The Evolution of Lean in Healthcare:

The Evolution of Lean in Healthcare:

The Evolution of Lean in Healthcare: From tools and events to coaching and daily improvement Kevin Bahadur Craig Wickens Change Management Specialis...

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The Evolution of Lean in Healthcare: From tools and events to coaching and daily improvement Kevin Bahadur

Craig Wickens

Change Management Specialist

Manager, Support Services

Rouge Valley Health System

About Rouge Valley

Rouge Valley Centenary (RVC)

Rouge Valley Ajax and Pickering (RVAP)

2867 Ellesmere Road, Toronto

580 Harwood Avenue, Ajax

RVHS formed in 1998 as part of a provincial amalgamation of hospitals: • Scarborough Centenary Hospital, originally opened in 1967, now is RVC; • Ajax & Pickering General Hospital, originally opened in 1954, now is RVAP.

Getting to Know Rouge Valley • 2 hospital campuses serving the communities of west Durham and east Toronto • $300 million annual budget • Part of Central East Local Health Integration Network (CELHIN), our funder •2,774 staff, 513 physicians

Our Burning Platform for Transformation 10 Year Surplus/Deficit Trend 10,000 5,000 -

Dollars ( Thousands)

(5,000) (10,000) (15,000)

(20,000) (25,000) (30,000) (35,000) Surplus / (Deficit) Nothing Done


























2011/12 B 2012/13 P 2013/14 P

The Early Days of Our Journey 2007

Board Appoints New CEO



Strategic Plan 2008 -11 Approved

Peer Review



Strategic Plan 2011-14 Approved Financial Sustainability Plan Launched

Lean as our Management Philosophy

The STAR Framework Corporately Defined Expectations for Lean Deployment and Sustainment STANDARD


All of the following are in place:

All of the following are in place:

Process Control Boards

Performance Trending Boards




Safety Calendar (can be part of Kamishibai system)


Idea Board with problemsolving huddles

Kaizen Participation

Leader Training

Department leads and sustains its own kaizen events (at least 2 per yr)

Sustainment of Standard level

ROLE MODEL All of the following are in place: • Sustainment of Standard and Advanced levels •

Internal knowledge sharing (joint kaizen with another dept; facilitator for another dept’s Lean event; lead an in-service; internal article or poster presentation)

External knowledge sharing (e.g. joint kaizen event with external partners; conference presentation; published article)

Use of one or more higherlevel Lean tools (e.g. Kanban, Andon, SMED, etc.)

From: “Assessing and Accelerating Your Lean Transformation - the Shingo Model” Jake Raymer, 2013 Lean Healthcare Transformation Summit

From: “Assessing and Accelerating Your Lean Transformation - the Shingo Model” Jake Raymer, 2013 Lean Healthcare Transformation Summit

RVHS Executive Team identified 2 key areas for corporate development:

Continuous Improvement and Capability Building Graphic From: J. Liker, ‘The Toyota Way to Continuous Improvement’

Objective of the Lean Management System Our Goal: To develop our people to solve problems and improve performance.

Developing a Lean Management System Visual Management Department Performance Board

Daily Stat Sheet

Staff Improvement Board


Daily Performance Huddles Supervisor / Manager Daily Coaching

Department Scorecard

Driver Metrics

Manager / Director Coaching

Watch Metrics Director / VP Coaching

Monthly Performance Reviews VP (Week 3) Director (Week 2)

Manager (Week 1)

Developing a Status Sheet

Daily Status Sheet

Adapted From: ThedaCare Centre for Healthcare Value

The Daily Status Sheet and Lean Practices Objectives of Status Sheet

Linkage to Lean Practices

• To proactively plan the day

• Use of Standard work

• To learn and understand the business

• Respect for People (Develop our Staff to Solve Problems)

• Gain insights for future problem solving

• Create visibility between normal and abnormal

• To better understand coaching needs for staff around problem solving

• Developing ‘Andon’ Systems

• To develop our leaders

• Use of PDSA thinking to solve problems

Structure of the Daily Status Sheet Manager to Director Daily Status Sheet

Frequency Manager-Charge: Daily Director-Manager: Weekly VP-Director: Monthly

Adapted From: ThedaCare Centre for Healthcare Value

Status Sheet: Clarifying Roles Coach for First Coach

Coach for ‘1-Up’

Second Coach Learner for Second Coach

First Coach

Coach for Respondent

Learner for First Coach

‘1-Up’ Learner for ‘1-Up’

