1 What is the problem???? Jack Billi, M.D. sitemaker.umich.edu/jbilli Michigan Quality System: med.umich.edu/mqs Terry Platchek, MD Hospitalist, Lucile Packard Children’s Stanford University Medical Center Adapted from John Shook and Dave LaHote, with permission Michigan Quality System: Quality Safety Efficiency Appropriateness Service Engaging Physicians in Improvement

StandardActual PROBLEM!! ADJUST CHECK PLAN DO Modified from Dave LaHote, with permission

4 Lean Thinking: Troubleshooting Guide 1.What is the problem? 2.Who owns the problem? 3.What is the plan? 4.What is the current status of the plan? How will it be monitored? 5.What worker training is needed? 6.How does this problem relate to the organization’s most important goals?* 7.What leader development is needed? Adapted from John Shook. Ask questions in order. *As a variation, 6 may be asked second. J Billi

5 Physician Engagement in Improvement 1.What is the problem? 2.Who owns the problem? 3.What is the plan? 4.What is the current status of the plan? How will it be monitored? 5.What worker training is needed? 6.How does this problem relate to the organization’s most important goals?* 7.What leader development is needed? Adapted from John Shook. Ask questions in order. *As a variation, 6 may be asked second. J Billi

Title: What we are talking about. Background Current Situation Goal Analysis Recommendations Plan Follow - up Of all our problems, why this one? The “ugly story”… Where do we stand? Problem Statement: What is the specific change we want to accomplish now? -What are the root causes, requirements, constraints? What are your proposed countermeasures, strategies, alternatives? What activities will be required? What, Who, When? How we will know? What remaining issues? Modified -Verble/Shook Date: Owner: An A3 Template

Title: What we are talking about. Background Current Situation Goal Analysis Recommendations Plan Follow - up Of all our problems, why this one? The “ugly story”… Where do we stand? What is the specific change we want to accomplish now? -What are the root causes,requirements, constraints? What are your proposed countermeasures, strategies, alternatives? What activities will be required? What, Who, When? How we will know? What remaining issues? Modified -Verble/Shook Date: Owner: A3 - A Template For Structured Problem Solving… …Does this sound familiar??

Name of Patient: History Physical Exam Impression - Diagnoses Plans Follow - up Date: Clinician: New Patient H&P Chief Complaint History of Present Illness Past Medical & Surgical History Medications and Allergies Family and Social History Review of Systems General Appearance, Vital Signs HEENT Heart & Lungs Abdomen Extremities Neuro Diagnostic: 1, 2, 3, Treatment: 1, 2, 3, Monitor x, y, z Return visit:

Title: What we are talking about. Background Current Situation Goal Analysis Recommendations Plan Follow - up Of all our problems, why this one? The “ugly story”… Where do we stand? Problem Statement: What is the specific change we want to accomplish now? -What are the root causes, requirements, constraints? What are your proposed countermeasures, strategies, alternatives? What activities will be required? What, Who, When? How we will know? What remaining issues? Modified -Verble/Shook Date: Owner: Where would “Increase Physician Engagement” fit on the A3?

Title: What we are talking about. Background Current Situation Goal Analysis Recommendations Plan Follow - up Of all our problems, why this one? The “ugly story”… Where do we stand? Problem Statement: What is the specific change we want to accomplish now? -What are the root causes, requirements, constraints? What are your proposed countermeasures, strategies, alternatives? Increase Physician Engagement with Improvement What activities will be required? What, Who, When? How we will know? What remaining issues? Modified -Verble/Shook Date: Owner:

Work alone, then in groups to fill out the left side of the A3 1. Why engage physicians in improvement? 2. What are the barriers to engaging physicians? Are the causes in: –Motive? –Means? –Opportunity? Before addressing the upper right 3. What strategies might help? 11 Physician Engagement in Improvement = Countermeasure

Title: Physician Engagement in QI Background Current Situation Goal Analysis: barriers Recommendations Plan Follow - up Why engage physicians in improvement? Where do we stand? Problem Statement: What is the specific change we want to accomplish now? -What are the root causes? -Motive? -Means -Opportunity? Proposed countermeasures Increase Physician Engagement with Improvement What activities will be required? What, Who, When? How we will know? What remaining issues? Modified -Verble/Shook Date: Owner:

