continuous performance improvement. agenda cpi at children’s waste & value just in time built...

Continuous Performance ImprovementContinuous Performance

Improvement

Continuous Performance Improvement


Agenda

• CPI at Children’s

• Waste & Value

• Just in Time

• Built in Quality

• Results


Our Vision

We will be the best children’s

hospital.


• Safety concerns– Serious safety events

• Service deficiencies – Access– Communication

• Healthcare finance reform

• Declining staff engagement

To achieve our vision

we needed a new management philosophy

Our Reality in the Late 1990s…


A Benchmark: Toyota

• High quality and reliability

• Safety record that exceeds others in the industry

• Cost effective with a short response time to customers

• High levels of employee engagement and morale

• Organization-wide philosophy and management system


Our CPI Philosophy: Benchmarking Lean

• Focus on the patient and family: involve them in our improvement work; listen!

• Engage staff at all levels: those that do the work, can improve the work; use the scientific method

• Leaders provide guidance and commitment: this is our management system and we support staff in their improvement work

• Long term view: this is a generational effort without an end point, that utilizes P-D-C-A


Our CPI House


What Does That Mean?

Balance the Work

Standard Work

Continuous Flow: Pull vs. Push

5S and Visual Control

Value Stream Improvement Through Waste Reduction

“Just In Time”

Right service in the right amount at the right time

in the right place

Eliminate batches

Rapid Changeover

“Built-In Quality”

Make problems visible

Never let a defect pass along to the

next step

Error Proof

Stop when there is a quality problem

Engage Everyone in a Patient-Focused Philosophy

No Waiting

No Harm

Waste & Value


1) Understand value for the customer: • Identify who is your customer• Identify what product or service the customer wants

How do we do this?


2) Focus on Flow • Identify the process of how the value is created (The Value Stream)• Eliminate steps that do not create value (The Waste)



Point Improvement Approach

Value Stream Approach

Admission EvaluationAncillaryService Discharge Billing

Admission EvaluationAncillaryService

Discharge Billing


The Basic Strategy

• Most processes are 95 – 99% non-value-added. • Everything we do in a work process either adds value or is waste• We want to design systems that provide value with as little waste as possible

Value-Added

Necessary Non-Value- Added

WasteEliminate Reduce


Non-Value Added Activity (8 Wastes)

Over-processing DefectsOverproduction

Transportation

Unused Creativity

WaitingInventory Motion

Google Image Photos; some rights reserved

“Activity that consumes resources but adds no value to the product/service”

http://creativecommons.org/licenses/by-nc-sa/2.0/deed.en


5S - What are the 5S’s?

1. Sort – separate unneeded from needed

2. Straighten – a place for everything and everything in its place

3. Scrub – visual and physical inspection

4. Standardize – everyone doing the same thing

5. Sustain – hold the gains through audits and accountability

Was 5S used in our airplane factory?


Workplace Organization Helps Eliminate Waste

How does the setup of the fire truck and code cart impact the ability to do the jobs they were designed for?


What needs to be re-stocked?

Visual Workplace (cont’d.)

BLANKETSWASHCLOTHS

GOWNSTOWELS

Re-stocking Rule

Do not re-stock until level falls below red line.

Re-stock only up to green line.

© 2005v.2 Joan Wellman and Associates, Inc.


Visual Workplace

Visual workplaces use visual devices to:

• Tell us at a glance how we are doing

• Allow us to see abnormal conditions as they occur

• Understand the status of an area in 5 minutes or less by simple observation, without use of computers or speaking to anyone

Google Image Photo; some rights reserved


http://creativecommons.org/licenses/by-nc-sa/2.0/deed.en


5S is More Than Tidying Up

5S is a visually oriented system for organizing the workplace to…

• Wasted time• Training time• Errors• Maintenance• Inventory• Hazards• Barriers to success

