1. Conflict of Interest Ann Dohn – No conflicts of interest to disclose
Nancy Piro – No conflicts of interest to disclose

2. SES:065 Using C-Suite Business Models and Tools to Address Issues faced by DIOs/GME in the New Era of Healthcare Reform
Ann Dohn, MA
DIO, Director of Graduate Medical Education
Stanford Health Care
Nancy Piro, PhD
Education Specialist/Program Manager

3. Background
The adoption of business models and metrics historically found in the corporate world are now being widely used by Healthcare C-Suite executives.
This places DIOs/GME leaders in a vulnerable position. We must learn new ways of communicating and process thinking that align themselves with philosophies such as “Streamlining” and “Lean".
We need to think in terms of empirical data, metrics, quality indicators, dashboards, A3s, fishbone diagrams, etc.
However, the C-Suite models and processes actually can enable the DIO /GME to better advocate for resources based on data, empirical evidence, and focus on high priority areas for the institution.

4. Objectives & Session Focus
This session will focus on use of available data tools as well as evaluation metrics that enable DIOs/GME to communicate effectively with the C-Suite.
Participants will be exposed to the A3 tool, which is extremely useful in solving inter-departmental problems
Other tools, e.g., scorecards, fishbones, paretos, and trend analyses will be incorporated into the presentation.
At the conclusion, participants will be able to apply the A3 model to challenging institution specific situations and discuss available metrics and development of an approach to resolution the situation.

5. Understanding C-Suite Priorities
STANFORD OPERATING SYSTEM
Purpose
Mission, Vision, Values
Strategies
Complex Care, Coordinated Care
Objectives
Goals, Operating Plans, Dashboards
Performance
Improvement and Management

6. Understanding C-Suite Language “Hot – Spots”
RVU’s
Visibility Wall
KAIZEN – Continuous Improvement
GEMBA
problems are visible (or make them visible) and the best improvement ideas come form going to the genba – leadership goes to the departments/wards to look for waste and opportunities to improve or practice kaizen.
Five Whys – ask why 5 x’s to get to the ….
RCA – Root Cause Analysis
4 M’s
5 S’s
A3s
SMART
Fishbone Diagram – Ishikawa Chart

7. Understanding C-Suite Language: “Lean” – Focus and Tools
Make problems visible – not hide them or “not talk about mistakes/problems”
Fix problems permanently – get to the “root cause” and eliminate it.
Focus on the value and respect for people.
Lean Tools
Kaizen
Gradual, unending continuous improvement of processes
Processes must be improved to get improved results
By improving and standardizing activities and processes, Kaizen aims to eliminate waste
GEMBA – make problems visible
the best improvement ideas come form going to the genba – leadership goes to the departments/wards/units to look for waste and opportunities to improve or practice kaizen.
Elimination of WASTE - 3Ms
Problem Solving – A3s
5 Whys
Fishbone Diagrams (Ishikawa Charts)
4 Ps / 4 Ms
5 Ss

8. Kaizen Basics
Focus is on small, incremental change (not necessarily huge leaps, innovation)
Quality Control = quality of people
“A company that is able to build quality into its people is halfway to building quality outcomes”
Respect for People
“Only people produce improvements…machines only degrade over time””

9. Lean Tools: 3M’s All about Waste- Identifying it and Removing it
MURI = Waste of overburdening people or equipment/resources
MURA = Waste of unevenness, variability in processes
MUDA = Waste of using resources without creating added value

10. Five Why’s Problem Solving Method
Keep asking ‘Why’ until you discover the root cause of the problem
No magic in 5 –
might be 3, or 7, or 10
Why do we? (conduct orientation in person, fill out multiple forms, take on line training for non MDs)
Developed at Toyota

11. Lean Tools: – Fishbone Charts using the 4Ms – 4 Ps
Manpower/Personnel
Materials
Method(s)
Machines / Equipment
People
Process
Policy
Principles

12. Ishikawa Diagram of ER Prolonged Wait Times
Materials
Methods/Process
WHY?
WHY?
xxx hr wait time in ER
WHY?
WHY?
Manpower/People
Machine\Equipment

13. 5Ss - Mnemonics Retained
Sorting
Simplifying
Sweeping
Standardizing
Self Discipline
= Seiri = Seiton = Seiso = Seiketsu = Shitsuke
Quick Exercise

14. 5Ss in Action
PATRICE

15. Very simply….a piece of paper that is 11” in height and 17” in width
What is an A3?
Very simply….a piece of paper that is 11” in height and 17” in width

16. 4 Steps of A3 Thinking: The Simple A3
2. What causes are preventing us from meeting our target(s)? What are the “root” causes?
What is the problem or gap? (What are we trying to improve?)
Cause
Gap
Cause
Target
Cause
Effect/Problem
Current Performance
Cause
Cause
Cause
4. Which actions will address the most important causes?
3. Based on data, what are the causes in order of importance?
Goals (Cause)
By Who & When
Actions
Cause #1
Cause #2
Cause #3
Cause #4

17. 4 Steps of A3 Thinking: The Simple A3
What is the problem or gap? (What are we trying to improve?)
2. What causes are preventing us from meeting our target(s)? What are the “root” causes?
4. Which actions will address the most important causes?
3. Based on data, what are the causes in order of importance?
Goal (Cause)
Actions
By When/ By Who

18. What is an A3?

19. Presenting the A3 fosters consensus to move forward
Why Use an A3?
Creating the A3 encourages systematic problem solving and a standardized method of communication
Presenting the A3 fosters consensus to move forward
Discussing the A3 fosters critical analytic skills, communication, respect

20. When to use an A3?
Determining when to use an A3 can be as simple as asking the following questions:
Is the situation difficult enough to warrant using the A3 to provide structure?
Will there be ongoing discussion for some time so the report has communication value?
Is there a good reason to document and capture the knowledge in some fashion?

