Patient Business Services –

Patient Business Services –
L.I.T. Level 2 Workshop

Agenda Opening Remarks / Agenda Review Review Progress To Date
Level 2 Visual Management Education Identification Of Level 2 Visual Indicators – Including What We’re Making Visual & How A3 Structured Problem Solving Education Use A3 Structured Problem Solving Form to Solve Common Theme Problem(s) – Team Activity Team Reflection & Festivus

A Prize Will Be Awarded! Anytime you see this image, it is an opportunity to earn a playing card. The individual with the best poker hand at the end of the day will win a prize!

When Thinking Of The Lean In Daily Work Model….
Incoming!!! Pop Quiz!!! Incoming!!! A card will be given to each person who names a way in which problems were surfaced during the level 1 implementation

L.I.T.’s Lean In Daily Work Model
= Level 1 Implementation = Level 2 Implementation L.I.T.’s Lean In Daily Work Model Kickoff with Leadership, Lean Culture Survey Lean Overview & Level 1 Visual Mgmt (Aligned Value Metrics) Train & Implement Huddles / Daily Problem Solving (ELI) Train & Implement Leadership Standard Work #1 #2 #3 Continuing Cycles #4 Problems, Root Causes & Solutions Recorded For Knowledge Sharing Daily Problem Solving Built Into Daily Work (ELI) Structured Problem Solving Built Into Current Meeting Structure Daily Problem Solving Built Into Daily Work (ELI) Daily/Weekly Team Huddles & Leadership Gemba Walks Level 2 Visual Mgmt.- Monitoring Key Problem Trends Daily/Weekly Team Huddles & Leadership Gemba Walks #5 Problems Surface & Andon Responses #6 #12 #7 Ongoing Visual Monitoring Of Value Metrics #13 Ongoing Visual Monitoring Of Value Metrics #8 #15 Continuing Cycles #14 Targeted Lean Education Based on Surfaced Problems Train & Implement Level 2 Visual Mgmt (Key Problems) Train & Implement Process to Systematically Prioritize Key Problems Train & Implement Structured Problem Solving #9 #10 #11 After Several Continuing Cycles Of L.I.T.’s Lean In Daily Work Model Initiate L.I.T. Process Audit Cadence (Completed By Lean Coach) Implementation Of Additional Lean Systems & Structures Based On Need Re-take Lean Culture Survey Create Proposal A3s For Identified Issues Outside Of Influence Replicate & Roll Out Model To Internal Supplier

What Have We Accomplished So Far
Team Value Metrics Identified Visual Boards Developed and Implemented To Manage Team Value Metrics Implemented The Use Of Everyday Lean Ideas (E.L.Is) To Surface & Solve Problems On A Daily Basis Implemented A System To Record & Post Lean Learning Solution Summaries Implemented Leadership Standard Work - Evaluation of Meetings (To Free Up Time For Gemba Activities) - Leadership Gemba Walks - Confluence (To Record Lessons Learned) How many problems have been surfaced and solved to date using the Everyday Lean Idea process?

What Is Next… Begin visually managing the problems with the most impact in the work area Use of Structured A3 Problem Solving within existing meetings to solve the root cause of common themes & trends Identify targeted Lean Education/Implementation of a specific Lean Tool based on problem trends (if applicable) Replicate model with connecting area Focus Of Level 2 We Are Well On Our Way To Creating A Sustainable Continuous Improvement System In Patient Business Services!!!

When Thinking Of The Level 1 Visual Management Boards….
Incoming!!! Pop Quiz!!! Incoming!!! A card will be given to each person who identifies a benefit from using the Level 1 Boards

Visual Management (Review)
Attributes of visual management tools: Create “status at a glance” – enabling quick and simple detection of normal vs. abnormal operating conditions Provide clear information actionable at the point of communication Be maintained by those carrying out the work Those performing the work are the first to detect abnormalities Opens the lines of communication between front line staff and leaders Provide a clear and common understanding of goals & measures and allow employees to align their actions and decisions with the overall strategic direction of the department

