1. Kurt Knoth, Vice President Performance Improvement May 20, 2016 How does lean support a high reliability culture? 1

2. Spectrum Health at a Glance Spectrum Health is a not-for-profit health system, based in West Michigan, offering a full continuum of care through the Spectrum Health Hospital Group, which is comprised of 12 hospitals, including Helen DeVos Children’s Hospital; 178 ambulatory and service sites; more than 3,400 physicians and advanced practice providers, including about 1,400 members of the Spectrum Health Medical Group; and Priority Health, a health plan with about 721,000 members. Spectrum Health is West Michigan’s largest employer, with 24,300 employees. The organization provided $283 million in community benefit during its 2015 fiscal year. Spectrum Health is the one of two health system in Michigan to be named one of the nation’s 15 Top Health Systems® by Truven Health Analytics for 2016. This is the fifth year in a row that the organization has received this recognition. Spectrum HealthHelen DeVos Children’s HospitalSpectrum Health Medical GroupPriority Health spectrumhealth.org

3. Structure to support Process Improvement Performance Improvement Process Improvement Patient Experience Kaizen Culture Value Streams Regional Support Chief Medical Officer Medical Group Quality, Safety & Informatics PI Coach Training & Yokoten Improvement Specialist Improvement Specialist PI Coach Sensei Support Improvement Specialist Operations (27 FTE) (18 FTE) (1 VP, 4 Directors, Internal Sensei's) Physician / PI Engineer Patient Feedback PE Consults PFACs Linked to PI

4. 4 Two “Pillars” of Lean Respect for People Continuous Improvement

5. SH Performance Improvement System (SHPIS) Tools 5 A3 Problem Solving Value Stream Analysis Rapid Improvement Event  Define the customer and what they value  Develop understanding of the Current State process  Develop the Future State for the process  Develop metrics to measure success  Develop detailed action plan  Small teams of people focused on improving a part of a value stream  Using a structured process (PDCA and A3) with clear targets  Developed to train staff and deliver results by the end of the activity  Rapid Improvement Events engage teams in generating, testing and implementing new ideas. 2P  A four day event, with a Sensei mentor, that integrates design and operations. It involves running operational simulations through a proposed space, ideally at actual

6. SHPIS Tools continued … 6 Golden Tickets Standard Work 6S Kamishibai  Improve the flow of people, supplies, equipment and information through the application of visual tools and standard practices  Assist in identifying waste in the work to maximize Value Add work Before After  Visual Audit Cards  Cue cards or work instructions for auditing a process.  Used to diffuse accountability to those doing the work.  Used when you wish to ensure that a new process is routinely followed.  Can be used hourly, by shift, daily or weekly.  Fostering a culture that takes real time corrective action.

7. Value Added versus Non-Value Added Value Added Non-Value Added Any activity that contributes directly to satisfying the needs of a customer. Any activity that takes time, space or resources, but does not contribute directly to satisfying the needs of a customer. 7

8. How is SHPIS different? 80-95% Non-Value Added 5-20% Value Added A Typical Process is 80-95% Non-Value Added to 5-20% Value Added 8 SHPIS is an improvement methodology that focuses on reducing Non-Value Added (NVA) activity.

9. Elements of a healthy lean culture Serve the customer first (patient centered care) Seek what’s right, regardless Decide carefully, implement quickly Candidly admit imperfections (humility) Problems are viewed as jewels Leadership involvement – Go, see and listen to learn Adapted from George Koenigsaecker. Leading the Lean Enterprise Transformation, Second Edition (2013). 9 How much of the culture is really dependent on “lean leadership”?

