St. Joseph’s Health Centre, Toronto Central LHIN, Toronto, Ontario • 350 Bed Acute Care Community Teaching Hospital serving SW Toronto • 86,000 Emergency Visits, 12,000 Urgent Care Visits and 7,000 Just For Kids Visits (Largest volume of Emergency Visits in a single site hospital in the GTA and 2 nd highest in Ontario) and best performing ER of full service hospitals in GTA • 2 nd Highest population density in Toronto • Higher % of seniors who live alone • 2 nd highest % of low income households in Toronto • 2 nd highest % of non English or French speakers in Toronto • Higher mortality rates than the rest of Toronto
Transcript
St. Joseph’s Health Centre, Toronto Central LHIN, Toronto, Ontario
• 350 Bed Acute Care Community Teaching Hospital serving SW Toronto
• 86,000 Emergency Visits, 12,000 Urgent Care Visits and 7,000 Just For Kids Visits (Largest volume of Emergency Visits in a single site hospital in the GTA and 2nd highest in Ontario) and best performing ER of full service hospitals in GTA
• 2nd Highest population density in Toronto• Higher % of seniors who live alone• 2nd highest % of low income households in Toronto• 2nd highest % of non English or French speakers in Toronto• Higher mortality rates than the rest of Toronto
If everyone is thinking the same thing, someone isn’t thinking….General George S. Patton
Be clear on what you are doing, why you’re doing it, why are you doing it now and why you’re not doing
something else and who you are doing it for…
ALIGNMENT: A KEY TO LEADERSHIP CAPABILITY FOR ACCESS AND FLOW
2
Deliver better and safer care
Set new standards in patient access
and flow
IMPROVE PATIENT SAFETY
1 Delivering a superior care experience by:
• Speeding up diagnosis andtreatment
• Delivering better frontlinecare
Deliver superior
care experience
1
2 Creating a dynamic work environment by:• Teaching staff how to more efficiently deliver care• Enabling staff to mold their workplace to help the patients
Create a dynamic
work environment
23 Exceeding
accountability agreement targets by:Exceed
accountability agreement targets
3
• Consistently deliver thebest care
• Continue to improveour patientservice levels
Our vision for…
Be clear on what you are doing, why you’re doing it, why are you doing it now and why
you’re not doing something else…
Patients exceeding wait time targetsPercentage, March 2006
Situation at initiation of effortSheer volumeHospital Accountability agreementPressure from Emergency to implement Full Capacity ProtocolHours of non value added time for patients and staffPatients exceeding wait time targets
Why Bother
Heightened awareness of the importance of reducing wait times for ED through GIM continuum –Mounting pressure to deliver safer, more timely, high quality care with increasing volumes –Patient Safety Strategy with Access and Flow as a predictor of Patient Safety –•nternal Greater desire by our staff to create a dynamic work environment -Internal
67%75%
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CTAS 1‐3(6 hours)
CTAS 4&5(4 hours)
Target
*Based on expected patient load for 2006‐07: 80,000**Estimated for consistent admitted/ discharged, acuity levels*** Includes 2E, 4E, 4M, 6G, 6M
Source: Team analysis
Focus everyone: Why this?
Assumptions:• In‐patient admissions into 5 medicine units (2E, 4E, 4M, 6G, 6M) are 7.1% of ER visits
•Aggressive improvement potential in wave 1 targets capacity addition @8%
Growth in ER volumes will test our operations…
…as will growth in volume of medicine admissions
Patients treated in ERVisits per annum,thousands
Patients admitted in Medicine units***Thousands per annum
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Focus the attention of everyone but remember that some people aren’t interested in what interests
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* Based on expected patient load for 2006‐07: 80,000; estimated for consistent admitted/ discharged, acuity levels** Based on improvements in ALOS for 94% of patients with ALOS < 20 days, reduced ALOS from baseline of 5.6 to 4.7 days (Jan 31 – Feb 20, 2007)
Source: Team analysis
Medicine admissions**Numbers per annum
750
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5,000
Current # of admissions
Improvementin acute patient LOS
Improvement in ALC patient LOS
6,050
Potential # of admissions
Improving discharge process can increase inpatientmedicine capacity by over 20%
Optimizing flow can increases ER capacity by over 30% to accommodate SJHC’s annual 9.7% growth
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Patients treated in ER*Visits per annum, thousands
Projected growth based on current rate
Conservative improvement potential
Aggressive improvement potential
Our ChallengeExponential growth in ER visits10% per year = 82,000 visitsPatient dissatisfaction with access to careStaff feeling that there were no solutions – “sometimes we just pray”
Our GoalSafer and Better, More Timely Care by improving patient access and flow
Relentless Attention to Metrics and Visual Management at Every Level…
PLACING METRICS ON THE DESKTOP OF EVERY LEADER AND ENSURING THAT THEY LOOK AT IT!
