Atrium Building, Innovation Place 241-111 Research Drive Saskatoon SK S7N 3R2
Phone: 306-668-8810 Fax: 306-668-8820 www.hqc.sk.ca
November 24, 2014
Ms Judy Ferguson Acting Provincial Auditor Provincial Auditor of Saskatchewan 1500 Chateau Tower 1920 Broad Street Regina SK S4P 3V2 Dear Ms Ferguson: Re: Health Quality Council’s response to the Provincial Auditor’s Memorandum of the Audit of Processes to Coordinate the Use of Lean On behalf of the HQC Board, I would like to thank you for the opportunity last week to discuss with you and your colleagues the results of this recent audit. It was both informative and helpful. During this discussion you requested we submit to you in writing a summary of the general direction HQC is taking in response to the recommendations included in the memorandum. Here is a brief expression of what we envision in the immediate weeks ahead, fully appreciating we will need to develop a more detailed, collaborative implementation plan with our health system colleagues. Auditor recommendation #1: We recommend that HQC implement a risk management framework for coordinating the use of Lean across the health sector. •
Since completion of the audit, HQC, in collaboration with other health organizations, has developed a comprehensive Lean Transition Matrix outlining key transition elements. A timeline and set of work plans have been developed to assist with monitoring and managing risks and gaps. HQC’s CEO is also meeting on a regular basis with other health system CEOs (approximately once a month) to implement transition strategies as well as a risk management framework. Organizations are similarly completing and updating Transition matrices, which will help HQC better assess gaps and issues. HQC continues to solicit information actively from health organizations through attendance at each organization’s Quarterly Review meetings and Kaizen Planning events. HQC Board of Directors will add “Status Update on Provincial Auditor’s recommendations” as a standing agenda item until it is determined they are fully implemented.
As discussed, we look forward to receiving additional risk management framework information and examples from the Provincial Auditor’s team. …/2
Ms Judy Ferguson November 24, 2014 Page 2 Auditor recommendation #2: We recommend that HQC promote alignment of Lean activities across health sector agencies by sharing information that demonstrates how activities contribute to strategic priority areas •
Since this past summer, with HQC now taking a more active role in supporting the health system strategic planning (i.e., Hoshin Kanri at Level 1 and 2), we believe there will be greater opportunity to influence alignment of regional priorities to system priorities. Related to this, HQC, in partnership with Saskatchewan health organizations, is redesigning the PLT Strategic and Operational Walls, to better align monitoring and reporting to strategic priority areas. HQC will lead the province in an Integrated Kaizen Planning process to identify future kaizen events to be populated. HQC will have the opportunity to influence a shift in focus of RPIWs to better align and support system priorities. HQC continues to be involved in health system priorities’ integrated planning (e.g., HQC was involved in the recent ED Waits and Patient Flow - integrated kaizen planning meeting (held in September 2014).
Auditor recommendation #3: We recommend that HQC collect information from health sectors agencies on ongoing results achieved through Lean events in the agencies •
Since late summer, HQC in partnership with health system organizations, has been working down the backlog of Health System RPIW Audit Reports. All health organizations have been asked to upload their RPIW Audits to kaizen tracker.ca by November 30, 2014. Once these Audit reports are up to date, HQC can and will more consistently report on what ongoing results are being sustained following RPIWs. At upcoming Kaizen Network meeting in January 2015, HQC will co-develop a Work Standard related to data collection and time frames. Outstanding submissions will be brought to the CEO community for remediation. All health organizations have access to the online data repository, kaizentracker.ca. We will continue to help develop capability in health organizations to query and fully utilize the database (including generating relevant reports for local needs).
Auditor recommendation #4: We recommend that HQC give written reports to the Ministry of Health and health sector agencies on the results of Lean events have achieved and the sustainability of those results •
HQC currently produces monthly reports that are shared with the Ministry of Health and health sector agencies on current kaizen activity. …/3
Ms Judy Ferguson November 24, 2014 Page 3 • •
With RPIW Audits updated, HQC can better report on the sustainability of results. In early 2015, HQC will work with health organizations and Ministry to determine appropriate reporting formats, schedule and audiences. All health organizations have access to kaizentracker.ca and we continue to develop capability in those organizations to query the database (including generating relevant reports for local needs).
Auditor recommendation #5: We recommend that HQC report to the public on the outcomes achieved through the use of Lean across the health sector •
The BetterHealthcare.ca website – hosted by HQC – serves as a launch point for public access to information related to lean activity occurring across the province. We will continue to populate progress on Lean activities across the health sector alongside organizations’ own promotion efforts. HQC continues to improve our publicly accessible QualityInsight.ca health system quality indicators website. In particular HQC intends to align the display of indicators within categories derived from health system improvement goals. HQC will continue to develop a variety of ways to raise broader public awareness of the province’s application of Lean principles and methodologies to improve health care and the lessons learned on that journey.
I hope the above work plan is sufficient for you to understand our initial actions in response to your recommendations. We look forward to future exchanges with you and your colleagues as this work unfolds. Yours truly,
Susan Shaw, MD Board Chair cc: Gary Teare, Interim CEO Max Hendricks, Deputy Minister, Ministry of Health Pauline Rousseau, Executive Director, Strategy and Innovation, Ministry of Health