Respondent Adapted From: The Toyota Kata, Mike Rother

Key Messages: •The pattern repeats at every level to ensure everyone has the opportunity to get feedback and improve • In the typical Manager Status Sheet, the First Coach would be the Director with the TMO providing additional support during LMS training • In the Manager Status Sheet, the Second Coach would be the VP or TMO during LMS training. The Second Coach is focussed on providing feedback for the First Coach

Creating an Area Improvement Centre

Visual Management

Performance Board Structure Create a single ‘lane ‘ of focus for each dimension of corporate performance Post current strategic plan as reference

Describe goal in a single statement

Post framework of key initiatives and Patient Declaration of Values

Chart key performance metric over time to demonstrate current performance level

Post A3 which describes the key initiatives that are focussed on driving improved performance

Post ‘top 10’ metrics & highlight area of focus

Post other related ‘process metrics’ or initiative implementation information (pictures ect.)

The layout of the board tells the ‘improvement story’ of the department and each initiative. The information should flow like an A3

The ‘Bottom Up Story’ of the Performance Board Linkage to RVHS Strategy • Want to visually demonstrate how departmental outcomes link with RVHS objectives

Lose Weight Measure: Body Weight (LBS)

Department Outcome Measure • Tracking performance over time to see variability and support sustainment • The LMS department scorecard standardizes the display of the outcome measure

Calories In Measure: Total Calories Consumed

Process Measures • Process control supports daily management of key drivers • Primary tools include process control boards, daily run chart, safety cross, Pareto chart and Kamishibai cards

Measure: Number of chocolate bars consumed per day

Ideas for Change • Countermeasures are developed based on root cause analysis and best practices • The A3 and ‘WWW’ are the primary tools to support the team

Eat less chocolate

Layout of the Idea Board In Progress Work & Ideas

Implemented Ideas


New Improvement Ideas

Just Do Its


PICK Chart

Implement Possible


Challenge Kibosh

Stephanie passed her AQ Exam!

Almost Implemented Ideas Week 1


Adapted From: ThedaCare Centre for Healthcare Value

Week 2

Week 3

Week 4

Week 5

Zero department pressure ulcers!

with work in progress: and record new Work &Start In any Progress Ideas Implemented Ideas a) Just Do Its – any barriers improvement opportunities: to moving forward? -e.g., opportunities identified b) PDSAs – if the status Briefly review each lane in your onArea stat sheet indicator is green, Improvement Centre -Ask staff what barriers they acknowledge the work Briefly review PDSAs associated are with encountering in their day and move on; if the status lanes. If the status indicator is green, is red, ask about barriers. acknowledge the work and move on. If Move completed from staffwork to the the status indicator is red, ask the • Use the PICK chart to get feedback “Improvement about whether working on this will have highIdeas or following questions: 1) Any new PICK Chart Implemented” section low impact and whether it is easy or hard to do defects? 2) Adequate resources? 3) • Monthly (+/- daily) tracking on a run chart • If an falls into Kibosh, circle back Barriers to moving forward? or opportunity simple bar chart with the originator but doand not PDSAs place onget the Discussion points may vary day by day. • Improvement Tickets PICK chart End on a high note – identify reasons to moved over to this area once completed celebrate and make them visual • All patient or employee safety or quality issues Celebrations NOTE – we will learn more about theare immediately moved to be worked on • If opportunity is related to existing PDSA, standard Implement work for the Area Challenge driver, or other work in progress, move the Improvement Centre in a later module Kibosh Possible Improvement Opportunity form to that PDSA Almost Implemented Ideas to be incorporated • AsWeek capacity becomes available, 1 Week 2 Week 3 Weekproblems 4 Week 5can be moved from PICK chart to work in progress • Assign resources to new work in progress with owner(s), & mentor / coach Difficulty

• • •

Adapted From: ThedaCare Centre for Healthcare Value

Just Do Its



New Improvement Ideas Review

Monthly Performance Communication Diagram Two Options:

VP Monthly Performance Review

1) Portfolio Leadership Team The VP and Directors meet to discuss progress on department drivers as it relates to strategic deployment and ‘Top 10’

• Review of Countermeasures, • Review strategy and execution tactics • Review of other projects


2) VP / Director Huddle

3rd week of the month

The VP and Director meet at each performance board to discuss progress on department drivers as it relates to strategic deployment and ‘Top 10’

Director Monthly Performance Review

Director / Manager Huddle Director meets with manager (+ other members of the ELT, if desired) at their performance board. Countermeasure summaries are presented, and additional resources are allocated if needed.

2nd Week of the Month • Lessons Learned • Review of Countermeasures

Countermeasure Summary

… Repeat for each Director

Leadership Team Monthly Performance Review Leadership Team The manger meets with leadership team following defined Standard Work around scorecard. When areas are not meeting goal-countermeasures are developed and summarized.

