Going Lean
Agenda• Introduction and Objectives• Borgess Ambulatory Care and its Guiding Principles• Overview of Lean Thinking• Benefits of Value-Stream Mapping• Transforming Office Practice• Outcomes• What We Learned• Summary and Next Steps
We Are a Place People Can Call Their Medical Home
Borgess Ambulatory Care330,000 Provider Visits Per YearOver 650,000 Total Visits Per Year10 Practices16 Locations98 Providers
• 58 Physicians• 40 Non-Physician Providers
Predominately Primary CarePractices Owned by Hospital System
Borgess Ambulatory Care Guiding Principles
Your Care Will Be Safe
We Know Who You Are and Are Ready For You
We Will See You When You Want to Be Seen
You Will Know What to Expect
We Will Be Your Trusted Partner in Health
We Will Exceed Your Expectations
Changing Priorities Ahead
Health Plan Partnership• Support for Lean consultant• Initially conducted Lean workshop• Trained and mentored Lean coach
– Observe, partner, lead model• Worked with Borgess Ambulatory Care
leadership• Initially disease focused• Seen as core competency for process
improvement
Change is like going to heaven, everyone wants to go but not
right now!
What is Lean?
Lean is a set of concepts, principles, and tools used to create and deliver the most value from the customer’s perspective while consuming the fewest resources.
From “Mapping to See,” Lean Enterprise Institute, www.lean.org
Encourages Front-Line Initiative“Having a meeting that pulled people from each department and allowing them to work together was very beneficial. It was a great concept in which it allowed input and say from each department to create change and better the work place. We all felt valued. Implementing more meetings like we just had will create a great team environment.”
–Maria, Medical Records
Develops Structured Thinking Around Problem-Solving
“Your system is perfectly designed to
produce the results you are getting”
- Frederick Taylor
Fosters Dialog Within the Organization
“Even on the best day with the best team, the worst can happen because we’re not really trained to talk to each other. If you’re preparing for a concert, you would never ask the violins to practice on the third floor, the flutes on the second and the cellos in the basement, and then expect them to come together for a symphony.”
- Karyn Baum, University of Minnesota Medical School
Molly Kelash, “Closing In on Bad Communication,”Pictures of Health, Fall 2006.
Overall Performance - Not Silos
Serves as an Organizational/Operational Learning Tool
Point of use storage
Building Blocks of Lean Healthcare
Quick changeover
5S’sLayout
Batch size reduction
Visual
Value-stream
mapping
Poka-yoke
Self inspection
AutonomationPull system and kanban
Cellular and flowJust-in-timeTotal productive maintenance
Change management
Standardized Work
Teams and teamwork
Continuous Improvement and Kaizen Events
A. Manos, M. Sattler, and G. Alukal, “Making Healthcare Lean,” Quality Progress, July 2006, pp. 24-30. www.asq.org
Benefits of Value-Stream Mapping
• Helps people understand how the process works now• Helps people understand and reach agreement on how
well the process is working• Helps uncover waste and problems with flow in the
value stream• Helps people reach agreement on what changes need
to be made • Helps people reach agreement on how to ensure that
those changes are made
From “Mapping to See,” Lean Enterprise Institute, www.lean.org
Roles for VSM or Kaizen Event• Lean Coach• Process Owner• Executive Sponsorship• Leadership Panel • Workshop Participants
Capabilities for Selection of Lean Coach
Social Aspects of Lean Thinking• Problem Solving • Group Process
• Change Management• Conflict Management
Technical Aspects of Lean Thinking
• Concepts and Tools• Data Analysis
Leadership of Lean Thinking• Listening• Influence
Work Structures and Management• Business Understanding
• General awareness of process• Excellent coaching/facilitating
skills• Respected by organization• Encourages humor and creates a
fun environment
Developed by Margie Hagene and Beau Keyte, Lean Transformations Group and Chris Wise, University of Michigan Health Systems
Identified Staff Educational Gaps
• Comprehension of the need to change• QI terms and concepts• Change management techniques• Project management skills• Lean terms are confusing
Structure of a VSM WorkshopPre-Work: Define Problem/Scoping
1.5 hr meeting
Lean Coach
Leadership Team Member
Sponsor
Process Owner
Define Project Scope
Determine VSM Participants
Identify Key Decision Makers
Develop Data Collection PlanIdentify Concerns, Issues, and Barriers
Day 1: Current State Map
Common Problems• Waiting/delay• Rework• Excessive handoffs• Interruptions• Many requirements for decisions and
approval• Poorly defined requirements
From “Mapping to See,” Lean Enterprise Institute, www.lean.org
Day 2: Future State Map
Common Solutions• Combine steps• Manage interruptions• Standardize processes• Build in quality checks
From “Mapping to See,” Lean Enterprise Institute, www.lean.org
Solutions should be…
• Within your control• Easy to implement• Can be started immediately • Low cost or no cost
Day 3: Implementation Planning
Develop a 90-Day Work Plan to:
• Clarify goals• Develop action plan for each goal• Determine who will be responsible• Determine when reviews and checks
will take place
From “Mapping to See,” Lean Enterprise Institute, www.lean.org
30 – 60 – 90 Day Reviews1.5 hr
Lean CoachLeadership Team Member
SponsorProcess Owner
VSM ParticipantsLeadership Team
Other Providers/Staff
Report Implementation Plan Progress
Your Care Will Be SafeCommon Themes in Plan Success StoriesDevelop standing orders/protocols
Eliminate interruptions
Increase IT functionality
Test trackingColor-coding Vaccine Information Sheets
Physician sat with a scheduler and listened to calls for one day
Labeled diabetic patients in practice management software
We Know Who You Are And Are Ready For You
Common Themes in Plan Success Stories
Team huddle
Provide proactive care
Scripting
Team has plan in place for the day
Schedulers provide patients with a lab slip for routine tests at the time of scheduling health maintenance exam
Before: When was your last mammogram?
