High Reliability: AIM4Excellence Improvement Model Saint Thomas Health is on a journey to becoming a High Reliability Organization (HRO). www.studergroup.com © 2010 Studer Group

Is Healthcare Highly Reliable? Is healthcare highly reliable? Based on this graph, the likelihood that that someone may die as a result of hospital care can be compared to mountain climbing and bungee jumping, and is less safe and more likely to result in a death than driving a car! As an industry, healthcare has some work to do in order to become highly reliable.

Death due to plane crash: 1 in 10 MILLION Highly Reliable? Medical Errors (ME) 3rd leading cause of death; more than heart disease and cancer. (Source: M. Allen, Scientific American, 2013) 1 in 10 chance of a medical error upon entering hospital (Source: World Health Organization) 1 in 300 chance of wrongful death due to medical error (Source: World Health Organization) Medical errors are the 3rd leading cause of death in the U.S.. Hospital patients have a 10% chance of experiencing a medical error and a 0.33% chance of a wrongful death due to medical error. (Source: WHO) Death due to plane crash: 1 in 10 MILLION

What is an HRO? "High reliability organizations (HRO) are organizations with systems in place that make them exceptionally consistent in accomplishing their goals and avoiding potentially catastrophic errors…" -Quint Studer High reliability organizations (HRO) are organizations with systems in place that make them exceptionally consistent in accomplishing their goals and avoiding potentially catastrophic errors.

What is St. Thomas Health doing to become an HRO? Introducing ……………. The AIM4Excellence model was created because Ascension Health recognized the need for its ministries to become highly reliable. The AIM4Excellence model simply recognizes that despite pockets of excellence throughout Ascension, we have lacked an overall Improvement Model. As a result, we speak different languages when it comes to improvement and struggle to share best practices. AIM4Excellence is designed to serve as that overall Improvement Model to provide common structure, principles, concepts and behaviors necessary for improving and achieving excellence.

The Ascension Improvement Model for Excellence “AIM4Excellence” Cultural Enablers Respect Every Individual Lead with Humility Embrace Transparency Enterprise Alignment Create Constancy of Purpose Think Systemically Continuous Process Improvement Focus on Process Embrace Scientific Thinking Focus on Flowing and Pulling Value Assure Quality at the Source Seek Perfection Presented as a visual, it is clear that the focus of our model (the center) is to enable Extraordinary Person-Centered Care. Let’s focus on the 3 dimensions shown: Cultural Enablers – The Foundation of all that we do, this dimension is the most important. It’s about enabling a culture of Respect, Humility, and Transparency at all levels to create an environment of learning. We will touch on these 3 principles more in a minute. Enterprise Alignment- Ensuring that each department has clear goals that are connected to the overall organizational goals; and that each person in the department knows how their work enables the organization to meet its overall goals. Continuous Process Improvement – Recognizes that everything we do is a ‘process’; and that every process can be improved. As Quality Improvement Guru Dr Deming famously stated “If you can’t see what you do as a process, you don’t know what you’re doing.”

Importance of Culture St. Francis teaches: “He who works with his hands is a laborer. He who works with his hands and his head is a craftsman. He who works with his hands and his head and his heart is an artist.” St. Francis teaches: “He who works with his hands is a laborer. He who works with his hands and his head is a craftsman. He who works with his hands and his head and his heart is an artist.” AIM4Excellence teaches: When people feel respected they give far more than their hands; they give their minds and hearts. AIM4Excellence teaches: When people feel respected they give far more than their hands; they give their minds and hearts.

The AIM4Excellence Standard Improvement Philosophies and Techniques The AIM4Excellence model focuses heavily on: Lean – A quality improvement philosophy and set of principles originated by Toyota Plan-Do-Check-Act (PDCA) – A central tenet of continuous improvement and Lean where the Scientific Method is applied to improve daily work processes Management System - A disciplined, closed-loop, visual management system that: Communicates what’s important Reveals current performance Identifies gaps Empowers people to continually improve Ensures leadership accountability The AIM4Excellence model is heavily focused on the methodologies of: Lean - A quality improvement philosophy and set of principles originated by Toyota Plan-Do-Check-Act or PDCA - A central tenet of continuous improvement and Lean where the Scientific Method is applied to improve daily work processes. And the Management System necessary to drive Continuous Improvement each day.

