Lean In High Stakes Medicine - Massachusetts Hospital Association

Annual Hospital‐Physician Leader Conference: Incorporating Lean into High‐Stakes Medicine Friday, March 16, 2012 9:00am – 2:30pm Conference Center at Waltham Woods, Waltham, MA Agenda 9:00am Lean Thinking for Physicians in a Hospital Setting Eric W. Dickson, MD, MCHM, FACEP, Senior Medical Director, UMASS Medical Group 10:15am NETWORKING BREAK 10:45am Lean in High‐Stakes Medicine: Kaizen Without a Net Panel: Kevin J. McGuire, MD, MS, Chief of the Orthopedic Spine Service, Co‐Director of the Spine Center, Director of Combined Spine Fellowship at BIDMC and Spine’s section editor Health Care Delivery Science. Carrie Tibbles, MD, the Associate Director of Graduate Medical Education, and the Associate Program Director of the Harvard Affiliated Emergency Medicine Residency. Michael D. Howell, MD MPH is the Director of Critical Care Quality and the Director of the Research Core for InSIGHT (Integration of Standard Information Gathered using Healthcare Technology) at BIDMC. 12:15pm LUNCH 1:00pm Lean Performance Improvement Journey Dot Goulart, MS, RN, Dir., Performance Improvement for the Center for Clinical Excellence Katherine Santos, Senior Consultant, Performance Improvement Brigham & Women's Hospital 2:30pm Adjourn Lean Thinking in a Hospital
Setting
Eric Dickson MD
President and Senior Associate Dean
UMass Memorial Medical Group
Nothing to Disclose
• Sells for $32,389
• 4,756 lbs
• Parts and raw materials
($11,890)
• Man Hours 38.7 ($3,405)
• Overhead ($15,342)
• Profit ($1,752)
• Sells for $33,969
• 4,439 lbs
• Parts and raw materials
($7,990)
• Man Hours 29.5 ($2,596)
• Overhead ($13,861)
• Profit ($9,522)
Toyota now makes cars that last twice as
long using 25% less man hours and 25%
less raw materials.
Lean = The Operational Philosophy
behind the Toyota Production System
Lean Philosophy
Lean Is…
“The endless transformation
of waste into value from the
customer’s perspective”.
Womack and Jones, Lean Thinking
Lean increases product value by removing waste
and slowly driving a process towards perfection.
Cost To Build Highlander
The cost of
value added
activities
($11,002)
+
The cost of
non-value
added
activities
($13,445)
=
The total
cost to build
Highlander
($24,447)
Cost includes the space and materials necessary to perform activities
Non-Value Added Activities in The Automobile Industry
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Quality defects
Time spent looking for things
Time spent filling out request forms
Extra tools in the work area
Any kind of rework
Excessive administrative expenses
Underutilized staff
Underutilized space
Use of a more expensive part than is required
Addition of parts that are not needed
Poor flow in the plant
Unorganized supply rooms with outdated inventories, too much
inventory and unnecessary variety
Confusing goals & metrics
Underutilized human potential - skills, talents, and creativity
Typical Waste in Healthcare
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Quality defects including hospital acquired infections and avoidable
medical errors
Time spent looking for things
Time spent filling out request forms
Extra instruments on surgical trays
Any kind of rework
Excessive administrative expenses
Underutilized staff
Underutilized space
Use of a more expensive drug or device than is required
Use of any drug or therapy that is not needed
Hospitalizations that are unnecessary
Hospital lengths of stay that are longer than are necessary
Unorganized supply rooms with outdated inventories and unnecessary
variety
Confusing goals & metrics
Underutilized human potential - skills, talents, and creativity
Physician muda
What activity does
Mr. Potato Head value?
What Percentage of Your Clinical
Day is Spent Doing Value Added
Work?
An Average Day for an Attending Physician at UMMMC
Miscellaneous
Waste, 11%
Social, 3%
Charting, 23%
Signing in/out,
7%
V
Educating
Resident, 20%
V
On Computer,
8%
V
Patient Contact
Alone, 16%
On Phone, 4%
Patient Contact
With Resident,
10%
Relationship Between Job Satisfaction and
Performing Value Added Activities
Activity
Satisfaction 0-10
Percent of Time on Activity
Patient Contact Without
Resident
8.9
16%
Patient Contact With
Resident
8.8
10%
Educating Resident
8.6
20%
Social
6.7
3%
Sign-out
5.3
7%
Time on Computer
3.7
8%
Phone Time
2.7
4%
Charting
2.6
23%
Looking For Things and
Miscellaneous Waste
1.2
9%
Eliminating Clinician Muda
Improve the quality of care you deliver
Improve clinician productivity
Improve the experience of receiving care
Improve the experience of giving care
What percentage of your annual
budget is spent on non-value
added activities?
0-25
26-50
51-75
76-100
In the past year have you asked
for..
• More space?
• More people?
• More resources?
WHY?
You that know the waste exists in
your organization so why haven’t
you taken it out?
Does this salt
shaker need to
be filled?
Coffee line
Coffee line
Lean Managers move ideas from left to right
Idea Card Format
㻺㼛㼠㻌㼖㼡㼟㼠㻌㼍㻌䇾㼏㼛㼙㼜㼘㼍㼕㼚㼠䇿㻌
㻔㼞㼑㼝㼡㼕㼞㼑㼟㻌㼍㼚㻌㼕㼐㼑㼍㻕㻌
㻺㼛㼠㻌㼖㼡㼟㼠㻌㼍㼚㻌㼕㼐㼑㼍㻌
㻔㼞㼑㼝㼡㼕㼞㼑㼟㻌㼍㻌㼜㼞㼛㼎㼘㼑㼙㻌
㼟㼠㼍㼠㼑㼙㼑㼚㼠㻕㻌
㻲㻾㻻㻺㼀㻌
㻮㻭㻯㻷㻌
Slide Courtesy of Mark Graban
QS x AS = likelihood of success
Standardization must occur before
you can have innovation and
improvement
“It is impossible to improve any process until it is
standardized. If the process is shifting from here
to there than any improvement will just be one
more variation that is occasionally used and
mostly ignored. One must standardize the
process before improvements can be made.”
Masaaki Imai
The first step in improving the treatment of any
disease is standardizing its care. If the treatment
of an acute or chronic condition within our system
is variable, any effort at improvement will just be
one more variation that is occasionally used and
mostly ignored. We must standardize our care
using evidence- or consensus-based pathways
before we can improve it using discovery and
innovation.
Based on work by Masaaki Imai in the book Kaizen
Inflexibility is the greatest barrier to
successfully applying Lean in health care
and it is best overcome by Genchi
Genbutsu
ED Work Load Leveling
Patient Arrivals Per MD/RN
8.0
7.0
6.0
5.0
Arrivals/hr/MD
4.0
Arrivals/hr/RN
3.0
2.0
1.0
0.0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Hour of Day
80
70
60
50
OR Admissions
40
ER Admissions
30
20
10
Tu
e
on
da
M
s
W
ed day
ne
sd
T h ay
ur
sd
ay
Fr
id
Sa ay
tu
rd
a
Su y
nd
ay
0
y
Average Number of Admissions
Work Load Level OR Admissions
Do you have a standard method for solving
problems in your organization?
35
You are
Here
Need to be
Here
GAP
AP
SD
AP
SD
Target
Condition
AP
SD
AP
SD
Current
Condition
The A3 tells this
story
A good A3 is a reflection of the dialogue that
created it...
-John Shook
Who is teaching Lean in your organization?
What is the current state of you core processes?
