Lean Leadership Practices to Achieve Business Results

Transcription

1 Lean Leadership Practices to Achieve Business Results Craig T. Albanese, M.D., M.B.A. Vice President, Quality and Performance Improvement John A. and Cynthia Fry Gunn Director of Surgical Services Stanford Children s Health Professor of Surgery and Pediatrics Stanford School of Medicine Stanford, California 1

2 Learning Goals Understand that a lean leader s primary job is align the organization Understand the four lean leadership practices necessary to achieve long term business results Be able to describe the ascension paradox of the lean operating system Review a 3 year journey to decrease preventable harm in one hospital

3 Healthcare challenges Patient is customer Patient is the product complex mixed product lines Secondary products are trainees Emotional connection required Medical/Nursing training teaches disease management not process management Deeper than usual silos in an academic hospital; disconnected reporting structures Unusually powerful position of MDs, outside of management hierarchies The mindset that MDs are the internal customers of many processes Conservative, evidence-based nature of attitude to change Truly 24/7 nature of a hospital

4 Why Lean? Clinical Outcomes *Experience of Care Value Cost Healthcare reform and consumers demanding: Cheaper, faster, better, safer, kinder for individuals and populations *Patient and Staff Experience

5 QCDSE = Business Results or Enterprise True North metrics Q -- Quality C -- Cost D -- Delivery (Access) S -- Safety E -- Engagement/Experience (Patient & Staff)

6 A lean leader s primary job is to garner alignment Vision Mission Strategy Culture Goals Values Activities Lean Behaviors Processes Outcomes Quality Cost Delivery Safety Engagement/Experience

7 Level 5 (optimize) Level 4 (takt environment) Level 3 (match capacity to demand) Level 2 (Stability) Level 1 (Foundation) No Waiting Innovation to improve access, cost, empathy Set staff cycle times Staff Standardized Work Clinical standardized work Detail patient flow & lead times Establish flow Initiate clinical std work Leader engagement Extraordinary Patient Care Highest Quality, Safety and Empathy; Easiest and Timely Access and Lowest Cost Level loading Quality & service stds. Management System / People Development Refine leadership s & workforce s PDCA skills Refine strategy deployment Manage to standardized work & level flow Immediate andon response Workflow control Control process variation Visual management and problem solving Customer = patient Success metrics Shared values Staff to demand Quality First Innovation to improve quality / safety Verify at the source Use andon for process stop to meet the standard Successive check Understand cadence (takt) Methods, Equipment, Staffing, Supplies (MESS) + 5S Value stream thinking

8 Frontline feedback that can be addressed with lean leadership practices I don t ever see the senior leadership team members Senior leadership doesn t understand our issues We are being asked to change and we don t know how I am overwhelmed by the number of problems we have We are overwhelmed by the number of initiatives to be worked on I ask for help and I rarely get it in time The leadership team is always in meetings Leadership says they are supportive but I don t see evidence of it except they are supporting all of these high priced consultants

9 Leadership Practice One: Goal Alignment/Deployment

10 Catchball Top Down Themes: Process looks easy hard to get true alignment Deprioritize work! Room for LODO activities Catchball: Negotiation Takes time Better buy-in = better goals Develop the enterprise vision and mission Define Strategic Initiatives Define the Core Goals for next year Cascade goals to all levels and functions Execute monthly process, review, and adjust Execute yearly process reviews Catch ball

