10% of hospitals for all publicly reported quality and patient safety metrics • Reduce Cost of Care by 10%
Improvement Projects
May‐14 ‐ KCVI Value Stream Assessment/ Mapping/ Aug‐14 Alignment Complex Heart Valve (CHV) ‐ Standardize
Referral Requirements / Communication
Sep‐14
CVICU ‐ Standardize Provider Documentation CHV ‐ Improve Follow‐Up Care Aortic ‐ Alignment Oct‐14
CHV ‐ Identify One Location for Evaluation Activities Nov‐14 CHV ‐ Improve Clinic / Evaluation Flow Aortic – Build Standards for Capturing Registry Data Dec‐14
CHV ‐ Standardize the Medical Review Process Jan‐15 CHV ‐ Standardize Inpatient Pathways CHV ‐ Standardize Patient / Family Feb‐15
Education Aortic ‐ Build Aortic Center Leadership & Mar‐15 Support Struture CHV ‐ Improve Pre‐Op Flow Aortic ‐ Define Aortic Inpatient Apr‐15
Management Aortic ‐ Standardize Inpatient Pathways May‐15 Aortic ‐ Standardize Referral & Surgery Scheduling
Aortic ‐ Standardize the Medical Review Jun‐15
Process
Jul‐15 Level Loading the KCVI Clinics Aug‐15 ‐
Complete Remaining Aortic Work Dec‐15
Initial Results
South OR Value Stream (since 2012)
Rayna Tuski and Randy O’Donnell
Problem
Target State continued…
Results
The patient moving through the value stream is delayed and fragmented. This is the result of non‐standard work and poor communication.
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Standards require doing the same work the same way every time
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Innovation comes from planning, experimenting and observing
Management System
Barriers surfaced & resolved, standard work confirmed, metrics reviewed, staff engaging. •
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the OPEx House)
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Value is defined by our patients
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Leaders facilitate learning and engaging everyone in continuous improvement
Our management system fosters an environment of self accountability and self regulation
Metrics
Areas of Opportunity & Improvement Projects
To excel at creating value, we must constantly improve
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There is only one customer, our patient
Minimal patient waiting
Right patient at the right OR site We view problems as treasures and opportunities
We have transparency of data and feedback, visually managed
We remove barriers to performing standard work (it’s easier to do the standard than to not)
For all of us to excel, each of us must learn, teach, and lead
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Target State (South OR’s explanation of Work facilitated by visual cues
Clear systems and standards to achieve benchmark patient experience and surgical quality
Problems are opportunities: The only failure is not trying to improve
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Standard work is defined and followed Timely and accurate information regarding surgical procedure, instruments, supplies, duration, special requirements; and the patient’s medical information (components of pre op check list, H&P)
Efficient operations through just‐in‐time flow of personnel, materials, supplies, and equipment
Level loaded
Cycle times / standard work
Improvement depends on standards and thoughtful innovation
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Standard work is the basis for improvement
Safety of staff and patients ensured Next Steps
1. Standardize intra‐op work
2. Level Load the OR operations
3. Continue to strengthen the
Daily Management System
4. Surface and address barriers
Act
Plan
Study
Do
Ambulatory Services Strategic A3
Judy Carlson, Kevin O’Boyle, Stephanie Winchester
Jared Davis, Gretchen Landgraf, Travis Wilds
Problem Statement
Areas of Opportunity
OHSU Ambulatory Services consists of over 70 independent
practices that strive to provide a consistent, high quality
experience for our patients. Ambulatory practices suffer
from a lack of standardization, alignment, and
resources/tools necessary to meet the Ambulatory
Strategic A3 goals.
