There began to be buzz around the organization about .... Lean, there was topâdown monitoring of key metrics that casc
Leading Process Improvement From The Front Line A Case study outlining University Health Network’s Journey Around Process Improvement (Focusing on ED and General Medicine) Aaron Berk, writer ED PIP
Introduction For years, people have looked to the University Health Network (UHN), Ontario’s largest hospital, as leaders in care. Notwithstanding this, UHN knew that improvements were needed. UHN had a vocal physician group who felt that something had to be done to improve care. This case study tells the story of UHN’s investment in Process Improvement well ahead of most hospitals in Ontario. UHN’s experience ultimately helped influence the development of the provincial Emergency Department Process Improvement Program, which has introduced Lean process improvement practices across over forty hospitals in Ontario. In 2005, there was a movement within UHN that explored a strategic shift towards an academic, speciality‐based hospital that would threaten the existence of Emergency Department (ED) and General Internal Medicine (GIM) as programs. To add to the anxiety, the quality indicators in medicine were not reaching targets. During this time, there were significant capacity issues in the Emergency Department and patient and staff satisfaction levels were particularly low in the ED and GIM. A culture of apathy plagued the clinical leaders and there was a lack of attention/interest in the Emergency Department from the hospital leadership, which resulted in poor engagement overall. Compounding these cultural issues, decisions were being made outside the Emergency Department that impacted the ED. There was a genuine sense of frustration from the front line clinicians who were committed to providing the best patient care possible. There were clear drivers for change; however, they were not necessarily unique to UHN. Fortunately, the Ministry of Health and Long Term Care (MOHLTC) and the negative publicity around ED wait times created a burning platform to force hospital leaders to look for solutions to capacity issues in the ED. At UHN, the leadership took notice. Very quickly there became a common appreciation that if you want to fix problems in the Emergency Department, you have to look beyond the four walls of the ED. The problems became known as system issues, which required a systems approach. UHN decided to take an end‐to‐end view, and focus on the improvement opportunities between the ED and General Internal Medicine. The CEO and the Board educated themselves on the need to improve patient access and flow in the ED and Medicine. Solving the ED issues became a large “Patient Access and Flow Transformation” project. At this time, a new group of physician leaders emerged –most of whom were involved in the ED‐GIM Transformation right from the beginning. The focus became improving patient flow from the ED to GIM and the organization chose Lean as the way they would accomplish their goals. The initial leadership team was educated in Lean and involvement in the process improvement journey would cascade its way through the levels of the organization right to the front line delivery of care in the months and years to come. 1
Anchoring Process Improvement to a Transformation Agenda In 2005/06, there was a movement afoot that would challenge the organization to do better –in particular around ED and Medicine (e.g. ED access and inpatient length of stay). UHN would eventually adopt Lean methodologies to improve processes; however, this would not happen in isolation. The hospital initiated an ED‐GIM Task Force as part of an overall transformation, which represented an overarching structure that essentially acted as a steering committee for improvement. Specifically, six working groups were assigned to deliver on what was known as the six pillars. Each of the pillars represented a working group or team who oversaw 3‐4 mini projects within the overarching improvement agenda. The six pillars included: (1) Care Model Review; (2) Care coordination; (3) Interdisciplinary Communication; (4) Team Renewal; (5) Work Flow; and (6) Work Environment. Adopting Lean to Facilitate Transformation in the ED and General Internal Medicine UHN had begun to define its transformation. However, there was still a gap between the overarching agenda and how they would accomplish certain elements. Early in 2006, UHN enlisted the help of consultants to facilitate their transformation using Lean methodologies. For a few months, there was a significant focus on education and training of both the leadership team and front‐line staff related to Lean principles and methodologies. Getting started was rocky as expected. Dr. Anil Chopra (Medical Director, Emergency Department, Toronto Western Hospital) said, “The Lean approach to improvement was refreshing, but time‐ consuming. There were measurements coming from everywhere, and I thought, what did I get myself into?” Overall, Lean seemed to be working. By demonstrating early successes through “just do it” projects, UHN began to engage more than just the leaders in the organization. When UHN started down their process improvement journey with Lean, there were no templates. The organization had to work hard to help people in healthcare accept Lean as the vehicle to support their ED‐GIM transformation. Beth Curiale, a manager of one of the inpatient medicine units recalls that as they were being educated about Lean, people were motivated by the concept of inefficiency. They wanted to work better, smarter. They were motivated by Spreading the word... change and excited to be able to influence improvement There began to be buzz around the opportunities. UHN invested the time of internal resources to focus on driving Lean process improvement work across the ED and GIM units in both the Toronto Western and Toronto General Hospital sites (in parallel). Project management resources from Shared Information Management Services (SIMS)1 were in place to support and guide the front line clinical teams with their desired process
organization about Lean. The nursing leadership (including front line and management) created a video about the nursing experience around process improvement and shared it with other floors. This helped to create positive momentum and something that nurses could be proud of.