Department Drivers

Manager Adapted From: ThedaCare Centre for Healthcare Value

1st Week of the Month • Lessons Learned Shared, • Stratification of Red Metrics • Develop Countermeasure Summaries … Repeat for each Manager 21

ay things really are

7.0 4.7

Wave 1 Staff Feedback (All Model Cells)

rt of our daily work

ent and/or hospital 1. I understand what the department goals are for the next year


2. There are regular meetings on units/departments that focus on the review of unit/department performance metrics and result in plans to improve processes


4. Senior Leaders are aware of front line issues and challenges (the way things really are around here)

5.7 7.0


aring forums across 5. Learning is an important part of our daily work provement 6. Employee and physician suggestions on how to improve department and/or hospital

8.2 7.7



7.1 5.1

performance are actively solicited

7. Employees and physicians understand how their area's performance metrics impact the d and used to drive whole organization's performance 4.5

9. Visualare displaysinvolved of hospital performance data are regularly reviewed and used to drive sicians improvement




7.3 5.1


10. When changes are made in my unit/department, employees and physicians are involved in the process







2.0 3.0 4.0 POST LMS Score PRE LMS Score Negative Response










8. The organization facilitates regular knowledge/idea sharing forums across units/departments that are related to hospital improvement




on a regular basis




metrics theare openly displayed and reviewed with front line staff 3. Department impact performance metrics



7.1 5.7






Positive Response


Experience of A Model Cell Support Services: Hospitality What is “Hospitality”?

• • • • • •

Patient Transport Daily Cleaning Discharge Cleaning Patient Meal Delivery Nursing Assistance Approx. 300 Multi Skilled Employees

What Can Be Learned From This Model Cell? How does the Leadership Management “System” help us with “the problems we are trying to solve”?

First Things First…The Lean Context After 6 years what does “Lean” mean to us? • • • •

What is required for best patient care? What needs to be done to achieve that? What is our plan? Continuously improve Safety, Quality, Efficiency?

Our Approach The plan is our foundation on which to build; our approach is…

• Have a Plan • Visualize the Plan

• Respond to the Plan • Improve the Plan (safety/quality/efficiency)

Our First Problem! …and solutions so far How do you build a Plan when

• Develop Standard Work • Select/Train Master Trainers

• Train 300 Staff • Sustain


Our Next Problem! …solutions to follow How do you build a Standard Plan when the day is so

• The day depends on who comes in the door


Our Next Problem! … solutions so far Maintaining flow

• • • • • •

75% of the day is predictable 2 different tactics Staff and plan to 75% Additional staff move to multi-skilled pool 75% exceeded – send in reinforcements Problems now separated

Yet Another Problem! …and solutions so far Everyone is so spread out, how can we

• • • •

Call Centre tracking (actual vs. plan) Maps and door magnets Control boards Colour coded carts/equipment


Another Problem Still! …and solutions so far A Supervisor has 55 direct reports, how can they

• Leader Standard work • Group Leaders • Red/Yellow Pager


Introducing LMS …congratulations you have been selected Initial thoughts on being selected as a pilot site?

from implementing the plan • Need

not indicators (yet)

• Focus needs to be plan; • Staff ideas will not be • Out of sequence; • Either way – ok, sure, we’ll do it – so we start.

Big New Problem … in the mean time a new problem begins to emerge

“how do we maintain the base and continue to move ahead?”

Defining the Big New Problem! … ok so it took 6 why’s!

• Why is the plan not always followed?

• Lack of front line passion for it – why? • Leadership has not fostered passion – why? • We may not really know how – why? • We are still managing the old way – why? • We are comfortable with it – why? • We haven’t practiced anything else

Can LMS Help? … maybe this “distraction” can help with our problem

LMS as a Solution … a new way of thinking

• Process is performed by people • People are the process

• Develop people to develop the process • Not one before the other

How LMS Helps … changing the way we manage

• Build Leadership discipline

• Develop Leaders as coaches • Practice implementing ideas

• Build ownership/passion of process • Build PDCA know how

“Habit is the most effective form of motivation”

LMS Purpose? … how does LMS help solve our problem

Builds “people capacity” for:

LMS Next Steps? … what’s next for Support Services… now that we kind of get it

• Pilot expanded • LMS in other “plan” cell • “Plan” and LMS together forever • Grow future Leadership from within

Thank You! Session Code: ThP/11

The Evolution of Lean in Healthcare Kevin Bahadur Rouge Valley Health System [email protected]