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Implementing and Leading Collaborative Lean Performance Improvement Culture in an Inter- professional Primary Care Clinic Marilyn Skrocki JD, MBA, MISM, FACHE Professor Health Sciences Saginaw Valley State University University Center, Michigan, USA Dorothy Lee PhD FNP Professor Nursing Saginaw Valley State University University Center, Michigan, USA

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Page 1: Implementing and Leading Collaborative Lean Performance ... · Implementing and Leading Collaborative Lean Performance Improvement Culture in an ... • Lean Principles • Kaizen

Implementing and Leading Collaborative Lean Performance Improvement Culture in an Inter-

professional Primary Care Clinic

Marilyn Skrocki JD, MBA, MISM, FACHE Professor Health Sciences

Saginaw Valley State University University Center, Michigan, USA

Dorothy Lee PhD FNP

Professor Nursing Saginaw Valley State University

University Center, Michigan, USA

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Agenda

• Lean Principles • Kaizen Steps • Everyday Lean Ideas (ELI) and A3’s • Lean and Interprofessional Education (IPE)

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Lean is • The systematic pursuit of perfection • A discipline of incremental changes • Not attempting to create the perfect process but

make small changes one step at a time • No quick easy fixes; process changes must be the

brainchild of each of us and learned through both clinical and operational experiences

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Lean Principles in Practice Lean-based budgeting process is founded on basic guiding principles: 1. Identify your customer, and define value from their

perspective (patient or client perspective, focus on value and eliminate waste)

2. Map the process, and scrutinize for value, identify waste (non-value added activities)

3. Optimize the process, designing for efficiency 4. Keep improving and brainstorming daily to move toward

organizational effectiveness and assurance toward patient safety (PDCA, morning huddles)

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Value Stream Map

• A value stream map is a visual depiction of a process or workflow

• In our example, a value stream map follows the patient through most of a clinic visit

• Each step in the process is mapped for review to identify whether it actually impacts or improves the patient experience – Value Added – Non-Value Added / Waste (Muda)

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Patient Workflow by Nurse (Andrea)

Kari puts the clipboard on the door

Reviews patient information on computer

Patient

New Established

Based on patient needs

reviews purpose of visit

Patient brought in

Nurse Room

Obtain patient Vitals and

weight

Review patient history and medications

Talk about the current purpose

of the visit

Specialty determination

Pharm Student

S.W

OT NP Student

Patient is taken to examination room for NP to diagnose and treat

Review labs/medications

and previous records

Previous records

No

Obtain consent for medical

record release

Yes

Request form handed over to Kari to obtain

Labs available

No

Yes

Calls provider

Review medical history and obtain purpose of

visit

Labs done or not

Yes

No Document labs not

done

Request for faxing report

Print lab reports

Kept for NP to

review

MAPS done on all patients

Patient knows medication

Pharm student obtain

medication list

Call Pharmacy

Medication list is

documented in VHN

Yes

No

Page 7: Implementing and Leading Collaborative Lean Performance ... · Implementing and Leading Collaborative Lean Performance Improvement Culture in an ... • Lean Principles • Kaizen

Current State Map vs Future State Map

• Aim of this initial workflow current state map is not to create an ideal future state

• Through continuous improvement, additional opportunities for improvement will continue (morning huddles where adding value and elimination of waste is discussed)

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Steps in the Kaizen (Japanese for continual process improvement) event

• Step 1: Defining Your “Current State,” or Existing Process

– First step is to create what’s known as a current state map, which represents our current workflow process; designed after a Gemba walk observing the process steps and interviewing all involved

– This process can help us identify workflow inefficiencies—for example, time spent hunting for patient charts, supplies, treatment necessities etc. - and implement improvements

– A team reviewing is more effective than just one individual – We may be making changes to our clinic visit process as a result of the value

stream map we create, having our entire team involved in reviewing the current state map and conceptualizing a future state map hopefully will result in pride for the team with performance improvement as everyone will be invested in implementing those changes

• IPE Modules TEAMS and TEAMWORK and ROLES / RESPONSIBILITY

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Steps in the Kaizen event

• Step 2: Identifying Waste • We have created our current state map, so the most time-intensive part is

over. The next step is to identify the waste in our workflow process. • Look at each step on your map and ask yourself whether that step is directly

valuable to a patient. (Receiving treatment? Valuable. Waiting in the waiting room? Not valuable.) Mark each step to indicate whether it delivers direct value (Red no value, green value)

– IPE module Patient Centered Care and Ethics

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Steps in the Kaizen event • Step 3: Creating a “Future State Map,” or Ideal Process

– Rearrange / revise / add / delete redundant processes or waste to create a future state map representing our ideal workflow sharing as a communication vehicle.