What Is Level 2 Visual Management?
Level 1 Visual Management is in place and working great, let’s try and take it to the next level! Creates an “in-process” visual system highlighting key problems Supports Leadership Gemba Walks by drawing attention to the key problems Allows for meaningful dialogue on the reasons the problems are occurring Creates a visual history of common themes and trends

Decide what type of Level 2 Visual System you prefer
For the example provided…. Hang individual Level 2 White Boards – outside each work area Laminate pictures representing key problems (& place on the board) When that problem occurs, place a check or a count in the appropriate section Level 2 – Individual As problems are solved and new problems emerge, laminate new pictures to visually monitor the frequency of occurrence At month end, unsolved problems are totaled by the team leads & submitted to the designated leader The leader looks for common themes/trends and identifies problems to bring forward to existing team meetings (based on frequency and impact) Structured A3 Problem Solving (SPS) is then used during the meeting to identify root cause & determine potential solutions for experimentation

Decide what type of Level 2 Visual System you prefer
For the example provided…. Hang a single White Board near the team’s Level 1 Visual Board Laminate pictures representing key problems (& place on the board along the X-axis) Extend the colored bar to the appropriate count on the Y-axis once the problem occurs, or when the problem is discussed during a team huddle or leadership walk Level 2 – Pareto 15 10 Y-Axis 5 As problems are solved and new problems emerge, laminate new pictures to visually monitor the frequency of occurrence The leader reviews the visual Pareto Chart and identifies problems to bring forward to existing team meetings (based on frequency and impact) Structured A3 Problem Solving (SPS) is then used during the meeting to identify root cause & determine potential solutions for experimentation X-Axis

As a team – determine your Level 2 standard
Decide what type of Level 2 Visual System you prefer Level 2 – Team Creates When creating your Level 2 Visual Board…It Must… Have a visual representation of your key problems Allow you to document the frequency of occurrence of your key problems Provide a system for leadership review connected to Leadership Walks and A3-Structured Problem Solving sessions Be Creative!!!! A card will be given to whomever can provide an explanation of why Kevin chose the lightbulb with goldfish image to denote “Creativity”…. As a team – determine your Level 2 standard

Team Activity (For Individual Boards): Level 2 Visual Management
1) In your teams, review the list of problems that have been surfaced (and not solved) 2) Identify those problems with the highest frequency of occurrence and result in the most (negative) impact on your team’s value metric 3) Individually, determine the top 3 Problems you believe to have the most (negative) impact on your team’s value metric & determine a picture that best represents each problem (hand in to team lead)

Team Activity (For Pareto Boards): Level 2 Visual Management
1) Create your Level 2 Visual Display (With X and Y axis) 2) In your teams, review the list of problems that have been surfaced (and not solved) 3) As a team, determine the Problems you believe to have the most (negative) impact on your team’s value metric – identify pictures to represent the problem

Team Activity (For Team Created Boards): Level 2 Visual Management
1) Create your Level 2 Visual Display 2) In your teams, review the list of problems that have been surfaced (and not solved) 3) As a team, determine the Problems you believe to have the most (negative) impact on your team’s value metric – identify pictures to represent the problem

PBS LIT Level 2 – Identified Key Problems

A Reminder From Super Bowl MVP ELI MANNING
Level 2 Visual Management The Leadership Team will work with the Team Leads to set up the level 2 Visual Boards The goal will be to have them up and running in the next two weeks A Reminder From Super Bowl MVP ELI MANNING Remember, this is just the starting point for your Level 2 Visual Management. You will have the opportunity to evolve the standard over time…

An Analogy From Super Bowl MVP ELI MANNING
What Is Structured Problem Solving (SPS)? A simple and practical way for groups to walk through the problem solving process and get to actionable root cause(s) Best used on problems that you don’t have a quick and simple solution for (if you do have a quick and simple solution, use ELI!) Best used with problems which are routinely getting in the way of our value metrics (common trends and themes from our level 2 visual management) After enough repetition, you will begin to naturally walk through the steps without any prompting from the form….this is where Lean Organizations gain a true competitive advantage! An Analogy From Super Bowl MVP ELI MANNING Let me share a story to help illustrate The importance of Structured Problem Solving…