1
SIMS is part of UHN and works on integrating projects across several partner organizations (in the Greater Toronto Area), helping health care workers deliver care that is centred on the patient regardless of where the care is delivered.
2
improvement projects. For example, the SIMS project team helped with facilitating the improvement events as well as planning and communications (e.g. daily huddles, written communications, posters, etc). Debra Davies, Manager of the ED at the Toronto General Hospital site, talks about seeing a speaker from another hospital give a talk about 5S and their experience implementing a rapid assessment zone. This led to a site visit, which supported some of the early drivers for Lean transformation work in the ED. A lot of work went into how UHN would tackle process improvement to ensure that it lived at the staff level. Eventually, they conducted their first value stream mapping event in the ED (from a patient’s perspective), and in Debra’s words, “I’ve never looked back... I even use Lean in my own personal life”. Lean events such as the value stream mapping sessions acted as an education for different stakeholder groups. In particular, there seemed to be a new appreciation/understanding around the complexity surrounding the nursing environment. At UHN, Lean became a vehicle for engaging people at the point of care. By bringing a team together from different perspectives (e.g. physician, nursing, allied health, management, etc.), from ED and Medicine, better results were achieved and there was a feeling that common sense would prevail. Adopting Lean created a common language for everyone to use and over time a new sense of optimism emerged where people felt that they could themselves influence change. Gaining Support and Buy‐in Early in the process, the feedback received from the front line staff was that the leadership was sending messages that were interpreted as “you are broken... we need to fix you”. This caused resentment and, therefore, resistance around change. However, the leadership team adapted and persevered. In order to support Lean process improvement methodologies as part of the ED‐GIM transformation, a group was put together that represented the interests of the whole organization (the group included roles like managers of allied health, and patient care units, physician leaders and other credible front line staff). In examining opportunities for change, there were a lot of meetings between medicine and the ED related to the scope of the transformation work, Lean itself, resource availability, and required skills. Developing a positive relationship between the department of Strong Physician Leaders help ease medicine and the ED was a critical step towards positive change. the burden of change... As UHN undertook their transformation project, the task force proactively targeted a group of physicians to engage beyond the conventional group of clinical leaders. . These physicians were educated in lean and were part of the journey every step of the way. The physicians selected were credible leaders (formal and informal) and also maintained a clinical practice. As a key strategy, the leadership team took those who typically resisted change or complained about it and asked them to participate in the process as decision makers.
To help drive Lean process improvements as part of the ED‐GIM transformation work, new physician leaders emerged who would ultimately be an important part of UHN’s success. One key success criteria that should not be underestimated is the importance of physician engagement. Although not necessarily the norm for hospital governance, UHN’s medical leaders had budget responsibility.