Triage
-vitals
-history
Patient
arrives
To waiting room
Registration
7 min
28 min
4-5 min
Orders by
provider
Provider
to Room
-history
-exam
5 min
Wait for
provider
14 min
Patient to
Room
-RN history
-RN exam
15 min
9 min
Patient
wait
RN returns collects
and sends labs
13 min
14 min
Therapy
begins,
lab results
available
Disposition
decision
62 min
Home
Home with labs 193 min
admit 268 min
Admit
Nursing Units Storage Areas Standardization & Scanning Compliance
Rapid Process Improvement
Osborn Campus: OB Triage Supply Room
After
Before
$ 600,000
in supply savings
Courtesy of Abdul N. Mansour
Scottsdale Healthcare
Our
Patients
We will focus
first and foremost on
the health and wellbeing
of the Patients we serve
High Quality Efficient
Integrated Care
Engage and
Empower our
People to Innovate
AQC Quality Metrics
Patient Satisfaction
PC Covered Lives
Meaningful Use
Financial
Sustainability
Net Income to Plan
Productivity:Salary Ratio
Physician Engagement
Physician Turnover Rate
Research Funding
UMMMG Framework for Performance Excellence
UMMMG Mission/Vision
We Will Focus First and Foremost on the Health and Well Being of the Patients We Serve
Strategic Plan Aligned with Mission/Vision
High Quality Efficient Integrated Care, Engage and Empower Our People to Innovate and Financial Sustainability
Measurement System Aligned with Strategy (True North Metrics)
10 True North Metrics
Performance Management
Project Management
Individual Goals Aligned With True North Metrics
Execution of 10 Key Strategic Projects
Process Management
Revenue Cycle, Physician Comp, Dept Variance etc
Any
Questions?
46
ED medicine is inherently risky
• Constant variability in work
demands
• High Cognitive Load / Continual
Decision Making
• Production PRESSURE
• Variable individual
competency/workforce issues
• Poor feedback mechanisms
• People have complex /
unknown health issues
• Communication Challenges
• Electronic communication
replacing interactive
conversation
LEAN ED TEAM
LEAN in the ED
• Support
– LEAN Steering
Committee
– Project Manager
– MD/RN Leadership
Team
• Leadership
– Management Meeting
– LEAN Leadership
Course
Lean Training Series by the
Business Transformation Department
Lean
101
Lean 101
An Introduction
Introduction to
An
to the
theLean
Lean Principles
Principles
49
PD
AC
Emergency Department
V1:
V2:
V3:
V4:
V5:
Owner/
Date
5. Proposed Countermeasures
1. Problem
Direction
Business Measure
Performance
Measure
Process Name
Pla
n
2. Current Condition
Brainstorm potential
countermeasures
Narrow down ideas
Build consensus
Actual current
situation informed by
direct observations
Short-Term
(Temporary)
Long-Term
(Permanent)
List selected
countermeasures to
address the
problems identified
Break down the
problem and its
effects
PROBLEMS
COUNTERMEASURES
EFFECTS
2
3
4
5
RESULTS
1
1
P
U
S
H
P
U
L
L
2
3
4
Pla
Pla
5
n
n
3. Goals/Targets: What would the ideal state look like?
6. Implementation Plan
What
Do What?
Who
When
Where
Status
To What?
How Much?
By When?
Pla
n
4. Cause Analysis
Do/
Check
Brainstorm potential
cause factors of
stated problems
above based on facts
7. Follow Up & Verification (Check both Results & Processes)
Check Method
Check Frequency
Continually question
WHY?
Who will Check?
Check/
Adjust
8. Standardize and Share Success
Specify the root
causes
Set successful
processes as new
standard
Pla
S:\Lean\Resources by Topic\A3\Tools & Templates\(2010-03-09) PDCA 8 Step Problem Solving A3 Template
Author: ______________________________
Created: ________/________/________
Share new standard
Adjus
n
t
Updated: ________/________/________
By: ______________________________
LEAN in the ED
•
•
•
•
•
•
Staff Engagement
Education
Weekly Updates
Team Invitations
LEAN Call out Flag
Newsletter
Call out Flag
Greeter Tech
Determine
a need for
EKG
Triage patient
Ambulatory
patients bypass
Greeters
Find an
available
Tech
Find a room
and/or wait
for a
machine
2 minute average
Prints prior
EKG
Patient
occasionally left
on machine if
they look sick
Puts info into
EKG machine
and takes read
Find PGY 3 to read
EKG
In core <1 min
Elsewhere 2-5 min
Tech sets up
room/hooks up
patient
Past the 8minute mark
EKG machine is
broken
Doctor asks
Repeat EKG
2ndary question due to defective
and Tech
read (rare)
returns to
Triage (rare)
Total average
time during
non-peak: 15
minutes
Patient Label
8 Minute EKG
All
o
o
o
o
patients with:
Chest Pain (unless obvious traumatic etiology)
Shortness of Breath (unless obvious asthma)
Syncope
Nursing Concern
All patients over
65 with:
o
o
o
o
o
o
OR
All patients over
40 with history of
CAD, MI, DM,
CRF, or HTN
with:
Nausea / Vomiting
Epigastric Abdominal Pain (not reproducible)
Thoracic Back Pain
Weakness
Altered Mental Status
Other:____________________________
Not Part of Medical Record. Please place in EKG bin at triage or at Uco desk
Alarm Fatigue
Alarm
Soft Inop (inaudible) - Table 2
Frequency (2 Months)
Percent
17224916
90.26%
1180125
6.18%
449225
2.35%
Yellow Inop
71938
0.38%
Yellow
52302
0.27%
Short Yellow
39502
0.21%
EctSta
37720
0.20%
Red - Table 4
17143
0.09%
Temp
6516
0.03%
Severe Inop
1951
0.01%
Trect
1487
0.01%
7
0.00%
19082832
100.00%
Hard Inop - Table 3
RhySta
T
TOTAL
Red Alarm Frequency Over 2 Months
9307
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
3502
1670
1483
1180
co
nn
ec
t
to
le
ys
AB
P
D
is
As
Br
ad
y
hy
Ta
c
es
at
D
Ap
ne
a
1
Alarm Fatigue - Silence is Not a Solution
BP Cuff –
Sat Probe –
EKG Leads –
Apnea –
Monitor Standby -
Troubleshooting Tips
1.Are the BP Cuff and Sat Probe on the same arm?
2.Are the EKG leads positioned properly? Does your patient require an adjustment?
3.Has the monitor been turned on “Standby” if the patient is not in the room? Has the patient been re-connected once back in the room?
REMEMBER: SILENCE IS NOT A SOLUTION!!
Alarm Fatigue - Silence is Not a Solution
Staff Roles and Responsibilities
Who
Alarm
Response
Recognize
Blue
Troubleshoot and address mechanical and anatomical issues.
Re-adjust
Recognize
Technician
Yellow
Re-adjust
Troubleshoot and address mechanical and anatomical issues.
Report
Red
Respond
Respond to patient.
Recognize
Blue
Troubleshoot and address mechanical and anatomical issues.
Re-adjust
Recognize
Nurse
Yellow
Re-adjust
Re-adjust parameters, frequency of alarm and need for the monitor.
Report
Red
Respond
Respond to patient.
Recognize
Blue
Recognize and re-adjust the obvious. Report to a nurse/tech.
Re-adjust
Recognize
MD
Re-adjust
Yellow
Report to a nurse/tech or Respond to patient.
Report
Respond
Red
Respond
Respond to patient.
ED to Inpatient flow
Opportunity
Problem
Current State
Communication within the
nursing and physician
handoff process can be
uncoordinated and
inefficient
• Admitting patients to
Medical and Surgical
services requires a verbal
handoff of patient
information from the
Emergency Nurse and
Physician team to
Inpatient care teams
• Optimizing flow for these
handoffs is critical for the
overall flow of patients.
Barriers
Inconsistencies in current hand off practices
include:
•Content or information communicated
•Number of attempts to connect on both ends
•Duration of the process
•Physician and nurse handoffs occur in
isolation
Goal
• Decrease variation in content/quality of
information presented
• Increase patient flow by removing barriers to
communication
• Remove waste from process to create a
standardized, predictable process
• Safe patient transitions
• Staff satisfaction
ED
Dashboard
The team handoff
template created by
both in patient and ED
teams lives on the ED
Dashboard.