“A3 Thinking” in Many Fields
Many professions use standard formats to present information Physicians use a standard format for communicating a patient’s history and physical exam, their impression and plans Scientists use a structured abstract, standard format for presentations and research reports These standard formats facilitate clear communication, dialogue, detailed debate and building consensus

What makes process improvement fail?
John Shook * David Verble lack of knowledge? lack of a plan? lack of leadership? lack of discipline? lack of commitment? lack of passion? lack of…AGREEMENT! May 1, 2001 12

How do you get agreement?
John Shook * David Verble Sample answers… Persuade with logic Appeal to emotion Dictate Threaten Manipulate Trade favors Compromise Others? How effective are these methods? 26

How do you get agreement?
John Shook * David Verble Most effective is to tell a persuasive story,  if so, Would it not be best to tell it concisely, preferably visually, in a standard format? May 1, 2001 26

A Format for Solving Problems: “A3 Thinking”
“A3” is just a paper size (international 11 x 17) A3 planning began in the 60s as the Quality Circle problem-solving format. It evolved to become the standard format for problem-solving, proposals, plans, and status reviews within Lean Management Systems. Adapted from John Shook

A Format for Planning and Proposing: “A3 Thinking”
What is important is not the format, but the process and thinking behind it, and the conversations it facilitates. An A3 lays out an entire plan, large or small, on one sheet of paper. It should be visual and extremely concise. It should tell a story, laid out from upper left-hand side to lower right, which anyone can understand. Adapted from John Shook

A3 Benefits As a standard process, it becomes easier for you to persuade others and to understand others. It fosters dialogue within the organization. It develops thinking problem-solvers. It encourages front-line initiative, cascades responsibility and clarifies who is responsible for problems or steps. It exposes lack of agreement that can undermine plans. Adapted from John Shook

A3 Benefits - Continued It encourages PDCA (Plan, Do, Check, Act).
It forces “5S for information.” It clarifies the link between problems, root causes, and countermeasures. It serves as an organizational learning tool. It leads to effective countermeasures and solutions based on facts and data. Adapted from John Shook

A3 Thinking The purpose of the A3 process is to:
structure effective and efficient dialogue to foster understanding followed by agreement. Creating an A3 Imagine clearly the story of the improvement you want to initiate or the problem you want to solve. The A3 need not have every word or fact. It is almost always presented live, without interruption, in 10 minutes or less. If in a group, have copies to write on. Adapted from John Shook

A3 Thinking – Summary of Benefits
Creating the A3 encourages systematic problem solving Presenting the A3 fosters consensus, commitment to move forward Discussing the A3 fosters critical analytic skills, communication, respect The conversations fostered by the A3 are important, not the paper or the format The consensus on the A3 gives the authority to take action

A3 Structured Problem Solving Process
*Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Based on Level 2 Visual Boards Prioritize highest frequency / biggest impact problems based on the team’s level 2 visual boards Choose 1-3 problems to focus on during a regular standing team meeting (i.e. department meeting or equivalent) *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Grasp the background, current condition & goals In order to solve a problem, you must first thoroughly understand the process or system in which it commonly surfaces Grasp the Background: Use the “Therefore Exercise” to create an “ugly story” that will rally others around the importance of solving the problem Start with the problem and continue asking “therefore what” to establish a clear link between the problem and key strategic concerns *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Document the results in your background section
“Therefore Exercise” It takes 40.6 minutes to confirm a patient bed assignment (31 min gap) There are over 71 days of patient wait time each year There is a reduction in capacity There is a reduction in UMHS market share There is a Reduced Margin There is a reduced ability to invest in the future Therefore Lower Patient Satisfaction Patient tells friends & family about bad experience, goes elsewhere There is a reduction in UMHS market share There is a Reduced Margin There is a reduced ability to invest in the future Therefore Lower Staff Satisfaction Lower Morale Increase in Staff turnover High training & replacement cost There is a Reduced Margin There is a reduced ability to invest in the future Therefore Increased Cost to Deliver Care There is a Reduced Margin There is a reduced ability to invest in the future Therefore Document the results in your background section

