LEAN ON A SHOESTRING

ACHD Annual MeetingOctober, 2019

JoDee Tittle, CEO Plumas District Hospital, Quincy, CA

•Critical Access Hospital•Laboratory•Full-Spectrum Imaging•Surgical Services•Nursing•Respiratory Therapy •Rural Health Clinic•Behavioral Health•Specialty Services

Services MissionWe provide outstanding compassionate care with exceptional customer service

VisionTo be the communities first choice for healthcare, while growing as a rural teaching institution and center of excellence.

Values• Quality with• Unrelenting• Excellence • Service and• Teamwork

JODEE’S STORY….• St. Charles Health System– Bend, OR

– 25 bed Critical Access Hospital’s in Prineville and Madras

– Lean as a strategy for culture change

• Southern Coos Hospital and Health Center– Bandon, OR– 19 bed Acute Care Hospital– Need for foundational quality work

• Plumas District Hospital– Quincy, CA– 25 bed Critical Access Hospital– Need for foundational quality work

OVER THE PAST 3 YEARS IN HEALTHCARE LEADERSHIP

Culture of Improvement• Developed a strategic plan• Redefined mission, vision, values with

input across the organization• Transparency/Visual Management• Daily Tiered Huddles• Developed an interdisciplinary

approach to patient safety and quality• Introduced communication tool

– SBAR– Check back– AIDET– A3

• Onboarding A3• Department and organizational

pipeline• 5S (sort, simplify, sweep, standardize,

self-discipline) Materials Management & Dietary

• Work flow processes with Cerner• Root Cause Analyses and Debriefs• Transitional Care Project (swing bed)• Patient Safety and Quality Committee• TeamSTEPPS Implementation • Studer Partnership

PARTIAL LIST OF PROJECTS

Examples of Measurable Improvements• Increased Transitional Care Days by 100%• Reduced patient falls by 14%• Improved staff retention by 10%• Reduced incidences of outdated products by 15%• Reduced the cost of meals served from $36 to $9• Improved co-pay collections by 50%• Reduced write offs related to pre-authorizations by $3,000• Increased peer to peer recognition by 100%• Achieved UC Davis Rural Center of Excellence

KEY IMPROVEMENTS OVER THE PAST 3 YEARS

ROADMAP FOR LAUNCHING LEAN ON A SHOESTRING IN YOUR ORGANIZATION….

1. Shared Learning: Executive Team, Board Chair and Chief of Staff

2. Identify Internal Champion3. Explore Training Resources4. Design Lean 101 for

Managers, Board and Staff5. Develop No Layoff Policy6. Transformational Plan of

Care7. Set up Data Tracking,

Alignment and Sharing System

8. Begin Lean Events – Model Cell

9. Implement Department and Organizational Huddles & A3 Thinking

ROADMAP… STEP 1: SHARED LEARNING

• Book Club• Site Visits• Past Experiences

ROADMAP… STEP 2: IDENTIFY INTERNAL CHAMPION

The Value Improvement Manager has overall

responsibility for implementing and overseeing lean and

continuous improvement thinking, philosophies,

structures, tools and processes throughout the health district.

Attributes of a successful Value Improvement Manager include:• Create an engaged

environment• Open mind• Draw out all members of the

team• Respected by the staff

ROADMAP… STEP 3: EXPLORE TRAINING RESOURCES

• St. Charles Health System (138 miles to the west) –training and participation

• Purdue Healthcare Advisors - $20,000 grant from the Oregon Office of Rural Health to assist with additional lean training and mentoring on value stream mapping and rapid improvement events (collaborative with neighboring health districts).

ROADMAP… STEP 4: DESIGN LEAN 101

ROADMAP… STEP 5: DEVELOP NO LAYOFF POLICY

The purpose of the Lean No Layoff Policy is to address the potential elimination and/or reduction of positions as a result of productivity improvements made during the Lean transformation process.

Respect for people… Kara’s story

ROADMAP… STEP 6: TRANSFORMATIONAL PLAN OF CARETransformational Plan of Care (TPOC): A team event which focuses on developing a plan for transforming the culture of and organization to one of continuous improvement

ROADMAP… STEP 7: DATA TRACKING, ALIGNMENT AND TRANSPARENCY

2017 2/12 3/2 4/17 5/2 6/19 9/13 12/19True North Metric Base Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec Formula/How Resp Target FreqPeople Engagement 3.35 Gallup Grand Mean Dawn 4 Annual

Evaluations 56.7% 0% 0% 0% 0% 0% 0% # done on time/# due Dawn 100% Monthly

PS & QLongest LOT since Adv Event (Cat. C&D)* 25 33 14 12 27 16 27 36 HIIN,IHI,PSA Elaine 30 MonthlyLongest LOT since Adv Event (Cat. E-I)* 87 25 41 34 64 95 125 152 33 65 95 20 HIIN,IHI,PSA Elaine 95 MonthlyLongest LOT since last Prev. Readmit.* 53 62 82 121 151 182 212 243 274 HIIN,IHI,PSA Elaine 60 Monthly