11 Goal Alignment for Stanford Children s Health

12 Core Goals FY16 Category Quality Executive Owners Albanese FY16 Core Goal Achieve 2 Quality Metrics in HAC (Healthcare Acquired Condition) aggregate and SSE s (Serious Safety Events) SSE s <=1 per month, HAC s <= 8 Service McCune, Roberts Ambulatory Care: LTR across specialties to equal 92.3 or above or 80% of specialties (with more than 25 responses) above 92.3 Inpatient Pediatrics, OB and Ambulatory Surgery achieve or exceed their FY 15 Likelihood to Recommend mean score. Affordability Haering Achieve FY 16 Operating Expense & Capital Budget (where applicable) in each Division Innovation & Education Respect for People Sandborg Souza Improve manager, physician, and employee effectiveness by developing leaders as coaches. In FY 16, 200 people managers (including managers, directors, VPs, executives, medical directors and service chiefs) will attend Coaches Academy and lead, co-lead or otherwise participate in Quality, Affordability and/or Service improvements in their respective areas of responsibility throughout the enterprise. Increase Grand Mean Engagement score by 0.1 point. Reduce the Rate of Injury for all employees to 5.3 per 100 FTE s Implement 3000 staff/provider generated improvements (STP s) Situation Target Proposal

13 Strategic Initiatives FY 16 Strategic Initiatives Hospital Expansion, Transition and Activation FY16 Executive Owners McCune Initiative Statement To deliver a facility that optimizes the hospital s services and infrastructure, supports innovation, enhances the patient and family experience and enables extraordinary care as a top-tier children s hospital. Strategic Partnerships current, expanded and new Roberts, Lund Be the indispensable pediatric (specialty) partner for leading healthcare systems. Physician network/practices - includes Enterprise Wide Scheduling, Epic Optimization, Telehealth Vision 2025 clinical program initiatives Centers Of Excellence, others Roberts, Lund McCune Be the must have pediatric and obstetric physician practice [or network]. Develop programs and services, leveraging our preeminent faculty and staff, to advance our capability to provide care, create leading research and innovation, and to achieve unparalleled quality, outcomes, service and access. Accountable Care Infrastructure and capability development for population health, complex care management Brown, Sandborg Prepare Stanford Children s Health to participate successfully in current and future accountable care and population health management contracts with commercial payers, large employers, and state agencies.

14 Operational Initiatives FY16 FY 16 Strategic Initiatives Executive Owners Initiative Statement Better Patient Flow Albanese Better patient flow for patients, staff and the organization; today and for the future. PCARES Plus McCune PCARES Plus is an enterprise-wide learning platform that governs respectful, empathic, nurturing and meaningful interactions across the entire human experience spectrum to include all staff and physicians, their interactions with each other and with families and patients.

15 Enterprise Strategic Initiatives Visibility Wall Cross-functional communication Cross-functional accountability Biweekly 30 minute huddle run by CEO, COO or delegate Invited attendance by C-level, VPs, applicable Directors Initiative owner provides brief status update ( 5 minutes) Focus on reds, with appropriate countermeasures Annual planning process starts & ends with the wall contents

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17 Leadership Practice Two: Promote Continuous Improvement

18 Value stream flow = Patient flow Home Home Transport Admission Treatment Discharge Transport

19 Focus on the X s not the Y Y is the outcome we want X s are the processes/drivers that need to be controlled to get the Y Y X1 X2 X3 X4 Q D C S E Method Equip. Supply Staffing Standardized Work Std work and DMS are how to control the X s Daily Management

20 Using standards as problem solving tools Make issues (abnormalities) visible by implementing standards and measuring the actual output against the expected output Then do PDCA to solve the issues at their root (in contrast to quick countermeasures) so that they don t continue to reduce efficiency This approach requires leaders to be very tenacious about continuously applying the PDCA cycle

21 A Daily Management System Sustains the Improvements

22 Components of Daily Management DMS Principle Definition Reliable Method/ Standardized Work A documented procedure (i.e. how to) with sequence, supplies and quality toll gates, owned by a named individual, used by everyone. When the element of time is added, it is deemed Standardized Work. Reliable Method or Standard Work Audit/Check A structured check of the process to ensure Reliable Method is followed Abnormality & Andon Problem Solving: Improvement Ideas (STPs) Visual Management Tiered Huddles Andon Response A system to immediately notify appropriate management, maintenance, providers and other team members of a safety, quality, process or problem requiring a countermeasure. May involve abruptly stopping a process. Continuous improvement process generated and implemented by the frontline, with assistance and coaching from leadership. STP = Situation, Target, Proposal. A strategy for creating, supporting, and sustaining process stability through the use of visual cues. Brief, structured, stand-up meetings used to review area readiness and identify problems. A tiered system to immediately respond to an andon. Involves team leads and a variety of managers. Quick countermeasure and root cause problem solving required Leader Standardized Work: Responsibilities for Leaders A working document (checklist) for leaders specifying the actions to be taken each day to focus on the processes in that leader s area of responsibility. Leader Gemba Walk Each level leader above the work unit routinely observes the workplace with the department leader/student for the purpose of supporting the work processes

