The Flinders JourneyJane BasshamClinical Facilitator Redesigning CareJane.Bassham@fmc.sa.gov.au

Healthcare in Australia• Healthy private sector

– > substantial amount of all elective surgery is done privately for all sectors> public hospitals are emergency driven

• Links between Primary Care & secondary/tertiary are problematic – Primary Care fee based & Federally funded; – secondary & tertiary care hospitals are output formula funded, by state

govt> messy & linking primary to hospitals is an issue. – By international standards, people have good access to primary care.

• Hospitals are funded through a casemix approach> los in hospital are short by international standards

• Hospitals like FMC are very well equipped with capital investments eg CT, MRI, angiography capability, etc.

Flinders Medical Centre

• Adelaide, South Australia, population 1 million• FMC catchment of 350,000 • Public tertiary teaching & research hospital• 4,000 employees• Trauma centre (incl. obstetric trauma), infant to old,

medical, surgical, gynaecological, obstetric, paediatric, neonates, Mental Health (regional service)

Flinders Medical Centre

• 500 beds• Of overnight stays: 15% elective; 85% emergency

work• ED 54,000 presentations a year- highly predictable

arrival– 55% discharged from ED, 45% admitted

• Admitted medical/surgical patients:– 51% short < 60hours, – 36% longer >60+ hours – 4% > 14 days

So where did the FMC Lean Journey start?

• With a crisis, of course!• Winter (May-June 03) FMC struggling: we’re in the

paper regularly• Overcrowding in ED, delays in timely treatment, elective

surgery cancelled, regular hospital executive crisis meetings, ambulance diversion, clinical outcomes being compromised, staff unhappy

• FMC exec were taking this seriously & wanted a serious response

• Internal review of safety in the ED, external review of safety in the ED

What had we tried in the past?

• Managing Emergency Demand day: made all aware of problem, no real strategies came up

• Long stay outliers work• ED things: fast track, MAAT, nurse initiated things• Big Picture mapping-but what to do with it?• Best efforts but nothing had helped• Nationally other metro hospitals under same

pressures with little resolution

Why Lean?

• Looked internationally for ideas> went to UK, visited Modernisation Agency, saw 5 ED’s

• UK MA came to FMC the next week & we ended up doing a few things– Read Lean Thinking book (or bits of it)– Set up an improvement team/structure: each stream should

have a clinical leader & executive sponsor– Hospital targets based on flow– Redid ED flows & order patients were seen, the next week

Redesigning Care• An improvement team set up 2 1/2 years ago in response to

hospital crisis• Originally set up with Director, 4 Clinical Facilitators responsible

for a “Stream” each, with executive sponsor & clinical leader for each Stream, for 1 year.

• RDC team came from a variety of sources & backgrounds: medical & nursing clinical, epidemiology, management skills, project, research

• We are passionate about patient care• Managed our own, modest budget• Decided to use Lean Thinking, with Quality Improvement Wheel

& PDSA’s• So far RDC has survived a regional restructure & change of

hospital manager

Photo of the team with bandanas

Redesigning Care: Organisational Structure

Streams• ED Works• Surgical Stream• Medical Stream

• Support services Stream

• Combined work

FMC Management Executive

Redesigning Care Steering Group

StreamStreamClinical FacilitatorClinical Facilitator

Redesigning Care Program TeamDirector: David Ben-Tovim

Stream Work Stream Work GroupsGroups

LeadershipLeadershipGroupGroup

Executive support critical

• GM & Director key– For credibility- the hospital is taking this seriously– Knew more data than others– Able to address barriers– Authorise access to some data, meet with key

stakeholders, attend key mappings etc.– Attended the Lean Thinking studies, Lean service

summit etc– Driving forces

Redesigning Care

• Include access to data rich/hospital info, clinical epidemiology expertise, office manager support, computer programming support

• Attends weekly hospital executive• Reports regionally via Safety & Quality board

Education of the Team• Peter Walsh from LEA met with us for 3/7 where he discussed how Lean

Thinking applied to the manufacturing industry. EDON & RDC members attended

• 8 hospital members including GM, Clinical Governance Director, Senior Epidemiologist, RDC members attended 1 subject for 10/52 of LeanManufacturing Systems

• Conferences: including Lean in manufacturing, Uni of Michigan• Visited a local car factory• See (or read about) one, do one, teach one> taught staff ourselves• Read stuff: Lean Thinking, Lean articles, Toyota Way, Learning to See, Lean

