Conflict of Interest
 Ann Dohn – No conflicts of interest to disclose
 Nancy Piro – No conflicts of interest to disclose
Confidential – For Discussion Purposes Only
SES:065
Using C-Suite Business Models and Tools to Address Issues
faced by DIOs/GME in the New Era of Healthcare Reform
Ann Dohn, MA
DIO, Director of Graduate Medical Education
Stanford Health Care
Nancy Piro, PhD
Education Specialist/Program Manager
Stanford Health Care
Background
 The adoption of business models and metrics historically found in the
corporate world are now being widely used by Healthcare C-Suite
executives.
 This places DIOs/GME leaders in a vulnerable position. We must learn
new ways of communicating and process thinking that align themselves
with philosophies such as “Streamlining” and “Lean".
 We need to think in terms of empirical data, metrics, quality indicators,
dashboards, A3s, fishbone diagrams, etc.
 However, the C-Suite models and processes actually can enable the
DIO /GME to better advocate for resources based on data, empirical
evidence, and focus on high priority areas for the institution.
Confidential – For Discussion Purposes Only
Objectives & Session Focus
 This session will focus on use of available data tools as well as evaluation
metrics that enable DIOs/GME to communicate effectively with the CSuite.
 Participants will be exposed to the A3 tool, which is extremely useful in
solving inter-departmental problems
 Other tools, e.g., scorecards, fishbones, paretos, and trend analyses will
be incorporated into the presentation.
 At the conclusion, participants will be able to apply the A3 model to
challenging institution specific situations and discuss available metrics
and development of an approach to resolution the situation.
Confidential – For Discussion Purposes Only
Understanding C-Suite Priorities
 Purpose
STANFORD OPERATING SYSTEM
− Mission, Vision, Values
 Strategies
− Complex Care, Coordinated
Care
 Objectives
− Goals, Operating Plans,
Dashboards
 Performance
− Improvement and
Management
Confidential – For Discussion Purposes Only
5
Understanding C-Suite Language “Hot – Spots”
 RVU’s
 Visibility Wall
 KAIZEN – Continuous Improvement
 GEMBA
− problems are visible (or make them visible) and the best improvement ideas come form going
to the genba – leadership goes to the departments/wards to look for waste and opportunities
to improve or practice kaizen.
 Five Whys – ask why 5 x’s to get to the ….
 RCA – Root Cause Analysis
 4 M’s
 5 S’s
 A3s
− SMART
− Fishbone Diagram – Ishikawa Chart
Confidential – For Discussion Purposes Only
6
Understanding C-Suite Language:
“Lean” – Focus and Tools
 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
− 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

GEMBA – make problems visible
− the best improvement ideas come form going to the genba – leadership goes to the
departments/wards/units to look for waste and opportunities to improve or practice kaizen.
− Elimination of WASTE - 3Ms
− Problem Solving – A3s

5 Whys

Fishbone Diagrams (Ishikawa Charts)
− 4 Ps / 4 Ms

5 Ss
Confidential – For Discussion Purposes Only
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…machines only degrade over time””
Confidential – For Discussion Purposes Only
Lean Tools: 3M’s
 All about Waste- Identifying it and Removing it
− MURI = Waste of overburdening people or equipment/resources
− MURA = Waste of unevenness, variability in processes
− MUDA = Waste of using resources without creating added value
Confidential – For Discussion Purposes Only
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)
Confidential – For Discussion Purposes Only
Lean Tools: – Fishbone Charts using the 4Ms – 4 Ps
 Manpower/Personnel
 Materials
 Method(s)
 Machines / Equipment
 People
 Process
 Policy
 Principles
Confidential – For Discussion Purposes Only
Ishikawa Diagram of ER Prolonged Wait Times
Materials
Methods/Process
WHY?
WHY?
WHY?
Manpower/People
Confidential – For Discussion Purposes Only
WHY?