All providers will have
access to this new
information in addition
to the many other data
points available on the
dashboard
Labs, Radiology,
Consults etc
Template for
Team
Handoff
Created by both in
patient and ED nurses
and physicians
Identifies critical
information requested
by each team to
transition care
STOP
A verbal safety check
between the ED nurse
and MD has been put
in place to ensure the
accuracy of the
information conveyed
during the handoff.
This check is designed
to make sure the most
accurate up to date
information on the
patient and the ED
course is presented to
the inpatient teams.
Page #1
Floor & ED Notification
Bed available
0 min
Page #2 to In patient
ED Report Available
15
Min
RN Handoff
The RN handoff
process is initiated at
the time a bed is
assigned .
The activation of the
RN MD handoff is
triggered by the green
A (bed assignment) .
Page #3 In patient to ED
RN Acknowledges Report
Or
Requests Verbal
Page #4
If no acknowledge
To Floor
60
Min
45
Min
The dashboard and
pagers are the
mechanism for
communication
Bed Request for
Medicine Service
Bed Assigned
Auto-page ED MD
Auto-page Medicine MD
ED MD updates
ED dashboard, including electronic
sign out template
ED MD pages
Medicine MD once
update complete
Medicine MD
reviews
ED dashboard
Acknowledges,
no verbal clarification
needed
Acknowledges,
with request for
verbal clarification
ED MD confirms
Medicine MD
acknowledgement
Medicine MD
pages ED MD
ED MD enters
POE holding orders
Transfer to inpatient
bed pending chart, RN
signout, and transport
5S:Trauma Room
Needed in Red
Zone?
Item Requested
Needed in Red
Zone?
Item Requested
Supplies
Needed in Red
Zone?
Item Requested
Supplies Continued
Equipment
IVF with KCL
No
Saline Flush
Yes
BP Cuffs
Yes
Restform
Yes
50 cc NS
Yes
Stretcher
Yes
Gloves
Yes
A Line Equipment
Yes
Commode
No
Urinals
Yes
Lumbar Puncture Kit
Follow Up Needed
X2
Yes
250 NS
Yes
Needle Drive
No
Rolling Monitor
Yes
Sheets/Blankets
Yes
Gastrocult
Follow Up Needed
Thermometer
Yes
Food
No
Suture Kit
Follow Up Needed
Rolling IV Pole
Yes
Big Cups
No
Towels
Pillowcases
Yes
Sutures
Yes
Insulin
Cath Secure
Yes
Unasyn
Yes
Sat Probe
Yes
Gyn Stretcher
No
Yes
Slideboard
Yes
Follow Up Needed
Chairs/Stools
Yes
Medications
Water
Yes
Ceftriaxone
Follow Up Needed
US Machine
Yes
Gyn Pads
No
Td
Yes
O2 Tank
No
Straws
Yes
Size 9 OPA
Yes
Other
Blood Culture Tubes
Yes
Blue Bags
No
Pillows
Yes
Tubes Station 9
Yes
Insulin Needles
Yes
Discharge Papers
No
Lock Intubation
Follow Up Needed
Patient Liaison Phone #
Follow Up Needed
Spinal Needle
Follow Up Needed
POE Stickers
Yes
N95 Mask
No
EKG Q Trace Leads
Yes
Porta Cath
No
Computer
Yes
Future Steps
• Trained all attending MDs
and 80 nurses
• Moving from leaders to
facilitators
• Improved our project
framework
• Built into the hiring
interviews
• Prioritization of projects
• Strategic Planning
Sustaining Quality and Performance
Improvements in Critical Care
MICHAEL D. HOWELL , MD MPH
DIRECTOR, CRITICAL CARE QUALITY
A S S O C I AT E D I R E C T O R , M E D I C A L C R I T I C A L C A R E
BETH ISRAEL DEACONESS MEDICAL CENTER
H A R VA R D M E D I C A L S C H O O L
Bored To Death
Operational Failures in the ICU
MICHAEL D. HOWELL , MD MPH
DIRECTOR, CRITICAL CARE QUALITY
A S S O C I AT E D I R E C T O R , M E D I C A L C R I T I C A L C A R E
BETH ISRAEL DEACONESS MEDICAL CENTER
H A R VA R D M E D I C A L S C H O O L
Disclosures
y Employment
{ Beth Israel Deaconess Medical Center
y Grants
{ Robert Wood Johnson Foundation
Ù
{
Grant # 65121 (PI): Advancing the Science of Quality Improvement
Ù Grant # 66350 (PI): Physician Faculty Scholars Program
Center for Integration of Medicine and Innovative Technology (CIMIT)
Ù Clinical Systems Innovation Grant 2010 (Co-investigator)
y Other (Commercial / Financial / Etc.)
{ None
Why should you care about the ICU?
Why should you care?
y Common
y Expensive
y Lethal
y Improveable
Why should you care?
Common … in the U.S. alone
y 6,000 ICUs
y 66,200 adult ICU beds
y 55,000 patients per day
y Over 5 million patients / year
{
(Think “about the size of the Greater Boston region”)
Why should you care?
Expensive… in the U.S. alone
y ~15% of acute hospital costs
y 0.7% of U.S. GDP !!!
Why should you care?
Variably Lethal
y Average 10 – 20% mortality
Outcome Variability
Poor ----------- Cost ---------> Better
Poor ------------------- Survival -------------------> Better
The first implication: Different
practices lead to different outcomes.
The next implication: Some
practices are better than others.
Why is the ICU a particularly
challenging place to do quality
improvement?
Remember what critical care looks like.
Critical Care in action…
THROUGH THE MIRACLE OF GOOGLE, FIVE PICTURES FROM THE
INTERNET
Notice anything?
Quality and Safety
Improvement Opportunities
in
Five Pictures from the Internet
I wonder how the
Red Sox are
doing…
Let’s face it.
The ICU is an exciting place.
Three True Stories
BY MHOW ELL
Let’s face it.
The ICU is an exciting place.
… with high-risk meds …
… lots of procedures …
… fancy monitoring devices …
… and really sick patients …
… but a lot of the most important
things we ask ICU providers to do…
…turn out to be the most boring …
(yes, that was a narcoleptic dog)
Why is b
boringness
oringness important?
To err is human
y The brain is n
not
ot wired to deal with boring very well.
{ Every remembered
meembered something
for your
list while you
Acordcing
togrocery
a resarech
at were in
the shower?
er?
Caridmbge Univristey, it
oerdr
in a in
word
are.tasks.
The
y Even a little
tlle actionthe
can lrettes
cause errors
routine
olny
iprtnmoat
is that
{ Imagine co
counting
ounting medica
medications
ations
or calculatingtinhg
a dose …
the frsit and last leettr be in
the rghit pclae.
y The brain sees what it expects to see.
dsoen't matetr in what
{ Imagine trying
rying to prevent medication errors …
How many basketball passes did
you count?
Who saw the moonwalking bear?
In the ICU, unexpected things happen.
Causing providers to focus too much
on regimented tasks
may mean that
we cause them to miss the unexpected.
Part 2: Another reason
Organizational Context
This can be summed up in one question:
“Who is in charge of
Critical Care at your
hospital?”
Department of Medicine
(Chair)
Medical Center
(Board of Directors, CEO, etc.)
Nursing
Residency (163)
Pulmonary/Critical Care
Health Care Quality
Cardiology
Information Systems
etc.
Materials management
Pharmacy
Respiratory Therapy
etc.
Department of Anesthesia
(Chair)
Department of Surgery
(Chair)
Residency
Residency
Critical Care
Critical Care
etc.
Other surgeons
Part 2: ICU staff are often transient.
Transients in the ICU
y How many days a week do our nurses work?
y How many days a week do our RTs work?
y How often do our students, interns, residents, fellows,
and attendings change rotations?
