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Leading With Lean at Rouge Valley

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Central East LHIN Board of Directors

April 25, 2012

Rik Ganderton

President & CEO, RVHS

Agenda

1. What is Lean?

2. Transforming with Lean at RVHS

– Leadership

– Examples of Improving the Patient Experience

through Lean

3. Where are we now?

4. Lessons Learned

5. Opportunities and Next Steps for RVHS

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What is Lean? Lean is a management philosophy by which customer value is

maximized, while waste is minimized. Lean is a process for optimizing value for customers, while making the most effective use of resources.

• Lean is not mean – quite the opposite – it respects and engages team members

• Lean does not mean cutting jobs in the name of cutting costs (In fact, cost cutting should not be connected with Lean)

Our “customers” are patients. Lean puts patients first through these basic tenets

• Respect for People• Respect patient/family time, input, privacy, dignity – e.g. deliver on our Patient

Declaration of Values

• Respect staff skills – involve staff and physicians; use their time wisely; optimize the processes in which they work; connect their role – wherever they work – to the corporate vision/mission

• The elimination of waste• Waste is non-value-added activity; Value is defined by patients

• Making good quality repeatable, sustainable

• Eliminate long wait times

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What is Lean?

• Fundamentals of Lean

– Data driven measurement – If you can‟t measure it you can‟t manage it

– Visual Management – transparency and accountability –you have to see it to manage it

• See the exceptions, measure them, fix them

– You have to be visible to manage

– Management is about coaching and developing not telling and doing

• Front line staff know more about the problems and solutions than the manager

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Transforming with Lean at RVHS• Since 2008, we have been using Lean as our enterprise-

wide management philosophy and supporting tool kit

to help our resource-constrained management team

address the broad scope of change required; all leaders

are required to lead and manage using the Lean

Management Philosophy

• We provide extensive Lean training and management

development to give all leaders a consistent approach

for how we expect the organization to be run

• We established a Transformation Management Office

(TMO) to assist leaders and frontline staff with ongoing

coaching, support , facilitation and basic training (we use a 4

step approach: engagement, improvement, sustainment and spread)

• We access external Lean expertise (less every year)

for regular coaching, advanced training, facilitation of

new techniques

• We have developed the STAR framework (see next

slide) to communicate a common set of expectations for

all departments

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" In a lean environment, the expectation is

that everyone has two

responsibilities. The first is to run the

business on a day-to-day basis. The

second is to improve the business, or

contribute to improving it

continuously."

(David Mann in “Creating a Lean Culture: Tools to

Sustain Lean Conversions”)

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Continuous improvement – Our STAR FrameworkDefining Goals for Lean Deployment and Sustainment

STANDARDAll of the following are in place:

• Process Control Boards

• Performance Trending

Boards

• 6S

• A3

• Rounding

• Kaizen Participation

• Leadership has had Lean

Expert Tools Training

ADVANCEDAll of the following are in place:

• Sustainment of Standard

level

• Kamishibai (daily quality

audits)

• Safety Calendar

• Idea Board with problem-

solving huddles

• Department leads and

sustains its own kaizen

events (at least 2 per yr)

ROLE MODELAll of the following are in place:

• Sustainment of Standard and

Advanced levels

• Internal knowledge sharing(joint kaizen with another dept;

facilitator for another dept‟s Lean

event; lead an in-service; internal

article or poster presentation)

• External knowledge sharing(e.g. joint kaizen event with

external partners; conference

presentation; published article)

• Use of one or more higher-

level Lean tools (e.g. Kanban,

Andon, SMED/changeover, etc.)