Current Conditions: Observe the process in action…Go to where it occurs and observe/document the steps (i.e. create VSM) Quantify the extent of the problem How freqently does it occur? (% of total) What is the cost impact of the problem ($) How much of a delay does it cause to complete the process (Minutes) Each time the problem occurred, document what was causing it? If you are not sure – document that as well! *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Goals: Set improvement goals related to the problem A “problem” is defined as a gap from a target, standard, or goal. Make sure your goals are quantifiable and time bound *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Problems & Waste are symptoms We need to identify the root causes of our problems & waste We must get to actionable, measurable, processes in the future state that: Eliminate root causes of waste / problems Prevent similar problems from reoccurring Make future reoccurrences visual *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Complete analysis – Identify the Root Cause Root cause is defined as the cause of the problem that (if taken care of and fixed) would eliminate the majority of occurrences of the problem “5 Whys” Root Cause Analysis: Using the list of observed “Causes” collected during observations, identify the cause that lead to the majority of problem occurrences If you do not know – may require additional data collection & analysis to determine Begin asking “Why” the cause occurred & document. Continue asking “Why” until you reach a point where recurrence can be prevented by addressing the cause It usually takes between 2 and 5 “Whys” to land on the root cause of the problem *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

“5 Whys” Root Cause Analysis: The root cause of the majority of operational problems are typically linked to a violation of one (or more) of the following three rules: Activities are non-standard and poorly communicated to the users Unclear connections – “I didn’t know you needed it THAT way…” Complicated or Undefined Pathways – “I do not know where this is supposed to go next…” *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Problem Definition Trees (5-Whys)
1) Start by defining the problem 2) Document potential causes (ask Why?) 3) Which is the most likely cause or largest contributor? It takes 40.6 minutes to confirm a patient bed assignment with 7L (Target is 10 minutes) 90% of the 40.6 mins (36.5) is spent waiting for approval Why? Based on the team’s observations, not the most likely cause Based on the team’s observations, not the most likely cause They are not aware the bed is waiting to be confirmed (79%) Confirming beds is not a priority for the Physicians Busy dealing with multiple assignments at once Forgot to complete bed confirmation Why?

80% of the 40.6 mins (32.5) is spent waiting for physician approval
It takes 40.6 minutes to confirm a patient bed assignment with 7L (Target is 10 minutes) It takes 40.6 minutes to confirm a patient bed assignment with 7L (Target is 10 minutes) 80% of the 40.6 mins (32.5) is spent waiting for physician approval Why? 90% of the 40.6 mins (36.5) is spent waiting for approval Why? Confirming beds is not a priority for the Physicians Why? 4) “Drill down” by asking “Why” on the most likely cause(s) The team is not aware the bed is waiting to be confirmed (79%) Why? Less than 1% of the patients are being denied by Physicians Why? No standard approach to notify the team of bed assignments Why? At the time of physician review, the patient had already been reviewed by the Nurse Why? A standard approach to notify has never been created Why? At the time the unit opened, there was a perceived need for 2 levels of review Why? When using “5 Whys?” ask the following . . . Do you think this is the root cause? Should we ask “Why” again? If you address the root cause will the problem be permanently fixed?

5-Why Root Cause Analysis – Things to consider
Use a pencil with an eraser (you will be starting and stopping many times) At first it will be awkward and frustrating Just like any skill with time and practice it will become 2nd nature Warning!!! Be on the look out for… Working down a causal chain you have no control over Morphing into the 5-Who’s Heading down a dead-end path which is not actionable Root cause often comes down to: “No standard existing for a particular problem” or “an existing standard which is not being followed” Ask yourself if this is true for the problem you are analyzing