Delivery Transitional Care 58.3 100 43 33 59 61 80 114 96 62 74 32 Allevant Census Elaine 70 MonthlyTrans. Denials 5 0 0 0 0 0 Allevant Data Elaine 2 MonthlyTrans. Delay Days 11 0 1 5 0 0 Allevant Data Elaine 5 MonthlyTrans. Patient Load 7 5 5 6 7 4 4 6 4 5 4 # Patients in Month Elaine Monthly

Value/Cost Discharge Phone Calls 25.9% 9% 10% 18% 13% 44% 39% 42% 37% 33% 86% 100% # done on time/# due Dawn 100% MonthlyCompassion Inf About Delays-ED 81% Press Ganey Top Box Elaine 88.3% Qtr

Would Recommend-ED 70% Press Ganey Top Box Elaine 81.0% QtrExp in Ways-IP 77% Press Ganey Top Box Elaine 81.3% QtrWould Recommend-IP 71% Press Ganey Top Box Elaine 81.0% Qtr

2018

NURSING

3.07 (17)

60% (50) 59.5% (42) 57.1% (42) 68.8% (16)

100%

75% (20)69.2% (13)58.3% (12)74.1% (27) 68.4% (19) 74.1% (27)

62% (50) 70.8% (48) 66% (50)55.6% (27) 84.2% (19) 85.2% (27)

ROADMAP… STEP 8: BEGIN LEAN EVENTS

• Select an energized team• Commit to a set window

of time• Include a provider

champion

ROADMAP… STEP 9: IMPLEMENT TIERED DAILY HUDDLES

TOOLS TO BEGIN USING RIGHT AWAY• A3 Thinkin• Tiered Huddles

A3 THINKING

3 Common Problem Solving Mistakes

1. Assuming you know what the problem is without seeing it

2. Assuming you can fix the problem without verifying the problem

1. Assuming you’ve identified the cause of the problem without verification

Theme/Area/Process/Company

Description of Current State• What are we trying to solve?• Identify gap between target & actual

Background & Supporting Data• Share facts & figures• Use chart & graphs

Root Cause Analysis• 5 Why & Other Practical Problem

solving methods• Root Cause Analysis should lead to

action

Check & Follow Up• Verifying results of actions• Who, What, When

Action Plan• Counter Measures for each root cause• Who, What, When

DAILY TIERED HUDDLES• The primary goals of the Huddles are:

– Explore department readiness for the day with general categories like Safety (possible harm for patients/staff), Methods (is everything going as it should), Equipment/Supplies (do we have what we need), Staffing (what is our staffing situation today) and High Risk (do we have high risk patients or situations which we should prepare for today).

– Discuss department metrics and any projects for improvement that are taking place.

– Discuss Announcements/Information (“flu shots are available today from 11 – 2”)

– Discuss Recognitions/Good Catches (“Darbie has completed her perioperative course”)

– Improve Communication as department members get on the same page for the day and eventually as we add the second Tier, information moves throughout the organization

Be consistent and hardwire the practice in a standardized

manner

Announcements

HIGH ALERTS

Recognition & Good Cataches

SAFETY + MESSH Metrics/Logs

SAFETY Something that creates harm or increase the risk of harm for our

patients and staffMETHODS

Something did not go as it should

EQUIPMENT Broken, missing or misplaced

SUPPLIES Needed but not avaialble or not in

the right place STAFFING

Not enough people to do the work

1/8 Life flight can’t land due to lighting concerns

1/8 City of receiving hospital must be noted on all transfer documentation

1/8 Replacing toilet in room 3 anticipate completion 1/9

1/8 Chest tube kits were relocated to ER Hall

1/8 3 RN, 2 CNA’s 1 Unit Clerk

1/8 Room 3, 5 & 6 Fall Risk1/8 Room 3 & 7 FoleyOximetry, Telemetry, Falls, Foley,

Isolation, Wounds, Braden

1/8 Verify payroll check with Paycomimplementation

1/8 Clinical Skills fair scheduled for 1/31

1/8 Heather for her excellent work with survey1/8 HR and Payroll for paycomimplementation efforts1/8 Ruben for becoming Mr. Incredible and easing the fears of a pediatric patient needing a blood draw

Finance Week:

Maintain positive net income: Current net income is positive

Gross AR Days:Goal: Decrease AR days to less than 50. Current AR days are 61.

Days Cash on Hand:Goal: At or above 60 days. Current Cash on Hand 120 days.

Maintain Current Ratio at or above 3.0 Current Ratio is 5.1

Maintain Long-Term Debt to Capitalization Ratio below 20. Current Long-Term Debt is 12