MemorialCare: System-Wide Management System – Putting Joy Back in Work Helen Macfie, Chief Transformation Officer Lorra Browne, Exec Director, Lean Resource Office & Materials Management Q7, IHI Forum, December, 2017
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MemorialCare: System-Wide Management System –Putting Joy Back in Work
Helen Macfie, Chief Transformation Officer
Lorra Browne, Exec Director, Lean Resource Office & Materials Management
Q7, IHI Forum, December, 2017
Helen Macfie, Pharm.D., FABCCertified Lean Leader
Chief Transformation Officer(BIG PI, Strategy, Pop Health)
Goals & Introductions
Lorra Browne, RCPMaster Fellow
Exec Director, Lean Resource Office & Materials
Management
1. LEAN – QUICK TUTORIAL2. UNDERSTAND LEAN MANAGEMENT
SYSTEM ROLE IN “BIG PI”3. STANDARDIZING WORK &
CREATING JOY4. CREATING A LEARNING SYSTEM5. A FEW RESULTS6. LEVERAGING LEAN FOR BIG PI
About MemorialCare
Total Assets $3.3 billion– Annual Revenues $2.3 billion– Bond Rating AA- stable
Hospitals– Patient Discharges 67,000– Patient Days 317,000– ER Visits 214,000– Babies delivered 10,500– Surgeries – IP/OP 31,700
Ambulatory Access– “At Risk” Lives/ACOs 260,000– Seaside Health Plan 40,300– Medical Group Visits 600,000– Ambulatory Surgeries 57,000
Workforce– Employees 11,000– Affiliated Physicians 2,600– Employed Physicians 230
1 Lean – Quick Tutorial
Toyota Confronted the Same Challenges 60+ Years Ago
What Does Lean Mean?
“Provide the most value from the customer’s perspective while consuming the fewest resources and utilizing the talents of the people who do the work”
Principles of Lean
1. Specify Value
2. Identify the Value Stream
3. Create Flow
4. Establish Pull
5. Seek Perfection
What is of value to the customer?
Quality monitoring and continuous improvement
Don’t do anything until it’s needed and
then do it first
Occur in a sequence so that work flows smoothly
and on time
All activities required to bring a service or
product to the customer
Lean Philosophy
Remove the waste that is a barrier or burden to delivering valueLook for leadership at all levels
Value people…
use the scientific method…
challenge traditional thinking…
• Use facts and data• Rapid cycle PDSA to promote continuous learning
• Refuse to let silos become barriers• Recognize that tech is an enabler, not the answer
The Scientific Method Applied to Daily WorkThe same PI Model
Scientific Method Lean Thinking
Observation Go see, ask why, show respect
Hypothesis Plan
Intervention Do
Results/reflection Study
Revise hypothesis Act/Adjust
New intervention Repeat
Structure abstract A3 report, Value Stream Map Source: Dr. Jack Billi, University of Michigan
Key learning: Incorporation of Five Lean “Kata” Coaching Questions
Coaching Kata – behavior or pattern What is the target condition?What is the actual condition now?What obstacles are preventing you from reaching the target condition?• Which are you addressing now?
• Who out there is doing it better?
• What toolkits already exist?
• What could work here?
Key learning: Incorporation of Five Lean “Kata” Coaching Questions
What is your next step?• What could work here?• Who will champion this?• Who should be on the team to work out the
details?• What tests of change can we do where, in order
to test our theories next Tuesday?• How to launch, educate, monitor and provide
feedback?When can we go and see what we have learned from taking that step?