Results
Practice Variation in pt flow/mgmt
Press Ganey Rank Scores (Q1 FY 14‐Q2 FY 15)
0.8
Lack of training and incentives for staff
0.7
Part‐time providers
Variable perspectives on practice mgmt RVU‐based reward system
Managers aren't trained in PI
Target State
Lack of consequences for poor performers (except MIP)
Hospital’s True North Goals
Variation in Mgmt structures 0.4
Patients informed
of wait time/delays
0.3
Practices not achieving Ambulatory A3 Breakthrough Goals FY 14‐15 Improvements
 Check‐in standard work
 Rooming Standard Work
 Communication of Provider wait Time
 Team communication of patient progression
0.2
FY14 FY14 FY14 FY14 FY15 FY15
Q1
Q2
Q3
Q4
Q1
Q2
Poor access to data/measurement systems
Lack of tracking external referrals
Goals
Overall patient
experience
0.5
Incentives through SOM
Variation in readiness for change
Goal = 60%
0.6
Quality support under‐resourced Two/Four Day Referral Metrics (Q1 FY14‐Q2 FY 15)
Improvement work is an unfunded mandate
Goal = 80%
Evaluated only by budget numbers, not PI, etc
0.8
FY 14‐15 Improvements
 Referral Scheduling Standard Work
 Referral Queue Fix‐It Team Ambulatory Goals
% of patients
contacted by the
2nd day
0.7
0.6
% of patients
appointed by the
4th day
0.5
Means to achieve the goals
Practice’s Goals
FY14 FY14 FY14 FY14 FY15 FY15
Q1 Q2 Q3 Q4 Q1 Q2
Improvement Projects
Focus on patient experience, access, and consistent service delivery
Appointment Lag (Q1, FY14‐Q2 FY15)
30
FY 14‐15 Improvements
 Improved Access Plan (planned)
 Referral Scheduling Standard Work
 Level Loading (planned) 25
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1
Engagement
• Level Loading Kaizen Rollout Strategy for FY 14‐15
• 100% practice leaders enroll in OPEx education • 100% of leaders practice Leader Standard Work
0
FY14 Q1
    4 Hold Level Loading Events
FY14 Q2
FY14 Q3
FY14 Q4
FY15 Q1
FY15 Q2
Next Steps
5 Roll out Referral Standard Work and SW confirmation
    6 Design future state ambulatory leader plan
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February
 7 Rollout enhanced Leader Standard Work
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8 Create ED & Hospitalization Follow Up Standard Work
9 Standardize Care Management processes
10 Standardize ED, Urgent Care avoidance practices
   11 GIM template improvement (Dr. Bonazzola's team)
TBD
Metrics
Oct‐15
Dec‐15
Jun‐15
Feb‐15
Target Dates
Apr‐15
Major Tasks
Major Tasks
Aug‐15
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Safety
Service
Affordability
Engagement
Affordability
• Exam Room Utilization (ex. visits per 1/2 day session or unbooked exam room) – Goal TBD
• Resource Consumption – Goal TBD
Goal = 14.8 Days
5
2 Develop resource consumption metric
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15
10
Develop safe staffing requirement
    3 Determine Level loading event calendar
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Access
• Median Appointment Lag Time ‐ new vs. return <14 days for all practices
• Practices achieve the referral metric goals at least 80% of the time:
• Patient Contact (w/in 2 days of referral)
• Patient Appointment (w/in 4 days of referral)
Project Completed By
Major Tasks
Days
Objectives
Major Tasks
Ambulatory Services A3 Goals Service
• Practices consistently achieve 60% on Press Ganey Rank Scores in: • Overall Satisfaction Measure
• Communication About Delays
20
Level Loading Pilot April
– Diabetes and Level Loading Pilot June
Endocrinology Evaluation and Center
Level Loading Rollout Planning
Rollout Continued Referral Ambulatory Scheduling Leader Standard Practice A3 Goal Standard Work
Work Point Enhancement Define Improvement Continued Affordability and Projects Safety A3 metrics
Leader Standard Roll out FY 16 Ambulatory Work Strategic A3 Enhancement
August
Level Loading Rollout Continued Ambulatory Practice A3 Goal Point Improvement Project
TBD A3: Venous Thromboembolism (VTE) Core Measures
Deborah Eldredge, PhD, RN; Dio Sumagaysay, MS, RN; Tashina Sharp, MS, RN; Cheryl Wyborny, MPH, RN
Problem Statement
Areas of Opportunity
OHSU is performing below target (100%) on venous thromboembolism (VTE) Core Measures
Results
Goal – 100%, Current rate – 96%
Target State
To achieve 100 % on all process measures:
• Pharmacologic and/or mechanical prophylaxis on patients >18 on acute & critical care nursing units
• Pharmacologic overlap therapy for 5 days in patients with confirmed VTE and/or pulmonary embolism (PE)
• Written instructions provided to patients with confirmed VTE at discharge including: compliance, dietary advice, follow‐up monitoring and drug ‐ drug interactions
To sustain 0% on outcome measure:
• Preventative pharmacologic and/or mechanical prophylaxis was administered to patients prior to incurring VTE /PE during hospitalization
VTE Composite
100%
90%
80%
70%
60%
50%
Improvement Projects
• Nursing and clinical technology to collaborate to reduce sequential compression device (SCD) breakage.
