1. Colleen Roylance Director of Quality and Education

2. “We are headed into the next century which will focus on quality… ….we are leaving one that has been focused on productivity.” 8/30/2013 Dr. Joseph M. Juran 1904 - 2008

3. 8/30/2013 Culture of Safety and Quality PathologicalReactiveBureaucraticProactiveGenerative Systems are purposefully designed to see no evil, hear no evil and speak no evil. Actions of improvement only come when necessary to survival Actions are driven by outside forces and what is perceived to create negative consequences by regulators or entities with the power to create such consequences Actions are very task oriented with most existing to satisfy the rules and requirements of a bureaucratic structure with little focus on achieving the larger goal There is a genuine interest in advancing safety and quality but leaders struggle with cohesively supporting quality as an equal— although safety wins out more and more frequently Safety and quality are equal to other competing priorities and is an integral piece of day-to-day operations as leaders recognize its importance to operational, financial and reputational success

4. QAPI Defined A systematic approach to assessing services and improving them on a priority basis  Customer Focus  Employee Empowerment  Leadership Involvement  Data-Informed Practice  Statistical Tools  Prevention Over Correction 8/30/2013

5. What it really boils down to…  Is this a safe, comfortable place to receive care?  Do people feel comfortable speaking up?  How do you know? 8/30/2013

6. Lean TQM CQI W. Edwards Deming Joseph Juran SPC DMAIC Taiichi Ohno 8/30/2013

8. Value-added actions in the best sequence, without interruption whenever someone requests them, and perform them more and more effectively Voice of the Customer and Recognize Waste Visual Control and 5S Establish Flow: Pull vs. Push and one piece flow Level the Workload Fool Proof and Standardize LeanSix Sigma 8/30/2013

10. Quality Product Features Freedom from Deficiencies That Customers Want Design for Six Sigma At Six Sigma Levels Improve to Six Sigma 8/30/2013

11. Lean is about understanding what is important to the customer Lean increases the activities that add value and decreases or eliminates those that don’t Lean focuses on eliminating waste in processes (i.e. the waste of time, supplies, transportation) Lean is about expanding capacity by reducing costs and increasing process effectiveness What is Lean? 8/30/2013

12. Key LEAN Leverage Points  Eliminate Waste: Eliminate Inefficiency  Standardize Work: Eliminate Variation Key Implementation Leverage Points  Managers and staff working side by side to solve problems when and where they happen  Incremental improvement over and over and over… 8/30/2013

14. Voice of the Customer ASK: “What is the customer paying for?” The answer tells you what adds value and you should keep doing OR what doesn’t add value and you should stop doing. 8/30/2013

15. 3 non-value-adding steps x 3 minutes per step x 25 residents x 3 times per day 675 non-value-adding minutes per day / 60 minutes in an hour 11.25 hours per day x 365 day per year 4,106.25 hours per year / 1800 hours in an FTE 2.28 FTEs 8/30/2013

16. 7 Wastes  Over production  Waiting  Motion  Inventory 8/30/2013  Transportation  Defects  Excess processing

17. 7 Wastes: Overproduction Doing what is unnecessary when it is unnecessary in an unnecessary amount 8/30/2013 Example: Setting up meal trays for residents only to learn several residents are gone, thus having to throw out food Solution:  Improve communication with direct care and dietary staff  Design form or tear-off for kitchen when resident(s) leave facility during meal hour (Common on weekends and during holidays)

18. 7 Wastes: Waiting Staff: For information, approval, supplies Customers: For assistance, information, supplies, comfort 8/30/2013 Example: Call light not being addressed and residents waiting for help Solution:  Review staffing patterns for timely availability (3 - 5 mins)  Staff awareness of high-risk residents – patient safety

19. 7 Wastes: Motion Movement that is too fast, slow or unnecessary 8/30/2013 Example: Not having towels and washcloths in AM for staff to assist with residents’ personal hygiene before breakfast Solution:  Night shift stocks towels and washcloths during last rounds  Place at resident bedside as appropriate

20. 7 Wastes: Inventory When anything is retained longer than necessary 8/30/2013 Example: Outdated supplies or medication Solution:  Design system so medication/supplements and supplies are checked at least monthly  Can be incorporated into night shift duties while stocking medication carts

21. 7 Wastes: Transportation Transferring or moving unnecessary items and the problems created 8/30/2013 Example: Supplies are off-loaded at dock  central supply closet  floor supply closet  resident’s room Solution:  Solicit supplier to off-load stock to central supply closet  Eliminate floor supply closet and stock residents’ rooms