After: Could please verify that your last mammogram was …?
We Will See You When You Want To Be Seen
Common Themes in Plan Success StoriesRealign responsibilities and clarify roles
Eliminate duplication of work
Review scheduling templates and protocols
Removed unnecessary paperwork from physicians’ dutiesProvider charts are screened and organized by priority
Time and date stamping faxes
Eliminating appointment typesHaving schedules in the computer seven months in advance
You Will Know What To ExpectCommon Themes in Plan Success StoriesPatient education
Standardized work
Empowering and enabling patients – pediatric vaccines
Letter explaining the group’s policy, includes current vaccination schedule, list of billing codes, instructions on how to contact insurance company to see if they are covered, and options if they are not covered.
Forms were standardized at all pediatric sites
We Will Be Your Trusted Partner In Health
Common Themes in Plan Success Stories
Increase communication
Increase post-visit contact with patient
Providers and staff building relationships with other providers/services within the organization/communityDepartment at hospital was able to provide a solution
Developing care management protocols
We Will Exceed Your Expectations
Common Themes in Plan Success Stories
Schedule diagnostic and referral appointment before patient leaves
Create a visit summary sheet for the patient
Realign meeting structure
Family practice sites are currently doing “live” referrals
Visit summary sheet was created in electronic health record
Problems are solved more efficiently and effectively
5S Workplace Organization• Sort: Sort out unneeded items • Straighten: Have a place for everything • Shine: Keep the area clean • Standardize: Create rules and standard
operating procedures • Sustain: Maintain the system and continue
to improve it
• Organized and labeled cabinets
• Removed doors where applicable
• Posted an inventory form• Created a stocking checklist• Inserted blood pressure cuff
shelving• Determined who is
responsible for restocking• Placed frequently used
handouts/forms in the room
ProMed Pediatrics: Provider Interruptions
Woodbridge Family Practice Medical Records 5S Event – Pursue to Perfection
Medical Records Improvements• Reduction in Chart Pull Prep Time 67%• Reduction in Loose Filing 100%
– Kanban System Created for Incoming Mail
• Increase in 5S Scorecard rating 100%– Pre 5S = 11; Post 5S = 22
• Significant Reduction in Wasted Floor Space• Significant Reduction in Transportation Waste for
Transcription Process
Data provided by Ed Blackman, MA, CSSBB
Before and After
Staff Satisfaction: Gallup SurveyGallup Questions % Improvement
(Post- Lean Workshop)How satisfied are you with Borgess Health as a place to work?
22.4%
This last year, I have had opportunities at work to learn and grow
17%
At work, my opinions seem to count
27.8%I always trust my organization to be fair to all associates
27%
My organization treasures diverse ideas and opinions
34%
Your Care Will Be SafeProMed Internal Medicine Diabetic Patient Immunizations
45
55
65
75
85
2007 Baseline 2008 Q1 2008 Q2 2008 Q3 2008 Q4
Timeframe
Perc
enta
ge
Pneumo Vac Td/Tdap
Lean Workshop
10.8
8.8
7.36.8
5.0
2.11.0 1.0
Jul Aug Sep Oct Nov Dec Jan Feb
Day
(avg
/mo)
2 days
3.5
4.1
3.3
1.8
1.0
2.0 2.0 2.0
Jul Aug Sep Oct Nov Dec Jan Feb
# of Screening Mammograms by Month
Day
s (a
vg/m
o)
2 days
Average Screening Mammograms per Month: 370
We Know Who You Are and Are Ready For You
MammographyTwo Business Days from Screen to Initial Pt. Call
Back
Mammography Two Business Days from (post- screen) Contact with Patient to Offer Date for Additional Views
Lean Workshop
Lean Workshop
We Will See You When You Want to Be Seen
Pediatrics 3rd Available Appointment for Well-Child Visit
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July 2008 Sept 2008 Jan 2009
You Will Know What to ExpectPatient Satisfaction Expectation Questions
86889092949698
Before I came to mydoctor's office, I expected
high quality care.