• Nursing and Operational Effectiveness to ensure all RNs and CNAs complete Compass training of VTE prevention.
• Epic workflow analyst to partner with workgroup to identify, build and implement decision support. • Nursing Informatics to modify VTE prevention dropdown menu options in Epic to support timely and effective documentation of applying SCDs.
Next Steps
Provide education on VTE prevention to all staff and physicians involved in the care and treatment of patients >18.
Leverage Epic to support VTE prevention documentation.
Make sure adequate numbers of properly functioning SCDs are available on the nursing units.
Continue to monitor performance and provide feedback to staff and physicians when evidence based practice is not followed.
Surgical Site Infection Prevention
Dr. Renee Edwards, Dr. Daniel Herzig
Brenda Quint‐Gaebel, Gretchen Landgraf
Problem Statement
Areas of Opportunity
OHSU’s number one goal in the Clinical Enterprise Strategic Plan is to achieve a top 10 ranking in the University HealthSystem
Consortium (UHC). Currently, it is ranked 27/73 with respect to Surgical Site Infection (SSI) rates for colon and abdominal hysterectomy surgeries with a Standardized Infection Ratio (SIR)* of 0.75.
Variation in pt. prep (PMC)
Batched SSI data from lab
Standard bowel prep
Pre‐op and Intra‐op skin prep
Antibiotic selection, dosing, and discontinuation
Colon & Abd Hyst SSI rate higher than UHC top 10 goal
Nursing variability in practice
High BMI
*Standardized Infection Ratio = Observed SSIs
Expected SSIs
# of SSIs 2
1
1.82
0
Q1‐2013
2.22
1.82
0
0
1
2
Q2‐2013
Q3‐2013
Q4‐2013
# of SSIs
1.89
1
Q1‐2014
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
S
S
I
R
A
T
E
OHSU Adult & Peds Colon SSIs (Q1, 2013 ‐ Q2, 2014)
10
10.00
8.65
9
9.00
8
8.00
6.48
# of SSIs
7
6
5.56
7.00
5.45
6.00
4.65
5
5.00
3.41
4
3
3.00
2
1
4.00
2.00
7
7
6
4
9
3
Q1‐2013
Q2‐2013
Q3‐2013
Q4‐2013
Q1‐2014
Q2‐2014
0
S
S
I
R
A
T
E
1.00
0.00
# of SSIs
Focus on standardizing best practices in pre‐, intra‐, and post‐op phases of care
Improvement Projects
Pre-Op (PMC or
Surgery Clinic or
Inpatient Unit)
Q2‐2014
SSI Rate
• Pt. skin
cleansing
• Glycemic
Management
• Standard
Bowel Prep
(13y.o.+)
Pre-Op (6A, day
of surgery)
• Pt. Skin
Cleansing
• Glycemic
Management
• Patient
Warming
• Antibiotic
prophylaxis
prep
Intra-Op
• Standard
wound care
• Glycemic
Management
-TBD
• Patient
Warming
• Standard
Antibiotic
prophylaxis
• Clean/Dirty
Instrument
Separation
SSI Rate
Target State
• SSI SIR < 0.37 for patients undergoing colon and abdominal hysterectomy surgeries
• Be among the top 10 UHC institutions
• Standardize community best practices for SSI prevention
Standardize:
 Patient Skin Cleansing with CHG
 Bowel Prep
 Periop Glycemic Management
 Antibiotic Prophylaxis
 Wound Care
 Patient Warming
 SSI Surveillance and Case Review
• Surgeons received individual SSI rates • Case reviews & learnings shared with surgeons, Anesthesiology and nursing staff.
