4th Annual Advancing Philanthropy Conference

 LEAN: Working Smarter Not Harder by Chuck Derus, MD

Advocate Good Samaritan Hospital: Who We Are

• Part of Advocate Healthcare• 333 bed hospital Downers Grove, IL• 2,700 associates, 950 affiliated

physicians and 500 volunteers• Community hospital with level 1

trauma and level 3 NICU• 46,000 ED visits, 156,000 outpatient

visits and 19,500 admissions

Advocate Good Samaritan Hospital: Who We Are

Who We Are

• Thompson Reuters Top 100 Hospital

• Midas Platinum+ Award

• Patient satisfaction ≈ top decile

• Associate satisfaction 91st percentile

• Physician satisfaction 96th percentile

• 17% market share growth

• 106% operating income growth

Problem Solving Versus Fire Fighting

• The story of the missing supply…

• Hunt, gather and assume the problem is solved

• What if you…1. Get what you need to fix now

2. Ask how and why did this occur?

3. Ask how can we prevent this (make a change) from happening again?

Leaning Objectives

• To learn the 8 wastes

• To learn a systematic, repeatable approach to problem solving (A3 PDSA)

• To hopefully go back to your offices and apply this systematic repeatable approach to a problem in your area and to improve that process

The Eight Wastes

DEFECTSInspection and rework

1

OVERPRODUCINGToo much and too early

2

WAITINGQueuing, idle time

3

NOT BEST USE OF TALENT

Not using problem solving skills of people

4

TRANSPORTINGAll patient, staff and material movement

5

INVENTORYAll stock and corresponding control systems

6

MOTIONReaching, bending, searching ...

7

EXTRA PROCESSING Unnecessary activities, Over-complicated

8

Defects Definition:

A product or service needing repair to fulfill customer requirements

blemish fallacy misprintblooper false step misstepblot stain fault mistakeblotch faulty muffblunder flaw off the beambobble flub omissionboner foul-up oversightboo-boo fumble rough spots

botch goof scare deformity

breach human error scratchbugs illogical screw-upbungle imperfection shortageclinker imprecise shortcomingclunker inaccuracy slip-upcockeyed inadequacy snafucrack incomplete snagsdefect incorrect spotdeficiency inexact teardrawback kinks triperror leak unsoundfailing louse-up weak pointfailure miscue weakness

Characteristics:

Medication error

Wrong patient

Wrong procedure

Missing information

Overproduction

Definition:– Producing more

than needed– Working ahead– Producing at a faster pace than needed

Characteristics:– Pills given early to suit staff

schedules– Testing ahead of time to suit lab

schedule– Treatments done to balance

hospital staff or equipment workload

Waiting

Definition:– Idle time in which no value

added activities take place

– People wait time

– Product wait time

Characteristics:

– Bed Assignments

– Admission to ED

– Patient lab test results

– Discharge

Not Best Use of Talent

Definition:– Work-related personnel injuries– Lack of training inhibits flow of

services– Not encouraging creativity and

use of problem-solving skills

Characteristics:– Injured personnel

– Poor flow of services

– Nurses supplying

Transportation

Definition:– Any unnecessary

material, patient or staff movement

Characteristics:– Moving samples or specimens– Moving paperwork– Moving patients for testing or

treatment– Moving equipment

Inventory Characteristics:

– Pharmacy stock

– Lab supplies

– Specimens waiting analysis

– Paperwork in processDefinition:

– Any unnecessary supplies or materials that do not support just in time delivery

Motion

Definition:

– Any movement of people which does not add value to the product

Characteristics:– Searching for meds

– Searching for patients

– Reaching for charts

– Handling paperwork

Extra Processing

Definition:– Unnecessary

process steps

Characteristics:

– Multiple bed moves

– Excessive paperwork

– Unnecessary procedures

– Multiple testing

– Scrap

Exercise: Identify eight wastes in your work

Systematic, Repeatable Improvement Approach

• The PDSA cycle is shorthand for testing a change by:1. Developing a plan to test the change

(Plan),

2. Carrying out the test (Do),

3. Observing and learning from the consequences (Study),

4. And determining what modifications should be made to the test (Act).

What Is A3?

A3 is 16.5 x 11.7 inches

A3 PDSA - Problem Solving/Teaching Tool

• Executed on A3 size (11 x17) paper

• 9 steps (boxes) that make problem solving visual

• Fast, effective consensus building

• An “artifact” that tells the change story

1

2

3

4

5

6

7

8

9

How to Achieve A3 Thinking

• Process is as inclusive as possible– Hand drawn– Pictures and text

• Work step-by-step – Work with consensus– Distill thoughts to fit each box – Capture the essence – Tell the story without “interpretation”

Where does it apply?

• A3’s work for all types of activities– Personal development– Sharing ideas/proposing change– Problem solving/decision making– Strategic planning – Should become the default way of

making improvements

Blank A3 Form

Starting an A31.1. Fill in Fill in

Description, Description, Process Owner, Process Owner, Sponsor Sponsor

2.2. Fill in Start Date Fill in Start Date (start of A3) and (start of A3) and Current Date Current Date (Date and Rev)(Date and Rev)

3.3. Record the Record the Team membersTeam members

4.4. Select the Select the review team review team (team that will (team that will support the A3 support the A3 team with team with relevant relevant knowledge & knowledge & guidance)guidance)

PP-D-S-A-D-S-A

Box 1 – Reason for Action• What is the problem What is the problem

(no causes or (no causes or solutions!) and why solutions!) and why do I care?do I care?

