Conflict of Interest Ann Dohn – No conflicts of interest to disclose Nancy Piro – No conflicts of interest to disclose

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

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.

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 C-Suite. 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.

Understanding C-Suite Priorities STANFORD OPERATING SYSTEM Purpose Mission, Vision, Values Strategies Complex Care, Coordinated Care Objectives Goals, Operating Plans, Dashboards Performance Improvement and Management

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

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

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””

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

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) Developed at Toyota

Lean Tools: – Fishbone Charts using the 4Ms – 4 Ps Manpower/Personnel Materials Method(s) Machines / Equipment People Process Policy Principles

Ishikawa Diagram of ER Prolonged Wait Times Materials Methods/Process WHY? WHY? xxx hr wait time in ER WHY? WHY? Manpower/People Machine\Equipment

5Ss - Mnemonics Retained Sorting Simplifying Sweeping Standardizing Self Discipline = Seiri = Seiton = Seiso = Seiketsu = Shitsuke Quick Exercise

5Ss in Action PATRICE

Very simply….a piece of paper that is 11” in height and 17” in width What is an A3? Very simply….a piece of paper that is 11” in height and 17” in width

4 Steps of A3 Thinking: The Simple A3 2. What causes are preventing us from meeting our target(s)? What are the “root” causes? What is the problem or gap? (What are we trying to improve?) Cause Gap Cause Target Cause Effect/Problem Current Performance Cause Cause Cause 4. Which actions will address the most important causes? 3. Based on data, what are the causes in order of importance? Goals (Cause) By Who & When Actions Cause #1 Cause #2 Cause #3 Cause #4

4 Steps of A3 Thinking: The Simple A3 What is the problem or gap? (What are we trying to improve?) 2. What causes are preventing us from meeting our target(s)? What are the “root” causes? 4. Which actions will address the most important causes? 3. Based on data, what are the causes in order of importance? Goal (Cause) Actions By When/ By Who

What is an A3?

Presenting the A3 fosters consensus to move forward 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

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?

A3 Template Title Issue/Problem Statement: Background and Importance: Problem Analysis: Goals/Dashboard Metrics: Future State and Counter Measures: Follow Up: Sustain Results: Implementation Plan: Sponsor: Participants: Title Date Revised: Version #: Start Date: Revised Date

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

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.

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

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

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

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…

A picture is worth a thousand words… 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…

EXERCISE 2 - Creating an A3 Think about a problem you’d like to solve “back home” Use the A3 Template Hand Out :

A3 Template can be downloaded @ www.gme.stanford.edu GME Community Templates – A3

Visibility Wall Examples

Dashboard Examples Overall Program Report Card AIR - APEs Program Expansion CCC Matrix

Overall Program Report Card Example - Comparison

AIR / Annual Program Review Dashboard Example

Program Expansion / Funding Dashboard

Report Card Trending Example Complete with auto-fill colors

Resident Performance Dashboard Complete with auto-fill colors

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

Questions?

Contact Information: Nancy Piro, Program Manager/Education Specialist npiro@stanford.edu Ann Dohn, DIO adohn@stanford.edu http://gme.stanford.edu/