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Ann M. Dohn, M.A.
Stanford DIO
Nancy A. Piro, Ph.D.
Program Manager/ Education Specialist
Changing the Culture: GME-Streamlining and Standardizing for Cost
Savings and Efficiencies
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Disclaimer
No Conflicts of Interest to Report
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Session Core Competency Focus
This presentation addresses the GME Leader Core Competencies of:– Developing and Supporting
Residency Program Directors & Coordinators
– Managing the Institution’s GME Operations.
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Three Key Session Objectives
1. Provide a foundation for the understanding and application of lean philosophies and practices to GME.
2. Describe specific process improvement measures that can result in increased efficiency and cost savings in a graduate medical education (GME) setting.
3. Provide a Toolkit Forms Templates Examples to streamline and standardize
GME processes at their respective institutions.
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Thinking Out of the Box?
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Thinking Outside the Box – Looking to Industry and Corporations
What does industry have that we can use?– Conveyor belt to move patients in
and out of OR’s?
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No….
But they do use a “Lean Philosophy”– Respect for People– Total Elimination of Waste
And they use “Lean Tools” such as – Kaizen– 5S’s– 3 M’s
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Lean – Toyota Production System (TPS)
TPS system managed to get by with “half of everything”!– Physical space– Personnel– Capital Investment– Inventory
Resulted in far fewer than half the defects and safety incidents
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NUMMI
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Lean Culture Shift
Make problems visible – not hide them or “not talk about mistakes/problems”
Fix problems permanently – get to the “root cause” and eliminate it.
Focus on the value and respect for people.
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Lean Tools --- A Sample
Kaizen Elimination of WASTE - 3Ms Problem Solving
– 5 Whys– Fishbone Diagrams (Ishikawa
Charts) 4 Ms– 4 Ps
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Lean Tools: Kaizen
What is ‘Kaizen’?Gradual, unending continuous improvement of processesProcesses must be improved to get improved resultsBy improving and standardizing activities and processes, Kaizen aims to eliminate waste
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Kaizen Basics
Focus is on small, incremental change (not necessarily huge leaps, innovation)
Quality Control = quality of people– “A company that is able to build
quality into its people is halfway to building quality outcomes”
Respect for People– “Only people produce
improvements”
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Lean Tools: 3M’s
All about Waste- Identifying it and Removing it– MUDA = Waste of using resources
without creating added value– MURI = Waste of overburdening
people or equipment/resources– MURA = Waste of unevenness,
variability in processes
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Five Why’s Problem Solving Method
Keep asking ‘Why’ until you discover the root cause of the problem
– No magic in 5 – might be 3, or 7, or 10 Why do we? (conduct orientation in
person, fill out multiple forms, take on line training for non MDs)
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Lean Tools: – Fishbone Charts using the 4Ms – 4 Ps
Manpower/Personnel Materials Method(s) Machines / Equipment
People Process Policy Principles
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Ishikawa Diagram of ER Prolonged Wait Times
Materials Methods/Process
Manpower/People Machine\Equipment
WHY? WHY?
WHY? WHY?
xxx hr wait time in ER
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5Ss - Mnemonics Retained
Sorting Simplifying Sweeping Standardizing Self Discipline
= Seiri
= Seiton
= Seiso
= Seiketsu
= Shitsuke
QUICK EXERCISE
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5Ss in Action
19
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AFTERBEFORE
ER Rooms
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Now ---How Can this be Applied to GME?
Have read the books Know the materials Understand the tools Have stolen former Toyota
Manager …– So what do we do
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Putting Philosophy into Practice
Flowchart the processes– Ask- “Why are we doing this?”
Fishbone the problem Huddle to discuss with the team Look for the 3Ms Apply the 5Ss
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Start with the Current State
CURRENT CULTURE– Paper driven registration (forms,
forms, and more forms)
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CURRENT CULTURE
– 87 programs (87 fiefdoms all doing their own thing….but having common requirements)
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Current Culture
Lack of standardization/inconsistencies (MURA)
Overburden (MURI) Waste (MUDA) of both materials
and time– Lots of files– Time to file personnel folders or
ACGME letters
Time-consuming institutional oversight of programs (MUDA, MURI)
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Streamlining a GME Process Example
What GME Processes would be the best targets to streamline and improve eliminating waste and redundancies?
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Where to start?
Low hanging fruit vs. most impact on residents/faculty/GME staff
Actually you can do both!!!
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Drivers: Where to start?
Areas of largest number of ACGME citations?
Questionnaire data?– Program Directors’ Needs Analysis– Incoming House Staff survey data– Annual GME resident survey data– Program Coordinator requests
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Where to start?
Huddle-need team involvement– Respect for people– Respect can lead to elimination of
unnecessary work
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Real Time Examples of What We Standardizing We Have Done
Project One: Program evaluation standardization
Project Two: Orientation standardization/streamlining
Project Three: Policy standardization
Project Four: Summative evaluation standardization
Project Five: Paperless Office/Registration
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Project One: Standardize Program Evaluations
Factors driving decision to standardize:– Largest number of program citations
from ACGME– Lack of consistent data on program
evaluation for APRs (MURA)– Huge amount of paper generated to
produce suboptimal evaluations (MUDA)
– Burden of work on the coordinators (MURI)
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Standardized Program Evaluations
What did we do?Developed standardized comprehensive core competency-based Program Evaluations – by Faculty and Trainees Presented the draft templates to the Program Directors who edited and approved them.