• Surgeons, nursing, anesthesia providers support establishing an SSI prevention bundle
Q3‐Q4, 2014 SSI rates to be reported in early 2015
Variable pt. flow to OR
OHSU Abd Hyst SSIs (Q1, 2013‐Q2, 2014)
3
Results
Post-Op (PACU +
Ward+ Surgery
Clinic)
• Standard
wound care
• Glycemic
Management
- TBD
• Patient
Warming
• SSI
Surveillance
and Case
Review
Next Steps
1. Concurrent monitoring of bundle compliance 2. Earlier identification of SSI cases
3. Home wound care – Case Management 4. Periop Glycemic management implementation (see graphic below)
Iatrogenic Pneumothorax Strategic A3 Project
Nancy McCully, MSN, MBA, RN, CCRN; Erin Reback, RN
Hai Molinaro, Brenda Quint‐Gaebel and Matthias Merkel, MD PhD
Problem Statement
Improvement Projects
Results (continued…)
University Healthcare Consortium (UHC) data demonstrated that our patients were exhibiting a higher rate of Iatrogenic Pneumothorax (I‐
PTX) as compared to our Top 10 UHC peers. We recognize that I‐PTX will increase length of stay, increase tests/interventions, can lead to more complications, and decrease patient satisfaction. • Assure compliance with new Central Venous Catheter Placement and Follow‐up Policy
• Standardize documentation for central venous catheter (CVC) placement and Dobhoff tube (DHT) placement
• Require CVC training for new LIPs and for LIPs with low CVC placements
• Standardize DHT placement • Implement algorithm for care escalation for difficult DHT placement • Standardized access approach in EP lab
• Proactively identify preventive measures for surgical procedures Implemented hospital‐wide standards and expectations for staff training in central venous catheter (CVC) placement and Dobhoff tube (DHT) placement
• Simulation training for central line placement expanded to include APP and faculty
• Algorithm for site selection of CVC insertion reducing subclavian vein catheterization
• Algorithm for escalation of difficult feeding tube placement • Standard documentation of CVC placement to promote standard workflow and improved data tracking
Results
Next Steps
Target State
To achieve UHC Top 10 status, we must have a less than 0.1 incidence rate of reportable I‐PTX.
Areas of Opportunity
A drilldown of the UHC reportable cases of Iatrogenic Pneumothorax for FY12, FY13, and FY14 YTD show the following causes:
1. Central Venous Catheter (CVC) placement: the number subclavian lines placed were one‐tenth the number of internal jugular lines placed with double the incidence rate, poor documentation of placement 2. Dobhoff tube (DHT) placement: poor documentation of placement and number of attempts, multiple placement attempts, escalation process unclear for multiple failed attempts. 3. Pacemaker / ICD Placement: lack of standardization in training of fellows, multiple placement attempts
4. Surgical procedures: entering the pleural space during surgery due to increased complexity or unanticipated complication
Implemented standard for training fellows in pacemaker placement
0.1
Implemented Central Venous Catheter Policy • Roll out Risk Stratification Tool and Consultation Protocol for DHT placement
• Continue to refine standards for CVC placement and DHT placement as these standards become more widely adopted at OHSU • Epic Documentation of OG/NG/NJ Procedure note for DHT placement and DHT LDA
• Establish training program for US‐guided SC vein cannulation
• Continue to work with surgical teams on rare surgery‐specific I‐PTX
• Ongoing monitoring of reportable UHC I‐PTX cases • Monitor staff compliance with policies and protocols
A3: Perioperative Hemorrhage & Hematoma Paul Flint, Ericka Mitchell, Karoly Crawford, Dan Kenron
Problem Statement
Improvement Projects
To achieve UHC Top 10 performance in the AHRQ Patient Safety Indicator – Perioperative Hemorrhage & Hematoma (PSI‐09).
Documentation & Coding
‐ Disconnect between documentation and coding: define what constitutes a “hemorrhage” or “hematoma” Target State
To reach the UHC target, OHSU must have 5 or fewer Hemorrhage/Hematoma events per month (15/quarter) to achieve the quarterly target of 7.4 per 1000.
To achieve UHC Top 10 standing, OHSU must have less than 1.6/1000 events per month (4.8/quarter) to achieve a O/E ratio of 0.60
Areas of Opportunity
Root cause analysis led to focusing on three areas of opportunity:
• Documentation and coding
• Early vs. Delayed Hemorrhages
• Postoperative pain control
‐ Documenting planned re‐
operations for bleeding and clear relation to primary procedure
Results
Next Steps
Revision of Univ. of Michigan Health System’s Guidelines for Coding Postoperative Complications (2011). Used with permission.