Intern A
Intern B
Student A
Resident A
Attending
A
Attending
B
Student B
Resident B
Attending
C
Intern C
Student C
Resident C
Attending
D
Intern D
Attending
E
Resident D
Attending
F
Student D
Resident E
Attending
G
Attending
E
In this context, is it even conceptually
possible to build stability,
let alone improvement?
Person-centered
Non-DNR, Non-ICU Deaths per 1,000 Discharges
60
critical care
1000
Patient
Days
Non-DNR, Rate
Non-ICU
Deaths
1,000
DischargesDays
VAPperCases
Perper
1,000
Ventilator
1.1
1.0
50
5.0
0.9
40
4.14
0.84.0
Odds of
Benchmark = 1.06 (intervention arm of largest RCT – Lancet 2005)
"CompleteVentilator-associated
pneumonia
prevention
Triggers
period
95%
Satisfaction"
4.05
with
Confidence
Reducing
unexpected
deaths outside the Interval
p value
Decisionmaking
ICU
What happens
when
1.0
--Baseline PeriodCentral line infection
you do
all these
prevention
20 86% reduction
0.02
1.2 - 5.2
2.5
Jul 2008 - Dec 2008
things?
Severe sepsis
0.0006
1.7 - 6.6
3.3
10
0.7
30
2.91
FY Mean
3.0
0.6
0.52.0
1.55
1.30
0.4
Jan1.02009 - Jun 2009
0.70
0.60
0.60
0.3
1.9 - 7.0
<0.0001
3.6
0 Intensivist
Jul
2009
Dec
2009
24x7
0.20.0
FY06
FY08 FY08
FY09 FY09
FY10 FY10
FY03FY06 FY07
FY04 FY07
FY05
FY06 FY08
FY07
FY08 FY09
FY09
FY10 FY1
2.6
18.2
<0.0001
6.9
Q2* - Q3
Q2* Q3 Q2* Q3 Q4* Q2* Q3 Q4* Q2* Q3 Q4
0.1 2010
Jan
present
Closed
or semi-closed
ICUs
0.0
2003
2004
2004
2005
2005
2006
2006
2007
2007
2008
2009
2010
* only two months
of quarter assesse
2008
2009
2010
Adjusted for survival status
5
4
ICU Length
of Stay
(Days)
3
2
Ð ICU LOS by 25%
1
0
6000
2004
2005
2006
2007
2008
2009
2010
5000
ICU
Throughput
(Patients)
4000
3000
Ï1,807 admissions per year (45%)
2000
1000
0
14%
2004
2005
2006
2007
2008
2009
2010
12%
In-Hospital
Mortality
(%)
10%
8%
%
6%
%
4%
%
Ð Mortality by 2.8% (24%)
For every 35 ICU patients, one fewer death.
2%
%
0%
2004
2005
2006
2007
2008
Throughput Effects
2009
2010
>50% increase
2010 vs. 2004
Vent Bundle Compliance Vs. Throughput
600
550
R² = 0.3485
500
450
400
350
70%
75%
80%
85%
90%
95%
100%
Change in Patients and Bed Capacity, Compared With Baseline
100%
90%
Patients
80%
70%
60%
50%
40%
30%
20%
Beds
10%
0%
2004
2005
2006
2007
2008
2009
2010
This is the part where I would
usually talk about how we did that
and what we’ve learned.
… Instead …
I want to talk about the hard part.
How do we make the rest of it better?
What do I mean?
y We’ve talked about 5 – 10 processes.
y How many do we have in our ICU?
{ 1000?
{ 5000?
{ 10,000?
Arterial lines
y Common ICU procedure
y About 2500 times per year (out-of-OR) for us
Arterial Line Placement:
Typical State
What do MDs do to set up for an arterial line?
How have we mistake-proofed a similar process?
THE EXAMPLE OF CENTRAL LINES
Central lines
y Common ICU procedure
{ Much more complex procedure than arterial line
{ Riskier procedure than arterial lines
Compare the Two
Complexity of Procedure
Arterial Line
Central Line
Less
More
# of items required to
successfully complete
procedure
Fewer
More
Risk to patient
Lower
Higher
Complexity of procedure
Workload for Setup
Number of things
gathered by hand
Time required for set-up
Arterial Line
Central Line
17
3
4 minutes 28 seconds
35 seconds
Quality of Setup
Arterial Line
Central Line
Number of items laid on
floor during setup
9
0
Number of other
providers interrupted to
help with setup
2
0
Defects in set-up
4
0
A Third Approach
M I S TA K E - P R O O F I N G T H R O U G H 5 S
Whew.
Thank you.
A teaching hospital of
Harvard Medical School
Lean In High Stakes Medicine:
Kaizen Without A Net
Thoughts on Engagement
Kevin J. McGuire, MD MS
Chief of Orthopedic Spine Surgery
Co-Director of the Spine Center @ BIDMC
[email protected]
Harvard
Medical
School
DISCLOSURE
I/we disclose the following financial relationships with
commercial entities that produce health-care related
products or services relevant to the content I am presenting:
COMPANY
TYPE OF RELATIONSHIP
CONTENT AREA
(IF APPLICABLE)
Harvard
Medical
School
Harvard
Medical
School
Harvard
Medical
School
Standard Work
Harvard
Medical
School
Variation in Utilization
Harvard
Medical
School
Autograft
Allograft
Interbody Device
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
–Utilization of Autograft, Allograft and Interbody Device in Cervical Discectomy / Fusion Cases Exam Year
Harvard
Medical
School
Environment / Structure
Hospital
Physicians
Harvard
Medical
School
Accessed 1/21/2012- http://www.casasugar.com/Casa-Quiz-Greek-Columns-1109870
Harvard
Medical
School
Gemba
–Accessed 1/22/2012http://upload.wikimedia.org/wikipedia/commons/3/34Gen._McChrystal_
News_Briefing2010_cropped2.jpg
Harvard
Medical
School
Spinal Implant Waste
Harvard
Medical
School
Current State
–Incidence of Intra-Operative Waste
–Implants are the driver of Costs.
–Surgical implants : 42% of the number of items wasted, 85.3% of total
cost
Harvard
Medical
School
Current State
Reasons for Intra-Operative Waste
–䇾Surgeon䇻s change of mind䇿 accounted for the majority of the wasted
items.
Harvard
Medical
School
RESULTS – Post Intervention
Incidence of Intra-Operative Waste
Incidence pre : 20.2% ; incidence post : 10.3% (49% decrease)
Harvard
Medical
School
RESULTS – Post Intervention
Monthly Costs Attributable to Waste
Monthly costs pre : $17600.29 ; monthly costs post : $5876.29
(66.7% decrease)
Harvard
Medical
School
RESULTS – Post Intervention
Percentage of Total Operative Spine Budget
Percent of total operative spine budget pre : 4.24% ; post : 1.20% .
Harvard
Medical
School
RESULTS – Post Intervention
Proportion of Items Wasted 2ndary to Surgeon䇻s Change of Mind
Items wasted because of surgeon䇻s change of mind :
pre=42.20%, post = 24.10%.
Harvard
Medical
School
Physician Engagement
• BUY IN:
– Consensus Definition of
waste
• COMPETITION
– Email
Harvard
Medical
School
Instrument Reduction
Harvard
Medical
School
Instrument Reduction
• 152 Lami 1 / 2
• Audits: 38
• 58% Utilized
• 89 Lami 1
• -17.5lbs
• $36,040
Harvard
Medical
School
Physician Engagement
Harvard
Medical
School
Physician Engagement
Harvard
Medical
School
Thoughts On Lean
Lessons Learned
• Value / Gemba
• Peer to Peer, Cross Column Collaboration
•
Time Commitment
Communication
• Get it right.