Machine\Equipment
xxx hr
wait time
in ER
5Ss - Mnemonics Retained
 Sorting
= Seiri
 Simplifying
= Seiton
 Sweeping
= Seiso
 Standardizing
= Seiketsu
 Self Discipline
= Shitsuke
Quick Exercise
Confidential – For Discussion Purposes Only
5Ss in Action
14
Confidential – For Discussion Purposes Only
What is an A3?
Very simply….a piece of paper that is 11” in height
and 17” in width
Confidential – For Discussion Purposes Only
4 Steps of A3 Thinking: The Simple A3
1. What is the problem or gap?
(What are we trying to improve?)
Target
2. What causes are preventing us from meeting
our target(s)? What are the “root” causes?
Gap
Cause
Cause
Cause
Effect/Problem
Current
Performance
Cause
Cause
Cause
4. Which actions will address the
most important causes?
Goals
(Cause)
Actions
3. Based on data, what are the
causes in order of importance?
By Who &
When
Cause #1
Confidential – For Discussion Purposes Only
Cause #2
Cause #3
Cause #4
4 Steps of A3 Thinking: The Simple A3
1. What is the problem or gap?
(What are we trying to improve?)
4. Which actions will address the
most important causes?
Goal
(Cause)
Actions
Confidential – For Discussion Purposes Only
By When/
By Who
2. What causes are preventing us from
meeting our target(s)? What are the
“root” causes?
3. Based on data, what are the
causes in order of importance?
What is an A3?
Confidential – For Discussion Purposes Only
18
Why Use an A3?
 Creating the A3 encourages systematic
problem solving and a standardized method of
communication
 Presenting the A3 fosters consensus to move
forward
 Discussing the A3 fosters critical analytic
skills, communication, respect
Confidential – For Discussion Purposes Only
19
When to use an A3?
Determining when to use an A3 can be as simple as
asking the following questions:
 Is the situation difficult enough to warrant using the A3 to provide
structure?
 Will there be ongoing discussion for some time so the report has
communication value?
 Is there a good reason to document and capture the knowledge in
some fashion?
Confidential – For Discussion Purposes Only
20
A3 Template
Sponsor:
Participants:
Issue/Problem Statement:
Start Date:
Revised Date
Title
Future State and Counter Measures:
Background and Importance:
Implementation Plan:
Goals/Dashboard Metrics:
Follow Up:
Problem Analysis:
Sustain Results:
Confidential – For Discussion Purposes Only
Date Revised:
Version #:
What Type of Information is Included in an A3?
The Top of the A3 Chart
 Accountability
− Who is responsible for the project?
− Sponsors, Team Leaders
 Project Title
− Brief description of the project
 Project Team
− All people involved in the development and completion of the project
 Draft Status
− Date and version
Confidential – For Discussion Purposes Only
22
What Type of Information is Included in an A3?
Left Side
 The left side contains information and discoveries about the current state
− Issue (the problem)
 Objective description with data
 Stated through the customer
− Background
 History
 Significance (how does this fit within the organizational goals?)
− Baseline
 Simple graphic of current state
− Requires observation
− Includes major pain points (problem areas within the process)
− Goals / Dashboard Metrics
 Data that will be measured to provide evidence of success
− Problem Analysis
 Identifies the root cause of current state problems
− The 5 Whys, Fishbone, Pareto, etc.
Confidential – For Discussion Purposes Only
23
What Type of Information is Included in an A3?
Right Side
 The right side develops the vision and action plan for the goal
− Future State
 The ideal state you want to achieve
− Countermeasures
 What you will need to change to get from current state to the desired future state
− Implementation Plan
 How the countermeasures will be achieved
 Show who, what, when and outcome (accountability)
− Follow-Up
 What will be done to ensure the project is maintained
− Sustain Results
 The measured outcome or ongoing measurement of the project’s impact
− Often the direct measure of the problem
Confidential – For Discussion Purposes Only
24
How Do You Create an A3?