E-MAILS FROM “THE TOP” FOCUS THE ATTENTION OF THE ORGANIZATION
DISPLAYING IMPROVEMENTS AND SLIPPAGE FOCUSES ATTENTION FROM THE BOARD ROOM TO THE POINT OF CARE TEAM
CELEBRATING SUCCESS AT EVERY OPPORTUNITY ENGAGES STAFF AND ENCOURAGES BUY-IN…
A GUIDE TO SOLVING ACCESS AND FLOW ISSUES FOR SENIOR LEADERS FROM SJHC
KEY MESSAGE:
If Senior Leadership (CEO and Board) are not paying attention to the metrics, no one will pay attention for long…something else will take its place…
Version 15.0All dates are in DD/MM/YYYY format
User Guide available on N:\Everyone\Access and FlowIf you have further questions related to the DAIR please contact Boyan Kovic x6479
(Should be prior to yesterday's date)
Area MetricsBaseline
(Oct 15 - Nov 14, 2006)
Yesterday (Tue, 17/04/07)
Average for 11/04/07 to
17/04/07 (7 days)Target
ED visits (number) 217 242 226Ambulance offload (minutes) 11.6 18.0 10.0 30Patients left without being treated (%) 2% 2% 2% 2%Discharged patients: Discharged in < 4 hours (%) 55% 59% 53% 80%Patients admitted (number) 22 27 23Admitted patients: Triage to unit in < 8 hours (%) 10% 15% 11% 70%Admitted patients: Triage to decision to admit in < 4 hours (%) 6% 11% 11% 70%Admitted patients: Decision to admit to unit in < 4 hours (%) 36% 37% 39% 70%Admits - no bed (number) 12 7Patients discharged (number) OVERALL 24 30 27
Patients discharged (number) Medicine 14 15 14Patients discharged (number) Surgery 10.0 15 14
Patients left before 11:00 am (%) OVERALL 20% 43% 37% 50%Patients left before 11:00 am (%) Medicine 22% 47% 25% 50%Patients left before 11:00 am (%) Surgery 18% 40% 48% 50%
Patients left before 2:00 pm (%) OVERALL 57% 83% 73% 80%Patients left before 2:00 pm (%) Medicine 50% 87% 65% 80%
Patients left before 2:00 pm (%) Surgery 66% 80% 81% 80%Average length of stay (days) - non-6G Medicine units 8.0 7.1 5.4Average length of stay (days) - Surgery units 5.5 3.1 3.5Planned discharges vs Actual discharges (%) OVERALL* NA 67% 63% 75-125%Planned discharges vs Actual discharges (%) Medicine NA 73% 57% 75-125%Planned discharges vs Actual discharges (%) Surgery NA 60% 70% 75-125%Bed assigned to next patient in (min) OVERALL* - MEDICINE FLOORS NA #DIV/0! #DIV/0! 70
Admissions and Discharges
Yesterday's Date
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Management Forum Presentation:Ambulance Offload (minutes)
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Demonstration Project
Sustained Performance
Management Forum Presentation: Patients left before 11:00 am (%)
Data Source: DAIR
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Medicine Patients left before 2 pm (%)
Data Source: DAIR
Target
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Demonstration Project
Sustained Performance
St. Joseph’s Health Centre, TorontoPatient Satisfaction Results
Relentless attention to metrics (the right metrics).
The Impact of Selected Metrics on the Senior Leader!
Ambulance offload (minutes)
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7/22 8/5
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Relentless attention to metrics (the right metrics).
