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Observation at the Front Line (Gemba) Revealed Waste & Rework

Our aim was to design an effective, systematic approach to a

healthcare quality program that engages the entire workforce,

proactively identifies and addresses problems through front line and

manager input, minimizes number of committees to the “vital few”,

and advances the strategic plan, all of which is supported by a quality

oversight committee comprised of health system executives and

medical staff leaders. Implementation timeline for assessment,

design, restructure and Lean implementation was 9 months, to be

completed by October of 2014.

Aim Statement

Transformation of the quality management system and as a result,

the workforce culture, requires a deliberate vision, infrastructure,

and the coupling of Lean theories and tools. In addition, the hospital

employees have a tremendous amount of collective wisdom; to reach

organizational quality goals, these ideas and experience needed to be

harnessed.

Success was defined as 1) the creation of a multidisciplinary quality

improvement oversight committee co-led by the CEO and physician

chief of staff 2) a reduction in the number of organizational

committees within the quality structure 3) physician alignment of

quality metrics with improvement goals 4) educating 90% of staff

with Lean in the first 3 months 5) creation of a system to collect

improvement ideas/ identified problems from front line staff, and 6)

reaching goal, for the first Lean rapid improvement event that was

initiated using all components of the new quality program.

Our experience has resulted in a recommended approach and

sequence to quality program implementation, which strengthens

quality infrastructure, reduces duplication and rework, streamlines

communication, develops staff as problem solvers, and drives day to

day accountability. The evolution has resulted in a more engaged and

aligned workforce of patient-centered innovators, with an effective

pathway to redesign or create reliable processes and achieve

consistently excellent outcomes.

Project Design

Structural Redesign

Redesign of Quality Oversight and Committee Structures – After a whole house assessment, the Board, hospital leaders and medical staff

leadership met to have candid conversations to evaluate the work of current committees, streamline meetings to reduce duplication and create

efficiencies. Goals, metrics and a charter were created for each committee. A Quality Improvement Committee was created to steer all Quality

and Performance Improvement in the hospital. This change eliminated the work done in silos and enabled the coordinated, systematic

identification and prioritization of improvement opportunities. Integrated into this structure is an improved peer review and medical staff quality

process to provide ongoing monitoring of safety and quality. Information flow was adjusted to ensure feedback to all stakeholder groups, to

support both departmental and cross continuum care.

Implementation: Total Workforce Engagement

Education for All Staff Dept Performance Improvement Boards Selection/ Prioritization of Improvements

First Lean Rapid Improvement Event with Multidisciplinary Team

• Quality Structure/ Peer Learning - Involve physicians with depth of

improvement experience to speak to other physicians for faster

engagement

• Improvement/ Learning to See – Identified extra effort and

unnecessary effort for routine work. Realized “things fell apart” in

the past because rationale for change not well explained to all

involved in the process.

• Improvement/ Process Ownership- First attempts to manage

process were “owned” by Quality leader, resulting in lack of

ownership at Department leader level. Needed to create

accountability at department level through huddles, director to

director huddles and director accountability to QIC.

• Executive Oversight – Learned that presence or absence of

executive oversight between meetings is highly visible to front line,

and highly correlated with success.

Jamie Harkins, Erika Sundrud and Judy Krempin

Outcomes by Design:

Sustainable Improvement Through Quality Structure, Total Employee Engagement & Lean Practices

Multidisciplinary Team Identifies the Organization’s "Critical to Quality" Needs based on Strategic Plan & Customer Input

Committees Restructure & Streamline to the "Vital Few"

Physicians Set Priorities and Metrics for Ongoing Improvement

Lean Education Provided to All Staff

Lean Implementation of Daily Practices & Rapid Improvement Events

Contacts Quality Redesign: Jamie Harkins

Lean Implementation: Judy Krempin

Lessons Learned

A3 for ED TAT Rapid Improvement Event (RIE)

Sustainability Requirements 1) Ongoing QIC Oversight of Quality & Total Workforce Engagement

2) Data Transparency at the Front Line/ PI Board

3) Huddles at the Performance Improvement Board for Focus

4) Managers on the Gemba Every Shift to Coach/ Support Staff

5) Senior Leader Gemba Walks to Demonstrate Commitment, Become

Familiar with Process, Coach Direct Reports

6) RIE Team Leaders (Department Leaders) Accountable to QIC

Current State (2013): 1) Medical Executive

Committee overburdened and unable to effectively address all quality improvement requirements

2) Not all staff represented (e.g. ED)

3) Barriers to information flow

Future State (2014): 1) Reduced number of medical staff

and operational committees 2) Created of a Quality Oversight

Committee led by Executives and Physician Leaders

3) Represents all departments/ providers in the system

4) Ensures timely, concise information flow

33VA 159 min 21% VA minutes

11 VA 52 total 21% VA steps

Voice of the Customer: Examples of Common Feedback, Supported by Data

Patients/ Families: -Quite a wait. I’m sure it was two hours. -I didn’t expect to wait that long.

Staff: -Need seamless communication -No standard work -ED/ Diagnostic Imaging relationship is argumentative -“So much time is wasted”

Medical Providers: -Priority is imaging turn around time