Postoperative pain control
‐ Establish pain control for Otolaryngology patients ‐ hypertension due to uncontrolled pain increases chance for hemorrhage
• Continue to track instances of Peri‐op hemorrhage/ hematoma
• Establish workflows for prospective (before UHC submission) of Peri‐op hemorrhage/ hematoma cases
• Understand emerging trend in hysterectomy surgeries and hemorrhage/hematoma
A3: Postoperative Respiratory Failure Matthias Merkel, Christopher Dodgion, Dan Kenron, Jennifer Watters, Karoly Crawford, Michelle Dedeo, Paul Lopinski, Stephanie Nonas
Problem Statement
Areas of Opportunity
To achieve UHC Top 10 performance in the AHRQ Patient Safety Indicator ‐ Postoperative Respiratory Failure measure (PS‐‐11).
Intraoperative Ventilation
‐ Tidal volume per body weight settings not <=8mL/kg
‐ PEEP settings ≤ 5
‐ Ideal body weight documentation
Target State
Ventilation wean
‐ Spontaneous Breathing Trial not performed
To reach the UHC Target, OHSU must have fewer than 6 Respiratory Failure events per month (18/quarter) to achieve the quarterly target of 16 per 1000.
Documentation & Coding
‐ Disconnect between documentation and coding
‐ copy forward of progress notes
‐ definition of diagnoses
‐ Smartphrase in Epic does not have correct language
‐ Lack of education: proper documentation for proper coding
To achieve UHC Top 10 standing, OHSU must have fewer than 2.5 events per month to achieve a O/E ratio of 0.49; quarterly, this target is 9 per 1000.
Sedation used ‐ Intra‐operative
‐ Post‐operative
‐ Daily sedation hold not occurring
Improvement Projects
• Validation work queue for proactive Quality Specialist review
• MD review team for case review
• Spontaneous Breathing Trails (SBT) & Epic improvements
• Understand & Track reasons for failure
• Documentation handbook to define “respiratory failure”
• Collaboration with Coding on PSI‐09 measure
Results
Clinical review of Occurrences
Next Steps
1.
2.
3.
4.
5.
6.
Present to All‐Hill ICU M&M on Jan 21st
Continue to work with RT to improve SBT trials
Improve data integration in Epic with ICU Navigator
Be perfect: no patient outside of 90% O2
Case review by ICU Fellows and vent patients discussed at huddles
Reporting on continued success at M&Ms
Kaizen
[ kahy‐ZEN ]
What is a Kaizen?
Kaizen is a Japanese word
meaning “good change” and
often used to communicate
“continuous improvement.”
A Kaizen Event is a
performance improvement
event lasting anywhere from
several hours to several days to
continuously improve
processes.
It requires involvement from all
levels of workers.
No matter the size, the same
problem solving steps are
completed
Phases of Kaizen Events
Assessment
Planning
Refine
Refine
Assessment
Planning
Act
Plan
Act
Plan
Study
Do
Study
Do
Evaluate
Sustain
Kaizen
Event
Evaluate
Sustain
Kaizen
Event
The Improvement Process
Encountered
Current State
Improved State
Obstacle
Perfection
Understand and overcome
Assess, Plan
Discovery, Design, Implement
Kaizen Event
Leading up to the Kaizen Event,
there is an assessment of the current
state and planning of the event.
The yellow signifies that we go slow
with assessing the current state so
that we can go fast with the
improvement.
How is OHSU using Kaizen
Events?
• OHSU has been using and
learning about Kaizen Events as
an improvement method since
2011
• Kaizen Events are conducted:
o 1/mo per value stream
( 48/ year)
o Across ambulatory care
o On hospital units (HAI
Reduction, Patient Experience
Improvement, Lunches &
Breaks, Documentation &
Coding, Supply Outdates,
Clinical Alarm Safety)
o Unit/Department-specific
(Mother Baby Unit Length of
Stay, Interventional Recovery
Unit Scheduling, Labor &
Delivery C-section
improvement, GI Patient Flow
o Various 5S events
Check out posters explaining OPEx, Daily Management System, 5S, Leader Standard Work & Value Streams.