2 Understanding Lean Management System Role in “BIG PI”
Strategic focus and evolution
MemorialCare Lean Journey
Awareness• 2006 - 2008
Insight• 2009 - 2010
Acting• 2011 - 2013
Reliability• 2014 - 2016
Generation• 2017 and
beyondExpand Leader capability… Incorporate enterprise excellence
LMS and A3 Problem Solving… Advanced Lean Fellow development… Exited external consulting support
Executive leader learning… ExternalLean consulting… Creation of Lean Resource Office… Proof-of-concept
Grew events and Lean Fellows… Value Stream work in key areas… Leadership training internal… Org Dev Plan
Advance Teams… Internal Lean Fellowsreplaced consulting support… Intentional about Lean Leaders
Our People
How
What
Strategic DeploymentLean is the Way We Do Things … & PDSA is our Standard Work
“ At the beginning of this process, I didn’t want to change anything. But now
I want to change everything! It makes my workload manageable ”
Allan David, Lean team member
Lean Culture: An aligned organization of individuals who are continually learning together to add value to the customer
Shaping CultureImproving Joy in Work through Lean
LEAN AND CULTUREFocus is on what matters to our patients, customersBreakthrough redesignDaily management
Strategic imperativeConserve use of precious resourcesProductivity, Lean, Utilization & Care Model Redesign
Linking to ValuesFocus on people, process and relationships
LEAN MINDSET, METHODS AND MANAGEMENT SYSTEM
Management System: Structures and processes used to manage systems This is how we operate
Mindset: The way people think and feel about their work and conduct themselvesI can’t imagine doing it any other way
Methods: The tools that are used everyday –This is what we do
Methods
Mindset ManagementSystem
The 3 Ms of LEANInterdependent
LEAN METHODS• Cross Functional Improvement
– Rapid Process Design (RPD)
– Rapid Process Improvement (RPI)
• Daily Management / Continuous Improvement
– 5S (sort, simplify, sweep, standardize, sustain)
– A3 (PDSA)
– Gemba walks
– Visibility Boards and Huddles
• Strategic Deployment
Systematic ProcessesMethods
3 Standardizing Work & Creating Joy Cross Functional Improvement Examples
CASE STUDY• Ambulatory Clinic
– Aim: To improve patient satisfaction by designing work processes that support the flow of patients while in the clinic
– What They Did:• Scripting developed• Medical Assistant role as patient navigator• Needed supplies reorganized, available• Workstation locations for physicians moved closer to
patients, U-shaped cell– Big Wins:
• Reduced wait times• Improved physician efficiency• Removed patient, staff frustration• Improving patient satisfaction
– Team Feedback:• “Before Lean, I didn’t know the voice of the
patient”• “There is a lot of retraining to be done”• “A clinic is complex needs standard work!”
Examples of Joy ReturnedOrganizing flow around patients
CASE STUDY• Mother Baby Bonding
– Aim: To establish guiding principles and processes for ensuring families (mother, baby, and father) are kept together during their post-partum stay
– What They Did:• Created standardized educational materials on bonding
and breastfeeding• Moved procedures “in room”• Standard work and communication
– Big Wins: • Increased time for mom and baby together• Increased exclusive breastfeeding rate• Improved staff and parents/baby wellbeing
– Team Feedback:• “LARGE undertaking … but we did it!”• “Sharing problems was hard, but it helped create
our future vision”• “We can do so much more as a TEAM”• “Babies need their moms and dads!”
Examples of Joy ReturnedKeeping patients and families together
CASE STUDY• Care of Stroke Rehabilitation
– Aim: To design Best Practice Care Model for individuals who have experienced a stroke that is consistently delivered by staff throughout the continuum
– What They Did:• New workflows, clear roles & responsibilities• Rehab presence at every level of care• Timely evaluations, streamlined documentation
