Lean + REMEDI = Continuous Team Learning Melanie Cline, RN, MSN, LPC Senior Advisor, Lean Healthcare Purdue Healthcare Advisors Cline3@purdue.edu 317-389-0530 (mobile)

Purdue Healthcare Advisors Established in 2005 Partnership among Indiana Hospital Association, RCHE, and Technical Assistance Program Focus to improve healthcare quality, efficiency, and safety Apply the principles of engineering, management, and science Self-funded department Team of 30+ staff, located throughout IN Expertise in process/quality improvement, health IT, IT security

A Working Definition of Lean An improvement philosophy and method for continuously eliminating waste and enhancing flow A lean production or service system delivers customer value while continuously making adjustments: Eliminate waste Improve flow Uniqueness Broad concern - multiple sources of waste Focuses first on flow through process rather than staff and machine productivity Much of the effort of continuous improvement (CI) happens while you work! Waste CI Where did lean come from? Flow Value

PHA Lean Service Offerings Working with clients to create value by fostering lean skills and capabilities within their organization.

Client Impact Examples Success Stories Client Impact Examples Time on wait list from 18 to 9 to 3 days % barcode med scan errors to zero Registration errors from 10% to 5% Med list availability from 40% to 90% Maintained par levels (supplies) from 40% to 85% First review of sewage permit application in 4 days (goal of 30 days) Hard to recruit positions filled in average of 30 days (down from 66 days)

Application of Lean Process improvement work implemented in 2014 established Cameron as a top performer in the REMEDI database however results are not sustaining. What are the reasons for the change in compliance with guardrail utilization?

Root Cause An initiating cause of either a condition or a causal chain that leads to an outcome or effect of interest Visible Problem Problem symptom First-level cause The goal is to understand what happens, why it happens, and how to keep it from happening again. Definitions: Visible problem – water dripping Problem symptom – stained ceiling tile (just the tip of the iceberg) First level cause – deteriorated seal Higher level cause – lack of maintenance Root cause-Lack of preventative maintenance system checking system Causal chain Cause and effect relationship - can you turn it off and on like a light switch? Higher level cause Root Cause https://en.wikipedia.org/wiki/Root_cause

High Level Issues Identified Nursing audits stopped December 2015 EPIC Go-Live November 2016 OB compliance dropped after Go-Live Deep dive to verify impact on nursing workflow from EPIC Go-Live Missing visual cues from pumps Hardwire nursing leadership owning data and process improvement

Recommendations from Site Visit Need to validate findings with front line staff Rapid Improvement Event Nursing, Pharmacy, Clinical Engineering Lean Daily Improvement with Nursing Leadership Hardwire adoption and learn from practice Cameron is using the REMEDI database to adjust practice- great news! Current performance still at 90%

Engines of Improvement A3 Thinking Applied to Lean Improvement or Kaizen Events Deming's Plan-Do-Check-Act Cycle Hand out full-size working A3 (or include in packet). Discuss general A3 thinking and how it is applied to Kaizen to get A3 problem solving for lean improvement events. 3 stages and 9 steps documented in 9 boxes on A3 (really 11x17) sized paper. Visual, tool for collaboration and inclusion, lite-weight project charter, story of improvement. We will prove electronic spreadsheet template on day 4. Have two paper version – stylized (with icons) and working (empty boxes) When and why do you use Japanese terms. Use Kaizen as it helps us focus on event versus project and a system for doing them (while we deliver service via daily huddles all the way up to five day workshops or rapid improvement events where most of the change happens in the event. We will talk more about PDCA when we look at rapid experiments in RIEs, post Kaizen event work (lean daily improvement) and waste walks. Introducing it now to explain that your don’t always need to do a full A3 if you are doing a smaller improvement actions. CHECK FOR ACTIVE NOTE TAKING. This is a good example where we could have another slide or teach them the observation/learn skill of active note taking. Kaizen is a Japanese term that references a system for constantly making things better (continuous improvement). A Kaizen event is a team-based action that drives continuous improvement by making seemingly small changes for the better. They range in length from a few minutes to five days. Why do we use Japanese terms?

Lean Daily Management PDCA Getting Started with LDM Pick metric Establish baseline and goal Define data capture process Create graphs and forms Set up board Brief/train team and hold initial huddle Start data collection and daily huddles 1 Project 10 Rapid Events 1000 Daily Improvements