going lean - bcbsm

Going Lean

Agenda• Introduction and Objectives• Borgess Ambulatory Care and its Guiding Principles• Overview of Lean Thinking• Benefits of Value-Stream Mapping• Transforming Office Practice• Outcomes• What We Learned• Summary and Next Steps

We Are a Place People Can Call Their Medical Home

Borgess Ambulatory Care330,000 Provider Visits Per YearOver 650,000 Total Visits Per Year10 Practices16 Locations98 Providers

• 58 Physicians• 40 Non-Physician Providers

Predominately Primary CarePractices Owned by Hospital System

Borgess Ambulatory Care Guiding Principles

Your Care Will Be Safe

We Know Who You Are and Are Ready For You

We Will See You When You Want to Be Seen

You Will Know What to Expect

We Will Be Your Trusted Partner in Health

We Will Exceed Your Expectations

Changing Priorities Ahead

Health Plan Partnership• Support for Lean consultant• Initially conducted Lean workshop• Trained and mentored Lean coach

– Observe, partner, lead model• Worked with Borgess Ambulatory Care

leadership• Initially disease focused• Seen as core competency for process

improvement

Change is like going to heaven, everyone wants to go but not

right now!

What is Lean?

Lean is a set of concepts, principles, and tools used to create and deliver the most value from the customer’s perspective while consuming the fewest resources.

From “Mapping to See,” Lean Enterprise Institute, www.lean.org

Encourages Front-Line Initiative“Having a meeting that pulled people from each department and allowing them to work together was very beneficial. It was a great concept in which it allowed input and say from each department to create change and better the work place. We all felt valued. Implementing more meetings like we just had will create a great team environment.”

–Maria, Medical Records

Develops Structured Thinking Around Problem-Solving

“Your system is perfectly designed to

produce the results you are getting”

- Frederick Taylor

Fosters Dialog Within the Organization

“Even on the best day with the best team, the worst can happen because we’re not really trained to talk to each other. If you’re preparing for a concert, you would never ask the violins to practice on the third floor, the flutes on the second and the cellos in the basement, and then expect them to come together for a symphony.”

- Karyn Baum, University of Minnesota Medical School

Molly Kelash, “Closing In on Bad Communication,”Pictures of Health, Fall 2006.

Overall Performance - Not Silos

Serves as an Organizational/Operational Learning Tool

Point of use storage

Building Blocks of Lean Healthcare

Quick changeover

5S’sLayout

Batch size reduction

Visual

Value-stream

mapping

Poka-yoke

Self inspection

AutonomationPull system and kanban

Cellular and flowJust-in-timeTotal productive maintenance

Change management

Standardized Work

Teams and teamwork

Continuous Improvement and Kaizen Events

A. Manos, M. Sattler, and G. Alukal, “Making Healthcare Lean,” Quality Progress, July 2006, pp. 24-30. www.asq.org

Benefits of Value-Stream Mapping

• Helps people understand how the process works now• Helps people understand and reach agreement on how

well the process is working• Helps uncover waste and problems with flow in the

value stream• Helps people reach agreement on what changes need

to be made • Helps people reach agreement on how to ensure that

those changes are made


Roles for VSM or Kaizen Event• Lean Coach• Process Owner• Executive Sponsorship• Leadership Panel • Workshop Participants

Capabilities for Selection of Lean Coach

Social Aspects of Lean Thinking• Problem Solving • Group Process

• Change Management• Conflict Management

Technical Aspects of Lean Thinking

• Concepts and Tools• Data Analysis

Leadership of Lean Thinking• Listening• Influence

Work Structures and Management• Business Understanding

• General awareness of process• Excellent coaching/facilitating

skills• Respected by organization• Encourages humor and creates a

fun environment

Developed by Margie Hagene and Beau Keyte, Lean Transformations Group and Chris Wise, University of Michigan Health Systems

Identified Staff Educational Gaps

• Comprehension of the need to change• QI terms and concepts• Change management techniques• Project management skills• Lean terms are confusing

Structure of a VSM WorkshopPre-Work: Define Problem/Scoping

1.5 hr meeting

Lean Coach

Leadership Team Member

Sponsor

Process Owner

Define Project Scope

Determine VSM Participants

Identify Key Decision Makers

Develop Data Collection PlanIdentify Concerns, Issues, and Barriers

Day 1: Current State Map

Common Problems• Waiting/delay• Rework• Excessive handoffs• Interruptions• Many requirements for decisions and

approval• Poorly defined requirements


Day 2: Future State Map

Common Solutions• Combine steps• Manage interruptions• Standardize processes• Build in quality checks