What is Lean? Is… Eliminating waste Providing value Focused on customer Engages the frontline as process experts Makes the right work easier to do Is Not… An FTE reduction strategy Only focused on cost A quick fix or silver bullet Possible without leadership commitment

Creating “Value” Value is defined as: Outcome or activity for which the customer is willing to pay The right work at the right place, the right time, and without delay Our ultimate goal is to “Create Value for Extraordinary Person-Centered Care” So “What is the definition of Value?” Value can be thought of as those things the customer is willing to pay for. Value is always defined from the customer’s perspective. Remember that “customer” is almost always the patient. But the direct customer of a specific process may be someone other than the patient. For example, the MD is the customer of the nurse charting I’s and O’s; but the ultimate customer is still the patient (as the work of both the nurse and the doctor is still to ultimately benefit the patient). Review the Chart below for each Column – focusing on the first 2 columns, specifically “Optimizing the amount of time spent in Value-Added Activity” and “Eliminating the time spent doing Non-Value Added Activity”.

Examples of Value-Added vs. Non-Value-Added An Outpatient Office Visit

The Destroyer of Value = Waste Waste: Any activity that consumes resources but creates no value. (Lean Lexicon, 2006) Waste is disrespectful to: Patients or guests by asking them to endure processes with no value You as associates because it asks you to do work without value Society because it wastes scarce resources So now that you understand “value”. Let’s talk about what destroys value. That is waste. “Any activity that consumes resources but creates no value for the customer. Eliminating the large wasteful activities is the greatest potential source of improvement in performance and customer service.” Read the boxes showing how waste should be viewed as disrespectful.

What is PDCA? The Backbone of Continuous Improvement PDCA is the four-step methodology for continuous improvement, also known as the Deming Cycle. Plan Respect the problem enough to fully understand it Do Attack the waste with Countermeasures/Improvement Methods Check Check results - Is our improvement plan working? Act/Adjust if working great – standardize and spread; if not working, learn & plan next intervention) PDCA is the backbone of continuous improvement. It stands for Plan-Do-Check-Act, and has been at the heart of continuous improvement since the 1950’s. It’s four steps are based on the Scientific Method (which started in the 1600’s). When understood and used by a disciplined team, it is extremely powerful and successful.

How does all of this work together? The AIM4Excellence Management System It’s simply a disciplined system to: Communicate what is most important Goals and Key Performance Indicators we must win each day Reveal current performance Are we winning or losing? Identify gaps between actual performance and expected performance (goal) Visual, daily management of the most critical goals Empower people to continually improve Total Associate Involvement Ensure leadership accountability Standard Leadership Follow-up/Rounding So how does all of this fit together? The answer is our Management System. Here is what we mean by the term Management System: Simply review each bullet point. The Management System is what turns all the tools of Lean and Performance Improvement into a true way of doing business, as it aligns and focuses the organization toward the most important work of all – using this knowledge to improve our most critical goals and objectives for overall success.

A3 Thinkers/Problem Solvers “A3” Problem Solving Is “Deeper Thinking” It’s HOW we solve problems by following the scientific method & PDCA cycle Prevents “Solution Bombs” Helps you tell your story to build consensus AIM4Excellence Goal: Create an army of A3 Thinkers/Problem Solvers A3 problem solving is a way of thinking in order to solve problems, not just a tool. Basically, it is a highly structured, step-by-step way of solving problems by identifying the root cause and following the steps of true Plan-Do-Check-Act, or PDCA. It helps to deepen the understanding of the problem or opportunity, and it gives really strong insight into the best way of addressing the problem.”

