A8 - Bruce Roe - From Vision to Reality

Tales from…On the Road to Perfect Care

February 2013

Dr. Bruce Roe, Executive Director Clinical Programs

and Chief Medical Officer

Overview

Who we are

Where we started

Our reason for action

Our approach

Our journey

Where we are going

Challenges, learnings

Our tradition

Arrival of the Grey Nuns, Red River Colony, 1844

First hospital in Western Canada, 1871

Strong tradition of working with partners to serve our community

St. Boniface Hospital 2013

Number of employees 4,000

Doctors admitting 461

Number of beds 520

Outpatient activity 221,377

Annual budget $ 260,000,000

St-Boniface Hospital

Tertiary Care Hospital

Winnipeg Regional Health Authority

Affiliated to the University of Manitoba

Major Clinical Programs:

Cardiac Sciences – Provincial Referral Center

Women’s Health/NICU

Internal Medicine

Surgery

Our vision

To deliver the safest and highest quality of care to every patient, every encounter, every day, with the best outcomes….

At a price we can afford!

Transformation - where we were in 2007

Regionalization challenges

Financial pressures

Employee engagement and staffing issues

Harm to patients

Lean transformation – an opportunity to accelerate pace of change and improvement

Board commitment to embrace transformation through lean

In Winnipeg?

In healthcare?

Experience demonstratesthat it can be done in healthcare

Local business - mentors

Lean … in healthcare?

D.M. D.G. J.D. B.B.

Our reason for actionIndividuals we know we harmed

Strategic DirectionsPerfect Patient Care

Transformation using Lean Thinking

Lean Thinking provides the principles to transformation at SBGH:

• Identify what patients value and remove the things that are not valued

• A bias for rapid experimentation and trying new things

• Solutions come from those doing the work

• Improvement occurs where the work takes place

Lean Thinking is not:

• Loss of Employment

• A collection of tools or research methods

• Performed by External Consultants

• A project

Our initial stages

Created a Guiding Coalition:

• High Level Leadership

• Steering Committee and Sub Teams

• Recruiting /developing full-time Transformation Core team

• Partnership with Simpler

• 2 value streams launched – ER-Cardiac, Acute Care Surgery

“Lean tools are great!”

5S

One-piece flow

• A3 • Value streams & mapping• Kaizen• Rapid Improvement Events• 6S• 3P• Kanban• Audits /Kamishibai

Which of the following is not a Japanese Lean Term?

A. Muda

B. Kombu dashi

C. Concrete head

D. Heijunka

E. Kaikaku

Muda

Komb

u dash

iCo

ncret

e hea

d

Heiju

nka

Kaika

ku

0% 0% 0%0%0%

Rapid Improvement Event #1ACS Triage to EKG Interpreted

Trials

Team work

New EKG room

Measure Initial State

Confirmed State

Patient handoffs 7 4Patient Distance Traveled 306 ft 306EKG Tech Distance Traveled 1390 ft 10 ft

Presentation to EKG Interpreted RIE (example)

“People are everything!”Improvement ideas come from those who do the work, or experience the care

Rapid Improvement Events

Some early “wins” e.g. EKG times, but…..

We felt like we were failing.

• Couldn’t meet stretch targets

• Couldn’t reliably get the data

• Cast too a wide net

• Couldn’t know how to sustain gains

Impr

ovem

ent A

ctiv

ityOur Areas of Activity

Sep/08 Jan/09 May/09 Sep/09 Jan/10 May/10

ED – Acute coronary syndrome (ACS)

ED Non Admitted Patients

Surgery- Acute care surgical services (ACSS)

Clinical Supply Chain

Medicine-Flow/Capacity/Productivity

Staff Scheduling

Surgery- Flow/Capacity/Productivity

Sept10

Surgery- On the Move

Clin. Documentation

Transformation - Pillars

Just A Few Of Our Proudest Moments …..

