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Creating a Lean Culture Transformational Leadership for Lean Health Care

Bruce Roe, MD

President and CEO

Executive Champion, Transformation February 15, 2017

180 Departments

7 Separate buildings on 20 acres of land

Number of employees 3,854

Number of beds 538

Patient days 169,265

Number of admissions 26,769

Outpatient activity 233,189

Doctors with admitting privileges 597

Annual budget $302,680.00

St.Boniface Hospital

• Tertiary care hospital, affiliated with the University of Manitoba

• Our major clinical programs include Cardiac Sciences (provincial referral

centre), Woman and Child, Internal Medicine, and Surgery

• 3,800 employees

• Total admissions in 2015: 20,147

• Total outpatient visits in 2015: 228,705

About St. Boniface Hospital

Our vision

To deliver the safest and highest quality of care to every

patient, every encounter, every day, with the best

outcomes….

At a price we can afford!

2007

• Patchy improvements in

quality

Could ”lean” help?

• In healthcare?

• Few pioneers

• Local business - mentors

Lean … in Health Care?

Let’s Talk About Lean

What are your assumptions about lean?

What role do leaders play in lean transformation?

What does an effective lean leader look like?

Measure Initial

State

Confirmed

State

Patient handoffs 7 4

Patient Distance Traveled 306 ft 306

EKG Tech Distance Traveled 1390 ft 10 ft

Emergency Cardiac Patients Presentation to EKG Interpreted RIE (example)

Rapid Improvement Event #1 ACS Triage to EKG Interpreted

Trials

Team work

New EKG room

Mission Control and Visual Management

“People are everything!”

Improvement ideas come from those who do the

work, or experience the care

“You’ve put the fun back into Health

Care”

“This gives us hope!”

A Few Of Our Proudest Moments...

• ER Results

• Direct Admit ACSS

• Surgical Safety Checklist

• Clinical Documentation

• Nurse-to-Nurse reports

• Surgery On The Move

• Inventory Right-Sizing

• Prevention of Falls

• Staff Scheduling

• Cardiac Transitions

• Accounts Payable Process

• Staffing Absences & WCB

Reflection Point

• Lots of activity

• Pockets of improvement

• Fragmented deployment – not connected

• Engagement at front line and connection to goals and vision

missing

“Lean tools are great!”

5S

One-piece flow

• A3

• Value streams & mapping

• Kaizen

• Rapid Improvement Events

• 6S

• 3P

• Kanban

• Audits /Kamishibai

But are they delivering the results you are looking for?

5S

One-piece flow

Tools, if not anchored in systems

or principles,

will not drive culture

Engaging SBH in Reflection

The “Whirl-Wind”

Cause & Effect Relationship

of Tools & Results

Cause & Effect Relationship

of Principles & Results

REFLECTION

POINT

Tool-based

Architecture

Long-term Sustainment

Source: Institute for Enterprise Excellence www.shingoprize.org

Result-oriented

Fragmented Thinking

Command & Control

Defensive

Knower’s

Thinking that Drives Complexity Thinking that Drives Continuous

Improvement

Result-oriented

Fragmented Thinking

Command & Control

Defensive

Knower’s

Process-oriented

Systems thinking

Leader as a teacher

Engaging

Learners

Source: LEI

Shingo Model of Operational Excellence

1. There is a relationship

between principles, systems

and tools.

2. We focus on both key results

and the best behavior to

achieve those results.

3. We actively leverage our

systems to drive the best

behavior.

Key Systems:

• Strategy Deployment

• Daily Management System

• Visual Management System

• Coaching System

• Leadership Development System

Key Behaviors

Building Systems to drive Right Behaviors

Systems Roadmap 2017 - 2018

Key Behaviours

Leadership Managers Staff

• Set high but achievable targets

• Align strategies to TN and Regional Priorities

• Organize and allocate resources

• Connect, translate, filter at next level

• Connect, translate, filter TN direction

• Align problem solving efforts to TN and strategic direction

• Allocate resources

• Connect work to purpose

• Monitor performance to TN visually

Purpose: Connect work to purpose at all levels. Create alignment, clarity, and focus problem solving efforts to get the best results

Strategy Deployment – Thumbnail Sketch

Results: • TN Metric Improvements • Strategic Objective A3s (Plans and Results) • Clear line of sight to results at all levels