Looking With New Eyes… At Things That Can’t Be Seen
Preventing Healthcare Acquired Infections at OHSU
HAI KAIZEN UNITS
Problem Statement
Areas of Opportunity
Healthcare Associated Infections 4th Leading Cause of Death “There is no more vulnerable population than the hospital patient, who is terrified of acquiring a hospital infection, yet powerless to avoid it. Making us aware of your concerns, and letting us know that you follow clear, consistent hygiene procedures, shows us you care. It helps make us a part of the team. It lets us know you acknowledge there is a serious issue, and you are working to fix it.”
~OHSU Patient
Target State:
• Achieve or maintain ZERO
Healthcare Associated Infections
• Create a Culture of Safety
• Improve Team Communication & Collaboration Improvement Projects
Results: HAI Kaizen Units:  “You can feel the culture and engagement of the team members in protecting our vulnerable patients by improving processes.” Infection Preventionist, after rounding @ OHSU Weekly Interdisciplinary Improvement Huddles
• Celebrating successes with implementing standard work that prevents infections • Identifying variations in practices that put vulnerable patients at risk • Planning rapid cycle improvement steps  Healthcare Infection Prevention Champions leading team members in early identification of patients who have gotten an HAI , thus facilitating early treatment “I’ve Got Your Back”
Team members speaking up to keep each other safe:… Ask a question Make a Request
Express Concern
Chain of Resolution
 Over 60 Interdisciplinary Case Reviews have identified issues for focused improvement: • Inconsistent bathing & perineal care • Inconsistent documentation raises concerns about consistency of care Next Steps
• HAI Kaizen Spread to all inpatient units
• More units being transparent in acknowledging to patients when an HAI occurs and committing to them to continue to fix any issue. Daily Management Systems
Tiered Huddle Structure
Standardize and Improve
Ongoing Improvement Efforts
Principles
• Design work to surface problems as they occur
• Develop problem‐solving capabilities
• Create and follow leader standard work
1.
1.
Escalation Process
a. Introduced blue dot to distinguish between issues that need to be escalated and those that do not
b. Added tracking to Big Issues that are escalated in order to ensure closed‐loop feedback
Leader Standard Work (LSW)
a. Empowering the leadership structure to support DMS
b. Helping better utilize time, set priorities, and align goals
Key Elements
1. Run the Operation
2. Standardize and Improve 3. Leader Standard Work
c. See LSW poster for more details
2.
2.
Expanding MESS to include Patient
Experience and Safety
a. Identification of patient experience risks and determination of appropriate countermeasures
b. Shifting safety focus from occurrences to risks in order to help prevent occurrences before they happen
Pre‐DMS Culture
Maturing DMS Culture
Problems described as vague issues
A problem described as a specific gap from standard
No trigger to indicate a problem
Signal occurs when an obstacle will keep standard work from being completed
Staff reluctant to say there’s a problem
Workarounds common
Poor
Staff readily surface problems without fear of blame
Rapid PDSA cycles resolve problems
Excellent
3.
Addition of Metric Tracking and Review
a. Adding review of previous day’s performance to daily huddles
b. Introducing weekly metric reviews to drive improvement
Expansion of Metric Reviews
a. Continuing to develop reviews of key performance metrics
b. Linking daily activities and improvement efforts to overall institutional goals
3.
Problem Solving
a. Utilizing a structured problem solving methodology to tackle big problems
b. Driving to real root cause in order to ensure problems do no reoccur
Leader Standard Work
Hue Chiang & Evan Durant
Problem Statement
Areas of Opportunity
Creating a lean culture requires a management system to sustain it and ensure continuous improvement. Lean leaders must understand and support the work at gemba (Japanese for “the real place” – where the work is done).
•
•
•
•
•
Reduce number of meetings
Improve meeting effectiveness
Use gemba time more efficiently
Increase visibility of priorities
Facilitate communication among all levels
Results
• Visual leader standard work tools created and in use
• Regular reviews and discussions about priorities and barriers
• Identification of opportunities to improve
However, there are many obstacles to providing effective, gemba‐based leadership – including external demands on leaders’ time, competing priorities, and firefighting.