ER Results

Direct Admit ACSS

Surgical Safety Checklist

Clinical Documentation

Nurse-to-Nurse reports

Surgery On The Move

Inventory Right-Sizing

Prevention of Falls

• Staff Scheduling

• Cardiac Transitions

• CI Investigation Process

• Accounts Payable Process

• Staffing Absences & WCB

Improvements in care

Goal Directed Care – communication boards to share information

between staff, patients and families and support patient safety

22

Improvements in care

Nurse to Nurse Shift Report at the Bedside involves the patient

23

Listening to the voice of the patient

Patient and Family Advisory Council

Daily Leadership Patient Visits

Patient and family participation in improvement activities & teams

Patient satisfaction surveys

Daily improvement

25

Engaging Physicians

Identify key physician leaders/champions

Strategic in exposure

One size does not fit all

Data speaks…

Find opportunities for physicians to tell the story

Align with academic mission

Engaging Physicians in Improvement

1. Discover common purpose

2. Reframe values and beliefs

3. Segment engagement plan

4. Use “engaging” improvement methods

5. Show courage

6. Adopt an engaging style

IHI White Paper, Reinertsen, 2007

Mission Control and Visual Management

29

Patients are more satisfied

Patients are exposed to less risk

Staff are more engaged

We are achieving real savings…

$6 million savings for fiscal 11/12

1% year over year

Positive impacts on:

Supply Chain

Length Of Stay

Staffing Costs

While improving our patient focus, safety, and employee

engagement

We are a better hospital

Our patients

Are surviving more than 4 years ago

are more satisfied than 4 years ago …

are recovering more quickly than 4 years ago…

Our capacity is greater than 4 years ago …..

Our staff are more engaged than 4 years ago…

We have achieved real savings….

3 year gut check

Transformation work “on top of”

Loss of pace/rhythm

Broader organization disconnected

Focus on breakthrough results at expense of incremental

improvement

Managing of operations vs. improvement

New bottlenecks to problem-solving

Result-oriented

Fragmented Thinking

Command & ControlDefensive

Knower’s

Thinking that Drives Complexity

Result-oriented

Fragmented Thinking

Command & ControlDefensive

Knower’s

Thinking that Drives Complexity Thinking that Drives Continuous Improvement

Result-oriented

Fragmented Thinking

Command & ControlDefensive

Knower’s

Process-oriented

Systems thinking

Leader as a teacherEngaging

Learners

Leadership Models

Shingo Model

“House” “Diamond”

SUPPLY MANAGEMENT

PRODUCT &SERVICE

DEVELOPMENT

CUSTOMERRELATIONS

RESULTS

ENTERPRISE ALIGNMENT

CONTINUOUS PROCESSIMPROVEMENT

CULTURAL ENABLERS

OPERATIONS

GUIDING PRINCIPLESCore Values Anchored to

INDIVIDUAL FOCUS

ORGANIZATIONALFOCUS

CULTURE(BehavioralEvidence)

RESULTS SYSTEMS

TOOLS

GUIDING PRINCIPLES SUPPORTING PRINCIPLES

Problem Solving by LevelA PC D

A PC D

A PC D

A PC D

A PC D

A PC D

A PC D

A PC D

A PC D

A PC D

A PC D

A PC D

A PC D

A PC D

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A PC D

A PC D

A PC D

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A PC D

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A PC D

Value Stream

Strategic

Value Added/Gemba

Line of sightClarity of ownership

Coaching and Support

Shifting the plane of problem solving

Historical approach

Value Streams

Broad – program-wide

Fragmentation

New approach

Strategy or horizontal A3s

Harm reduction

Financial stewardship

Engage staff

Program A3s (12 month action plans)

Breakthrough improvement

- Patient flow

St-Boniface Management System

Looking ahead

AlignmentEngaging in Daily Problem-solvingManagement systemFocus on Flow as organizational priorityTelling the story