Triggers • Strategic Planning • Annual Planning • Enterprise Performance

Meeting

Tools • True North Metrics • Watch Indicators • A3 • Countermeasure Summary

Process 1. Set Enterprise TN targets through Annual Planning 2. Catchball (Connect, Translate, Filter) at all levels 3. Define Strategic Objectives and resources 4. Deploy targets and objectives 5. Monitor, Maintain, Improve 6. Reflect

Related Systems Strategy Development Daily Management Problem Solving Visual Management

ALIGN: Connect To Our Purpose

Renewal Annual

Purpose: Recognize abnormal conditions (winning/losing) at a glance & trigger a consistent response at the right-level in real-time.

Visual Management System – Thumbnail Sketch

Results: • Near misses, good

catches, defects resolved

• Containment Plans • PDSA

Key Behaviours

Leadership & Managers Staff

• Set targets and make visual • Respond in real-time to abnormal

conditions • Promote problem-solving &

containment of defects at the source

• Engage staff or leadership in problem solving

• Huddle often • Measure, monitor visually and

report on performance daily • Identify and embrace defects as

opportunity to improve

Triggers • Huddles • Gemba • Follow-Up • Shift Change • Abnormal Condition

Tools • Visual Standards • Andon • Visual Management

Centres • Metrics / KPIs • Escalation Standards

Process 1. Define targets / normal vs abnormal 2. Make visual 3. Monitor Daily or Real-Time 4. Respond to Abnormal Conditions (Contain, Solve,

Escalate) 5. Follow-Up

Related Systems Strategy Deployment Daily Management Problem Solving Coaching

IMPROVE: Assure Quality At The Source

Renewal Annual

SBH Management System (v1)

Dai

ly Im

pro

vem

ent

Daily Status Exchange

Monitoring, Maintaining, & Sustaining

Un

it P

erfo

rman

ce M

anag

emen

t

P

DS

A

GTS2

GAC

Daily Stat Sheet

Weekly Stat Sheet

Daily Improvement Huddle

Visual Management

Unit Performance Steering Team

A3 Problem Solving

Monthly Scorecard

Unit Performance Meeting

Countermeasure Summary

Standard Work

Leader Standard Work

Process Observation

Model Cell Approach to Learning Wave 1 - Sep 2015 – Apr 2016

(32 weeks)

• Pharmacy

• Cardiac Surgery Inpatient Unit

Wave 2 : Sep 2016 – Dec 2016

(16 weeks)

• Intensive Care Cardiac Surgery

• Internal Medicine Inpatient Unit (E5)

• CT Scan

• Ultrasound

Management System - Assessment Management System - Assessment Scores

Dimension Target June August September October November December January February March April

Daily Status 4 4 4 4 4 4 4

Daily Improvement 1 2 2 2 3 3 3

Unit Performance & Management 1 3 3 4 4 4 4

Monitoring, Maintaining & Sustaining 1 1 2 3 3 3 3

Overall 1 1 2 2 3 3 3

Daily Status 2 4 2

Daily Improvement 2 3 2

Unit Performance & Management 1 2 1

Monitoring, Maintaining & Sustaining 1 1 1

Overall 1 1 1

Daily Status 2

Daily Improvement 1

Unit Performance & Management 1

Monitoring, Maintaining & Sustaining 1

Overall 1

Daily Status 3 3 3

Daily Improvement 3 3 3

Unit Performance & Management 1 1 1

Monitoring, Maintaining & Sustaining 1 1 3

Overall 1 1 1

Daily Status 2 2

Daily Improvement 1 1

Unit Performance & Management 1 1

Monitoring, Maintaining & Sustaining 1 1

Overall 1 1

Daily Status 2 3

Daily Improvement 1 3

Unit Performance & Management 1 1

Monitoring, Maintaining & Sustaining 1 1

Overall 1 1

ICCS

3

E5

DI - CT/Xray

DI - US

Wav

e 2

3

3

3

2016 2017

Pharmacy

3

3

CSIU

Area

Wav

e 1

Management System – Spread

Wave 3

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Wave 4 Wave 5

Wave 6

2017 2018

6 units

8 units

8 units

10 units

Transformation Journey

“Hubris is a dangerous enemy”

~Pascal Dennis

Relentless pursuit of perfection means

just that; self-critique and facing one’s

problems”

~Steven Spear

Questions?