Before I came to mydoctor's office, I expectedthe doctor's office to meet
my personal needsextremely well.
Before I came to mydoctor's office, I expectedthings not to go wrong.
2007 Lean Groups2008 Lean Groups2007 Non-Lean Groups2008 Non-Lean Groups
We Will Be Your Trusted Partner in Health
NPS Formula SA - (SD+D+N) = NPSI would recommend this doctor's office without hesitation to others.
Net Promoter Score for Borgess Physician Practices
65
66
69
63
64
65
66
67
68
69
70
FY07 FY08 FY09
Scor
e
We Will Exceed Your ExpectationsSatisfaction Lean vs Non-Lean groups
Non Lean groups - 0.34
Lean groups 1.64
-0.50
0.00
0.50
1.00
1.50
2.00
1
Cha
nge
in ra
w s
core
CY0
7-C
Y08
What did problem solving look like 6 months ago at your clinic?
• Took a long time to resolve issues/problems
• “We were basically on our own to figure out how to handle a problem…because we did not know who to ask.”
• “I would tell my boss about a problem, I could not go to my co-workers with problems. We had no way to discuss issues with a provider.”
What does problem solving look like at your clinic today?
• Improved Communication and Team Problem Solving– “Doctors are invited (and show up) at our staff meetings to
be involved as well, this is great!”– “People are more receptive to suggestions.”– “We were able to make some much needed changes using
Lean…things staff had been adverse to try. Once we did it, everyone realized it was for the best.”
– “We now have time at our staff meeting to “group-solve” and talk about problems.”
What does problem solving look like at your clinic today?
• Collaboration Between Staff Members– “Staff are making their concerns known while taking in
other opinions.”– “When suggestions are made, we try one to see if it works.”
• Improved Patient Care– “We are more aware of making the patient/family happy
and pleased with all aspects of the visit and care.”
What are you learning?• “That change isn’t always bad. I can learn new things even at
my age.”
• “Become more aware of how good my coworkers are – I knew they were good, but I truly appreciate all they do now.
• “That just because “we’ve always done it that way” doesn’t mean we have to continue to do it that way.”
• “I have learned I can find something that I think may need change and I have a way to present and discuss the possibilities.”
Leadership Key Learnings
• Front line associates are key to success• Lean is a great way to break organizational silos • Value-added work is in the eye of the beholder• Waste is also in the eye of the beholder• Allows inputs from others to influence
perspectives on waste and value-added work• It is important to be sure that stakeholders from
other major projects/departments are included in the work
Leadership Key Learnings
• Transformation is a continual process• Gaps in management of day-to-day work were
discovered • 90-day goals might involve closing those gaps • Lean allows us to live our Guiding Principles and
support objectives of IHI’s Triple Aim
Ongoing Lean Organizational Roles
• Directors: – Leadership cascades vision and strategy
• Drivers:– Management approves action plans and serves as a
coach/mentor
• Doers: – Staff identify and solve problems
From “Mapping to See,” Lean Enterprise Institute, www.lean.org
Next Steps• Introduce new employees into the culture• Identify and skill up coaches embedded at each of our
locations• Align organizational behaviors• Introduce additional system integration workshops
– Central Billing Office – Low Back Pain– Physician Recruiting– Childhood Obesity
Bottom Line = Changed Lives• Your care will be safe• We know who you are and are ready for
you• We will see you when you want to be seen• You will know what to expect• We will be your trusted partner in health• We will exceed your expectations
Tools for Getting Started
• BAC Pre-Workshop Checklist• BAC Lean Roles and Responsibilities• BAC Lean Meeting Schedule• BAC Communication Plan Template• BAC Implementation Plan Template• BAC Staff Homework• BAC Staff Training Agenda• BAC Post-Learning Cycle Evaluation
Improving Our Lean Process
• Evening meetings began to feel like a punishment
• Be mindful to include/inform staff not participating in workshop
• Be careful in combining this process with any other change out of your scope of control