5-Why Root Cause Analysis – Things to consider
There is often more than one root cause, come up with several! This will keep the team’s collective mind open to different possibilities Only address one root cause at a time in order to determine the effect of each change Perform the “Therefore Test” Start with your root cause and ask “therefore what” for each causal step up to your problem statement If it doesn’t make logical sense, try again…the team most likely skipped a few steps because of having a solution already in mind

Therefore Test It takes 40.6 minutes to confirm a patient bed assignment with 7L (Target is 10 minutes) It takes 40.6 minutes to confirm a patient bed assignment with 7L (Target is 10 minutes) Therefore Therefore “Work your way up to the problem from the root cause to verify logic / linkage between steps” 80% of the 40.6 mins (32.5) is spent waiting for physician approval 90% of the 40.6 mins (36.5) is spent waiting for approval Therefore Therefore Confirming beds is not a priority for the Physicians The team is not aware the bed is waiting to be confirmed (79%) Therefore Therefore No standard approach to notify the team of bed assignments Less than 1% of the patients are being denied by Physicians Therefore A standard approach to notify has never been created Therefore At the time of physician review, the patient had already been reviewed by the Nurse Therefore At the time the unit opened, there was a perceived need for 2 levels of review

Propose Countermeasures – Create Future State Countermeasures are the specific changes in process required to address the root cause of the problem Create the Future State: Taking the list of countermeasures – draw out the future state vision for your process when all the countermeasures are in place From available information/completed experiments describe the intended/expected impact of the changes…Will they allow you to reach the goals the team set? If not, continue to challenge yourselves *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Create the Implementation Plan Many times, great ideas/solutions fail because no clear path to implementation has been established Creating An Implementation Plan: Identify all the tasks required to realize and implement the proposed countermeasures Document the individual(s) responsible for leading the implementation activity Document when the activity will be completed *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Create the follow up plan & reviewing results Follow up plans verify that the intended results/goals of the changes have been met and that the countermeasures actually worked!!! Creating A Follow Up Plan: Identify the data comparisons required following implementation Document the individual(s) responsible for completing & communicating the data comparisons Document when the comparisons will be completed The review of results may lead to additional improvement cycles (Check – in the PDCA cycle) *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Obtaining necessary approvals The approval step of the SPS process is most importantly an explicit mentoring opportunity between manager and staff & a way to smoke out disagreement amongst stakeholders Benefits of obtaining approvals: Helps enhance and build deductive reasoning skills Builds communication and social networking skills Ensures rigor and objectivity of the process – method to verify SPS steps have been completed, countermeasures address identified root causes, timelines can be met, etc. Allows for involvement of the leader (if applicable) in supporting implementation of the countermeasures *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Establish Process Standards Once the process has been optimized – the last step is to ensure standardization across end users Benefits of process standards: Minimizes variation, promotes quality and allows for continued PDCA improvement cycles Useful in training existing/orienting new staff Minimizes the opportunity for miscommunication Simplifies and defines process pathways (Reduces work efforts) *Figure Modified from “Understanding Lean Thinking” - Sobek & Smalley

Create The Lean Solution Summary
7L Confirmation Of Bed Assignments - Display visually & upload to Confluence

PBS LIT Level 2 – Identified Problems

Team Activity: Solve Common Theme Problem(s)
In your teams, pick a problem identified in your Level 2 Visual Management Process Hint: pick a problem that you haven’t started an ELI on and that you do not know the solution to… Use the SPS A3 Template to walk through the PDCA cycle If you complete one full cycle, repeat the process with another problem Report out to the whole group A Card will be given to each person on the first team that finishes 2 - SPSs

Congratulations From Super Bowl MVP ELI MANNING
Future Application of SPS As previously mentioned, Problem Themes and Trends (learned through our Level 2 Visual Management) will be brought to our Monthly Department Meetings During these meetings, the Department will break up into teams and use the Structured Problem Solving A3 Template (SPS) to walk a Problem through the Plan Do Check Act (PDCA) cycle. Congratulations From Super Bowl MVP ELI MANNING Way to go everyone – I am proud of the great problem solvers you are all becoming… Remember, through repetition and practice, this will all become second nature!!!

Team Reflection & Festivus

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