The Impact of the Right Metrics Over Time on the Senior Leader!
Moving from Project to Moving from Project to Transformation: WhoTransformation: Who’’s s
job is it anyway?job is it anyway?The tangled web of accountability for results to sustain and transform access and flow…
The Senior Leader, Editor
Returning to his own office after the long-range planning meeting, Stanley immediately started viewing things from a different perspective.
MOVING FROM A PROJECT TO A TRANSFORMATION
Sustainability: The Elephant in the Room….
•A good implementation does not guarantee the sustainability of the change initiative•Sustainability is little understood but central to any transformative journey•Sustainabilty is about a change enduring over time and becoming part of the way we do things around here•Sustainability refers to the incorporation of new programs or practices within the routines of an organization or healthcare setting, changing norms and maintaining outcomes over time•Sustainability requires ongoing development of capability withinthe organization •Sustainability benefits from external rules and incentives•Sustainability is about organizational leadership, organizational learning and information and knowledge
MOVING FROM A PROJECT TO A TRANSFORMATIONCULTURAL PROFILE – OVERALL
Alignment
Execution
Renewal
Direction62%
Direction62%
External Orientation75%
External Orientation75%
Innovation53%
Innovation53%
Environment and values
66%
Environment and values
66%
Coordination and control
61%
Coordination and control
61%
Accounta-bility65%
Accounta-bility65%
Capabilities67%Capabilities67%
Motivation70%
Motivation70%
Leadership66%
Leadership66%
Source: St. Joseph's Organizational Performance Profile Survey (N=696)
Percent strongly agree and agree
OVERVIEW OF CULTURAL DIAGNOSTIC FINDINGS
1. Alignment/Direction• SJHC’s values are well defined and deeply
rooted in the organization• The overall atmosphere at SJHC is
perceived to be good
2. Execution/Accountability• Staff and physicians feel a high level of
individual motivation• People understand what they are
accountable for and feel a high level of personal accountability
• There is confidence in St. Joseph’s core capabilities, especially around knowledge
3. Renewal/Innovation• SJHC is responsive to patient needs and
trends in Canadian Healthcare• SJHC has a strong commitment to the
community
• Opportunities for Improvement• Strengths to Build Upon1. Alignment/Direction
• Staff and physicians do not feel adequately involved in direction setting and decisions that affect them
• People do not believe their colleagues/ leaders consistently “live the values”
• There is a perceived split in the culture between “old” and “new” and different silos
2. Execution/Accountbility• People are not held accountable, with little
relationship between performance and consequences
• Staff feel that they have insufficient resources and support to be successful on a daily basis
• There is a perceived lack of coaching and recognition
3. Renewal/Innovation• St. Joseph’s is seen as slow to change• Staff and physicians do not perceive that
innovation is encouraged or supported
Source: St. Joseph's Organizational Performance Profile Survey (N=696); leadership interviews; employees focus groups
BUILD CAPABILITY TO SUPPORT AND SUSTAIN CHANGE:
GOALS
•To engage the senior leadership in the change
•To provide the organization with a common vocabulary for discussing change and a common approach to problem solving
•To focus on resolving organizational challenges rather than working around them
•To build and strengthen the capacity of the organization
•To sustain improvement
•To innovate
SEVE
N T
RA
ININ
G M
OD
ULE
STO
BU
ILD
SK
ILLS
Influencing with integrity
Effective coaching and feedback
Root cause analysis
Meeting for impact
Developing trust
Lean operations
A Significant Change in Thinking: Changing the Culture and Empowering Staff to Improve the Patient Safety
Enhancing interprofessional practiceto optimize health outcomes
SKILL
BUILD CAPABILITY TO SUPPORT CULTURE CHANGE:
7 Modules•Root Cause Analysis
•Building trust
•Influencing with integrity
•Meeting Management
•Coaching and Feedback
•Lean Operations
•Interprofessional Collaborative Practice
St. Joseph’s Leadership Program
2007Module 1 – Introduction to Lean Operations
Module Goal• Build basic understanding of “lean
principles”
• Develop ability to apply identified concepts to process improvements
• Provide common language for discussing change and a common approach to problem solving
Moving from a Project to a Transformation:
Lean Tools
Visual Management
Standardized operations