3
Given that Lean is not a single tool, but rather a methodology with a series of supporting tools and techniques, it was important that front line team (including physicians) actively contributed to the Lean process improvement journey. Fortunately, as one of the early improvement events, UHN was able to come up with a solution that would really win over the trust of the front line clinicians. The catalyst event referenced above was the introduction of multidisciplinary discharge rounds in the General Internal Medicine units (called bullet rounds). Getting clinicians engaged in this structured, but brief daily, interdisciplinary ‘huddle’ helped align the team, remove frustrations, and build trust in the improvement effort. People still refer to this Lean event. It helped garner support for the Lean methodologies being used. Creating a Measurement Culture Clinicians are trained to pay attention to clinical evidence. They understand data and will respond positively to a good case for change that is grounded in evidence or best practice. Dr. Howard Abrams (Division Head, General Internal Medicine) recalled how the department of medicine had been collecting data to support the case for improving patient flow before the Ministry had flow improvement initiatives on the radar. As it happens, in addition to being a physician, Dr. Abrams is also trained as an engineer. The goals of the Lean ED‐GIM transformation work were to improve patient flow, increase quality of care, increase patient satisfaction, and increase staff satisfaction. To hold themselves accountable they measured ED Length of Stay, decision to admit time, and bed turnaround time. Through the adoption of Lean, there was top‐down monitoring of key metrics that cascaded down to the front lines. This helped to keep an ongoing focus on improvement. They used visual management and several different mediums to communicate performance data regularly. It was through the use of information that UHN was able to identify opportunities and drive improvements. Paradoxically, as the organization became proficient at capturing and sharing data, front line staff were becoming overwhelmed with the information. Dr. Anil Chopra (Medical Director, Emergency Department, Toronto Western Hospital) recalls daily updates, regular team huddles among other communication methods. His key take away was that “good communication needed to be succinct”. He felt that as the process improvement efforts matured and improvement teams got familiar with looking at information, there was an increasing value to summarizing and analyzing the data less frequently as opposed to sending raw data regularly. Achievements Throughout the years, UHN has implemented a number of pilot projects and full roll out of initiatives. There have been a wide variety of successful initiatives. Some of these include: standard order sets; team‐aligned allied health staffing models; GIM rounds with interdisciplinary team (bullet rounds); Electronic white boards; and a Rapid Assessment project in the ED.
4
Day(s)
Figure 1. Allied Health Alignment Results Traditionally, physicians working the ED and GIM are aligned by ALC days per patient & AH Referral to pt. D/C team, whereas previously at UHN, Allied Health providers were 18.2 20 14.7 Pre located geographically (i.e. by 12 15 10 Post floor). As the Allied Health staff 5.7 5 would regularly rotate floors, this 0 arrangement required them to ALC Days/Patient AH referral to Pt interact with multiple physicians. Discharge Communication between the two groups was difficult due to the lack of a consistent team structure. Through Lean, the improvement team suggested aligning Allied Health providers with physician‐based teams. As a result, there was improved communication, standardization and increased patient and staff satisfaction. There was an 18% decrease in ALC patient days and a 68% decrease in the time between Allied Health Provider referral to patient discharge due to the gained efficiencies in the new structure.
Early in the process, the team identified an improvement opportunity with bullet rounds. Previously, there was no standardized format for bullet rounds and no tracking of action items. An interdisciplinary team engaged in a 4.5 day focused event to create a standard agenda for all disciplines to follow during bullet rounds as well as a control board to monitor the progress of bullet round action items throughout the day. As a result, 3 months later, there was a 73% increase in ALC discharges prior to 11am, thus creating bed availability to move admitted ED patients early in the day. Staff commented that unnecessary delays were being reduced and noted an improvement in interdisciplinary communication and patient care planning. Prior to the Lean transformation work, relevant information was not being shared with the appropriate staff due to the large number of different data sources. Also, some information was lost or not documented, causing communication gaps between staff and disciplines. The improvement teams implemented a centralized electronic whiteboard that allowed interdisciplinary information to be inputted and displayed in real‐time. The electronic inpatient whiteboard became a centralized communication tool and captures new information captured (i.e. estimated discharge date). Staff reported improved interdisciplinary communication, continuity of care, improved discharge planning and reduced time searching for patient information. 85% of respondents strongly agreed or agreed that the Whiteboard improved and standardized communication within the care team. To illustrate “success”, Debra Davies (Manager of the ED, Toronto General Hospital) talked about what she felt were some of the biggest successes. She recounted a recent story about a staff meeting in her department. They were reviewing their daily metrics and realized that some of the numbers seemed off. She asked, “Why?” The team quickly identified that blood was sitting in the blood box ready for pick up, but nobody knew. They talked briefly about what could be done and moved on to the next item on the agenda. The next day, when Debra came to work, she noticed a flag that someone had made 5
Figure 2. Electronic inpatient whiteboard information flows (pre and post implementation)
Post state
Pre state
Verbal Comm.
