1. Creating the Michigan Quality System Jack Billi, M.D. jbilli@umich.edu Michigan Quality System: med.umich.edu/mqs Michigan Quality System: Quality Safety Efficiency Appropriateness Service Lean Thinking in Health Care

2. Lean Thinking in Health Care at UMHS Summary A3 J Billi 1/9/09 Background –UM has problems in quality, safety, efficiency, service –Problems harm patients, raise costs, frustrate workers –Economy: short & long term Current state –Inconsistent use of QI at UM; varied models –Toyota Production System: QI world standard (not health) -Brilliant process & outcome Goals –Ideal Pt Care Experience –Ideal Clinician Experience Happy workers – healthy pts –Safest health system in US –Financial stability Analysis –Workers/mgrs: +/- trained in problem solving; little std work –Problems complex, cross silos/units; work often invisible –Unclear responsibility for problems –Unclear priorities –Time, cost pressures: stress Strategies –Spread a consistent QI model across UMHS -Build on our CQI base -Study and adapt lessons learned from Toyota –18,000 problem solvers Plan –Michigan Quality System

3. Burning Platform for Change?

4. Traditional Health Care …or, the way I was trained Frequency….……......Episodic Initiation…….…..…....Patient Coordination...…..…..Spotty (patients & doctors) Communication……..Sporadic among clinicians Patient education.......Inconsistent Process of care……..Variable Basis of decisions…..Clinicians’ opinions Systems........…….....Not “Error-proofed” Outcomes…….....…..Not measured Cost……………….....Expensive

5. Gaps at UMHS (and most health systems): Quality: Not all CAD pts on statin, aspirin; DVT prophylaxis Safety: Medication errors (10x infusion pump dose) Labs labeled with wrong patient name Results sent to wrong clinician Hand sanitizing “in and out of rooms” less than 100% Efficiency: Nurse, doctor searching for equipment, forms, pts… Weeks waiting for appointment to the right physician Higher LOS: fewer admissions/transfers, less $$, RIFs Appropriateness: Antibiotics for URI, sinusitis; imaging for low back pain Service: Patients lost, staff look too busy to help

6. Where Do We Want to Go? Our future state vision: The Ideal Patient Care Experience Based on Institute of Medicine Report “Crossing the Quality Chasm” Care that is: Safe Effective Patient-Centered Timely Efficient Equitable

7. Crossing the Quality Chasm The IOM “Chasm” Report gives us a vision of where to go Lean Thinking gives us tools and business system to get there

8. The IOM “Chasm” Report gives us a vision of where to go Lean Thinking gives us tools and business system to get there Crossing the Quality Chasm

9. What is Lean Thinking? “The endless transformation of waste into value from the customer’s perspective”. ---Womack and Jones, Lean Thinking

10. 5 Step Process to Improve Value 1.Specify value from customer’s perspective 2.Identify the value stream for each product or service, and remove the waste 3.Make value flow without interruptions from beginning to end 4.Let the customer pull value from our process 5.Pursue perfection - continuous improvement - Do this every day in all our activities Source: Womack & Jones: Lean Thinking

11. The Customer’s Perspective: A Clinic Appointment Call the clinic, voice prompts, on hold, leave message. Clerk calls back and sets a date next week. Arrive for the visit, check in, sit in waiting room. Called into the exam room, wait for doctor. Doctor sees you, saying she’s been waiting for you. Diagnoses a URI, and BP is worse. Doctor prints antibiotic prescription, walks to the staffroom to get it. You are allergic to that drug. Doctor says to return in a week for the BP. Medical assistant does an EKG. At check out you ask the cost – clerk says they’ll bill you, No appointment is available next week. Pharmacist says your insurance prefers a different drug. Is there a problem?

12. Using the 5 Step Process in the Clinic Visit Specify value from customer’s perspective –A quick, effective clinic visit Identify the value stream for this service –Request > appointment > arrival > seeing doctor > check-out …and remove the waste –Time on hold, callbacks, walking, wrong drug, unneeded test Make value flow without interruptions from beginning to end –Staff and patient move continuously from check-in to exit –Less waiting for patient and staff –Errors surface immediately Let the customer/worker pull value from the process –Physician pulls next patient to exam room; patient pulls med refill when needed Pursue perfection – continuous improvement –Every day, every clerk, doctor, nurse thinks about how to redesign work to improve value to the customer, and ease for us

13. The Broken Office Visit

14. UMHS Example: MedSport Consult Long term problem: Long delays to get an appointment Frustrated referring physicians, patients, staff, physicians Incomplete records, phone tag Physician review records prior to scheduling Lots of hidden processes, errors, rework Patients/referring physicians seek care elsewhere Project scope: MedSport consult – from request to scheduling