– Big Wins: • Voice of the patient honored• Reduced lead time to < 24 hours, ↓ LOS• Matched skillsets to patient needs• Improving functional independence
– Team Feedback:• “Everyone has something to offer”• “The lean process is truly to improve a system and
add quality to the patient experience”• “There are amazing discoveries when you take the
time to ask the right questions”
Post
-Acu
teAc
ute
ED- Triage
- Treatment- Educate
- Order for Therapy- Best Practices
ICU- Treatment- Education- Consult
- Best Practices
Floor- Treatment- Education- Consult
- Best Practices- Outpatient Appointment
OP Rehab TRS Home HealthSNF-
Technology
EPIC/TechnologyEPICEPIC
EPIC/Technology EPIC/Technology
LTAC
HOME - Treatment
- Social Media- Wellness/Preventative Med
e-Chart Technology
Technology Technology
Outside Hospitals - Treatment
e-Chart Technology
10% 6% 24% 11%
37%
Diff. IRF
1%11%
IRFEPIC
OTHEREPIC/Technology
Examples of Joy ReturnedOrganizing care across the continuum
A note: Physicians as PartnersThe power of the Physician Society
The Physician Society Growth in Membership
Responsibilities• Professional association. Board level.• Committed to development and utilization
of evidence-based/best practice medicine• Lead development of best practice• Implement best practice guidelines at the
bedside / visit-side• Leadership of physician informatics and
outcomes
20 Years of Innovation• Over 300 Best Practice guidelines• Best Practice Teams, multidisciplinary
95% of admissions
Ambulatory OrthopedicsAnesthesia Palliative CareBlood Use PediatricsBreast Care Pulmonary & Critical CareAntimicrobial Stewardship SepsisCardiac StrokeColorectal WellnessEmergency Women’s HealthNeonatology Wound Care
CASE STUDY• Sepsis Best Practice redesign
– Aim: To achieve MemorialCare’s Bold Goal for Quality to reduce mortality from severe sepsis by > 50% by June’2016
– What They Did:• Set a BOLD goal• Best Practice Team sharing / collaborative• Standardized approaches & order sets – 3 hr, 6 hr, 24 hr• Flow algorithms, Best Practice alerts• Data mart with daily reporting & follow-up• Core measure set
– Big Wins: • Improved recognition and early intervention• Increased esprit de corps• Reduced mortality now by 55%• Reduced cost of care
– Team Feedback:• “We didn’t think it could be done”• “Now we’re striving for a 70% reduction”
Examples of Joy ReturnedSaving lives
4 Creating a Learning SystemLinking to engagement
INVESTING IN MANAGERS & STAFF• Recognizing it’s a hard job• Allowing to be part of something, connecting
to the bigger picture• All managers trained in Lean
and Facilitative Leadership– Facilitative Leader – 3 days– Lean Leader – 4 days with project– >1% now Certified Lean Leader
• Shared learning– Gemba events– Yokoten sessions– Intranet toolkit
Grooming for SuccessTraining, Practice & Resources
STARTS WITH ASKING• Lean idea submission
• Participant feedback
• Shared Report Outs
• Leadership coaching rounds
– Talking with patients
– Huddling with staff
• Surveys & action planning
• Focus groups
• Fun at work!
• Go See• Ask What, then Why• Show Respect
The Link to EngagementConnecting to Purpose
VISIBILITY BOARDS & HUDDLES• Lean Management System
– “Standard flexible” format• Metrics that matter• Celebrate success, capture ideas, create
follow-up• Huddle at frequency that makes sense
– Moving from manager led to staff led
Promoting VisibilityCelebrate, Learn, Harness and Improve
Initiative/ Tactic Who Target Action/Status
Automated Modified Early Warning System
MacfieA3 teamCNOs
2FQ’18 • Plan for MEWTS (OB) approved, rollout launched this Fall (triggers, order sets)
• Celebration held for MEWT planning team
Harm Across the Board –Infections Drill
WynnLeoMacdonald
MascottiQ Close
1FQ’18 • C.Diff protocols revised, launched July’17• Antimicrobial Stewardship BPT project plan,
working with new Epic ICON/AMS module (LB pilot launched Oct’17)
• Reviewing Xenex use at LB re: # robots/focus• All HAI count 2CQ’17 ↓52%
VBP/P4P $ Macfie 2FQ’18 • Calculating score for 2017 reporting – Oct/Nov• Will version for each hospital campus