Bullet Rounds
Patient Chart
Greaseboard
AH & CCAC Consult Status
Patient
Nursing Kardex
Paper Consult Misys Whiteboard
Patient Chart
Greaseboard AH & CCAC Consult Status eWhiteboard
Patient
Paper Consult
Misys Whiteboard Nursing Kardex
Bullet Rounds
themselves to put in the blood box when it was ready for pick up. What she’s most proud of is how far the staff has evolved with Lean and the initiative they demonstrate through issues like these where they were able to identify an issue based on the data monitoring, identify the root cause, and implement a simple solution almost immediately. Through the Lean transformation in the ED and Medicine, there were some side benefits that were not directly part of the metrics that were being monitored. The improvement teams made up of front line staff, physicians and managers became leaders in change. Now, the staff in the ED and Medicine understands the benefit of using a structured approach like Lean. This has helped to earn a lot of goodwill towards ongoing improvement projects. “Change has become easy”, said Debra Davies (Manager of the ED at Toronto General Hospital). Sustainability Two of the common themes in UHN’s reflection on this Lean journey are the self‐identified importance of sustainability and a shared frustration with their own success in sustaining performance gains. Sustainability planning took a back seat to achieving improvements in the early days of the transformation effort and plans to maintain gains lacked rigour and clear ownership. The expected frustrations of maintaining momentum and sustaining improvements should not, however, suggest that there have been no lasting benefits. Quite the opposite seems to be true. UHN has successfully created a Lean friendly culture. The focus for flow at UHN has now evolved to examine the entire system not just on ED.GIM. There is now a UHN revised Flow Strategy that reflects internal and external flow with many leaders across the organizations engaged in moving patients through the system efficiently and safely.
6
The initial transformation program worked because from the CEO down, there were mechanisms to provide resources and hold people accountable. To date, monitoring patient flow from the ED to Medicine continues to be a priority for the senior leaders. In addition to sustaining gains made through the Transformation initiative, one of the biggest challenges for staff, physicians and managers has been putting aside dedicated time to continue to innovate and implement new improvements. When dedicated time and resources were phased out, the program areas struggled to drive incremental improvements and the upward trajectory of performance levelled off. UHN is currently reviving its momentum around process improvement and is looking closely at what it takes to sustain improvements. One of the tributes to UHN’s success is the fact that although, they may not yet be able to declare victory that they have sustained their improvement program, they no longer have to face the same resistance that they did five years ago. Now, there is a willingness to participate and be part of process improvement in the ED and Medicine. Lessons Learned For UHN, there is no doubt that their focus and commitment to process improvement has been significant and the outcomes should certainly be considered a success. When the leaders at UHN were asked about their key lessons learned over the last few years, this is what they said:
“Get the entire team involved in improvement events”. They are not as successful if the whole team is not involved “Improvements need to be seen as a permanent fixture, rather than a project”. Projects inherently have a start and end date. Process improvements will ultimately fail if they are only associated with a project “Be mindful of all of the competing priorities”. Don’t try to implement too much change in parallel (focus on one big thing at a time). The sequencing of events can sometimes be very important “Make the focus of improvement patient‐centred” “Use evidence to drive changes”. Healthcare providers are trained using evidence. They understand data and will respond positively to a good case for change that is grounded in evidence or best practice “Do the right thing”. If the right people are engaged at the beginning of the process and are in alignment that they are all trying to do the right thing (i.e. whatever is in the best interest of the patient), these stakeholders will be more patient to go through a long process improvement journey “Language means everything”. Getting to a common language early will help avoid misconceptions when starting to talk about things like “non‐value‐add”. “There is a real cost to engaging front line staff in process improvement (with a significant related benefit)”. Typically front line staff need to be backfilled in their clinical roles. Too often organizations minimize engagement due to budget constraint. 7
“Front line staff needed to see their managers listening and supporting them”... For example, when trying to improve time to inpatient bed, there were occasions where a bed was available, but taking a new patient was not possible for a variety of reasons. Managers needed to show support when issues were legitimate. This helped to establish goodwill and ultimately resulted in greater support for doing the right thing. “When processes are people dependent, things fall down”. When tools were developed and rolled out, they were typically more sustainable. “It is important to spend time aligning on metrics”. Challenge the team to ask questions like “how do you know something has worked?” “Given that the issues in the ED reflect a systems approach, labelling the transformation projects as ED‐GIM made it seem like an “other” area to those not directly part of the program”. This can make it hard to get traction on initiatives outside of ED and Medicine.
About UHN: University Health Network (UHN) is a major landmark in Canada’s health care system and a teaching partner of the University of Toronto. Building on the strengths and reputation of each of our three remarkable hospitals, Toronto General Hospital, Toronto Western Hospital and Princess Margaret Hospital, UHN brings together the innovation, talent and resources needed to achieve global impact on the health care scene and provide exemplary patient care. For more information, visit www.uhn.ca
8