23 Leadership Practice Three: Develop Self

24 Servant Leadership Practices Communicate vision: what is ideal future state, create dissatisfaction with current state Appeal to head (intellect) and heart (emotions) Walk the Talk go see reality at least once a week Humble inquiry Listen more than talk Engage the frontline workers: What is getting in your way of doing your job? Review metrics with area management Foster value stream thinking: build span of support versus span of control (authority v responsibility) Celebrate the wins

25 Leader Standardized Work Calendar gemba time: used for time with direct reports and observing the real work in the hospital/clinic. No cross-functional meetings Debrief gemba walks at team meetings Attend weekly improvement report outs Attend daily Ops huddle Sponsor improvement event Participate improvement event Construct and own an A3 Complete STPs (Situation, Target, Proposal)

26 Traditional Management Focus on outcome ( get results ) Attaining goals trumps all else Lean Management Focus on standardized processes that get the desired outcome Developing people has equal weight to goal attainment Manage to industry benchmarks Metrics visible to few Batch and retrospectively review results Management tells staff what to do Manage from office Problems are bad Who produced the error? Autocratic, top-down problem solving Manage to customer requirements Metrics visible to all Real time and prospective view of data/results Management questions, challenges, coaches and offers help to staff Manage in gemba Problems are treasures What suboptimal work process(es) or system produced error Guided, distributed, participative problem solving Autocratic, top-down goal creation Organizational success attained by time-intensive analysis and design of perfect fix Guided, distributed, participative goal creation Success through continuous, rapid, small, incremental improvements

27 Leadership Practice Four: Develop Others

28 Creating a strong air campaign 1. Pit the vision of where you want to be against the reality of the current state to the organization 2. Educate and engage the workforce through: 1. Point improvements 2. Lean pedagogy 3. End of week improvement report outs 4. Plethora of varied communication methods 5. Lean learning trips and networking

29 Create a strong ground 1. 3 Actuals Walk campaign 2. Make good practices easier to do -Calendar gemba time, improvement time 3. Make bad practices harder to do -Decrease meeting times, s, outside interferences, etc 4. Reduce the choices of what to work on A items, B items, C items 5. Make losers whole 6. Emphasize succession planning and leader development

30 Gemba Coaching Kata Questions (Mike Rother, Toyota Kata) 1. What is the target condition? 2. What is the current condition? 3. What obstacles are preventing you from reaching the target condition? 4. Which one are you working on now? 5. What is your next step? 6. When can we go and see what we have learned from taking that step? Key concept: Coaching = asking, not telling

31 Ascension Paradox of the Lean Operating System Want to get to Level 5 as quickly as possible (biggest cost down and quality increases) Latent problem: real work is at foundational level 1 (alignment/understanding) Level 1, if done correctly, takes time, patience, learning to walk again, and is difficult No real QCDSE gain at during level 1 work

32 Lean Levels Quality / Safety Cost Reduction Leadership Effort Consistent Patient Experience Level 5 Mistake proof 45% Level 4 Self-inspect 30% Level 3 Unit inspects 10% Level 2 discharge 5% Level 1 Patient inspects 0%