• Teamwork• Quality• Safety• Cleanliness• Discipline• Consistency• Culture


“Just in Time”-No Waiting


Continuous Flow = Steady Velocity

Batch Processing Continuous Flow Processing

Right service, right amount, right place, right time

“Just in Time” – No Waiting


Batch Processing vs Continuous Flow Processing

Batch Processing Continuous Flow Processing

Large batches Batch of 1 (one-piece flow)

Process silos(operate independently)

Connected processes(dependent on each other)

Layout of space designed to optimize silo (promotes batching)

Layout of facility/space based on sequence of work

Schedule each process and push to the next

Entire process linked with no inventory or waiting between steps

Equipment & supplies are stored in “warehouses”

Equipment & supplies (including meds) are stored at the point of use

Problems remain hidden in buffers of inventory

Problems become visible (stop the line)


Continuous Flow Enables “Just in Time” Services

Physical layout eliminates transportation and movement

Product or service is provided on customer request

The customer and value is identified

Service is produced one-at-a-time to meet demand

Right Service

Right Amount

Right Place

Right Time

If… Then it’s Just the…

= No Waiting


Definition:• A signal for communication that allows the customer to say, “I am ready for

more” or “I need more”• Signal can be a card, empty space, cart, etc.• Used to create flow between disconnected processes often due to physical

layout

Purpose:• Paces the work to prevent batching• Authorizes work to begin• Authorizes supplies or equipment to be moved

Creating Flow with Signals: Kanban

Was kanban used in our airplane factory?

“Built in Quality”- No Harm


The Importance of Built in Quality

Errors become “defects” when work moves beyond where the error occurred.

Process Step Where Defect is FoundError

Occurs

Start

What are the effects of later detection?

Customer

A

B

E

C

D


1. DETECT the Abnormality

Need to rely on memory or look up acceptable level

Quick glance enabled by simple visual indicators

Knowledge in the World

Knowledge in the Head


1. DETECT the Abnormality


2. STOP

Give Stop-the-line authority to everyone and prevent defects from being passed on

= STOP

= Need Help

= Normal

STAR:Stop; Think; Act; Review

Stop and Resolve when uncertain

Andon


3. FIX or Correct the Immediate Condition

Respond immediately to the abnormality

ARCC:Ask a question; Request a change; voice a Concern; and Chain of Command

Stop and Resolve when uncertain


4. INVESTIGATE root cause…

Solve the problem to prevent recurrence

SBAR: Situation, Background, Assessment, Recommendation

A3


5S & Visual Standards

Standardized Processes

Visual Alerts

Audible Alerts

Error Proofing

4. …and INSTALL Countermeasure

Build quality into the process with…

Management System


Daily Management

7 am – Supply Chain Night/Day Shift Team Huddles

8:15am – Supply Chain Division Leadership Huddle

3 pm - Day/Evening Shift Team Huddles

7:30 am - OR Huddles7:45 am – Nursing Flow Huddle

1pm - OR Huddles

11 pm – Supply Chain Evening/Night Shift Team Huddles

3pm- Nursing Huddles

8am – Supply Chain Team Huddles

8:50 am – Daily Safety Briefing

9:30am – VP/Supply Chain Issues Communication

10:00am – Executive Leadership Team Huddle


Daily Huddles Agenda

Director • Shares Organizational Message to Team • Discusses Outstanding Issues/Projects• Discusses Patient Safety Issues

Manager • Updates Performance Metrics • Shares Barriers and Potential Counter Measures • Shares Barriers From Team Huddles • Shares Barriers from Nursing Huddles


Supply Chain Daily Management


Our CPI Management System


Present: Strategy Deployment

Continuous Performance ImprovementContinuous Performance

Improvement

ResultsOur Results

Our Results


Engagement: Gallup Q12® Results Over Time

Ratio of Engaged to Actively Disengaged:

1.32:1 2.92:1 3.42:1 4.20:1 3.75:1 5.56:1 5.56:1 6.25:1 5.67:1 6.50:1 6.00:1

Copyright © 2011 Gallup Inc.,. All rights reserved.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


2013Seattle

Children's

4.38

Performance Difference:

NationalChildren'sHealthcare

Average

+.09

WorkforceCommitment

Percentile Ranking

95th

NationalHealthcare

Average

+.22

Overall Workforce Commitment

Note – GREEN/RED notes a statistically significant difference.