10. Video Example 10 Does this sound like “lean leadership”?

11. Elements of a healthy safety culture 11

12. Culture of Accountability 12

13. Safety Is Safety… “Workforce safety is inextricably linked to patient safety. Unless caregivers are given the protection, respect, and support they need, they are more likely to make errors, fail to follow safe practices and not work well in teams.” Lucian Leape Institute at the National Patient Safety Foundation. (2013). Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. 13

14. Staff Harm in Health Care “In terms of lost-time case rates, it is more hazardous to work in a hospital than in construction or manufacturing.” –OSHA 14

15. Employee Safety at Spectrum Health No coordinated effort across the Spectrum Health System for Employee Safety Current State: A board will be created in the Management Operating System (MOS) room to highlight the prioritized projects A Hazardous Medication program is being developed and piloted Where are we going? 15 Results to Date: PI and Safety have partnered to create and develop a Safety Management System The Safety Mission Control room visually represents the current state of the Spectrum Health’s Safety program and initiatives The people closest to the work identified and prioritized hazards

16. 16 Healthcare ‘Truth’: We put the patient first. Healthcare ‘Truth’: We put the patient first. Universal Truth: You cannot help others if you do not help yourself. Universal Truth: You cannot help others if you do not help yourself. Safety Is Safety… Image source: andrealyip.com

17. 44,000 to 98,000 patient deaths per year from medical errors --To Err is Human, Institute of Medicine, 1999 210,000 to 440,000 patients, each year, suffer from preventable harm that contributes to their death. --A new evidence-based estimate of patient harms…, James, J. in Journal of Patient Safety, Sept- 2013 Patient Harm in Health Care

18. Health Care Safety vs. Airline Safety Health Care Safety Record Health care is the 3 rd leading cause of death in the US behind heart disease and cancer. This would be the equivalent of 20 wide-body jets full of passengers crashing every WEEK… With no survivors. 18 Airline Safety Record The last major US carrier to have a fatal crash of a large jetliner was in November of 2001. Literally millions of flights, tens of millions of passengers, without a single passenger fatality in nearly 15 years.* * Major US Airlines. Does not include commuter airlines

19. Aviation was not always a safe endeavor… Final phase of aircraft evaluations for the Army Boeing’s entry had swept all the evaluations The aircraft made a normal takeoff and crashed Investigators found "Pilot Error" as the cause It appeared that the Model 299 was dead But, the Army gave Boeing one more chance… 19 October 30, 1935 Wright Field, Dayton, Ohio Boeing 299

20. The advent of the checklist in aviation 20 They needed a way of making sure that everything was done What resulted was a pilot’s checklist 12 test aircraft flew 1.8 million miles without an accident B-17 Flying Fortress 12,731 ordered by the Army

21. Spectrum Health Surgical Checklist 21

22. Key characteristics of a good checklist Minimum necessary steps required Easy to read and use The vital few tasks that left undone may kill someone NOT a replacement for standard operating procedures Supplements standard work 22 Used to deal with extreme complexity* *Atul Gawande. The Checklist Manifesto: How to Get Things Right (2009)

23. Information overload… 23

24. Facts about Errors 24 1.Everyone makes errors – even very experienced and highly-educated workers. 2.We work in high-risk situations that increase the chance we will make an error. 3.We can avoid errors by practicing low-risk behaviors (error prevention tools).

25. We’re only human… 25

26. Poka-Yoke examples 26

27. Managing Daily Improvements (MDI) Visual display of daily improvements  Swim Lanes (5):  Kamishibai Rounding (HACs)  Safety & Quality  Incident reporting  SSE, PSE, NME data  “Days Since Last…”  Unit specific projects  Golden Tickets  Communication  At Risk Patients 27

28. Kamishibai ( 紙芝居 ) Cards  Japanese form of storytelling  Management tool: (Toyota production system)  visual control for performing audits  series of cards are placed on a board  selected at random or according to designated schedule 28

29. Audit Question Audit Details Follow Up Details Name of Audit / Area Instructions Each Interaction Should Take Less than 5 Minutes to Complete! Kamishibai Card Attributes

30. CAUTI Video 30

31. Hospital Acquired Conditions 31 14 HAC “Zero Months” for GR in CY15 Medical Critical Care 1 year without a urinary infection !! SHGR Central Line Infections SHGR Colo-Rectal Infections SHGR Urinary Tract Infections

32. When it Comes To Safety - We Believe: 32 We will achieve zero harm!

33. Questions? 33