Error proofing
Process/role redesign
Pull scheduling
• Change how many people are on one production line or how many lines are running
• Implement visual tools to speed up production and prevent errors
• Adjust and standardize the production steps and each person’s job
• Apply visual tools or change processes to prevent or detect errors
• Change process & batch size of material to meet real demand and reduce time waiting
BASICS OF LEAN OPERATIONS
Take unnecessary work out of the system
Take the perspective of the patient, to design our systems for the best care delivery
Permanently change the “way we work” by eliminating waste, variability and inflexibility in each process
Build the capabilities of the organization around system-design solutions, tools, analyses
Change the culture and performance management systems of the underlying organization
Successful LEAN practitioners
VISUAL MANAGEMENT BROADCASTS A COMMON MESSAGE• Wall
charts
1
Asking people to “just work harder”
Driving operational improvement through one department
Treat this as a “project with a definite start and stop
Expect to see sustained change in the organization as a result of a “ quick process fix”
What LEAN is not……
•LEGO GAME – Round 1
FORMS OF WASTE EXPERIENCED IN LEGO GAME ROUND 1
•Wasted motion
•Rework
•Excess inventory
•Overproduction
•Wasted transportation
•Excess processing
•Waiting time
•Wasted intellect
•LEGO GAME – Round 2
GOALS AND APPROACH: Trust Module
• Improve ability to build trust at St Joseph’s
• Module Goal
• Approach• Self-reflect on elements of trust
• Discuss personal strengths/challenges with partners
• Identify and set personal goals to foster increased trust at St. Joseph’s
POCT PLT NPC
P&TIPACMAC
Operations
Senior Management
How is Rapid Cycle Change Possible? Transforming decision making.
Why can’t we just plug and play?““Unthinking reliance on he processes and results of Unthinking reliance on he processes and results of another organization must be prevented: Plug and play another organization must be prevented: Plug and play is not sustainableis not sustainable
Plug and play is ignorant of culture and contextPlug and play is ignorant of culture and context
Plug and play ignores the leadership and capability Plug and play ignores the leadership and capability development ingredientsdevelopment ingredients
Welcome to the Found a New Solution Welcome to the Found a New Solution For Us To Implement wizardFor Us To Implement wizard
Patient Access and Flow:Next Steps
•Focused Work with Teams to Achieve Targets
•Implementation of Critical Incident Review on Admitted Patients > 24 hours in ED
•Implement Accountability Framework
•Roll Out to Mental Health and Women’s, Children’s and Family Health Program
•Implement Teletracking Electronic Bed Management System
•Capability Building for Staff
AN UNCOVENTIONAL GUIDE TO ACCOUNTABILITY FOR TRAHSFORMATION ANDIMPROVEMENT….
At SJHC Access and Flow Improvement is everyone’s business BUT the buck stops with the CEO
Access and Flow is Access and Flow is everyoneeveryone’’s business but s business but the buck starts and the buck starts and stops with the CEO as stops with the CEO as the senior leaderthe senior leader
We See a Significant Change in Thinking Throughout the Organization After Only
Six Months of the Initiative
Before After
We work better as a team now. You see people from the ER thanking the floors for their hard work, nurses on days thanking the nurse on night that prepared the
discharge – it is a better environment.‐PCM
I think the new way of working is to “just try it”. We can always work to make solutions better if we
listen and act on the feedback we get.‐Team member
When we started it was more work and it was tough. But I like it now, and I think it
was the right thing to do.‐Nurse
We have tried this before, many times, and it is not
going to work‐Focus group
Everyone works in their own group. People don’t offer to help
other units.‐Focus group
We already work too hard. The nurses are at their breaking point. The only
answer is more resources. ‐Focus group
Management Forum Presentation: Patients left before 2:00 pm (%)
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Target
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Post Initiative
Baseline 15/10/06 to
14/11/06
Baseline 15/10/06 to
14/11/06
LEAD FROM EVERY CHAIR
♦The conductor in an orchestra is silent – he does not make a sound♦Her true power derives from the ability to make other people powerful♦Sometimes an instrument only contributes a single note♦But the orchestra needs every seat in the orchestra to lead
