Quality Forum 2013
BC Provincial Lean Network
Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders
BC Provincial Lean Network:Background
• Lean Network established in January 2010• Provides expert advice to the Ministry on the Lean
KRA and deliverables• Coordinates Lean activities• Champions the use of Lean in HAs• Partners with the MOH to ensure KRA deliverables
are met
BC Provincial Lean NetworkNetwork Members
• Rena van der Wal (VCH)• Jennifer MacKenzie (PHSA)• Erin McGarvey (IH)• Mélie De Champlain (VIHA)• Bonnie Urquhart (NH)• Eric Demaere (FH)• Emmy Beaton, Frances Bryan and Kevin Samra (MOH)
BC Provincial Lean NetworkObjectives
• To promote the reduction of waste and increase value (efficiency and effectiveness) in the health care sector through the use of Lean methods.
• To create ways to share best practices, tools and promote collaboration across health authorities.
• To develop and share best practices in Lean education and training materials between the health authorities
• To foster an environment receptive to innovation, change and ongoing improvement.
• To document, quantify and monitor the gains of Lean initiatives.• To identify best practices (Lean initiatives) that should be implemented
system wide.• To integrate Lean thinking into new capital projects and planning.
Provincial Lean NetworkCo-Chairs: Kevin Samra (MOH) & Rena van der Wal
(VCH)
BC EducationWorking Group
Chair: Marg Seppelt (PHSA)
BC MetricsWorking GroupChair: Kate Yang
(VCH)
BC Community of Practice Working
GroupEric Demaere (FH)
BC Facilities Working Group
Rena van der Wal (VCH)
BC Provincial Lean NetworkSession Today
• Provide an opportunity to share our best practices and our learnings– What is working – what is an opportunity for
improvement
BC Provincial Lean NetworkSession Today
• Hear the presentations – it is not so much about the specific area of focus - listen for the themes– Successes– Challenges – Are they similar or different than yours
• Be prepared to share your learning and ask questions• Let’s talk about what you can take back to your practice on
Monday• What can the BC Provincial Networks do to support your work?
Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders – Part 1:
Improving Quality for Cardiac Device Implantation (Session E8)
Minnie Downey, Program Director, Cardiac ProgramShahzad Karim, Medical Director, Cardiac Surgery
Objective
• Cardiac and Surgical Services implemented a regional Implantable Cardiac Electrical Devices (ICED) program to:– improve patient access to services,– consolidate implant sites,– enhance efficiency of scheduling device implants
and replacement, and– standardize and integrate pre and post procedure
care in accordance with evidence informed practices.
Background• Patient dies waiting for a pacemaker,• Fasting for >3 days waiting for implant,• Implant cases cancelled/delayed due to
inconsistent physician availability,• Patients inappropriately prepared,• ISSUE:
– Capacity for 900 cases, actual 1400,– Budget for 1000 implants, actual 1400,– Inconsistent processes, and fragmentation,– Inconsistent physician availability.
Current State – pre change
• Pacemakers implanted at RCH, ERH, BH and SMH, ICD/CRTs implanted at RCH,
• SMH and BH worked independently,• All implants had an anethetist present for the
procedure,• IP frequently waited 10 days for implants and
were often added to OHS slate, or implanted during emergency OR time, and
• Pre and post orders were site based and not coordinated across the region.
Solution
Consolidation from four site model (RCH, ERH, SMH, BH) to two regional sites (RCH, JPOCSC),
Standardization of clinical practice tools, processes, inventory management, patient transfers, centralized intake,
Integration of Intra-Procedure care implant team, including the use of an AA for preselected cases.
Results
• Reduced duplications and redundancies,• Improved patient access – PPM wait list
reduced from 110 to 40, ICDs from 30 to 3,• Pacemakers are performed 5 days a week, ICD
CRTs weekly,• PPM IP implants within 72 hours and OPs 6
weeks – meeting or exceeding national stds,• No cancelled days due to resource availability,
Next Steps/Sustaining the Gains
• Comprehensive evaluation in progress,• Moving from project to operations,• ICED Phase 2 planning in progress:
– Post implant follow –up,– MUSE and PaceArt software integration,– Remote monitoring,– Integration of EOL care and ICD management,
• Continuous Quality Improvement• Share learnings internally and externally,
Lessons Learned
• Engagement with stakeholders early, • Cast the ‘net’ wide,• Develop the change in collaboration with
team members,• Prepare for the unexpected,• It is a lot of work – but it is worth it,• Effective communication, • Plan, Plan, Plan.
Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders – Part 1:
The Patient’s Journey Within the Continuum of Care: The New Nanaimo Emergency Department(Session E8)
Drew Digney, Executive Medical Direct, Site Chief, Nanaimo Regional HospitalSuzanne Fox, Director, Emergency Services & Trauma Care, Nanaimo Regional
Hospital
Objective
• Opening New Emergency Department
• Electronic Health Record
• New geography
Background
• 54,000 pts in small space 3x the size
• Vision development• Visionary Team • Engagement of team • LEAN – value stream mapping
Current State
• Integration
Change in staffing models Developed new patient flow (PES) Electronic methods Communication requirements Changed materials management
Solution
• Employee engagement/champions• Vision• Team approach established despite
the new ED • Implementation is key to success• Barriers were identified when the focus was
not on the patient/clinician interaction
Results
• A Place Where People Want to Work• MHAS – right patient, right place, right clinician• Better tracking, documentation and
communication • Legible clinical documentation to community GPs• Improved communication• Eliminated need for clinicians to deal
with stocking
Next Steps/ Sustaining the Gains
• Visioning session• Continued focus on patient/clinician
interaction• Sustainability of current solutions prior
to new initiatives• Revisit LEAN value stream maps
Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders – Part 1:
Improving Post-Renal Transplant services (Session E8)
Clare Bannon, Clinical Nurse Leader, Renal TransplantGary Nussbaumer, NephrologistTom Tautorus, Director of Quality
Disclosures
• None Relevant to this talk
Improving Patient SafetyRenal Transplant Clinic
• What is the problem• What was the approach• What is the solution
The Problem
• Exceptional Distribution Renal Transplants– Health Canada Regulations– Informed Consent
• Patients at increased risk of infectious disease transmission
– Inconsistent Communication• Organ Retrieval• Different Health Care providers involved• How is peri-transplant information communicated to
post transplant team?
Current State
• No clear or systemic process to ensure appropriate follow-up occurred.
• Communication/Documentation– Donor procurement – in-patient chart – post
transplant clinic – regional transplant center• Form was not 3-hole punched
Approach
• LEAN process used to document current state, identify problems, propose and implement solutions
Solution
• Standard Operating Procedure was developed and a process implemented
• Stakeholders involved– Pre-transplant Clinical Nurse Leader, BC Transplant Organ
Donation and Hospital Development (CDHD) Coordinator, BC Transplant Quality Assurance specialist, in-patient clinical leaders, post transplant care team, Infectious Disease leaders at BC Centre for Disease Control and SPH renal medical director
Solution
• Created a process that supports transfer of all pertinent information– Pre, peri, and post transplant areas (including
regional clinics)
Exceptional Kidney Distribution Process
Exceptional Kidney Distribution Process
Kidney Donation Identified
Donor Evaluation (MHSQ)
Risk identified and documented
Organ acceptedRecipient identified
Kidney in cooler with forms to OR
QA reviews ED form for disease
transmission
If risk, QA faxes follow-up form
Risks identified during retrieval
RPR not available STAT
Could require more tests
ED form part A (white) goes to
donor chart. Yellow copy to QA
(BCT)
Organ offered to nephrologist
Recipient arrives at hospital
Recipient informed of ED
Transplant surgeon/physician
signs part B
Pink and goldenrod forms go with cooler to
OR
Pink form surgeon signs part B and returns to BCT
Goldenrod goes to chart
Transplant occurs
Recipient goes to ward
Patient discharged day #4 and chart
to Medical Records
Non-standardized follow-up
Current ProcessAdditional
Information
ABO and virology results sent to 6B
- ODHD/BCTS send preliminary culture reports and final faxed cover sheet with
recipient name and donor ID- ODHD always pages nephrologist on
call if positive results
Where do faxes go?