• Innovative / Creative
Harvard
Medical
School
Building Process Improvement
(PI) Capability at Brigham and
Women’s/Faulkner Hospitals
Dorothy T. Goulart, MS, RN
Katherine Santos
BW/F Center for Clinical Excellence
Learning Objectives
• Explore strategies for building a culture of
continuous improvement
• Describe the roles BW/F physicians have
undertaken in our continuous improvement
journey
• Highlight differences in previous vs. current
approaches to improvement
101
Key Ingredients
for Building a Culture of Continuous Improvement:
1.
2.
3.
4.
Central group of PI experts
Common approach and language for PI
Department leaders engaging their staff in PI
Frontline staff developing and testing process
changes
5. Change acceleration process (CAP) strategy
for all PI efforts
102
BW/F Center for Clinical Excellence
Elizabeth Nabel MD
CEO & President BWH
Mairead Hickey RN, PhD
COO / Executive VP
David Bates MD, MSc
CQO / Senior VP
Stanley Ashley MD
CMO / Senior VP
Faulkner Hospital
Michael Gustafson MD,
MBA – COO
O’Neil Britton MD – CMO
Ed Liston-Kraft PhD – VP
Q&S, PI
Allen Kachalia MD, JD
Tom Walsh, MBA
CCE Co-Directors
Decision Support
Systems
Analysis &
Planning
Performance
Improvement
6 FTEs
Quality &
Safety
Programs
DFBW Cancer Center
Dir Quality Improvement
Faulkner Hospital
Support & Integration
103
Performance Improvement Program
Responsibilities:
1. Facilitation of complex, multi-departmental
improvement projects
– Service excellence, patient flow/throughput, cost
management and clinical care redesign
2. Building organizational process improvement
capability through training
3. Coaching and advisement of improvement
work
104
Partnering to Build Capability
Many People
Few People
One of the main
missions of the CCE
is to build
organizational PI
capability
Change Agents
Everyone
(Middle
Managers,
(Staff,
supervisors) MD Leaders,
Project Leads)
Operational
Leaders
Experts
(Executives)
CCE
Leadership
Managers
Frontline
Shared
Knowledge
Continuum of PI Knowledge and Skills
Deep
Knowledge
Courtesy of Robert C. Lloyd, PhD and Kaiser
Permanente performance improvement team
105
Key Ingredients
for Building a Culture of Continuous Improvement:
1.
2.
3.
4.
Central group of PI experts
Common approach and language for PI
Department leaders engaging their staff in PI
Frontline staff developing and testing process
changes
5. Change acceleration process (CAP) strategy
for all PI efforts
106
Common Model of Continuous Improvement
• Observations
• Interviews
• Shadowing
• Analogous observations
• Process mapping
• 5 Why’s
• Charter
• Sponsor, process
owner, team
member roles and
responsibilities
• Lean concepts
• Prototyping
• Rapid cycle testing
• Huddles
• High reliability concepts
• Ownership by leaders
• Standard work
• Metrics dashboard
• Accountability
• Share and spread
107
Project Framework
BW/F Lean/Performance Improvement
Project
Initiation
INITIAL
CHARTER
Assessment
REVISED
CHARTER
PROJECT
PORTFOLIO
WorkOut
Kaizen
Event
Mgmt
Decision
IMPROVED
PROCESSES
PDSA
Implement/
Standardize
& Sustain
Change Acceleration
• Creating Shared Need
• Shaping Vision
• Mobilizing Commitment
• Making Change Last
• Monitoring Progress
• Changing Systems and Structures
• Leading Change
108
Work-Out™
• Facilitated meeting (typically 1 day)
– Understand causes of current process improvement
opportunities & brainstorm solutions
– Develop recommendations and present to sponsors for
approval (same day)
– 30-60 day implementation plan
• Participants are experienced and knowledgeable,
with a stake in the process (can be frontline staff
and/or managers)
Work-Out™ General Electric Company
109
CABG ICU Work-Out (Oct 2011)
Objectives
Targets
• Standardize ICU care protocols for CABG patients
– Sedation
– Extubation
– Removal of lines
– Start of Beta Blockers
• Develop method for tracking metrics – when goal is met/not
met and reason why
• 70% of patients off sedation within 2 hours of admit to ICU
• 70% of patients extubated within 6 hours of admit to ICU
• 70% of patients with Beta Blockers started within 16 hours
of admit to ICU
• 70% of patients with radial A line removed on POD #1
110
CABG ICU Work-Out Team
Sponsors
Process
Owners
Team
Members
•
•
•
•
Division Chief of Cardiac Surgery
Chief Medical Officer, BWPO
Vice President, Surgical Services
Associate Chief Nurse, Cardiovascular Nursing
• Attending Cardiac Surgeon
• Medical Director, Cardiac ICU
• Nurse Director, Cardiac ICU
• 1 MD (Intensivist)
• 3 ICU RNs (1 RN Director, 1 RN Educator, 2 Staff RNs)
• 2 Stepdown RNs (2 Staff RNs)
111
CABG ICU List of Recommendations
Future State (Goal)
2 hrs
6 hrs
Admit Sedation
to ICU
Off
Extubation
Alternative
Medications for
Pain and
Anxiety Mgmt
16 hrs
Beta
Blocker
Start
Order Set
Change
POD 1
Radial A Transfer to
Line Out Stepdown
Use of
Lines
Guidelines
ICU Goal Sheet during ICU
Pause
Changes to Extubation
Practice
“What to
Expect” Video
for Families
CABG Plan of Care
Documentation of Metrics in ICU Flow Sheet and CSS Database
112
Process: Pre- & 60 Days Post-Work-Out
Current State (Average)
5 hrs
Admit
to ICU
Sedation
Off
8 hrs
POD 1
Radial A
Line Out
Extubation
36 hrs
Beta
Blocker
Start
Transfer to
Stepdown
Future State (Goal)
2 hrs
Admit Sedation
to ICU
Off
Pre-WO
Post-WO
28%
73%
6 hrs
16 hrs
Extubation
Beta
Blocker
Start
47%
77%
4%
53%
POD 1
Radial A Transfer to
Line Out Stepdown
50%
62%
113
PACU Needle Safety Project Context
• Increase in the number of documented needle sticks in the PACU and
preop holding have resulted in a need for improved safety
– 8 out of 22 total sharps injuries documented in PACU due to device being
left in inappropriate areas (Occ. Health data ‘02-’08)
• Opportunity areas identified through observation and interviews
– Inappropriate placement of needles on patient bed during procedure
– No standard approach and setup for procedure and standard process for
counting needles after procedure
– Location and accessibility of needle disposal boxes
– Near misses are not known and documented
– No direct feedback to staff about needles left in inappropriate areas since it
is difficult to know who is responsible
114
PACU Needle Safety Work-Out (Jan 2009)
Objectives
• Design a set of changes to improve needle safety in the PACU & preop
holding (room setup, equipment and supplies, pre-and post-procedure
processes, and roles of staff)
• Create a process for identifying and providing immediate feedback to staff
about incidents and near misses
Sponsors
•
•
Process Owners
Anesthesia Chairman
Chief Nursing Officer
•
•
•
Anesthesia Attending MD
RN Director, Preop & PACU
RN Supervisor, Preop & PACU
Team Members
•
•
•
Anesthesia Attending MD
Anesthesia Chief Resident
2 Anesthesia Residents
•
•
•
2 Preop RNs
2 Patient Care Assistants
1 Environmental Services
Supervisor
115
PACU Needle Safety Key Changes
• Creation of a “neutral zone” during the
procedure for needles not in use
• RN assistance and use of a procedure
checklist for epidural placement
• New schedule for emptying needle boxes each
day by night shift housekeeper
• Documentation and peer-to-peer
communication of near misses to staff
116
Metrics – Documentation of Near Misses
• Email is automatically sent to the leadership when a report is made
• All reports are individually reviewed and followed up by leadership
team
Documentation for Near Misses in Preop Holding/PACU
Name (optional):
Date:
Time:
Location (including slot #):
Type of Near Miss:
… Blunt needle
… Angio cath (plastic)
… Epidural needle
… Block needle
… Spinal needle
… Syringe w/o needle
… Unknown needle
… Glass vial
… Guide wire
Any harm?