33 No Waiting Extraordinary Patient Care Highest Quality, Safety and Empathy; Easiest and Timely Access and Lowest Cost Management System / People Development Quality First Level 5 (optimize) Level 4 (takt environment) Level 3 (match capacity to demand) Level 2 (Stability) Level 1 (Foundation) Innovation to improve access, cost, empathy Set staff cycle times Staff Standardized Work Clinical standardized work Detail patient flow & lead times Establish flow Initiate clinical std work Level loading Quality & service stds. Refine leadership s & workforce s PDCA skills Refine strategy deployment Manage to standardized work & level flow Immediate andon response Workflow control Control process variation Visual management and problem solving Leader engagement Customer = patient Success metrics Shared values Staff to demand Innovation to improve quality / safety Verify at the source Use andon for process stop to meet the standard Successive check Understand cadence (takt) Methods, Equipment, Staffing, Supplies (MESS) + 5S Value stream thinking

34 How do we go faster? The role of leaders Alignment, alignment, alignment Link to strategic/ops plan: What do we have to do? Decommission work! Develop improvement capability in ops (not just PI team) Management system: tenacity Value stream management: adjudicate responsibility v authority tensions Make the big decisions

35 Example of Faster: Periop Work Group On July 31 st 2015, the 3:15 Periop Scheduling Meeting ran for over 1 hour, due to sorting and accommodating bed requests for following day of surgery. Consensus was that another meeting needed to be scheduled earlier to confirm, organize, and accommodate all OR bed requests. Following the initiation of this daily huddle, a Periop Work Group formed to create a solution to manage the OR schedule further in advance in order to decreasing delays and cancellations, overburdening staff, and going through extraordinary measures to accommodate our scheduled cases. Aug 3rd Initiation of Scheduling Meeting Aug 17 th Aug 20 th Aug 26 th Aug 31 st Surgical Cap Implementation Meeting Future State Cap Implementation & Rescheduled Cases Meeting >T-1 Level Loading Meeting: Trial Process >T-1 Level Loading Meeting: Finalized Process Sept 8th GO LIVE 1. Level Loading Daily Timeline 2. Surgery Scheduler Daily Bulletin

36 A Business Problem We averaged over 3 serious safety events per month Most are preventable

37 Leaders Actions to Decrease SSEs Align organization around the problem: Do we agree? Deploy as an annual goal for all work areas Deprioritize work Support roll out of standardized processes, waste elimination, blend into our management system, PDCA Develop self: humble inquiry, review process metrics Develop others: coaching kata, tenacity

38 Escalating Safety Problems Tier 1a: 0700/1900 Charge RN and staff Tier 1b: ~0800 Charge nurse(s) and managers Tier 2: 10:15 Managers and Directors Tier 3: 10:30 Directors and VPs

39 Culture of Safety Survey (AHRQ) Question Description Change P-Value My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures 62% 73% 11% 0 The actions of hospital management show that patient safety is a top priority 67% 73% 6% We are actively doing things to improve patient safety 79% 84% 5% My supervisor/manager seriously considers staff suggestions for improving patient safety 73% 78% 5% In this unit, we discuss ways to prevent errors from happening again 65% 70% 5% When a mistake is made, but has no potential to harm the patient, how often is this reported? 47% 53% 6% After we make changes to improve patient safety, we evaluate its effectiveness 60% 65% 5% Mistakes have led to positive changes here 60% 65% 5% When a mistake is made that could harm the patient, but does not, how often is this reported? 64% 69% 5% Hospital management provides a work climate that promotes patient safety 72% 76% 4% Staff feel free to question the decisions or actions of those with more authority 43% 47% 4%

40 SSE Count Organization Wide Effort 54% Decrease! 9 Serious Safety Event Counts By Month Pre-Intervention Intervention Post-Intervention Year-Month SSE Count UCL +2 Sigma +1 Sigma Average -1 Sigma -2 Sigma LCL

41 Role of Leaders Promote Alignment Clinicians/Staff/Patients Managers Directors VPs Servant Leadership CEO Support Continuous Improvement Communicate Go See Remove Barriers

42 Role of Lean Leaders Vision Mission Strategy Culture Goals Values Activities Lean Behaviors Processes Outcomes (Business Results) Quality Cost Delivery Safety Engagement/Experience

43 Thank You! Please complete the session survey at: Session: TP/06 Achieving Business Results Craig Albanese Stanford Children s Health calbanese@stanfordchildrens.org