2010/11

2011/12

2012/13

90%

100%

10%

100%

0%

10%40%

67% 33%Target

achieved

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Embracing Lean as a Management PhilosophyLean thinking helps in moving leaders from crisis management mode to a greater focus

on improvement, innovation and strategy

Top Management

Middle Management

Line Management

Front line

Maintenance

Innovation

Traditional perception of job functions

Top Management

Middle Management

Line Management

Front line

Maintenance

Improvement

and

Innovation

World class perception of job functions

“Kaizen”, Imai, 1986

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A New Brand of LeadershipStrong Leadership Attention is Key

• Dedicated hospital-wide Gemba Time, 2 hours/day

• Transformation Rounds (twice per month by entire senior team)

• Regular Senior team walkabouts with the CEO

• Transformation Updates in monthly Leadership Forum, Town

Halls, President‟s Blog, newsletters, President‟s Report to the

Board and a standing agenda item in key meetings such as

Medical Advisory Committee

• Public blogs on how Lean works for patients – routinely posted

• Presentation on Transformation at every orientation session for

new staff

• Lean incorporated into Personal Business Commitments

• Lean sustainability measure reported on the corporate scorecard

• STAR Framework sets expectations for all departments

• Senior leaders deliver workshops on Lean topics

• Lean Leadership Culture Survey conducted every 6 months

Visibility

Communication

Role Models

Self-Reflection

Accountability

Lean and the Board

Lean used to drive and support the implementation

of corporate strategy

Board involvement is a key part of the oversight of

our accountability framework:

• Lean orientation and education

• Monthly Transformation Updates as part of President‟s Report to the

Board

• Monthly reporting on Lean indicators related to sustainability and

engagement on corporate scorecard

• Evaluating CEO performance on Personal Business Commitments

(PBCs) related to Lean

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Improving Patient Experience through Lean

Because of our application of Lean our patients now

Wait less time for

• Emergency department care at RVC and RVAP (plus improved ambulance offload times)

• Lab & diagnostic imaging results (hours vs. days)

Go home sooner thanks to improved patient flow, discharge planning

Walk less distance at pre-admit clinics / our professionals come to them

• Thanks to our pre-admit clinic introducing one-stop-shopping to reduce the # of steps walked by patients with bad hips and knees

Cancel fewer surgeries thanks to enhanced pre-surgical screening

Waste less of their time filling in forms

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1111

Start of Kaizen End of Kaizen

Manual cycle time

(sum of time spent

for all staff

involved)

53.3 minutes 33 minutes

OR changeover

time

15.6 minutes 12.7 minutes

# of room exits to

clean room

12 5

# of operating

procedures

performed each

year at RVAP

6700

Reducing OR changeover time

on every procedure by only 3

minutes saves 335 hours per

year that can be used for more

procedures!

Operating Room Changeover Kaizen Event

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RVAP Pre-operative Screening Visit Redesign (new)

Before Kaizen After Kaizen

Average Visit

Length

7.56 hours 1 to 3 hours

Patient

Movement

493 steps

Patients travelled to

various departments

(Lab, DI, ECG)

246 steps

Patients stay in one room; staff

come to patient and use coloured

„fingers‟ for visual management

% Patients

Screened

Pre-operatively

20% 90-100% (some by telephone)

Cancellations

of surgery

because

patient not fit

37 (08/09) 7 (09/10)

Timeliness of

Surgery

Surgery delayed due to

incomplete

documentation

95-100% of charts complete one

day prior to surgery and

93% of patients ready by 30

minutes pre-booked Operating

Room time

Antibiotic Use Unknown (but much

less than 100%)

100% of patients given IV

antibiotics pre-Total Joint surgery

as per national guidelines

Sustained and

spread to

Fracture Clinic at

RVAP

131

79%

TBD

TBD

77%

68%

59%

Post-6S

35%

TBD

TBD

5%

18%

11%

Pre-6S

81%2W Audit Score – Clean Utility

Room

73%2W Audit Score – Medication Room

TBDAvg Monthly Medication Cost

TBDAvg Monthly Medical Supplies Cost

93%2W Audit Score - Hallways

44%Staff Satisfaction (n=12)