Does device have safety mechanism?
If yes, was the safety mechanism engaged?
Does device have visible blood?
… Yes
… Yes
… Yes
… Yes
… No
… No
… No
… No
Other comments:
Zero needle sticks due to device being left in
inappropriate areas since January 2009
117
Emergency Department Redesign
WORK-OUTS
TABLE TOP SIMULATION
TESTING
March – September 2010
Summer 2009, April – December 2010
November 2010 – June 2011
All-day events at which ED staff
worked together to design the
new ED processes.
Patient flow simulations
Weekly testing, then daily
testing, of process segments
Role of
flow
manager
Patient
transfer to
pod
Teambased care
Informal
simulations
Formal
simulation
118
Kaizen
• 4 day session
• Design and iterative testing
• 30 day implementation plan
Standard work - blood draw process
Phlebotomy Cart
Assignment Communication
Board
119
17 Kaizen, 35 Work-Outs, 11 Facilitated
Sessions since start of Lean journey!
Dec 07 – Feb 12
• Obstetrics
– 4 Kaizen
– 4 Work-Outs
• Clinical Lab and Phlebotomy
– 8 Kaizen
– 4 Work-Outs
• Information Systems
– 3 Work-Outs
• Inpatient Oncology
– 1 5S Kaizen, then spread
• Emergency Department
– 4 Work-Outs
• Endoscopy
– 2 Work-Outs
• MRI
– 2 Work-Outs
• Pharmacy
– 1 Work-Out
• Cardiac Surgery
– 2 Work-Outs
• Support Services
– 1 Work-Out
• Surgical Services
– Faulkner Hospital
• 1 Kaizen
• 4 Work-Outs
– BWH
• 5 Work-Outs (PACU, OR Pharmacy,
OR, Preoperative Evaluation Center)
• 3 Kaizen (CPE, OR)
• Faulkner Hospital
– 2 Work-Outs
• 11 Facilitated Action Plan / Testing
Sessions
– Revenue Capture, Linen, Patient
Equipment, Discharge Transport, 5S
Collaborative, Biomedical Engineering,
Burn Trauma
120
Key Ingredients
for Building a Culture of Continuous Improvement:
1.
2.
3.
4.
Central group of PI experts
Common approach and language for PI
Department leaders engaging their staff in PI
Frontline staff developing and testing process
changes
5. Change acceleration process (CAP) strategy
for all PI efforts
121
Lean Practitioner Program
2 weeks
Define
Application
4 weeks
Measure/
Analyze
coaching
Application
coaching
4 weeks
5 weeks
Improve
Application
coaching
Sustain
Application
Present &
Celebrate
coaching
Learning objectives
–
–
–
–
–
–
–
–
See waste in processes
Use a common language for performance improvement
Scope a small project
Engage staff in diagnosis, testing of changes and implementation
Develop dashboards / metrics / targets
Facilitate acceptance
Sustain changes
Improve processes as part of daily work
At BW/F we want staff to be both “doers” and
“improvers” of their work
122
Accomplishments
• Now in our 9th round of the program (2 MDs)
• 207 graduates (26 MDs) from the previous rounds
– Outpatient office practices, inpatient units, hospital departments,
administrative services
• 89 projects completed, with local efforts to sustain
improvements
• Rated highly by participants in overall program evaluation
“Networking with peers”
“CCE coaching”
“confidence in applying methods to future opportunities”
123
Project Results Achieved (Primary Care examples)
Quality/Safety
Operational Efficiency
x Ç % of patient visits with documented
flu shot from 72% to 92%
x Ç Diabetic labs completed from 65%
to 90%
x Ç clinically significant radiology tests
completed from 73% to 91%
x Ç LPN patient engagement time from
0 min to 47 mins per day
x Ç % of Diabetic patients seen in past
month who have follow-up appts from
80% to 90%
x Ç Percentage of red team patients
seen by red team PCP from ~55% to
>70%
• È time from check-in complete to patient
ready for MD from ~4mins to ~2mins
• Ç percentage of check-out encounters
under 10 minutes from 50% to 70%
• Ç Out-of-compliance patients with appt
from 50% to 63%
• È MA average clinical check-in time from
5 mins to 3 mins
Revenue Enhancement
• Ç co-pay collection from 66% to
86% at time of visit
124
Partners Clinical Process Improvement
Leadership (CPIP) Program
Overview
• 7 days of classes over 4 months
• Based in part on Dr. Brent James’ QI advanced training program
• Process improvement, fundamentals of leadership, communication,
finance, and research are addressed by leaders from across Partners
institutions
Participants and Projects
• Interdisciplinary teams, consisting of a physician and nurse or
administrator pair
• Teams apply their learning to a project during the course
• Projects are focused on efficiency, quality and patient safety
125
BW/F CPIP Teams
• Now in the 4th round of the program (4 MDs)
• 35 graduates (21 MDs) from the previous rounds
• 16 projects completed
126
Project Results Achieved (CPIP examples)
Quality/Safety
Quality/Safety (cont’d)
• AMI discharge process: 0-52%
defect free discharge summaries;
1-80% cardiac rehab referrals; 4184% follow-up appointments
• Stroke data elements included in
resident discharge summary: 70-85%
• Documentation of pain scale
rating at initial Rad Onc visit:
increase from 40-93% compliance
• Post-colectomy diet resumption within 48
hrs of surgery end: 14-69%
• CVL removed when infant
tolerating 100ml/kg/day: 20-44%
• Follow-up time for hypertensive pts: avg
74 to 33 days
Appropriate Utilization
• Admission chest imaging for autologous
SCT: decreased from 55% to <1%
127
PI Learning & Networking Forum
Purpose:
‰ Share change ideas, improvement tools and approaches
‰ Network with others doing improvement work
Target
Audience:
Any Brigham & Women’s/Faulkner Hospital employee who has
experience or been exposed to process improvement
Approach:
‰ 90 min (over lunch): didactic, interactive and BW/F
employee presentations
5S: Maximizing the Use of Shared Work Areas (April 2010)
Strategies to Sustain Improvements (June 2010)
Making Improvement Part of Daily Work (September 2010)
Measuring Your Area's Performance (January 2011)
Effective Communication Strategies (April 2011)
Value of Standardization (July 2011)
Fostering Physician Engagement (January 2012)
~60 attendees (5-10 MDs) at each forum
128
Process Improvement Intranet
129
Key Ingredients
for Building a Culture of Continuous Improvement:
1.
2.
3.
4.
Central group of PI experts
Common approach and language for PI
Department leaders engaging their staff in PI
Frontline staff developing and testing process
changes
5. Change acceleration process (CAP) strategy
for all PI efforts
130
Frontline Staff Strategy
• Project Participation
‒ Work-Out / Kaizen
‒ Local improvement efforts
• Collaboratives
‒ Patient Equipment & Medical/Surgical
Supplies in Inpatient Units
‒ Ambulatory Medication Reconciliation
• Everyday Improvement Idea Programs
131
465 Participants & 78 Leaders/Sponsors
engaged in PI across BW/F
Dec07 – Feb 12
Roles
Number
Nurses
150
Physicians/Mid-levels
46
Other Clinicians
50
Technical Staff
74
Support Svcs
20
Information Svcs
17
Admin Svcs
62
Clerical Support
45
Patient/Family Advisor
1
Sponsors/Owners
78
Total
543*
* does not include additional front line staff involved in testing
132
Everyday Improvement Idea Programs
• Changes to one’s work or unit that decrease waste or add value
• Small scale - can be tested by submitter alone or with co-worker
Pharmacy
Information Systems
133
Everyday Improvement Idea Programs
General Surgery
Bring your ideas to life
talk about process improvements, we focus on making incremental improvements that over time
e efficient and fluid process. We can achieve this through identifying and eliminating waste in ou
t processes.
see examples of waste (see chart on reverse) and have an idea to help reduce it, please comple
nd submit it to the Ideas in Motion board in the GSS kitchen.
will be reviewed at weekly Drop-In and Coffee Time/Admin Meeting. Three projects will be selec
Ideas in Motion board.