MedicationReconciliation
MacfieLeo
2FQ’18 • Revising Discharge Med Rec indicator & leaning out Epic Navigator list for launch Nov’17
• Bold Goals focused on Perfect Care for Core Measures, rapid response teams, reduction of harm and sepsis mortality
• Launched new CMS core measure Sepsis perfect care set• MEWS (adult) and PEWS (peds) early warning – Epic, trackboards• Infections – UV robots acquired, rolled out, Task Force renewed• VBP/P4P $ - Reached 81% for 2016 reporting
• Participating in Hospital Engagement Network, IHI, Partnership for Patients
System-Wide Strategic Visibility Board Target: ↓ INPATIENT MORTALITY & HARMFocus: improve overall PI Radar plot, reduce key harms
Harm Across the Board ROLL-UP**
Hospital Acquired Infection ROLL-UP**
Updated: October 2017
(By: Macfie, Leo)
PatientsFamilies
MemorialCareBoard of Directors*
Medical Executive Committee
Performance Improvement - quality, risk and patient
safety committees
MEMORIALCARE NETWORKPERFORMANCE IMPROVEMENT/PATIENT SAFETY
Campus Governing BoardsPhysician Society Board*
(Serves as MHS Clinical Committee)
Physician Society*
Best Practice Teams*
Senior Management
Hospital Operations
Value Added Teams*
Councils, Teams, Collaboratives,
Task Forces
*System membership and function
Updated 2017
Clinical Committee of the Board* Lean Close*
Quality Close*
Lean Advance Team
Our Action Network “Map”
5 A Few Results
Operational ImpactCumulative over the years
Processing time (waste in process)
25,000 hours of staff cycle time reduced$253,800 Premium Labor savings
Patient Wait/Delay Time 800 days of patient wait/delay time0.762 days of GMLOS reduction for 2400 patients (Case Management)
Level of Quality (defect rates)
60% avg improvement in primary workshop quality metrics$4,100,000 Cost Avoidance
Throughput (revenue & cost)133 Admitted patients760 ED patients4150 Out-patients
Materials (one-time savings in workshops)
$3,800,000 supply/services savings$373,900 pharmaceutical savings
Space (reallocation of space)716 sq. ft. Savings$10,000 Cost Avoidance
Impact Potential Created by Lean Workshop Teams in FY17
Bold Goal MHS & *MCMG LBMMC & CHLB Miller Children & Women
OCMMC SMMC
MortalitySepsis MortalityOther Diagnoses Mortality (Crimson)
470726
1,196
264458
722
n/a (adults)13
13
94159
253
11296
208
Perfect Care & SafetyOB C-Section use (NTSV rate)AsthmaFalls, Pressure Ulcers, InfectionsRapid Response Team CallsMedication ReconciliationNote: MI, HF, PN, SCIP, VTE, Stroke Core Measure Sets retired
278322281
1,91713,201
15,999
n/an/a124
1,2623,797
5,183
182322
3738
3,8344,413
65n/a
9451
2,0452,570
31n/a111166
3,5253,833
Accountable CareReadmission Reduction (Crimson >18y)Medical Foundation Bold Goals
7603,617
4,377
428____428
n/a____n/a
246____246
86____
86
Total Annualized Lives Touched based on CY2016 volumes (these indicators 21,572 6,333 4,426 3,069 4,127
Based on Bold Goals each year compared to Baseline (CY)
MHS & *MCMF LBMMC & CHLB Miller Children & Women
OCMMC SMMC
2007 2,805 1,635 (n/a) 545 625
2008 5,765 2,812 252 1,419 1,282
2009 6,165 3,179 243 1,282 1,461
2010 6,084 3,129 347 1,292 1,316
2011 6,406 3,440 235 1,539 1,292
2012* 9,161* 3,630 533 2,020 1,260
2013* 9,809* 2,478 1,859 2,051 2,0602014* 32,180* 12,329 2,821 6,827 8,7282015*Note: MI, HF, PN, SCIP Retired
15,668* 3,772 2,368 2,341 3,385
2016Note: VTE, Stroke Retired
21,572* 6,333 4,426 3,069 4,127
TOTAL* 115,615* 42,737 13,084 22,385 25,536
Live Touched CY2016Inpatient and Ambulatory Bold Goals
Engagement Matters10 years +
Survey Question(0-5)
2007 Baseline 2017
FOUNDATIONMission & purpose of my team is clear to me 3.97 4.45
I spend majority of time doing what I do best every day 4.12 4.38
VALIDATIONMy contributions and opinions count 3.43 4.30
I feel I am a valued member of the team N/A 4.26
SUPPORTSupervisor committed to me personally & professionally 3.91 4.12GRAND MEAN 3.78 4.27
6 Leveraging Lean for BIG PI, Standard WorkDiscussion
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