% ChangeMetrics

79%

77%

68%

59%

Post-6S

35%

5%

18%

11%

Pre-6S

81%2W Audit Score – Clean Utility Room

73%2W Audit Score – Medication Room

93%2W Audit Score - Hallways

44%Staff Satisfaction

% ChangeMetrics

79%

TBD

TBD

77%

68%

59%

Post-6S

35%

TBD

TBD

5%

18%

11%

Pre-6S

81%2W Audit Score – Clean Utility

Room

73%2W Audit Score – Medication Room

TBDAvg Monthly Medication Cost

TBDAvg Monthly Medical Supplies Cost

93%2W Audit Score - Hallways

44%Staff Satisfaction (n=12)

% ChangeMetrics

79%

77%

68%

59%

Post-6S

35%

5%

18%

11%

Pre-6S

81%2W Audit Score – Clean Utility Room

73%2W Audit Score – Medication Room

93%2W Audit Score - Hallways

44%Staff Satisfaction

% ChangeMetrics

6S on Inpatient Medicine Unit

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Human Resources Recruitment Kaizen: Time to fill job vacancies

Before doing a kaizen on

recruitment, average time to fill

was 83 days. With the

improvements made, the

department has been able to

handle a 70% increase in

volume

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Where we are now?Lean improves current state, while being an investment in the future

Almost all areas of the hospital have made some form of Lean improvement (we have done close to 100 Lean events since 2008)

Financial and operational stability have occurred at the same time as we have preserved or enhanced the quality of care

We are building internal capacity to deploy and sustain Lean over the long-term consistent with LHIN and Ministry directions (we have provided over 300 hours of Lean training)

Cultural Change is happening (greater trust, transparency and accountability; Lean terminology is widely used; high use of A3 thinking)

Voluntary turnover is down and 2010 staff survey results indicate that trust, involvement in decision-making and satisfaction with the organization have increased since 2008

Physician leaders are engaged

Lean used to support corporate priorities including accreditation, enterprise risk management, redevelopment, pandemic planning

Positive change in our reputation with our community partners (e.g. LHIN, CCAC, EMS); joint kaizen events with other health care organizations

Growing external recognition for our achievements

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Lessons Learned Lean is not a project – it is a long-term journey

Lean is 80% culture and 20% tools

Having a corporate or system-wide burning platform to stimulate change is essential but not sufficient; individual value propositions are also necessary for real buy in –What’s In It For Me!

Strong, ongoing, united leadership commitment is essential

Lean is harder for leaders than for frontline staff Leaders must

Learn to lead differently

Be visible in the „gemba‟

Empower staff to identify problems and find solutions

Make problems transparent and not take it personally

Lean has to be supported by a rigorous accountability framework

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Lessons Learned

Physician involvement is critical

• But be strategic about it because they really are busy

Expect growing pains as Lean becomes standard

• Staff can feel frustrated or constrained (transitional states)• Improved results can be difficult to sustain and setbacks are to be expected

• Lean tools and creating more standard work can be perceived as loss of the

freedom staff members have to be impactful. This is a growing pain. The more the

process and tools are used, the better the engagement.

• Training and coaching staff to think and work within an increasingly Lean

environment is key to future progress, innovation for patients.

Lean is not about cost savings – It is about the patient

experience – Good quality costs less

Communicate, Communicate, Communicate!

• Did we mention communicate? – repetition helps

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Opportunities and Next Steps

1. Sustain our gains and further embed (or „hardwire‟) Lean thinking in

the fabric of our organization to help us to be The best at what we do.

2. Foster a culture of daily continuous improvement

3. Continue to build internal capacity and invest in our leaders

4. Strengthen the link between quality and Lean transformation

5. Collaborate with health system partners on transformation initiatives

(e.g. region-wide value stream analysis on diabetes)

6. Position RVHS to be an industry leader in a new health care

environment in which Lean is endorsed by funders – and hospital

revenue and leadership compensation are tied to quality,

performance and efficiency.

Thank you

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Questions / Discussion