15. Using the 5 Step Process on MedSport Consults 1. Specify value from customer’s perspective Patients, physicians and staff: quickly scheduled appointments 2. Identify the value stream for the service Request > review> schedule appointment …and remove the waste Variation in request, time on hold, callbacks, physician reviews

16. MedSport Appointments Current State Map

17. Using the 5 Step Process on MedSport Consults 3. Make value flow without interruptions from beginning to end Staff scheduling appointments on first phone call Uniform intake process No waiting for appointments Errors surface immediately

18. MedSport Appointments Future State Map

19. Using the 5 Step Process on MedSport Consults 4. Let the customer pull value from the process Same day appointments After school sports, till 7PM 5. Pursue perfection – continuous improvement Every day, every clerk, doctor, and nurse thinks about how to redesign work to improve value to the customer

20. MedSport Project Results Goal: reduce time from request to scheduling –Pre project: process time = 27 min of work wait time = 23 days –Post project: 91% of appointments made on first call in 2.5 min –Physicians, nurses, and clerks: Own the process, continue improvements Freed to create more value –Video www.med.umich.edu/mqs

21. Value Stream Mapping Workshop Understanding how things currently operate. This is the foundation for the future state Value Stream Scope Designing a lean flow through the application of lean principles Current State Drawing Implementation Plan Determine the Value Stream to be improved The goal of mapping! 30, 60, 90 day follow-up Implementation of Improved Plan Future State Drawing Developing a detailed plan of implementation to support objectives (what, who, when) Standardize for later improvement From John Long

22. Why Draw Maps? To find problems, we have to be able to see them! Ron Hirschl’s basement clean-up –If you make waste visible, it’s easier to remove –If you make problems visible, they’re easier to solve In healthcare: process steps are often invisible –Hard to find the non-value added steps We use Value Stream Mapping so we all can see the waste and find problems –How is work done now? –How could we make the job easier for workers and better for customers? –What experiment should we try first?

23. Value Stream Mapping: Learning to See Front-line workers: Create the map as a team Describe the way the work is actually done now –Not how we think it is, or how it should be… Verify in the real workplace (“go and see”) Managers support the effort

24. Value Stream Mapping: Learning to See “Aha” moments: –I never knew this is how it worked! –I can’t believe what a mess this process is! –No wonder we’re frustrated! –It’s a miracle a patient ever gets through it!

25. Improvements don’t have to wait for workshops… We all can: Do our work every day in a standard way that we created –Not just the way the work evolved! Be alert to things going wrong –They always do! Fix the problem now –For this patient or co-worker Find and fix the root causes of the problem –So it never happens again! Modified after Spear; Billi

26. Lean Thinking: How To Get It “Right Every Time” Steven Spear, Institute for Healthcare Improvement Catheter-related sepsis – a lot of little things: –No sink, no soap, no doormat reminder or buzzer –Gloves missing, wrong size, old and rip, on other side of patient, at bottom of kit –92% of nurses faced with impediments constructed ad hoc workarounds Steven Spear. Fixing Healthcare from the Inside, Today

27. Lean Thinking: How To Get It “Right Every Time” Steven Spear, Institute for Healthcare Improvement Short on Time??? Can’t find time to fix root cause??? Rather use the workaround every day for the rest of your career? Just take 10 minutes a day to fix root cause of one problem –Frees up time, so next week it will be 20 min. –Then it will be 30 minutes… Steven Spear. Fixing Healthcare from the Inside, Today

28. Lean is not about working harder or faster, it is about finding waste and transforming it into value our customers want.

29. How can we create (liberate) “18,000 problem solvers”? Help each worker take initiative to find and fix causes of problems he/she faces daily –This means each of us has two jobs: Do the work Improve the work Managers role: –Support improvement work (time, mentoring) –Align improvements so value flows to the customer Modified from J Shook

30. “18,000 Problem Solvers” Every worker applying the scientific method to every part of daily work. Turn all daily work into an experiment and every worker into an investigator. -Steven Spear

31. Lean Thinking as the Scientific Method Applied to Daily Work Scientific Method Observation Hypothesis Intervention Results/reflection Revise hypothesis New intervention… Structured abstract Lean Thinking Go see, ask why, respect PlanP DoD Check/reflectC AdjustA Repeat PDCA cycle… A3 report, Value Stream Map

32. Lean Thinking - An analogy to great medical care Tackle work problems with the rigor and systematic thinking we use for patient problems. Help every worker become an expert clinician.