• Who has the Who has the problem?problem?

• What is the scope What is the scope and are there any and are there any limitations?limitations?

• What are the stop What are the stop and start “fence and start “fence posts”?posts”?

• PP-D-S-A-D-S-A

Reason for Action:

The insurance payment posting process is inefficient and is costing us more to do.

In Scope: The process begins with submissions of insurance claims to payers and ends with the accurate posting of these payments in the billing system.

Out of Scope: The process does not include the patient statement process or Collection Agency process.

Trigger: Submissions of insurance claims to payers

Done: The accurate posting of these payments in the billing system

Box 2 – The Initial State• What is happening now What is happening now

in bullet points and a in bullet points and a picture?picture?

• Express the situation in Express the situation in time and units that can time and units that can later “prove the case”later “prove the case”

• Graphically present Graphically present initial state with metrics initial state with metrics when possiblewhen possible

• PP-D-S-A-D-S-A

Initial State

People: I am clear about my role and the roles of others in my department. 2.5 (scale 1–5)

Quality and Safety:

MD - “At the start of the visit I had all information needed to provide care. 2 (scale 1-5)

MA – “I had the information needed to assist patient at check out.” 60% (0-100%)

Cost: Call cost per encounter (based on June encounters & phone stats). 2.67 calls/encounter @ $4.21 per call = $11.24 cost/encounter.

Service: Average speed of answer 187 sec.

Growth : Market share in primary service area based on last 2 quarters is 18.5%

Box 3 – The Target State• Record required Record required

target not what we target not what we ‘think’ we can achieve‘think’ we can achieve

• Double the good or Double the good or half of the badhalf of the bad

• Wherever possible Wherever possible use voice-of-the-use voice-of-the-customercustomer

• Graphically present Graphically present Target ConditionTarget Condition

• PP-D-S-A-D-S-A

Target State

People: I am clear about my role and the roles of others in my department. Target 4.0

Quality and Safety:

MD - “At the start of the visit I had all information needed to provide care. Target 4.5

MA – “I had the information needed to assist patient at check out.” Target 90%

Cost: Call cost per encounter Target $6.00

Service: Average speed of answer 90 sec.

Growth : Market share in primary service area based on last 2 quarters is 26%

Exercise: Write a problem statement for box one and identify a metric for box two

Close the G

apWaste

Eliminate the WasteIdealIdeal

TargetState

TargetState

InitialState

InitialState

Clearly Defined Problem

Box 4 – Gap AnalysisRoot Causes!

• Identify all possible Identify all possible causes for the causes for the situationsituation

• Conduct an Conduct an investigation find investigation find “root causes” “root causes”

• Ask the “5 whys?”Ask the “5 whys?”

• Cause and effect Cause and effect diagramsdiagrams

• 8 wastes8 wastes

• PP-D-S-A-D-S-A

4. GAP ANALYSIS:

Box 5 – Solution Approach• Use the “If we Use the “If we

did did this,this, then we then we would would achieve achieve thisthis” approach ” approach to possible to possible solutionssolutions

• Use a 2x2 Use a 2x2 priority index to priority index to “rack and stack”“rack and stack”

• PP-D-S-A-D-S-A

5. Solution Approach:

Hard Easy

Sm

all

Pa

yoff

Big

P

ayo

ff

Box 6 – Rapid Experiments• Ties to solution Ties to solution

approaches based approaches based on actionable, on actionable, impactful root impactful root causescauses

• What happened What happened when we tried stuff? when we tried stuff? Did it work?Did it work?

• Conclusion?Conclusion?

• P-D-P-D-S-A S-A

Rapid Experiments

1.Communication of flow and signage throughout the department

2.Move printer closer to check out desk

3.Standardize and sort check out area to cut down on motion waste

4.Test standard work for the secretary

5.Redesign the prep work space for X-rays

6.Standardize check out process and train MA

Box 7 – Completion Plan• List activities List activities

by projects, by projects, events, do-its, events, do-its, and stop-its and stop-its

• List ‘What, Who List ‘What, Who and When’ and and When’ and track progresstrack progress

• P-D-P-D-S-AS-A

Box 8 – Confirmed State

• Relates all the way Relates all the way back to target back to target condition in box 3condition in box 3

• Have we achieved Have we achieved and closed the gapand closed the gap

• Does the Does the confirmed state confirmed state in box 8 = the in box 8 = the target state in target state in box 3?box 3?

• P-D-P-D-S-AS-A

Box 9 – Insights

• Lessons earned/ Lessons earned/ breakthroughs/ breakthroughs/ reflectionsreflections

• What new things What new things have we learned?have we learned?

• P-D-P-D-S-AS-A

INSIGHTS:

Completed A3

Exercise: go back to work and execute an A3 of your own

It’s Time for Jeopardy!!!

Thank You!

• For questions, contact me at charles.derus@advocatehealth.com

• Are You Solving the Right Problem?by Dwayne Spradlin, HBR, September 2012

• Leading the Lean Enterprise

by Koenigsaecker