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1
Leading With Lean at Rouge Valley
1
Central East LHIN Board of Directors
April 25, 2012
Rik Ganderton
President & CEO, RVHS
Agenda
1. What is Lean?
2. Transforming with Lean at RVHS
– Leadership
– Examples of Improving the Patient Experience
through Lean
3. Where are we now?
4. Lessons Learned
5. Opportunities and Next Steps for RVHS
2
What is Lean? Lean is a management philosophy by which customer value is
maximized, while waste is minimized. Lean is a process for optimizing value for customers, while making the most effective use of resources.
• Lean is not mean – quite the opposite – it respects and engages team members
• Lean does not mean cutting jobs in the name of cutting costs (In fact, cost cutting should not be connected with Lean)
Our “customers” are patients. Lean puts patients first through these basic tenets
• Respect for People• Respect patient/family time, input, privacy, dignity – e.g. deliver on our Patient
Declaration of Values
• Respect staff skills – involve staff and physicians; use their time wisely; optimize the processes in which they work; connect their role – wherever they work – to the corporate vision/mission
• The elimination of waste• Waste is non-value-added activity; Value is defined by patients
• Making good quality repeatable, sustainable
• Eliminate long wait times
3
What is Lean?
• Fundamentals of Lean
– Data driven measurement – If you can‟t measure it you can‟t manage it
– Visual Management – transparency and accountability –you have to see it to manage it
• See the exceptions, measure them, fix them
– You have to be visible to manage
– Management is about coaching and developing not telling and doing
• Front line staff know more about the problems and solutions than the manager
5
Transforming with Lean at RVHS• Since 2008, we have been using Lean as our enterprise-
wide management philosophy and supporting tool kit
to help our resource-constrained management team
address the broad scope of change required; all leaders
are required to lead and manage using the Lean
Management Philosophy
• We provide extensive Lean training and management
development to give all leaders a consistent approach
for how we expect the organization to be run
• We established a Transformation Management Office
(TMO) to assist leaders and frontline staff with ongoing
coaching, support , facilitation and basic training (we use a 4
step approach: engagement, improvement, sustainment and spread)
• We access external Lean expertise (less every year)
for regular coaching, advanced training, facilitation of
new techniques
• We have developed the STAR framework (see next
slide) to communicate a common set of expectations for
all departments
5
" In a lean environment, the expectation is
that everyone has two
responsibilities. The first is to run the
business on a day-to-day basis. The
second is to improve the business, or
contribute to improving it
continuously."
(David Mann in “Creating a Lean Culture: Tools to
Sustain Lean Conversions”)
6
Continuous improvement – Our STAR FrameworkDefining Goals for Lean Deployment and Sustainment
STANDARDAll of the following are in place:
• Process Control Boards
• Performance Trending
Boards
• 6S
• A3
• Rounding
• Kaizen Participation
• Leadership has had Lean
Expert Tools Training
ADVANCEDAll of the following are in place:
• Sustainment of Standard
level
• Kamishibai (daily quality
audits)
• Safety Calendar
• Idea Board with problem-
solving huddles
• Department leads and
sustains its own kaizen
events (at least 2 per yr)
ROLE MODELAll of the following are in place:
• Sustainment of Standard and
Advanced levels
• Internal knowledge sharing(joint kaizen with another dept;
facilitator for another dept‟s Lean
event; lead an in-service; internal
article or poster presentation)
• External knowledge sharing(e.g. joint kaizen event with
external partners; conference
presentation; published article)
• Use of one or more higher-
level Lean tools (e.g. Kanban,
Andon, SMED/changeover, etc.)