Solutions should be…

• Within your control• Easy to implement• Can be started immediately • Low cost or no cost

Day 3: Implementation Planning

Develop a 90-Day Work Plan to:

• Clarify goals• Develop action plan for each goal• Determine who will be responsible• Determine when reviews and checks

will take place


30 – 60 – 90 Day Reviews1.5 hr

Lean CoachLeadership Team Member

SponsorProcess Owner

VSM ParticipantsLeadership Team

Other Providers/Staff

Report Implementation Plan Progress

Your Care Will Be SafeCommon Themes in Plan Success StoriesDevelop standing orders/protocols

Eliminate interruptions

Increase IT functionality

Test trackingColor-coding Vaccine Information Sheets

Physician sat with a scheduler and listened to calls for one day

Labeled diabetic patients in practice management software

We Know Who You Are And Are Ready For You

Common Themes in Plan Success Stories

Team huddle

Provide proactive care

Scripting

Team has plan in place for the day

Schedulers provide patients with a lab slip for routine tests at the time of scheduling health maintenance exam

Before: When was your last mammogram?

After: Could please verify that your last mammogram was …?

We Will See You When You Want To Be Seen

Common Themes in Plan Success StoriesRealign responsibilities and clarify roles

Eliminate duplication of work

Review scheduling templates and protocols

Removed unnecessary paperwork from physicians’ dutiesProvider charts are screened and organized by priority

Time and date stamping faxes

Eliminating appointment typesHaving schedules in the computer seven months in advance

You Will Know What To ExpectCommon Themes in Plan Success StoriesPatient education

Standardized work

Empowering and enabling patients – pediatric vaccines

Letter explaining the group’s policy, includes current vaccination schedule, list of billing codes, instructions on how to contact insurance company to see if they are covered, and options if they are not covered.

Forms were standardized at all pediatric sites

We Will Be Your Trusted Partner In Health


Increase communication

Increase post-visit contact with patient

Providers and staff building relationships with other providers/services within the organization/communityDepartment at hospital was able to provide a solution

Developing care management protocols

We Will Exceed Your Expectations


Schedule diagnostic and referral appointment before patient leaves

Create a visit summary sheet for the patient

Realign meeting structure

Family practice sites are currently doing “live” referrals

Visit summary sheet was created in electronic health record

Problems are solved more efficiently and effectively

5S Workplace Organization• Sort: Sort out unneeded items • Straighten: Have a place for everything • Shine: Keep the area clean • Standardize: Create rules and standard

operating procedures • Sustain: Maintain the system and continue

to improve it

• Organized and labeled cabinets

• Removed doors where applicable

• Posted an inventory form• Created a stocking checklist• Inserted blood pressure cuff

shelving• Determined who is

responsible for restocking• Placed frequently used

handouts/forms in the room

ProMed Pediatrics: Provider Interruptions

Woodbridge Family Practice Medical Records 5S Event – Pursue to Perfection

Medical Records Improvements• Reduction in Chart Pull Prep Time 67%• Reduction in Loose Filing 100%

– Kanban System Created for Incoming Mail

• Increase in 5S Scorecard rating 100%– Pre 5S = 11; Post 5S = 22

• Significant Reduction in Wasted Floor Space• Significant Reduction in Transportation Waste for

Transcription Process

Data provided by Ed Blackman, MA, CSSBB

Before and After

Staff Satisfaction: Gallup SurveyGallup Questions % Improvement

(Post- Lean Workshop)How satisfied are you with Borgess Health as a place to work?

22.4%

This last year, I have had opportunities at work to learn and grow

17%

At work, my opinions seem to count

27.8%I always trust my organization to be fair to all associates

27%

My organization treasures diverse ideas and opinions

34%

Your Care Will Be SafeProMed Internal Medicine Diabetic Patient Immunizations

45

55

65

75

85

2007 Baseline 2008 Q1 2008 Q2 2008 Q3 2008 Q4

Timeframe

Perc

enta

ge

Pneumo Vac Td/Tdap

Lean Workshop

10.8

8.8

7.36.8

5.0

2.11.0 1.0

Jul Aug Sep Oct Nov Dec Jan Feb

Day

(avg

/mo)

2 days

3.5

4.1

3.3

1.8

1.0

2.0 2.0 2.0

Jul Aug Sep Oct Nov Dec Jan Feb

# of Screening Mammograms by Month

Day

s (a

vg/m

o)

2 days

Average Screening Mammograms per Month: 370

We Know Who You Are and Are Ready For You

MammographyTwo Business Days from Screen to Initial Pt. Call

Back

Mammography Two Business Days from (post- screen) Contact with Patient to Offer Date for Additional Views

Lean Workshop

Lean Workshop

We Will See You When You Want to Be Seen

Pediatrics 3rd Available Appointment for Well-Child Visit

020

4060

80100

Provide

r AProv

ider B

Provide

r CProv

ider D

Provide

r EProv

ider F

Provide

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ider H

Provide

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ider J

Provide

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ider L

Provide

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# of

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s ou

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July 2008 Sept 2008 Jan 2009

You Will Know What to ExpectPatient Satisfaction Expectation Questions

86889092949698

Before I came to mydoctor's office, I expected

high quality care.