1. Identify a project or problem
−
−
Write a description
 Be objective – customer focus
 Maintain a limited scope
Learn the significance or history
 Interview, study, read, etc.
2. Observe and draw workflows (process flows)’
−
−
−
−
−
Gemba
Interview staff
Map the process from A-Z (butcher paper)
Identify problem(s) within the process
Confirm findings with frontline staff
3. Measure the current state
−
−
−
Collect data
 Manual (i.e. Paper surveys, counts)
 Database (i.e. EMR)
Upstream vs. Downstream
Validate data with frontline staff
Confidential – For Discussion Purposes Only
25
How Do You Create an A3?
(Continued)
4. Set goal(s) around measurements
−
−
−
−
Consider what is ideal
Consider what is possible
Engage / speak with front line staff
Be SMART
 S = Specific
 M = Measureable
 A = Attainable
 R = Realistic
 T = Timely
5. Analyze the problem and identify root causes
− Interview stakeholders (ask the 5 Whys)
− Use measurements to identify biggest problem (Pareto)
6. Identify the future state and countermeasures
−
−
−
−
Describe/envision the ideal state of the process
Brainstorm solutions to root causes
Select countermeasures and list in A3
Draw a simple future state diagram
Confidential – For Discussion Purposes Only
26
How Do You Create an A3?
(Continued)
7. Determine how countermeasures will be implemented
−
−
−
−
Identify stakeholders (all persons affected by the changes)
Ensure the right people are involved/aware
Consider communications
Set timelines for achieving steps/countermeasures
8. Determine the follow-up plan
− Identify how you will maintain the intervention
 How will the intervention be “hard-wired”/
 What is the visibility plan?
− Consider future actions required to improve he outcome
9. Monitor results
− Allocate time for measuring results after implementation
− Measure and analyze results
− Report results
10. Continuously review the A3
−
−
−
−
Does the story flow well?
Is it easy to understand?
Is the report neat/organized?
Revise…
Confidential – For Discussion Purposes Only
27
Benefits of Using an A3
 A3s offer a simple & structured approach to reporting solutions to problems
 Helps define a standard for all of the organization to use
 Provides a clear and concise method of reporting information
 Content can be made visible and accessible to all
 Promotes communication and teamwork
 Leads to reduction of waste and improved processes
 Supports continuous improvement
A picture is worth a thousand words…
Confidential – For Discussion Purposes Only
28
EXERCISE 2 - Creating an A3
 Think about a problem you’d like to solve “back home”
 Use the A3 Template Hand Out :
Confidential – For Discussion Purposes Only
30
A3 Template can be downloaded @ www.gme.stanford.edu
GME Community
Confidential – For Discussion Purposes Only
Templates – A3
Visibility Wall Examples
Confidential – For Discussion Purposes Only
Dashboard Examples
 Overall Program Report Card
 AIR - APEs
 Program Expansion
 CCC Matrix
Confidential – For Discussion Purposes Only
33
Overall Program Report Card Example - Comparison
Confidential – For Discussion Purposes Only
34
AIR / Annual Program Review Dashboard Example
Confidential – For Discussion Purposes Only
35
Program Expansion / Funding Dashboard
Confidential – For Discussion Purposes Only
36
Report Card Trending Example
Confidential – For Discussion Purposes Only
Resident Performance Dashboard
Confidential – For Discussion Purposes Only
Dashboard Summary
 Data-driven decisions
 Multiple sources
 Comparable measures allows for “tiering” of programs
 Institutional Review / AIRs
 Timely, visual and easy to identify trends
 Pre-emptive
 Easy for Leadership “C Suite” to read
 Easy for CCCs to use
Confidential – For Discussion Purposes Only
Questions?
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40
Contact Information:
 Nancy Piro, Program Manager/Education Specialist
− npiro@stanford.edu
 Ann Dohn, DIO
− adohn@stanford.edu
http://gme.stanford.edu/
Confidential – For Discussion Purposes Only