2010/11
2011/12
2012/13
90%
100%
10%
100%
0%
10%40%
67% 33%Target
achieved
7
Embracing Lean as a Management PhilosophyLean thinking helps in moving leaders from crisis management mode to a greater focus
on improvement, innovation and strategy
Top Management
Middle Management
Line Management
Front line
Maintenance
Innovation
Traditional perception of job functions
Top Management
Middle Management
Line Management
Front line
Maintenance
Improvement
and
Innovation
World class perception of job functions
“Kaizen”, Imai, 1986
8
A New Brand of LeadershipStrong Leadership Attention is Key
• Dedicated hospital-wide Gemba Time, 2 hours/day
• Transformation Rounds (twice per month by entire senior team)
• Regular Senior team walkabouts with the CEO
• Transformation Updates in monthly Leadership Forum, Town
Halls, President‟s Blog, newsletters, President‟s Report to the
Board and a standing agenda item in key meetings such as
Medical Advisory Committee
• Public blogs on how Lean works for patients – routinely posted
• Presentation on Transformation at every orientation session for
new staff
• Lean incorporated into Personal Business Commitments
• Lean sustainability measure reported on the corporate scorecard
• STAR Framework sets expectations for all departments
• Senior leaders deliver workshops on Lean topics
• Lean Leadership Culture Survey conducted every 6 months
Visibility
Communication
Role Models
Self-Reflection
Accountability
Lean and the Board
Lean used to drive and support the implementation
of corporate strategy
Board involvement is a key part of the oversight of
our accountability framework:
• Lean orientation and education
• Monthly Transformation Updates as part of President‟s Report to the
Board
• Monthly reporting on Lean indicators related to sustainability and
engagement on corporate scorecard
• Evaluating CEO performance on Personal Business Commitments
(PBCs) related to Lean
9
Improving Patient Experience through Lean
Because of our application of Lean our patients now
Wait less time for
• Emergency department care at RVC and RVAP (plus improved ambulance offload times)
• Lab & diagnostic imaging results (hours vs. days)
Go home sooner thanks to improved patient flow, discharge planning
Walk less distance at pre-admit clinics / our professionals come to them
• Thanks to our pre-admit clinic introducing one-stop-shopping to reduce the # of steps walked by patients with bad hips and knees
Cancel fewer surgeries thanks to enhanced pre-surgical screening
Waste less of their time filling in forms
10
1111
Start of Kaizen End of Kaizen
Manual cycle time
(sum of time spent
for all staff
involved)
53.3 minutes 33 minutes
OR changeover
time
15.6 minutes 12.7 minutes
# of room exits to
clean room
12 5
# of operating
procedures
performed each
year at RVAP
6700
Reducing OR changeover time
on every procedure by only 3
minutes saves 335 hours per
year that can be used for more
procedures!
Operating Room Changeover Kaizen Event
12
RVAP Pre-operative Screening Visit Redesign (new)
Before Kaizen After Kaizen
Average Visit
Length
7.56 hours 1 to 3 hours
Patient
Movement
493 steps
Patients travelled to
various departments
(Lab, DI, ECG)
246 steps
Patients stay in one room; staff
come to patient and use coloured
„fingers‟ for visual management
% Patients
Screened
Pre-operatively
20% 90-100% (some by telephone)
Cancellations
of surgery
because
patient not fit
37 (08/09) 7 (09/10)
Timeliness of
Surgery
Surgery delayed due to
incomplete
documentation
95-100% of charts complete one
day prior to surgery and
93% of patients ready by 30
minutes pre-booked Operating
Room time
Antibiotic Use Unknown (but much
less than 100%)
100% of patients given IV
antibiotics pre-Total Joint surgery
as per national guidelines
Sustained and
spread to
Fracture Clinic at
RVAP
131
79%
TBD
TBD
77%
68%
59%
Post-6S
35%
TBD
TBD
5%
18%
11%
Pre-6S
81%2W Audit Score – Clean Utility
Room
73%2W Audit Score – Medication Room
TBDAvg Monthly Medication Cost
TBDAvg Monthly Medical Supplies Cost
93%2W Audit Score - Hallways
44%Staff Satisfaction (n=12)
% ChangeMetrics
79%
77%
68%
59%
Post-6S
35%
5%
18%
11%
Pre-6S
81%2W Audit Score – Clean Utility Room
73%2W Audit Score – Medication Room