Name _____________________________
Date ______________________
Briefly describe a problem that causes waste or an example of waste: (example: clinic prep takes
up too much time)
If you have an idea or suggestion that might help reduce this example of waste, tell us here:
(example: eliminate time-consuming chart prep)
Let us know how you think your idea could be measured. (example: we could time how long it
takes to prep clinic using charts and then time clinic prep using a chartless method)
What is the expected effect or outcome from your idea? (example: save time prepping for clinic so
we can focus on other areas)
134
Key Ingredients
for Building a Culture of Continuous Improvement:
1.
2.
3.
4.
Central group of PI experts
Common approach and language for PI
Department leaders engaging their staff in PI
Frontline staff developing and testing process
changes
5. Change acceleration process (CAP) strategy
for all PI efforts
135
Change Acceleration Process (CAP)
Leading Change
Creating a Shared Need
Shaping a Vision
Mobilizing Commitment
Current
State
Transition
State
Improved
State
Making Change Last
Monitoring Progress
Changing Systems & Structures
© 2003 General Electric. All rights reserved
Q
x A3
= E
Quality of idea X Alignment, Acceptance, Accountability = Effective change
136
CAP Workshop Agenda (2 Days)
• Designed for team leaders and project
facilitators
• Review of each component and tools (~ 35 tools)
• Interactive exercises to practice use of tools
• Facilitation tips
• Development of CAP strategy plan for a current or
future project
321 leaders trained to date
(30 MDs)
137
Summary: How We Do PI Differently
“Then”
Hattiesburg - Inventory Reduction
Metric Owner: J. Tucker
25%
20%
15%
10%
“Now”
Managers and project
managers
¾ Frontline staff, providers
and patients
Little measurement
¾ Metrics and targets
¾ Observations, interviews
Monthly, hour long
meetings
¾ Kaizen, Work Out, tabletop simulation
Implementation
¾ Rapid cycle testing
¾ Projects aligned with
strategic initiatives
¾ CAP strategy
Lexan
DFA
SAN
V alox
5%
0%
1s t Qtr 2nd Qtr 3rd Qtr 4th Qtr
Expectation: Lexan®-10%; DFA-5%; SAN-15%; Valox-5%
Action: Formalize Joint Inventory Reduction Team.
Minton/Tucker to Lead
Data (Strickland/Minton)
138
Kaizen (Continuous Improvement) Model
“We’re all doers and improvers of the work.”
Often multi-discipline, multi-department
Very few
large
problems
Few medium
problems
Many small
problems
Kaizen
Event
Dept.
focus
Local
project
WorkOut
Local
project
Dept.
focus
Local
project
Dept.
focus
Local
project
Everyday Lean
CCE facilitator,
with Lean
Practitioner
WorkOut
Dept.
focus
Lean
Practitioner
Local
project
Dept.
focus
Everyone, with
Lean
Practitioner
coaching
BW/F Center for Clinical Excellence - adapted from Liker JK, The Toyota Way Fieldbook
Erik Dickson, MD, MHCM, FACEP
Erik Dickson is President of UMass Memorial Medical Group, a 1050 physician multidisciplinary academic medical group based in Worcester Massachusetts and a Professor of Emergency Medicine and Senior Associate Dean at the University of Massachusetts Medical School. Dr Dickson completed his medical degree and residency training in emergency medicine at the University of Massachusetts Medical School and has a Masters Degree in Health Care Management from Harvard University. Prior to returning to Massachusetts he served as Professor and Head of the Department of Emergency Medicine at the University of Iowa Carver College of Medicine and Interim Chief Operating Officer for the University of Iowa Hospitals and Clinics. In addition to his other duties, Dr Dickson has served as a member of the Baldrige National Quality Award Board of Examiners, lectures nationally on the use of Lean manufacturing techniques in healthcare and is an active faculty member for the Institute of Healthcare Improvement, where he works with health systems around the world to reduce healthcare costs while improving quality. Dorothy Goulart, MS, RN
Dorothy Goulart, MS, RN is the director of performance improvement in the Brigham and Women’s/Faulkner Hospitals’ Center for Clinical Excellence. She oversees facilitation of teams seeking improvements in operational efficiency, building toward a culture of service excellence and continuous improvement. Dorothy has a master’s degree in nursing from Boston College and a bachelor’s degree in nursing from the University of Rhode Island. She joined BWH in 1980 as a cardiac surgical clinical nurse specialist. Her transition to process improvement work occurred in 1996 with the creation of a six‐person “systems improvement” team. Since that time, she and her team have worked to build a toolkit for staff throughout the institution to apply innovation, rapid cycle testing, change acceleration, and lean concepts and approaches. Michael Howell, M.D., MPH
Michael Howell consulted in materials purchasing workflow analysis and automation for the company which built most of the space shuttle, prior to entering medicine. His longstanding interest in putting the right person in the right place at the right time flowed naturally into his current career, which focuses on improving the value of care for acutely ill patients by blending research‐in‐the‐midst‐of‐actual‐
patient‐care with operational improvement strategies. Dr. Howell is the Director of Critical Care Quality and the Director of the Research Core for InSIGHT (Integration of Standard Information Gathered using Healthcare Technology) at BIDMC. He has held several national leadership positions in quality and safety in intensive care medicine and is a nationally recognized leader in critical care quality improvement. Kevin J. McGuire, M.D., MS
Kevin J. McGuire, MD, MS is the Chief of the Orthopedic Spine Service, Co‐Director of the Spine Center, Director of Combined Spine Fellowship at BIDMC and Spine’s section editor Health Care Delivery Science. He is a graduate of Princeton University and University of Pennsylvania School of Medicine where he completed his residency as well. During his residency he also obtained a Masters Degree in Epidemiology and Biostatistics. He is a graduate of the Traumatic and Reconstructive Spine Fellowship at Case Western Reserve University under the auspices of Henry Bohlman, MD. He has been awarded multiple honors including the Marshall Urist Award. He is involved in IDE trials currently with cervical disc arthroplasty. He is a co‐investigator on a submitted planning grant to the NIH for a multicenter randomized trial for cervical radiculopathy. His clinical and research interest include endoscopic spine surgery and outcomes research. Katherine S. Santos
Katherine S. Santos is a Senior Consultant in Performance Improvement with the Center for Clinical Excellence at Brigham and Women’s/Faulkner Hospitals (BW/F). Since joining BW/F in 2002, she has facilitated multidisciplinary project teams composed of clinicians, administrators, and support staff to advance BW/F’s mission of clinical, operational, and service excellence. Katherine has worked with numerous BW/F departments and various inpatient and outpatient practices to improve the quality and service of patient care, work efficiency, and staff satisfaction. By using innovation, rapid cycle testing, change management, and Lean methodologies, she has helped departments like Cardiac Surgery, Clinical Laboratory, Phlebotomy, Orthopedics, Pharmacy, Obstetrics, and Central Transport achieve their project goals. In addition to facilitating improvement events, Katherine regularly interviews patients and staff and analyzes data to evaluate current states, identify opportunity areas, and measure the impact of hospital care initiatives. Katherine holds a bachelor’s degree in Chemistry from Harvard College. She is trained in Lean, Kaizen, Work‐Out, and Change Acceleration Process by GE Healthcare Performance Solutions. Carrie Tibbles, M.D.
Carrie Tibbles, M.D. is the Director of Clinical Innovation and Education in the Department of Emergency Medicine and the Director of Graduate Medical Education at Beth Israel Deaconess Medical Center. Dr. Tibbles also works as the Risk Management Consultant for CRICO Risk Management Foundation. An expert in communication among health care providers and medical education, she is an assistant professor of medicine at Harvard Medical School. Attendees by Name
NAME
Femi Adewunmi, MD, MBA, CPE, SFHM
Benjamin Asfaw, MHSA
Richard L. Barnett
Sanjay Chaudhary
Nicholas Comeau, BS
Christopher Cotroneo, M.D.