33. Lean Thinking is Like Great Medical Care for Daily Work Great Medical Care Collect data personally, systematically, at the bedside (H&P) Impression and plans Tests and treatments Assess results & reflect Revise impression & plan Std write-up, presentation Lean Thinking Go see, ask why, respect PlanP DoD Check/reflectC AdjustA Value Stream Map, A3

34. Lean means seeing problems as interconnected: 5 admissions on “call day”, none for next 2-3 days Waste: -Muda –Errors (no beds on home unit) –Worker motion (patients scattered on 5 floors) –Inventory (patients waiting for rounds, orders, D/C) –Workers waiting (for the COW to arrive from last floor) Uneven workload, variability -Mura –Busy call day, “recovering” next day –Batch orders till end of rounds (none -> rush) Stress of overburden-Muri –Physicians, nurses, clerks rushing through work –Duty hour limits; nurse and PA shortages

35. Michigan Quality System: Strategy for Lean Transformation 1. People Development - Leaders -Managers - Frontline Staff “Just-in-time” training: Learn Lean by Doing Coaching and mentoring Courses, talks, web resources, book club 2. Process Improvement - Focused on institutional priorities Value stream analyses and workshops Rapid-cycle improvement and “Just do it” activities Lean in daily work

36. MQS Learning Project Results Radiation Oncology (6 teams – over 70 faculty & staff) Patients referred for brain metastases required 3 visits over 5 days (consult, simulation, treatment) After mapping the process, the team redesigned the process, removing unnecessary steps Now 95% of patients have all 3 parts within 24 hours Billing process first-time-quality increased 0% to >95% –Video www.med.umich.edu/mqs

37. MQS Learning Project Results Results Reporting ~ 99,000 lab results had no ordering physician, radiology requisitions lost, extensive rework Preprinted labels on requisitions implemented (12/06) Imaged requisitions increased by 880% (from 957 to 9380) 50% drop in orphan lab results

38. MQS Learning Project Results Emergency Dept. and CPU Acute coronary syndrome: Goal is “Door to Balloon” within 90 min. Go and see, mapping: time spent on EKG, serial paging Redesign patient flow, parallel paging Within 90 min. – Increased from 75% to 85% Time to ED discharge decreased 10 minute Before, nurses prioritized sickest, never got to discharges.

39. MQS Learning Project Results Care Transitions: MFH discharge from 5B –Timely appointments in hand at discharge –Management until the first follow-up visit –Mapped the discharge process, MLine pilot –Pilot results: Decreased 14 day readmissions by 33% Decreased visits to ED within 72 h. by 81%

40. MQS Learning Project Results Cardiovascular Center 32 projects and analyses over 2 years Non-value-added time during device clinic visit reduced from 100 to 10 minutes –Tech & nurse visits simultaneously Time for new medication delivery decreased from 90 to 41 minutes with implementation of “cart- less” system Standardized bedside stocking in ICU reduced extra supply runs from 4.5/bed/month to 1.7/bed/month

41. MQS Learning Project Results Vascular Access Doubled PICC lines placed within 12 hours by nurses from 35% to 71%; reduced by 46% cases needing interventional radiology Nurses standardized their cart, saved 1 hour/day CT scheduling and throughput In by 9, out by 5 for inpatients; no longer a weekend bottleneck

42. VAS Supply Cart 5S

43. Drawer: Pre-5S

45. Drawer: Post- 5S Saved each nurse an hour a day!

46. Engaged team: front line workers and managers

47. Questions and Discussion

48. Michigan Quality System & Lean References Books: Womack J, Jones D. Lean Thinking. Liker J. The Toyota Way; Liker J, Meier D. The Toyota Way Fieldbook. Shook J. Managing to Learn. Dennis P. Getting the Right Things Done. Rother M, Shook J. Learning to See. Womack J, Jones D, Roos D. The Machine That Changed The World. Sobek D, Smalley A. Understanding A3 Thinking. Marchwinski C, Shook J, eds. Lean Lexicon. Articles: Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med. 2006;1:191. Bush R. Reducing Waste in the US Healthcare System. JAMA 2007;297:871. Spear S. Fixing Health Care from the Inside, Today. HBR. 9/05. Spear S. Learning to Lead at Toyota. HBR 4/04 Spear S. Decoding the DNA of Toyota Production System. HBR 9/99 IHI Whitepaper: “Going Lean in Health Care” www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm Web: Michigan Quality System at UMHS: med.umich.edu/mqsmed.umich.edu/mqs Lean Enterprise Institute: www.lean.org webinars, books, meetings…www.lean.org Ideal Patient Care Experience at UMHS www.med.umich.edu/i/acs/ipe.htmwww.med.umich.edu/i/acs/ipe.htm Crossing the Quality Chasm (IOM): newton.nap.edu/catalog/10027.htmlnewton.nap.edu/catalog/10027.html Lean Enterprise Academy (UK): www.leanuk.orgwww.leanuk.org National Health Service (UK): www.networks.nhs.uk/networks.php?pid=211www.networks.nhs.uk/networks.php?pid=211 Wikipedia: en.wikipedia.org/wiki/Lean_manufacturingen.wikipedia.org/wiki/Lean_manufacturing