– We could create multiple future state maps: one that represents perfection, and one that represents a more realistic future state; allowing us as a the team to go to utopia, then back off for reality

– Our utopia map will represent the “perfect” process. It doesn’t need to be limited by what’s cost-effective or even completely realistic: it will help us conceptualize how the workflow could work without getting mired in the constraints of our existing process.

– Finally, we can construct an attainable future state map by looking at the ideal map for inspiration, but scale it down with reality by comparing it to our current state map

– IPE MODULE: INTERPROFESSIONAL COMMUNICATION

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Steps in the Kaizen event

Step 4: Taking our IPE clinic visits from Current to Future State • Once our attainable future state map has been created, we can

start brainstorming changes to our workflow as a team, asking ourselves what each of us (respecting the roles and responsibilities of each member of the team by not telling someone else on the team what they could or should do) to implement the process outlined in our future state. The changes made will be up to you. – IPE module Respect, Roles and Responsibilities

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Everyday Lean Ideas (ELIs)

• Virginia Mason Institute utilizes a program called Everyday Lean Ideas, which enables employees on the front lines of the organization to not only do great work on their assigned job, but simultaneously generated simple ideas to increase efficiency and reduce waste (Virginia Mason Institute, 2013).

Virginia Mason Institute. (2013). Using Lean Ideas In Our Everyday Work. Retrieved 2016.

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University Clinics’ ELI Board

• The Clinics’ ELI board was composed of 8 sections.

• The sections on the board include the following: 1. Problem/Current Situation 2. Proposed Countermeasure (Long Term or Short Term) 3. IPE Competencies 4. ELI Originator 5. ELI Owner 6. Date Initiated 7. Date Completed 8. Status

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IPE Competencies • Values and Ethics

– Work with individuals of other professions to maintain a climate of mutual respect and shared

• Roles and Responsibilities – Use the knowledge of our own roles and those of the other people who are part

of the team to address the healthcare needs of the client and the population served

• Interprofessional Communication – Use active listening and feedback with other professionals in a health care setting

• Teams and Teamwork – Apply relationship-building values and the principles of team dynamics to

perform effectively in different team roles to plan and deliver client-/population-centered care that is safe, timely, efficient, effective, and equitable

• Lean Principle: Keep improving and brainstorming daily to move toward organizational effectiveness and assurance toward patient safety

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A3, what is it?

• Structured tool for identifying and analyzing a problem

• Concise, easy to follow method for identifying a solution

• Serves as a communication tool • Provides a starting point when using

project management software

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A3 at the University Clinic • Obtaining a Meaningful Use EHR to meet both the health department and

the clinic needs • Maximizing reimbursement for all clinical aspects of the patient’s care

– Problem Background – Hypothesis (proposed solution) – Current Condition – Problem Analysis (Identify the root cause, 5 Why’s) – Target Condition (Desired Outcome) – Proposed Countermeasure (corrective action plan) – Implementation Plan – Results and measurement metrics (is it working as designed) – Standardization (standardize the new process, P&P, job descrip)

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A3 Project Management Program

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Gantt Charts

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Lean and IPE more similar than different?

• Two process improvement initiatives focus on patient safety and organizational effectiveness; IPE and Lean. The education and practice often provides siloed approaches to both

• IPE competencies such as Patient Centered Care, Evidence Based Medicine / Management, Value for the Customer / Patient, Roles and Responsibilities, and Respect intertwine with the goals of Lean process improvement

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References • Centre for the Advancement of Interprofessional Education, CAIPE 2002 • Virginia Mason Institute. (2013). Using Lean Ideas In Our Everyday Work.

Retrieved 2016. • Weiss, D., & Tilin, F. (2014). The interprofessional health care team:

Leadership and development. Burlington, MA: Jones & Bartlett Learning. • Zidel, T. (2012). Lean done right achieve and maintain reform in your

healthcare organization. Chicago, IL: Health Administration Press. • Zwarenstein M., Goldman J., Reeves S. (2009) Interprofessional collaboration:

Effects of practice-based interventions on professional practice and healthcare outcomes (Review) http://www.thecochranelibrary.com

• Lighter, Donald. (2013) Basics of Health Care Performance Improvement: A Lean Six Sigma Approach. Jones and Bartlett Learning. Burlington, MA.

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Grant support

• This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant D09HP26945 by the U.S. Department of Health and Human Services – Advanced Nursing Education Program – for the project “Nurse-led Interprofessional Clinic to benefit Underinsured Individuals and Veterans with Multiple Comorbid Conditions and Health Care Access Barriers” for $1,047,389. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.