•National Children's Healthcare Average +/- .04

•National Healthcare Average +/- .04

4.37 +.06 94th+.21

2012

FY13 Goals: Baseline = 4.37; Target = 4.39; Stretch = 4.41

Engagement: Morehead Associates


Quality: Family Experience Survey

A: Accountability – Nurses answered questions understandably. R: Respect – Involvement in decision making. T: Teamwork – Staff worked as team to care for child.

58.354.6

49.9 47.3 47.443.7

40.234.6

0

10

20

30

40

50

60

70Pr

oble

m S

core

ART

(FES Year)

2004 2005 2006 2007 2008 2009 2010 2011


Quality: Family Experience Survey

FY 2012 FY 2013 FY2014 YTD70.0%

72.0%

74.0%

76.0%

78.0%

80.0%

77.0%77.6%

79.4%

76.6%

78.4%

80.4%

Goal Cumulative Hospital Score

Using any number from 0 to 10, where 0 is the worst possible and 10 is the best possible, what number would you use to

rate Seattle Children’s Hospital?


Delivery: New Patient Wait Times

FY07 FY08 FY09 FY10 FY11 FY12 FY130

5

10

15

20

25

30

35

-

20,000

40,000

60,000

80,000

100,000

120,000

21 20 19 20 20 15 15

38,033 43,989

67,635 72,377 80,581

90,245 96,248

Wait Times for New Patient AppointmentsTrend by Year and Visit Volume Days

Me

dia

n D

ay

s

** FY13 Median Wait Times ex-clude PSY **


Safety:

FY HAI Rate Discharges # of Infections

FY 2008 14.2 13514 192FY 2009 11.9 14144 168FY 2010 10.1 14321 145FY 2011 8.6 14107 121

FY 2012 8.1 14594 116

FY 2013 8.35 14374 120


Cost: Supply Chain

• Two-bin kanban system: “Demand Flow” • $2 million reduction in excess supplies

• $539,000 (50%) reduction of Central Service Main Supply Area

• $410,000/year reduction of returned supplies cost

• 48,000 hours/year returned to staff (projected)

• Reduced off-contract supply orders (~$2 million per year)

• Eliminated ~20,000 stat/rush calls per year


Cost: Supply Chain

2008 2009 2010 2011 2012 2013 20140

10

20

30

40

50

60

70

80

90

$0.00

$2,000,000.00

$4,000,000.00

$6,000,000.00

$8,000,000.00

$10,000,000.00

$12,000,000.00

$14,000,000.00

$16,000,000.00

$18,000,000.00

$20,000,000.00

60.2 62.258.95 60.25 60.75 63.55 63.55

88 12

1619

21 21

$6,296,231$6,908,111

$8,132,662

$10,618,306

$12,701,182

$15,755,478

$18,359,540

Supply Chain Staff Supply Chain Quality Staff Supply Chain Managed Spend

FTE per Managed Supply $$

Quality Staff:*Increased Leadership*Strategic Sourcing Managers*Project & Quality Mgmt*Demand Flow*Value Analysis


Our Approach: Wins and Challenges

• Wins:• Early successes allowed us to prove the methods worked • Early leadership buy-in and enthusiasm provided a basis for

engagement throughout the organization• Executive leadership and Board support afforded a strong

foundation

• Challenges: • Value stream approach earlier on would have allowed us to see

the system-wide impacts • Early focus on the tools and event-based – RPIWs, 5S, etc.;

management systems approach did not start soon enough to support sustainment of work (audits, leader standard work, etc.)


Lessons Learned

• Requires a long term view

• Requires substantial leadership and financial investment

• This is hard work!

• Learn to fish – external consultants can get you started, but you have to develop leaders within your organization

continuous performance improvement. agenda cpi at children’s waste & value just in time built...

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