W. Keith Davis, AIA, LEED, AP
Kimberly A. Dever
Eric W. Dickson, MD, MHCM, FACEP
Brian Dolan, M.D.
Jill M. Ettori
Anne Fowler
Christine Galatis
Sandra Geiger
Dorothy Goulart, MS,RN
Lori Granger, BS
Eduardo Haddad, M.D.
Elizabeth Hale, R.N., MS
Bruce Hamilton
Michael Howell, MD, MPH
Myranne F. Janoff
Mark Jussaume, P.E., LEED
Dorothy Kelly‐Flynn
Sheila Kennedy, M.D.
Andrea S. Kerr
Lindalee A. Lawrence
Ashley Luppold
Timothy R. Lynch, M.D.
C. Gregory Martin, M.D.
Kevin McGuire, M.D.
Michelle McLaughlin
Neil Meehan, D.O.
Joan Menard
Jamie Millman
Richard D. Mirel, M.D.
Robert M. Mitchell
Eric Nathanson
Francis Powers, M.D.
Rebecca Roth
Jacqueline Royer, AIA, LEED
Katherine Santos
Leslie G. Selbovitz, M.D.
Theresa Dunn Sievers, MS, R.N., CPHQ
Kirsten Singleton, CAE
Charles Sommer, M.D.
John Stevenson, M.D.
Joan Strauss
Donna Sulley
James Sullivan, M.D.
Carrie Tibbles
Kara Tuohey, BS
Priya Vader, MB, BS, MHA
Natalia Villarreal
TITLE
Regional Chief Medical Officer
Director, Quality Management
Senior Vice President
Senior Consultant
Process Improvement Specialist
Design Principal
Chair, Dept. OB/Gyn
President and Senior Associate Dean
Dir., Hospital 1st Program
Events & Marketing Specialist
Dir., Outreach & Recruiting Services
Administrative Assistant
V.P., Performance Excellence
Director, Performance Improvement‐CCE
Process Improvement Specialist
President of the Medical Staff
CNO/V.P. Patient Care Services
President
Director of Critical Care Quality
President
Chief Executive Officer
Dir., Quality, Patient Safety & Clinl. Srvcs.
Associate
President
Sr. Learning Specialist
Int. Med./Pt. Care Assessment Coord.
CMO & SVP, Clinical Affairs
Chief, Orthopedic Spine Service
Sr. Search Consulting
CMO, CMIO
Physician Relations
Director of Sales
Chair, Dept. of Medicine
NE Institutional Marketing Director
Quality Management Project Specialist
Consultant
Sr. Healthcare Planner & Architect
Director, Performance Improvement
Chief Medical Officer
V.P., Quality & Patient Safety
Exec. Dir., Center for Ed & Prof Dev
Doctor
S.V.P., Clinical Affairs & CMO
Sr Process Improvement Consultant
V.P., Practice Developmnent
Associate Director
Process Improvement Specialiist
Senior Project Leader
Events Coordinator
COMPANY
Sound Physicians
South Shore Hospital
Colliers International
Massachusetts General Hospital
UMass Memorial Medical Center
Lawrence General Hospital
Lavallee Brensinger Architects
South Shore Hospital
UMass Memorial Medical Group
South Shore Hospital
Massachusetts Hospital Association
Sound Physicians
Massachusetts Hospital Association
South Shore Hospital
Brigham and Women's Hospital
UMass Memorial Medical Center
Lawrence General Hospital
Lawrence General Hospital
GBMP, Inc.
Beth Israel Deaconess Medical Center
ZurickDavis
TRO Jung|Brannen
Winchester Hospital
Emerson Hospital
TRO Jung|Brannen
Lawrence Associates
Hologic, Inc.
Signature Healthcare Brockton Hospital
Emerson Hospital
Beth Israel Deaconess Medical Center
Stiles Associates LLC
Lawrence General Hospital
Harrington Hospital
GBMP, Inc.
South Shore Hospital
InsMed Insurance Agency, Inc.
South Shore Hospital
Harrington Hospital
Steffian Bradley Architects
Brigham and Women's Hospital
Newton‐Wellesley Hospital
Lawrence General Hospital
Massachusetts Hospital Association
Harrington Hospital
South Shore Hospital
Massachusetts General Hospital
Sheridan Healthcare, Inc.
Harrington Hospital
Beth Israel Deaconess Medical Center
UMass Memorial Medical Center
Newton‐Wellesley Hospital
Sheridan Healthcare, Inc.
Attendees by Name
NAME
Patricia Wardwell
Billy Watson
Marlene V. Williamson, R.N., MSN
Teresa Wilson
Annie Yu
TITLE
Chief Operating Officer
Market Development Mgr.
Director of Inpatient Nursing
Architect
Dir., Corporate Learning & Development
COMPANY
GBMP, Inc.
Sound Physicians
Winchester Hospital
Steffian Bradley Architects
Hologic, Inc.
2012 Education Programs
Continuing professional education is a cornerstone of MHA’s service to its members and other healthcare professionals. The primary goal of MHA’s Center for Education and Professional Development is to support healthcare leaders in innovation and change in a complex and challenging environment. During these challenging economic times, professional development and education should not fall through the cracks. Healthcare changes rapidly and MHA will bring you programs with the latest “must know” information and best practices. As always, we continue to offer affordable rates for our members. MHA’s educational programming includes broad and visionary offerings, such as ethical and economic challenge facing healthcare leaders, the evolving relationships between hospitals and physicians, and improving the quality and safety of care. It also includes a wide variety of specific, need‐to‐know sessions on issues such as healthcare accreditation, trends in labor relations, and the status of Medicare risk products in the state. We hope you’ll join us for our upcoming conferences. Note: If your hospital belongs to your state’s hospital association we will extend the member rate to any of our events. March 20, 2012 Breaking New Ground: Value‐Based Physician Compensation WEBINAR March 21, 2012 The Healthcare Reform Marketing Opportunity New England Organ Bank Waltham, MA March 22, 2012 The Joint Commission Physician Environment Changes & Challenges in 2012: Achieving Survey Success WEBINAR April 10, May 15, June 12, 2012 Emerging Leaders in the Era of Healthcare Reform MHA Conference Center Burlington, MA April 17, 2012 Translating a Community Assessment into an Implementation Strategy WEBINAR April 27, 2012 6th Annual Healthcare Construction Conference MHA Conference Center Burlington, MA May 1, 2012 Hospital Contracts: Ensuring Compliance with Joint Commission and CMS Requirements WEBINAR May 4, 2012 46th Annual Human Resource/Labor Forum The Conference Center at Waltham Woods Waltham, MA May 11, 2012 Doctors & Documentation: Engaging Physicians in ICD‐10 Implementation MHA Conference Center Burlington, MA June 6, 2012 Annual Golf Outing Ocean Edge Resort & Golf Club Brewster, MA June 6‐8, 2012 76th Annual Meeting Ocean Edge Resort & Golf Club Brewster, MA July 13, 2012 14th Annual Emergency Medicine The Conference Center at Waltham Woods Waltham, MA August 17, 2012 The Final 2013 Inpatient Hospital IPPS Rule MHA Conference Center Burlington, MA September 14, 2012 6th Annual Administrative Professionals Conference MHA Conference Center Burlington, MA September 28, 2012 11th Annual Executive Women in Healthcare Conference Sheraton Framingham Hotel Framingham, MA For more information on upcoming events
& webinars, check our web site often:
http://www.mhalink.org/education
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Annual Hospital‐Physician Leader Conference: Incorporating Lean into High‐Stakes Medicine Friday, March 16, 2012 | Conference Center at Waltham Woods, Waltham, MA Thank you to our Exhibitors: Sheridan Healthcare | Sound Physicians