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Observation at the Front Line (Gemba) Revealed Waste & Rework
Our aim was to design an effective, systematic approach to a
healthcare quality program that engages the entire workforce,
proactively identifies and addresses problems through front line and
manager input, minimizes number of committees to the “vital few”,
and advances the strategic plan, all of which is supported by a quality
oversight committee comprised of health system executives and
medical staff leaders. Implementation timeline for assessment,
design, restructure and Lean implementation was 9 months, to be
completed by October of 2014.
Aim Statement
Transformation of the quality management system and as a result,
the workforce culture, requires a deliberate vision, infrastructure,
and the coupling of Lean theories and tools. In addition, the hospital
employees have a tremendous amount of collective wisdom; to reach
organizational quality goals, these ideas and experience needed to be
harnessed.
Success was defined as 1) the creation of a multidisciplinary quality
improvement oversight committee co-led by the CEO and physician
chief of staff 2) a reduction in the number of organizational
committees within the quality structure 3) physician alignment of
quality metrics with improvement goals 4) educating 90% of staff
with Lean in the first 3 months 5) creation of a system to collect
improvement ideas/ identified problems from front line staff, and 6)
reaching goal, for the first Lean rapid improvement event that was
initiated using all components of the new quality program.
Our experience has resulted in a recommended approach and
sequence to quality program implementation, which strengthens
quality infrastructure, reduces duplication and rework, streamlines
communication, develops staff as problem solvers, and drives day to
day accountability. The evolution has resulted in a more engaged and
aligned workforce of patient-centered innovators, with an effective
pathway to redesign or create reliable processes and achieve
consistently excellent outcomes.
Project Design
Structural Redesign
Redesign of Quality Oversight and Committee Structures – After a whole house assessment, the Board, hospital leaders and medical staff
leadership met to have candid conversations to evaluate the work of current committees, streamline meetings to reduce duplication and create
efficiencies. Goals, metrics and a charter were created for each committee. A Quality Improvement Committee was created to steer all Quality
and Performance Improvement in the hospital. This change eliminated the work done in silos and enabled the coordinated, systematic
identification and prioritization of improvement opportunities. Integrated into this structure is an improved peer review and medical staff quality
process to provide ongoing monitoring of safety and quality. Information flow was adjusted to ensure feedback to all stakeholder groups, to
support both departmental and cross continuum care.
Implementation: Total Workforce Engagement
Education for All Staff Dept Performance Improvement Boards Selection/ Prioritization of Improvements
First Lean Rapid Improvement Event with Multidisciplinary Team
• Quality Structure/ Peer Learning - Involve physicians with depth of
improvement experience to speak to other physicians for faster
engagement
• Improvement/ Learning to See – Identified extra effort and
unnecessary effort for routine work. Realized “things fell apart” in
the past because rationale for change not well explained to all
involved in the process.
• Improvement/ Process Ownership- First attempts to manage
process were “owned” by Quality leader, resulting in lack of
ownership at Department leader level. Needed to create
accountability at department level through huddles, director to
director huddles and director accountability to QIC.
• Executive Oversight – Learned that presence or absence of
executive oversight between meetings is highly visible to front line,
and highly correlated with success.
Jamie Harkins, Erika Sundrud and Judy Krempin
Outcomes by Design:
Sustainable Improvement Through Quality Structure, Total Employee Engagement & Lean Practices
Multidisciplinary Team Identifies the Organization’s "Critical to Quality" Needs based on Strategic Plan & Customer Input
Committees Restructure & Streamline to the "Vital Few"
Physicians Set Priorities and Metrics for Ongoing Improvement
Lean Education Provided to All Staff
Lean Implementation of Daily Practices & Rapid Improvement Events
Contacts Quality Redesign: Jamie Harkins
Lean Implementation: Judy Krempin
Lessons Learned
A3 for ED TAT Rapid Improvement Event (RIE)
Sustainability Requirements 1) Ongoing QIC Oversight of Quality & Total Workforce Engagement
2) Data Transparency at the Front Line/ PI Board
3) Huddles at the Performance Improvement Board for Focus
4) Managers on the Gemba Every Shift to Coach/ Support Staff
5) Senior Leader Gemba Walks to Demonstrate Commitment, Become
Familiar with Process, Coach Direct Reports
6) RIE Team Leaders (Department Leaders) Accountable to QIC
Current State (2013): 1) Medical Executive
Committee overburdened and unable to effectively address all quality improvement requirements
2) Not all staff represented (e.g. ED)
3) Barriers to information flow
Future State (2014): 1) Reduced number of medical staff
and operational committees 2) Created of a Quality Oversight
Committee led by Executives and Physician Leaders
3) Represents all departments/ providers in the system
4) Ensures timely, concise information flow
33VA 159 min 21% VA minutes
11 VA 52 total 21% VA steps
Voice of the Customer: Examples of Common Feedback, Supported by Data
Patients/ Families: -Quite a wait. I’m sure it was two hours. -I didn’t expect to wait that long.
Staff: -Need seamless communication -No standard work -ED/ Diagnostic Imaging relationship is argumentative -“So much time is wasted”
Medical Providers: -Priority is imaging turn around time