Before I came to mydoctor's office, I expectedthe doctor's office to meet

my personal needsextremely well.

Before I came to mydoctor's office, I expectedthings not to go wrong.

2007 Lean Groups2008 Lean Groups2007 Non-Lean Groups2008 Non-Lean Groups

We Will Be Your Trusted Partner in Health

NPS Formula SA - (SD+D+N) = NPSI would recommend this doctor's office without hesitation to others.

Net Promoter Score for Borgess Physician Practices

65

66

69

63

64

65

66

67

68

69

70

FY07 FY08 FY09

Scor

e

We Will Exceed Your ExpectationsSatisfaction Lean vs Non-Lean groups

Non Lean groups - 0.34

Lean groups 1.64

-0.50

0.00

0.50

1.00

1.50

2.00

1

Cha

nge

in ra

w s

core

CY0

7-C

Y08

What did problem solving look like 6 months ago at your clinic?

• Took a long time to resolve issues/problems

• “We were basically on our own to figure out how to handle a problem…because we did not know who to ask.”

• “I would tell my boss about a problem, I could not go to my co-workers with problems. We had no way to discuss issues with a provider.”

What does problem solving look like at your clinic today?

• Improved Communication and Team Problem Solving– “Doctors are invited (and show up) at our staff meetings to

be involved as well, this is great!”– “People are more receptive to suggestions.”– “We were able to make some much needed changes using

Lean…things staff had been adverse to try. Once we did it, everyone realized it was for the best.”

– “We now have time at our staff meeting to “group-solve” and talk about problems.”

What does problem solving look like at your clinic today?

• Collaboration Between Staff Members– “Staff are making their concerns known while taking in

other opinions.”– “When suggestions are made, we try one to see if it works.”

• Improved Patient Care– “We are more aware of making the patient/family happy

and pleased with all aspects of the visit and care.”

What are you learning?• “That change isn’t always bad. I can learn new things even at

my age.”

• “Become more aware of how good my coworkers are – I knew they were good, but I truly appreciate all they do now.

• “That just because “we’ve always done it that way” doesn’t mean we have to continue to do it that way.”

• “I have learned I can find something that I think may need change and I have a way to present and discuss the possibilities.”

Leadership Key Learnings

• Front line associates are key to success• Lean is a great way to break organizational silos • Value-added work is in the eye of the beholder• Waste is also in the eye of the beholder• Allows inputs from others to influence

perspectives on waste and value-added work• It is important to be sure that stakeholders from

other major projects/departments are included in the work

Leadership Key Learnings

• Transformation is a continual process• Gaps in management of day-to-day work were

discovered • 90-day goals might involve closing those gaps • Lean allows us to live our Guiding Principles and

support objectives of IHI’s Triple Aim

Ongoing Lean Organizational Roles

• Directors: – Leadership cascades vision and strategy

• Drivers:– Management approves action plans and serves as a

coach/mentor

• Doers: – Staff identify and solve problems


Next Steps• Introduce new employees into the culture• Identify and skill up coaches embedded at each of our

locations• Align organizational behaviors• Introduce additional system integration workshops

– Central Billing Office – Low Back Pain– Physician Recruiting– Childhood Obesity

Bottom Line = Changed Lives• Your care will be safe• We know who you are and are ready for

you• We will see you when you want to be seen• You will know what to expect• We will be your trusted partner in health• We will exceed your expectations

Tools for Getting Started

• BAC Pre-Workshop Checklist• BAC Lean Roles and Responsibilities• BAC Lean Meeting Schedule• BAC Communication Plan Template• BAC Implementation Plan Template• BAC Staff Homework• BAC Staff Training Agenda• BAC Post-Learning Cycle Evaluation

Improving Our Lean Process

• Evening meetings began to feel like a punishment

• Be mindful to include/inform staff not participating in workshop

• Be careful in combining this process with any other change out of your scope of control

going lean - bcbsm

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