22. 7 Wastes: Defects Related to costs for inspection of defects 8/30/2013 Example: Inadequate communication among shifts Solution:  Improve communication efforts with TeamSTEPPS handoff tools  Provide extra 15 mins between shifts for rounds and questions  Utilize standard handoff tool to address resident safety (i.e., weight loss, food intake, skin, falls, behavior)

23. 7 Wastes: Excess Processing Unnecessary tasks traditionally accepted as necessary 8/30/2013 Example: Redundant documentation for pressure ulcers – several different forms and/or documentation doesn’t match Solution:  Standardize documentation/assessment form  Wound/treatment binder  Keep binder accessible and include policies and standards

24. Visual Control  Makes abnormalities and waste obvious enough for anyone to recognize  Uses standardized control devices, information, color coded layout and signboards  Successful leadership depends on visibility of abnormalities 8/30/2013

25.  Method of workplace organization  Place for everything; everything in its place  Reduces wastes due:  To clutter  Time to find materials and equipment  Duplication of equipment  Floor space  Inconsistency 5S is essential 8/30/2013

26. 5S  Sort: Separate the necessary from the unnecessary  Simplify: Create a place for everything  Sweep: Control the work area visually and physically  Standardize: Document agreements made  Self-discipline: Follow through and maintain 8/30/2013

27.  Standardize the “least waste” way to work  Provide low variation in the output  Simplifies training, cross training and sharing resources  Provides a foundation for improvement Standard Operations “Without standard work there can be no improvement.” –Taiichi Ohno 8/30/2013

28.  Specified Activities  Outcome  Content  Sequence  Timing  Clear Connections Every connection must be direct with an unambiguous yes-or-no way to send requests and receive responses  Simple pathways The pathway for every product and service must be as simple and direct as possible Basic Principles for Lean 8/30/2013

29. PDSA and A3 8/30/2013

31. Project Planning A straightforward project prioritization tool that effectively ranks projects to ensure the facility is getting the ‘biggest bang for their buck’. 8/30/2013 Projects are mapped on a spectrum from:  Implement immediately  Postpone  Do not implement

32. 8/30/2013

33. Don’t wait for more than one missed opportunity to evaluate the process The Power of One 8/30/2013

34. Root Cause Analysis: Each Time… Every Time 8/30/2013 What Happened? Identify the issue How Did It Happen? Classify the cause(s) Why Did It Happen? State your findings How Can We Prevent It from happening again?

35. 5 Whys Problem Statement:  The patient was late to the OR; it caused a delay. Why?  There was a long wait for a transport bed. Why?  A replacement transport bed had to be found. Why?  The original transport bed’s safety rail was worn and had eventually broken. Why?  It had not been regularly checked for wear. Why? The Root Cause: There is no equipment maintenance schedule. Setting up a proper maintenance schedule helps ensure that patients should never again be late due to faulty equipment. This reduces delays and improves flow. If you simply repair the bed or do a one-off safety rail check, the problem may happen again sometime in the future. 8/30/2013

36. Establish Root Cause(s) A cause and effect diagram, also known as a “fishbone” diagram, is a graphic tool used to explore and display the possible causes of a certain effect.

37. What Is Failure Mode and Effect Analysis? FMEA is a systematic method of identifying and preventing problems before they occur. 8/30/2013

38. RCA vs. FMEA Similarities  Interdisciplinary Team  Develop Flow Diagram  Focus on systems issues  Actions and outcome measures developed  Scoring matrix (severity/probability)  Use of cause & effect diagram, brainstorming Differences  Process vs. chronological flow diagram  Prospective (what if) analysis  Choose topic for evaluation  Include detectability and criticality in evaluation  Emphasis on testing intervention 8/30/2013

39. FMEA: Your Crystal Ball FMEA Template 1234567 Step or link in processList all potential failuresPotential effect Severity of effect Probability of failure effect Criticality (col. 4x5) Rank by Criticality 8/30/2013

40. This material was developed by Mountain-Pacific Quality Health, the Medicare quality improvement organization for Montana, Wyoming, Hawaii, Alaska and the Pacific Territories of Guam and American Samoa and the Commonwealth of the Northern Mariana Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents presented do not necessarily reflect CMS policy. 10SOW-MPQHF-WY-IPC-13-10 For More Information: Colleen Roylance Director of Quality and Education (406) 457-5874 croylance@mpqhf.org