21. A3 Template Title Issue/Problem Statement: Background and Importance:
Problem Analysis:
Goals/Dashboard Metrics:
Future State and Counter Measures:
Follow Up:
Sustain Results:
Implementation Plan:
Sponsor:
Participants:
Title
Date Revised: Version #:
Start Date:
Revised Date

22. What Type of Information is Included in an A3? The Top of the A3 Chart
Accountability
Who is responsible for the project?
Sponsors, Team Leaders
Project Title
Brief description of the project
Project Team
All people involved in the development and completion of the project
Draft Status
Date and version

23. What Type of Information is Included in an A3? Left Side
The left side contains information and discoveries about the current state
Issue (the problem)
Objective description with data
Stated through the customer
Background
History
Significance (how does this fit within the organizational goals?)
Baseline
Simple graphic of current state
Requires observation
Includes major pain points (problem areas within the process)
Goals / Dashboard Metrics
Data that will be measured to provide evidence of success
Problem Analysis
Identifies the root cause of current state problems
The 5 Whys, Fishbone, Pareto, etc.

24. What Type of Information is Included in an A3? Right Side
The right side develops the vision and action plan for the goal
Future State
The ideal state you want to achieve
Countermeasures
What you will need to change to get from current state to the desired future state
Implementation Plan
How the countermeasures will be achieved
Show who, what, when and outcome (accountability)
Follow-Up
What will be done to ensure the project is maintained
Sustain Results
The measured outcome or ongoing measurement of the project’s impact
Often the direct measure of the problem

25. How Do You Create an A3? 1. Identify a project or problem
Write a description
Be objective – customer focus
Maintain a limited scope
Learn the significance or history
Interview, study, read, etc.
2. Observe and draw workflows (process flows)’
Gemba
Interview staff
Map the process from A-Z (butcher paper)
Identify problem(s) within the process
Confirm findings with frontline staff
3. Measure the current state
Collect data
Manual (i.e. Paper surveys, counts)
Database (i.e. EMR)
Upstream vs. Downstream
Validate data with frontline staff

26. How Do You Create an A3? (Continued)
4. Set goal(s) around measurements
Consider what is ideal
Consider what is possible
Engage / speak with front line staff
Be SMART
S = Specific
M = Measureable
A = Attainable
R = Realistic
T = Timely
5. Analyze the problem and identify root causes
Interview stakeholders (ask the 5 Whys)
Use measurements to identify biggest problem (Pareto)
6. Identify the future state and countermeasures
Describe/envision the ideal state of the process
Brainstorm solutions to root causes
Select countermeasures and list in A3
Draw a simple future state diagram

27. How Do You Create an A3? (Continued)
7. Determine how countermeasures will be implemented
Identify stakeholders (all persons affected by the changes)
Ensure the right people are involved/aware
Consider communications
Set timelines for achieving steps/countermeasures
8. Determine the follow-up plan
Identify how you will maintain the intervention
How will the intervention be “hard-wired”/
What is the visibility plan?
Consider future actions required to improve he outcome
9. Monitor results
Allocate time for measuring results after implementation
Measure and analyze results
Report results
10. Continuously review the A3
Does the story flow well?
Is it easy to understand?
Is the report neat/organized?
Revise…

28. A picture is worth a thousand words…
Benefits of Using an A3
A3s offer a simple & structured approach to reporting solutions to problems
Helps define a standard for all of the organization to use
Provides a clear and concise method of reporting information
Content can be made visible and accessible to all
Promotes communication and teamwork
Leads to reduction of waste and improved processes
Supports continuous improvement
A picture is worth a thousand words…

30. EXERCISE 2 - Creating an A3
Think about a problem you’d like to solve “back home”
Use the A3 Template Hand Out :

31. A3 Template can be downloaded @ www.gme.stanford.edu
GME Community
Templates – A3

32. Visibility Wall Examples

33. Dashboard Examples Overall Program Report Card AIR - APEs
Program Expansion
CCC Matrix

34. Overall Program Report Card Example - Comparison

35. AIR / Annual Program Review Dashboard Example

36. Program Expansion / Funding Dashboard

37. Report Card Trending Example
Complete with auto-fill colors

38. Resident Performance Dashboard
Complete with auto-fill colors

39. Dashboard Summary Data-driven decisions Multiple sources
Comparable measures allows for “tiering” of programs
Institutional Review / AIRs
Timely, visual and easy to identify trends
Pre-emptive
Easy for Leadership “C Suite” to read
Easy for CCCs to use

40. Questions?

41. Contact Information:
Nancy Piro, Program Manager/Education Specialist
Ann Dohn, DIO