Target State
•
•
•
•
•
Clear expectations and follow‐up by leaders
Alignment of goals at all levels
Prioritization of competing activities
Leadership at gemba
Continuous improvement
Improvement Projects
• Scheduled and on‐demand leader standard work classes and workshops • Leaders trained at all levels
• Supervisors
• Managers
• Directors
• Executives
• Leader standard work rounding to ensure effectiveness and alignment
Next Steps
• Broader deployment throughout the institution
• Training classes scheduled every month throughout 2015
• Continued learning and refinement of practices
GME Optimization
Patrick Brunett, MD, FACEP, Kim Irish, MS, CPHQ, Alison Lord, Hai Molinaro, Traci Rieckmann, PhD
Target State
Root Cause Analysis OHSU's Graduate Medical Education Division (GME) strives to continuously improve the clinical learning environment and the training provided to all residents and fellows, and to surpass accreditation standards of the ACGME while fulfilling the current and future healthcare needs of Oregon and beyond. To accomplish this mission , OHSU GME and Quality Management teams joined in an optimization process aligned with quality improvement and OHSU OPEx methodology. Lack of Data
• Correlating post‐OHSU training placement and geographic needs in Oregon
• Employer satisfaction with residents’ competency post‐graduation
• Aggregate data from ACGME not utilized or available to programs; insufficient flow of data from GME to programs and programs back to GME; poor capacity to aggregate data and reflect back to individual programs
•
Lack of IT infrastructure and personnel Areas of Opportunity
Lack of Standard Process
At our first session in October 2014, GME Program • No standard process or timeline for providing Directors identified nine areas of opportunity:
resident and faculty feedback after assignments Outcomes:
Lack of Resources and Incentives
1) Providers matched to geographic and specialty • Educational activity not valued/rewarded by needs of Oregon’s communities OHSU post‐training OHSU
2)Employer survey demonstrating competency and •
Resources for faculty development are not satisfaction with graduates available or readily accessible
Resident Experience: Above National Mean or 4.0 (whichever is higher) for the following ACGME Improvement Projects
Resident AND correlating Faculty Survey questions:
3) Resident satisfied with post‐assignment feedback At our second session in January 2015, the / Faculty satisfied with personal performance following projects were prioritized to work on over feedback
the next six months:
4) Information (not) lost during shift changes and patient transfers
#1: Improving faculty development opportunities, Resident Progression Performance: including enhanced skills for providing feedback to 5) Milestones Assessment and Achievement
residents.
6) Individual Academic Advancement Plan Tracking
Program Director/Faculty Development:
#2: Employer and graduate surveys demonstrating 7) Participation in faculty development graduate competency and satisfaction with training 8) Collaboration and spread of best practices
and assuring providers are matched with the needs 9) Collaboration and spread of innovation
of Oregon communities.
Rationale for Current Year’s Activities
• To improve resident experience and outcomes, we will need to standardize and improve resident/faculty feedback after assignments and provide faculty development opportunities, including feedback given to residents. • We will also need to standardize the way that employers and graduates are surveyed regarding competency and satisfaction with their training across GME programs. This will help us determine if graduates are being hired into practice environments that are aligned with the needs of Oregon communities.
Next Steps
Faculty Development and Resident/Faculty Feedback
• Conduct needs assessments for faculty development in resident feedback skills
• Compile and validate best practices in feedback for both learner and faculty
• Design faculty development tools and training plan for providing feedback
Graduate and Employer Survey • Develop, implement and track both graduate and employer surveys
• Establish a process for utilization of survey results in sustained program improvement This innovative work provides an opportunity for medical education and quality management to both develop efficacious partnership models and disseminate those findings nationally. UHC Quality and Accountability Scorecard
Goal 1 of OHSU’s Clinical Enterprise Strategic Plan is to be a national leader in clinical quality, patient safety, and patient experience.
Our 2014 Scorecard showed improvement with our overall ranking going from #41 in 2013 to #27 in 2014.
Safety
Success will be measured by scoring in the Top 10 of the
University HealthSystem Consortium’s Quality and Accountability Scorecard
Patient Centeredness
Our 2014 Domain Rankings
Mortality
Effectiveness
Safety
Equity
Pt. Centeredness
Efficiency
39
23
25
1
46
67
We focused our 2014 improvement work in three domains (Effectiveness, Safety, and Patient Centeredness) and saw significant gains.
Effectiveness
Our Work for 2015
• We will continue our work to get into the Top 10 ranking for Effectiveness, Safety, and Patient Centeredness.
• In 2014, we saw our rankings slip in Mortality and Efficiency.
• For Mortality, areas of opportunity include transfers, sepsis, and coding/documentation.
• For Efficiency, we will look at improvement opportunities related to length of stay and cost.