Lexicon etc.• Learning log• PDSA’s learning by doing• Visitors: Ben Gowland, Lynne Massey, Ian Glenday, Kaizen Institute, Graham

Eagles, John Long, Ann Esain, Dan Jones, John Shook & Kate Sylvester• Organised 2 Australasian Redesigning Care Healthcare Summits

The Lean Team

What is our methodology?• Improvement wheel:

– project phase- scope of work, stakeholders etc; – diagnostic phase- big picture mapping, tracking, data analysis; – intervention phase- PDSA’s; – sharing learnings phase; – embedding & sustaining phase

• Lean Thinking principles & tools: – define your customer & what adds value from your agreed

customer’s perspective; – identify value stream; – look at flow & waste in the context of the value streams; – where things don’t flow try pull; – aim for perfection (continuous improvement)

• Analytical tools:– Demand & capacity– Glenday sieve

Redesigning Care“The Flinders Way”

P DA S

12

3

45

Diagnostic Diagnostic PhasePhase

Project Project PhasePhase

Sustain Sustain new waysnew waysof workingof working

Share key Share key learningslearnings

Intervention Intervention PhasePhase

P DA S

P DA S

P DA S

P DA S

Lean Paradigm•Learning to see•Value stream approach•Staff empowerment•Leadership style•Continuous improvement•Constancy of purpose

Lean Tools•VSM•Visual management•Standard Work•Flow tools•Built in Quality•Load levelling

How do we decide what to tackle?

• ID the key value streams/core business- will it have high impact for effort?

• Meet with GM & EDON to ensure we’re on the same page

• For FMC surviving next winter is paramount

Flow improvementsArea / value stream Main strategies / focus

Emergency Department Streaming, Paeds, 5S, standardised practice, B side & A side improvements, clerical processes

Medical & Surgical admissions Short stay ward, ward pull, visual management of patient flows (traffic lights)

General Medicine Short stay & long stay value streams in General Medicine, team based care, abolition of take system, Acute Assessment Unit, Standardisation of Ward round, Discharge communication

Pharmacy Improving discharge medication lead time

Central Sterilising Supply Unit Total process flow redesign

Cardiology Discharge ‘Flow’ Nurse, Introduction of Redesigning care as QI system, Patient journey visual management, Low risk chest pain

Mental health Redesign of flows, introduction of short stay value stream

Endoscopy 5S, Demand & capacity, flow redesign

Whole of hospital 5S of medication rooms

Work in early stages ICCU, Admissions, Cancer, Older patient, Transition Care

Education of Hospital Staff: foundation for Transforming the Organisation• Key elements

– Communication: written, usual meetings, special meetings, regular forums

– Education strategies:• Lean Days• Immersion program• Summit

– Workgroups– Consistent approach to problem solving, language,

structure/methodology (quality wheel, PDSA’s applied on a background of Lean principles & thinking)

– Leaders: 1:1 focus by RDC members

• Impacted on 10% of employees to date

Struggles

• Change management– Personally challenging– communication

• What to work on & what/when to stop working on something• Not all immersees are go-ers• Some stakeholders not engaged• Embedding & sustaining work• Standardised work• Engaging junior doctors• Rotating medical staff• Different system in hours, after hours, weekends• Structures not aligned with value streams & flows• What is a value stream manager, anyway????• Regional engagement• Business case• When to transform the organisation

Learnings• Leaders essential:

– Executive support/sanction essential– Clinical leader for each stream

• Set up an improvement team structure if you’re serious: people time & tools to impact

• You don’t have to have a consultant to do this• Don’t start with a restructure or IT solutions• Have one or two targets for whole of hospital that are linked with flow• Start with a win, need to measure stuff (real time feedback for staff), even small

improvement of high volume stuff> biggest impact• Start with biggest problem v’s high volume• This is not a project & we don’t go away• Consistent approach- for us, that’s Lean• Deal with Value Streams & core business• Sphere of influence/scoping• Safety & Quality impact was surprising for us• Just do it!

What we think we have done

• Survived• Controlled the chaos• Tackled high volume in the core business• Found Value Streams• Made the hospital safer• Became Lean believers• Getting “flow” language into common use

Initial careM

Disch direct from ED type55-60%

Short Short stay Med/Card/Surg types

Op th 13%

Long

AAUprocess

CCUProcess

10%

Gen Med ward types

Spec Med Ward types

Surg spec ward types

Paeds short/long types

Mental HShort/long types

ED

Lab/Deliv

Gynaetypes

In-pt rehab

Adm careM

Med/card/surg

UNPLANNED

PLANNED

Paeds

EECU

Clinics

Op th76%

HDU28%

Surg + Gynae ward types

Ante/Post NICU/Nurs.Op th

Endos HODUtypes

Dial

ICU3.5% all acute

adms

Complex Discharge to

usual residence

Complex discharge- change

place residence

When complex discharge processes

required: staff move to pt.