- recipient chart- doctor’s file
Need to determine
Solution
• Safety Checks Established– BC Transplant faxes ED form to Post-Transplant as
a cross-check to ensure no cases are missed.– If patient transfers to another clinic, the ED status
is now included on the transfer form– Yearly audit done for all patients to ensure
screening bloodwork has been completed
Results/ Expected Results
Expected results are that 100% of patients will have appropriate follow up in the post transplant period at 4, & 8 weeks, 6 months and 1 year
Acknowledgements
Clare BannonJennifer ChowAmable Cruz
Camille RozonTom TautorusMichele Trask
• With the support of the Entire Kidney Transplant Team
Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders – Part 1:
Leading the Transfer of Care for Cardiac Patients from Cardiac OR to Pediatric Intensive Care Unit (Session E9)Tracie Northway, Strategic Project Manager, BC Children’s & Sunny Hill Health
CentreBarb Fitzsimmons, Senior VP Patient Care Services, BC Children’s Hospital &
Sunny Hill Health Centre
Objective
• The aim of this initiative was to streamline & standardize a safe admission and handover process of cardiac patients from the Operating Room to the Paediatric Intensive Care Unit.
Background
Background• Historically, post-op cardiac surgery
patients unstable• Identified need• Largest post-op group• Cluster/flock care• Chaos• No clear communication• Missed critical information• Delays in care• Previous improvement attempts had failed
http://img69.imageshack.us/img69/4634/chaosfieldhp0.jpg
Current State
Role cro
ssove
r
Tangle
d equipmen
t/lines
Supplie
s not w
here nee
ded
Increase
d unexplai
ned st
aff
Waiti
ng for p
eople
Deviati
ons fro
m "norm
"
"Pres
ence"
at han
dover
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5 4.2
2.8
1.5 1.51.2 1.3
0.7
Cardiac OR to PICU Handover of Care: Pre-Kaizen Average Defects per Handover
(6 Handovers)
Defect Category (n=# of occurences over 6 handovers)
Aver
age
Defe
cts/
Hand
over
• Team selectionPICU: staff nurse; charge nurse; quality & safety
lead (lead)Cardiac OR: anaesthesia assistant, anaesthetist; clinical resource nurse; perfusionistExternal: imPROVE facilitator (sub-lead); vice president; corporate executive assistant
Content experts: PICU physicians; cardiac surgeons; respiratory therapist;
professional practice leaders
Solution
Solution
Set and met 4 targets:1. Determine characteristics of a safe patient
handover from OR4 to PICU2. Define standard work (process,
roles and responsibilities) for a safe patient handover
3. Develop tools to guide & support standard work
4. Test standard work tools
SolutionActivity Day 1 Day 2 Day 3 Day 4 Day 5
Orientation to Lean principles
Team goal setting for the week
Define “standard work” for Cardiac OR to PICU safe handover of care
Development of Handover Tool
Bed Set-up (crib) defined, prototyped & tested on admission
Protocol for handover drafted
Education for OR #4 Team and PICU staff admitting CVS Patient
Digital recording of admission
Debriefing with OR & PICU staff about admission
Review of debriefing notes
Areas for improvement discussed
Strategies brainstormed
Handover Tool (Checklist) revised & tested
Protocol for handover revised & tested
Admission recording reviewed, standard work documented & defects counted
Daily “report out” to Sensei Iwata
“Stamping” of project work by Sensei Iwata
Practice for “Final Report Out”
Team “Final Report Out” to Sensei Iwata, other teams, sponsors and administration
Creation of sustainment plan Ongoing
Results of Kaizen
Role crosso
ver
Tangle
d equipment/lines
Supplie
s not w
here needed
Increase
d unexplai
ned staff
Waiti
ng for p
eople
Deviations f
rom "n
orm"
"Pre
sence
" at h
andove
r 0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.54.2
2.8
1.5 1.5
1.21.3
0.7
0.0
0.3
1.0
0.0 0.0 0.0 0.0
Cardiac OR to PICU Handover of Care: Comparison of Pre-Kaizen to RPIW Average Defects per Handover
Pre Kaizen (6 Handovers)
Kaizen Wk (3 Handovers)
Ave
rage
Def
ects
/Han
dove
r
Results of Kaizen
Results of Kaizen (2 Years Post)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.54.2
2.8
1.5 1.5
1.21.3
0.7
0.0
0.3
1.0
0.0 0.0 0.0 0.00.0 0.00.1
0.0 0.0 0.00.2
Cardiac OR to PICU Handover of Care:Comparison of Pre-Kaizen to RPIW to 2 Years Post Kaizen
Pre Kaizen (6 Handovers)
Kaizen Wk (3 Handovers)
2 yrs Post-Kaizen (19 Handovers)
Defect Category
Ave
rage
Def
ects
per
Han
dove
r
Next Steps/Sustaining the Gains
• Adopted for spinal surgery handover• Plans for spread to 100% of surgical teams for
2013-2014• Agreement from Surgical Council• Improvement planning group meeting
Lessons Learned
• A pull for change is easier to make happen
• Right people on the team• Value of senior leader on team • Create a process dependent protocol;
not person dependent• Don’t reinvent the wheel• Live quality improvement cycle; be
responsive
Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders – Part 1:Improving Mental Health Patient Flow in Emergency(Session E8)
Andrew Janiec, Patient Care Coordinator, Vancouver General Hospital Psychiatric Assessment Unit
Patti Maisonet, Psychiatric Triage Nurse, Vancouver General Hospital Psychiatric Assessment Unit
Objective
• To provide timely and quality care to mental health and addictions clients who arrive in ED and require hospitalization.