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Standardized Program Evaluations – Process Implementation
Annually the GME office:– Delivers --via our Residency
Management System (RMS)--176+ evaluations
– Aggregates each program’s data after the evals have been completed
– ‘Prints’ (electronically to pdfs) their aggregate Program evaluation reports
– Posts the Program Eval Reports (pdfs) on their APR site (in the RMS)
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Program Evaluation Standardization “Toolkit” Example
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Standardization of Program Evaluations
Benefits– Fewer citations– Can be input to our Institutional
Report Card– Easy oversight by DIO/GMEC– Early warning system
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Results of Project One
Less paper wasted (none used) Program evaluations sent out
centrally by GME using standard evaluation forms
Compliance with program evaluation can be easily monitored by GME
Reduction in ACGME citations Less concern about
confidentiality from house staff
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Project Two: OrientationStandardization/Streamlining
360+ incoming residents/fellows attending one day orientation sessions– Completion of various
mandated training– Issuance of computer codes,
pagers, ID badges, parking permits, etc.
How do we cope with residents unable to attend orientation?
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CURRENT CULTURE
– Face to face orientation great to know what we look like but big
differential in quality of some presentations
inability to really control content of each presentation and test knowledge of materials
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Wasted both incoming trainee time and staff time - MUDA– 20+ speakersLong lines waiting for such stations
as photo ID - MURI Lack of standardization of
presentations - MURA Loss of the one auditorium large
enough to hold groupDifficulty in keeping the attention of
the trainees (material overload vs. shopping at Nordstrom's) - MURI
Project Two: OrientationStandardization/Streamlining
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Project Two: Web-based Orientation
Based on the input from resident orientation questionnaires:– All mandatory modules became Web-
based Offered in advance of orientation Many have post tests Can verify completion of training Can be done from home/Starbucks
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Unintended Outcome
Have we gone too far?
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Project Three: Standardization of Policies
Design a policy template for common program requirement policies to reduce redundancies (MURA, MURI, and MUDA)– Supervision– Moonlighting– PLAs– Recruiting– Duty Hours– Work Environment– Beyond Duty Hours– etc.
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Policy Development
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Teaching the Use of Policy Templates
Program director noon conferences
Policy writing workshop
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Monitoring Implementation of the Policies
Verify in our residency management database (system which cannot be named)
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Easy Online Policy Verification for each program - Example
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Project Four: Summative Evaluations – The Drivers
ACGME Citations– Incoming and Outgoing!!
Multiple / variable forms (MURA) Redundant wasted paper (MUDA) Overburden PCs and PDs (MURI)
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How Do We Do This Efficiently and Effectively?
Fill in the blank?
Multiple Choice??
Can my coordinator help me out here?
Fill in the blank?
Multiple Choice??
Can my coordinator help me out here?
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Project Four: Summative Evaluations – What did we do?
Developed Standard Evaluation Template for Summative Evaluations
Comprehensive over program training years
Core-competency based
User friendly word document
Held Program Director and Program Coordinator Teaching Sessions / Workshops
Taught the use of the template and how to pair it with aggregated
evaluation data from our RMS
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Use of Resident Evaluations from RMS:
Programs could select the evaluations to use –– We recommended:
Evaluations Competencies by Resident Resident/Faculty Ranking Report
(aggregate) Aggregate Comments Report Evaluation Competencies Report
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Coordinate with Aggregated Evaluation Data
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Summative Evaluation Template
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Macro-enabled Word Doc
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Additional Considerations
Special Cases– At the end of a preliminary year
(internship) Need to list Rotations
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Final Points
Review report with trainee Place a copy of the summative
evaluation in the Trainee’s permanent file and upload to our residency management system
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Project Five: The Paperless GME Department
Files Program reviews Registration PIF reviews
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Project Five: The Paperless GME Department
Load all forms into the residency management system (RMS)– Scan– Upload– Direct enter
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Project Five: The Paperless GME Department
Program reviews– Review on line
Duty hours Policies Annual program review documentation Evaluations
– % complete– Ranking status– 360’s– Surveys– Board pass rates – etc…
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Project Five: The Paperless GME Department
PIF Reviews– shared document review on line
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Project Five: The Paperless GME Department
Incoming House Staff– Learning modules web-based
Standardized content Post tests Tracking that all modules complete Annual review of module content
– Registration Summative Evaluation Acquisition Access to RMS system to enter data Upload forms/documents
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Project Five: The Paperless GME Department - Results
500 fewer pages of paper per Internal Review x times 2 drafts and an average of 20 Internal Reviews per year = – Savings of 40 reams of paper =
Two entire trees saved (17 reams of paper = one tree)
Time Saved (walking, waiting, mailing eliminated)
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Questions?
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Contact Information:
Ann Dohn, DIO– [email protected]
Nancy Piro, Program Manager– [email protected]