Nobb

mmm

No stay: 0-12 hours Short stay: 12-60 hours Long stay: 60+ hours

Op thHDU

Process23%

Cath labShort med

Types

Op th Surg short +gynae sttypes

9% acute adms; 85% short,,75% emergency

1.3% acute adm, 91% long, 72% emergency

23% all acute adms, 48% all med/surg emerg adms.

(4% ICU)

19% all acute adms. 40% all med/surg emerge adms,

10% ICU

5% all acute adms, 11% all med/surg emerge adm

5%ICU

Long-4% acute adm, 76% med/surg elect used Op th

Short, 28% acute

adms

Short-11% acute adms, 40% short med/surg

elects

Short-16% acute adms, 60% short med/surg elects

9% acute adms

Continuous Continuous ImprovementImprovement

Environment of continuous learningCulture that embraceschange

Respect for Respect for PeoplePeople

Actively involve staffin improving their jobDevelop mutual trustWork toward commongoal

Best Quality Best Quality -- Lowest Cost Lowest Cost -- Shortest Lead TimeShortest Lead Time--Best SafetyBest Safety-- Highest MoraleHighest Morale

Plan Do Study Act (PDSA) Learning CyclesPlan Do Study Act (PDSA) Learning Cycles

The Toyota WayThe Toyota Way

Toyota house

So what does FMC’shouse look like after 2 ½ years of

work?

FMC’s Future StateHouse

Flow: we are coping with more activity

RC began Last year

Flow: we are coping with more activity

RC began This time last year

Flow: reduced long waits in ED

Rate for 12+ and 8+ Hours wait for Bed (triage to ward) Adult (>=17) Admissions to FMC from ED [Nov 2002 to March 2006]

0%

10%

20%

30%

40%

50%

60%

2002/01

2002/02

2002/03

2002/04

2002/05

2002/06

2002/07

2002/08

2002/09

2002/10

2002/11

2002/12

2003/01

2003/02

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2003/05

2003/06

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2005/05

2005/06

2005/07

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2005/09

2005/10

2005/11

2005/12

2006/01

2006/02

2006/03

600

800

1,000

1,200

1,400

1,600

1,800

12+ Rate 8+ Rate NumberPresentations

Flow has improved with a decreased ALOS of 1 day for General Medicine

Unit: GENERAL MEDICINE - average length of stay

0

1

2

3

4

5

6

7

8

9

Jan-

03

Mar

-03

May

-03

Jul-0

3

Sep-

03

Nov

-03

Jan-

04

Mar

-04

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-04

Jul-0

4

Sep-

04

Nov

-04

Jan-

05

Mar

-05

May

-05

Jul-0

5

Sep-

05

Nov

-05

Jan-

06

LOS

(day

s)

ALOS Linear (ALOS)

Redesign Work Commenced

Elective surgery cancellations due to lack of beds

Safety & Quality: Patients in the right place is safer & better for patients & staff

Medicine Outliers

0%

5%

10%

15%

20%

25%

29-S

ep-0

3

27-O

ct-0

3

24-N

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22-D

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19-J

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16-J

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6

Week Starts (Monday)

Out

lier H

ours

(% o

f tot

al h

ours

)

Percent of Outlier Hours Linear (Percent of Outlier Hours)

Safety & Quality: Patients who come to ED & don’t wait for treatment

Safety & Quality

Serious adverse events (as reported to our insurers).

Dec 02-Nov 0381 serious adverse events-

15 events in the Emergency Departments, including 7 patient deaths.

Dec 03- Nov 0427 serious adverse events

4 events in the Emergency Department, including 1 patient death.

Dec 04-Nov 0531 serious adverse events

5 events in the Emergency Department- no deaths.

Guru Quote:

Continuous Improvement:Think of the way you do your

work today as the worse possible way

Guru Quotes:

No Problem is PROBLEMKaizen (continuous improvement) doesn’t need

much money• If no money, use your brain• If no brains, sweat it out!

Don’t start with the solution

No blame, no excuses

Quote:

Go to the Gemba!

Jane.Bassham@fmc.sa.gov.au