• To enhance our ability to pull patients into our care from the ED as soon as safely possible while meeting P4P target timelines
Background
• Problem Statement: Currently some patients are not admitted within 10 hours of arriving in the ED - even when we have beds.
Current State% of PAU Admissions Meeting Target
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Period
% M
et
% of Patients Meeting Admissions Target
Issues Identified• Patients are asked to repeat their story to multiple
clinicians
• Redundant information gathering on forms
• Code white or agitated patient in the quiet rooms can delay admissions
• Admission delays due to not having empty beds available – no capacity
• Staff are being taken away from the unit to escort patients for diagnostic testing
• Timing of meals can delay patient transfers to inpatient units
• Staff time spent searching for charts, patient belongings, keys, forms etc.
• Patients/Families do not consistently have the information they need about the unit
SolutionImprovement Trial Benefit
Revised nursing assessment forms decrease redundancies and simply the forms with check boxes
Created nursing care plan template reduce repetitive handwriting
•Created laminated chart finding cards,
•Ordered keys for all staff,
•Established process for PTNs to collect old charts & indicate if patient has personal belongings
Decrease searching time
Developed guidelines for when staff accompanying patients for diagnostics testing
Decrease time staff spend away from the unit
Establish process to expedite after hours bed cleaning through Patient Access Decrease admission delay
Inpatient unit to call PAU when bed available or discharge planned Inpatient “pulling” patients & increase PAU bed capacity
Unit clerk to enter all orders & MAR requests & prep patient charts in AM Improved skill task alignment
SolutionImprovement Still Under Development Benefit
Conduct a 5S of PAU to make space for patients to be admitted beside the Quiet Rooms not through them
•PAU Open Side staff can admit patients •Decreases admission delays
Revise/ update PAU welcome booklet and provide to all patients / families
•Provides patients/family information they need•Decreases time clinicians spend answer the same question, multiple times
Work with food services to align PAU & Inpatient unit mealtimes and for bag lunches to be on the unit in case patient still needs to be transferred during mealtimes.
• Decreases transfer delays• Increases PAU bed capacity
Results
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4 5 6 7 8 9 10 11
11/12 12/13
% M
et T
arge
t
VGH PAU - % of ED Admissions with Target
Project implementation
Next Steps/Sustaining the Gains
• Continue implementing improvements eg. 5S
• Continue PDSA & sustain gains using Lean Management tools – Improvement huddles– Continuous improvement board– Gemba– Break through lanes
Lessons Learned - Challenges
• Communicating outcomes of RPIW to all staff and ensuring they are engaged through entire journey
• Accepting there are some quick wins but will be a journey to achieve the results we want – Rome was not built overnight!
• Finding a patient to participate in the RPIW
• Gaining buy-in from external stakeholders and support services to support improvement ideas (eg: change of meal times)
Lessons Learned - Benefits
• Staff have better understanding how their efforts impacts how long patients have to wait to get into the right bed
• Staff can see progress and impact of their actions (improvement board)
• Patients are getting to the right care sooner
Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders(Session F8)