A3 Problem Solving Why not treat problems like we treat patients? Chief Complaint Treatment Plan Physical Assessment If you are a clinician, I would challenge that you already use A3 thinking when you take care of patients every day. Physicians especially are trained in this manner, so let’s see how A3 thinking is applied when treating a patient. Chief Complaint is the same as Problem Physical Assessment is the same as Measurement/Background and Current Condition (where the clinician is checking Vital Signs, listening to heart and lung sounds, the full physical assessment). Blood work; CT Scans, X-rays, etc…are where you are delving deeper for Root Cause of the illness. This is known as Root Cause Problem Analysis in “A3 land.” Treatment Plan is where you begin to apply solutions (new medicines, therapies, even surgery) as you now understand the problem and its most likely root cause. These are simply the Countermeasures/Action Plan of A3.” A Follow-up visit (or even rounding on the patient the next day in the hospital) is the Check phase of A3/PDCA, where the patient returns or is monitored to see if the treatment (aka countermeasure) is actually working. Finally, Adjustments are made to the treatment plan based on whether or not it is working. This is the Act/Adjust phase of A3/PDCA where the same is done for process. Follow-up Visit Diagnostic Tests Adjustments

The Closed-Loop Management System Empowers team to Close the Gap Answers “If not winning, what are we doing about it?” Leaders coaching to Close the Gap “What can we do today to win more often?” Shows the Gap between actual results & Goal Answers “Are we winning or losing?” Communicates what’s important Answers “What does it mean to win or lose?” Enterprise Alignment Focused Visual Management Total Associate Involvement Standard Leadership Follow-Up Mission Critical Results The Management System recognizes 4 primary quadrants. Here is a quick overview. It starts at the top-left with Enterprise Alignment. Every organization has countless goals and priorities at the highest level. The challenge is to take those at the highest level and cascade them down to where every department and every associate knows what it means for their department (or even themselves) to win or lose. Basically, Enterprise Alignment ensures the department your in has not only a department scorecard with appropriately cascaded goals, but also that you know which of those goals are most important (aka “the critical few”). Once that is complete, you move into managing those “critical few” visually every day down to the process level – to ensure we are focused and improving the most critical goals to our organization’s success (this is Focused Visual Management). Once that begins, you must ensure the frontline associates are involved in improvement work and able to provide their expertise and guidance every day via Daily Huddles and an active Suggestion System. Finally, Senior Leaders must round on this improvement work to not only coach, but also to show appreciation for the worthwhile work that is occurring. If Senior Leaders fail to do this, the system will stop. Each piece is critical, which is why we say it is truly a closed-loop system.

Key Goals – Monthly Trending Visual Management Board Key Element of the Closed Loop Management System Key Goals – Monthly Trending The Critical Few, Not Important Many Department Scorecard Pareto Thinking (Don’t Assume) Major Reasons for not hitting target Suggestion System A3 or PDCA Log Activity Addressing the Root Cause(s) A key element of this Management System is the Visual Management Board. The objective of this board is to serve as the meeting place and visual reminder for leaders and staff to continuously: Communicate the critical few goals most important to our area Reveal current performance toward each critical goal; and Engage the subject matter experts (those doing the work) toward closing any gaps between current performance and the goal The board can be adapted for any ministry, but must include the following: Department Scorecard (showing the “Important Many Goals” of the department) The Critical Few Goals (top middle) being worked from Monthly outcome/lagging measure down to process level Associate Suggestion System “Check” via Process Indicators Process Metrics updated daily showing Performance toward Goal

Why is the Management System important? Provides Focus and Clarity to those doing the work Healthcare suffers from Recurrent Major Initiative Syndrome whose most devastating pathologic consequence is Managerial Attention Deficit Disorder (MADD) – Designed to Adapt, 2009, p.73. Engages the People Respects and Engages frontline staff to participate in solution development and builds ownership Focuses on bad process, not bad people Gemba Walks emphasize to frontline associates the importance of their work Culture focused on “we” (our overall performance) Drives Critical Results Focus on process indicators to better predict success for the Critical Few Goals in each department Such a Management System is critically important in today’s healthcare environment for the following reasons: Provide Focus and Clarity to those actually taking care of our patients – review bullet 1 Actively include the people who are taking care of our patients – review bullet 2 Drive the most critical results – review bullet 3

Revisiting our Objectives Introduce the AIM4Excellence model, so that you: Recognize that our top goal is creating Value to enable Extraordinary Person-Centered Care Develop a foundational understanding of Lean, Plan-Do-Check-Act (PDCA), and the Management System for driving focused improvement Apply and spread learnings within your daily work processes Instructor Activity: Did we accomplish our objectives?