13 Physician Engagement in Improvement 1.What is the problem? 2.Who owns the problem? 3.What is the plan? 4.What is the current status of the plan? How will it be monitored? 5.What worker training is needed? 6.How does this problem relate to the organization’s most important goals?* 7.What leader development is needed? Adapted from John Shook. Ask questions in order. *As a variation, 6 may be asked second. J Billi

The next 2 slides are photos of the results of the group discussions, written on white boards. 14

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A3 References Books with Focus on A3 Use: Shook. Managing to Learn. (Best book on leadership in a lean organization and A3 use) Sobek, Smalley. Understanding A3 Thinking. (Problem solving and A3 use) Dennis. Getting the Right Things Done. (Strategy deployment or hoshin kanri) Liker, Meier. Toyota Way Fieldbook. (Practical lean tools) Baker, Taylor. Making Hospitals Work. (Workbook from Lean Enterprise Academy, UK) Graban. Lean Hospitals. (General lean healthcare reference) Lean Web Resources: Michigan Quality System at UMHS: med.umich.edu/mqsmed.umich.edu/mqs Lean Enterprise Institute: webinars, books, meetings… Lean Healthcare Value Leaders Network Lean Enterprise Academy (UK):

Michigan Quality System & Lean References Books: Womack J, Jones D. Lean Thinking. Liker J. The Toyota Way; Liker J, Meier D. The Toyota Way Fieldbook. Shook J. Managing to Learn. Dennis P. Getting the Right Things Done. Rother M, Shook J. Learning to See. Womack J, Jones D, Roos D. The Machine That Changed The World. Sobek D, Smalley A. Understanding A3 Thinking. Marchwinski C, Shook J, eds. Lean Lexicon. Articles: Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med. 2006;1:191. Bush R. Reducing Waste in the US Healthcare System. JAMA 2007;297:871. Spear S. Fixing Health Care from the Inside, Today. HBR. 9/05. Spear S. Learning to Lead at Toyota. HBR 4/04 Spear S. Decoding the DNA of Toyota Production System. HBR 9/99 IHI Whitepaper: “Going Lean in Health Care” Web: Michigan Quality System at UMHS: med.umich.edu/mqsmed.umich.edu/mqs Lean Enterprise Institute: webinars, books, meetings… Ideal Patient Care Experience at UMHS Crossing the Quality Chasm (IOM): newton.nap.edu/catalog/10027.htmlnewton.nap.edu/catalog/10027.html Lean Enterprise Academy (UK): National Health Service (UK): Wikipedia: en.wikipedia.org/wiki/Lean_manufacturingen.wikipedia.org/wiki/Lean_manufacturing

Appendix 19

Problem and PDCA Tools for different levels Key to success: The Mid-management and First Line Supervisory Level FRONT LINES SENIOR MANAGEMENT MIDDLE MANAGEMENT MUST PROVIDE VISION AND INCENTIVE MUST “DO” MUST LEAD THE ACTUAL OPERATIONAL CHANGE Likes the involvement Likes the results Requires tools and support to lead RoleImpact Problem: MUDA PDCA tool: (HK) Strategy deployment PDCA tool: A3 or VSM PDCA tool: Standardized Work Problem: MURA, MURI Problem: MURI, MURA Shook Muri – overburden Mura – uneven workload Muda – waste HK – hoshin kanri (strategy deployment)

21 Pacing by Demand Continuous Flow Pull Systems Just-in-Time Built-in Quality Error Proof Surface Problems Stop and Respond to Abnormalities Solve Problems at Root Cause MQS Make Value Flow by Eliminating Errors and Waste Leveled Workload Continuous Improvement (P-D-C-A) and Learning Standardized Work Michigan Quality System Quality – Safety – Efficiency – Appropriateness – Service Customer Defines Value

Title: What we are talking about. Background Current Situation Goal Analysis Recommendations Plan Follow - up Of all our problems, why this one? The “ugly story”… Where do we stand? Problem Statement: What is the specific change we want to accomplish now? -What are the root causes, requirements, constraints? What are your proposed countermeasures, strategies, alternatives? What activities will be required? What, Who, When? How we will know? What remaining issues? Modified -Verble/Shook Date: Owner: An A3 Template