93%2W Audit Score - Hallways
44%Staff Satisfaction
% ChangeMetrics
79%
TBD
TBD
77%
68%
59%
Post-6S
35%
TBD
TBD
5%
18%
11%
Pre-6S
81%2W Audit Score – Clean Utility
Room
73%2W Audit Score – Medication Room
TBDAvg Monthly Medication Cost
TBDAvg Monthly Medical Supplies Cost
93%2W Audit Score - Hallways
44%Staff Satisfaction (n=12)
% ChangeMetrics
79%
77%
68%
59%
Post-6S
35%
5%
18%
11%
Pre-6S
81%2W Audit Score – Clean Utility Room
73%2W Audit Score – Medication Room
93%2W Audit Score - Hallways
44%Staff Satisfaction
% ChangeMetrics
6S on Inpatient Medicine Unit
14
Human Resources Recruitment Kaizen: Time to fill job vacancies
Before doing a kaizen on
recruitment, average time to fill
was 83 days. With the
improvements made, the
department has been able to
handle a 70% increase in
volume
1515
Where we are now?Lean improves current state, while being an investment in the future
Almost all areas of the hospital have made some form of Lean improvement (we have done close to 100 Lean events since 2008)
Financial and operational stability have occurred at the same time as we have preserved or enhanced the quality of care
We are building internal capacity to deploy and sustain Lean over the long-term consistent with LHIN and Ministry directions (we have provided over 300 hours of Lean training)
Cultural Change is happening (greater trust, transparency and accountability; Lean terminology is widely used; high use of A3 thinking)
Voluntary turnover is down and 2010 staff survey results indicate that trust, involvement in decision-making and satisfaction with the organization have increased since 2008
Physician leaders are engaged
Lean used to support corporate priorities including accreditation, enterprise risk management, redevelopment, pandemic planning
Positive change in our reputation with our community partners (e.g. LHIN, CCAC, EMS); joint kaizen events with other health care organizations
Growing external recognition for our achievements
16
Lessons Learned Lean is not a project – it is a long-term journey
Lean is 80% culture and 20% tools
Having a corporate or system-wide burning platform to stimulate change is essential but not sufficient; individual value propositions are also necessary for real buy in –What’s In It For Me!
Strong, ongoing, united leadership commitment is essential
Lean is harder for leaders than for frontline staff Leaders must
Learn to lead differently
Be visible in the „gemba‟
Empower staff to identify problems and find solutions
Make problems transparent and not take it personally
Lean has to be supported by a rigorous accountability framework
16
17
Lessons Learned
Physician involvement is critical
• But be strategic about it because they really are busy
Expect growing pains as Lean becomes standard
• Staff can feel frustrated or constrained (transitional states)• Improved results can be difficult to sustain and setbacks are to be expected
• Lean tools and creating more standard work can be perceived as loss of the
freedom staff members have to be impactful. This is a growing pain. The more the
process and tools are used, the better the engagement.
• Training and coaching staff to think and work within an increasingly Lean
environment is key to future progress, innovation for patients.
Lean is not about cost savings – It is about the patient
experience – Good quality costs less
Communicate, Communicate, Communicate!
• Did we mention communicate? – repetition helps
17
18
Opportunities and Next Steps
1. Sustain our gains and further embed (or „hardwire‟) Lean thinking in
the fabric of our organization to help us to be The best at what we do.
2. Foster a culture of daily continuous improvement
3. Continue to build internal capacity and invest in our leaders
4. Strengthen the link between quality and Lean transformation
5. Collaborate with health system partners on transformation initiatives
(e.g. region-wide value stream analysis on diabetes)
6. Position RVHS to be an industry leader in a new health care
environment in which Lean is endorsed by funders – and hospital
revenue and leadership compensation are tied to quality,
performance and efficiency.
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