TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Maintaining the Gain Process Ownership & Accountability Teresa Pinter, RN, Managing Master Black Belt Performance Improvement Division OSF Saint Francis Medical Center, Peoria, Illinois

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 2 E SSENTIAL ELEMENTS OF PROCESS MANAGEMENT An effective measurement system Performance analysis Performance to target (gap analysis) Variation (special cause or routine) Mean performance and range of performance Enrolling staff and key stakeholders in performance improvement efforts and goals Education, training, communication Developing, implementing, and monitoring action plans for improvement

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 3 K EY COMPONENTS ….. PROCESS MANAGEMENT PLAN Process Steps Key performance indicators Measurement Plan Targets Corrective actions to be taken when performance fails to meet expectations A measurement plan to assist the Process Owner to implement change and to manage performance of key processes Provides process owners with all the information needed to evaluate how well the process is meeting the requirements of Those We Serve

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 4 WHY IS PROCESS MANAGEMENTIMPORTANT? It is how we know that improvement solutions have been implemented and are effective. It is how we know that implementations have achieved projected benefits. It is how we sustain the gains over time. It is how we identify when our environment is changing and additional improvement is needed.

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 5 PROCESS MANAGEMENT IS NOT JUST ABOUTPERFORMANCE IMPROVEMENT PROJECTS Process Management is a critical competency that managers need to develop in order to achieve the organization’s strategic goals Process Management requires measurement To identify performance gaps To focus our improvement efforts To communicate performance objectives To demonstrate ongoing performance improvement outcomes

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 6 W HY USE A CONTROL CHART WITH PROCESS MANAGEMENT ? Control charts are tools used to monitor performance over time The control chart will allow us to view variation in the process Variation means that a process does not produce exactly the same result every time the product or service is delivered. Variation exists in all processes. Has the ability to determine the presence of routine causes vs. special causes that upset our processes Help us to detect, diagnose, and correct problems in a timely fashion Provide an easy to understand visual indicator of process performance Trending vs. Dashboard (red/yellow/green)

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 7 SUSTAINING THE GAINS…OBSERVING PERFORMANCE OVER TIME Improvement Methods Financial Benefit ($) Time Good Process Owner Y = f (x) Project Team # of Failures Implemented Solution Good Y = f (x) Process Errors Process Mgmt

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 8 T HE G OAL OF P ROCESS M ANAGEMENT Hardwire process management into our daily work Review measures Focus on closing your largest performance gaps First, reduce routine variation by finding and eliminating root causes Next, work on improving the mean Process Management may start with: The control phase of a performance improvement project Key indicators that you need to improve for your area

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 9 C ONTROL C HARTS Provides the “Voice of the Process” Method to detect process “signal” vs. “noise” Method to focus process improvement efforts Simple method for displaying and interpreting process performance over time and in context

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 10 C ONTROL C HARTS F UNDAMENTALS Time series data Central line for detecting shifts and trends Control Limits computed from the data Distance of the limits from the center line = 3σ Statistically there is <1% probability of data point falling outside of Limits Filters out the process noise so that real signals can be detected Control Limits help us understand what needs to change by demonstrating the type of variation Special Cause variation makes the process unpredictable and must be eliminated (dots outside of the control limits) Common Cause variation can not be eliminated without making fundamental process change (dots within the control limits) Helps us understand when to react…and when not to

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 11 W HY U SE C ONTROL C HARTS ? Allows us to focus on the important questions: Is the process stable and predictable? Is the amount of common process variation acceptable? If not, what is the root cause of variation? Is the average process performance acceptable? If not, work on eliminating variation. That will usually be sufficient to move the mean.

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 12 P ROCESS V ARIATION All work occurs in a system of interconnected processes Variation exists in all processes Understanding and reducing variation are keys to process and performance improvement

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 13 There are always inherent chance causes responsible for natural variation in all processes due to “normal” variation in materials, environments, methods, people etc. (common cause) Variation within a stable process is inevitable Do not react to this type of variation (process tweaking) C OMMON C AUSE V ARIATION

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 14 S PECIAL C AUSE V ARIATION Once we have an indication of a shift outside what seems to be normal in a previously stable process, we must discover the reason for the shift (special cause) We want to remove the influence of a special cause if it is adversely affecting the process If the special cause influence is improving the process, we want to permanently capture its effect

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 15 I DENTIFYING S PECIAL C AUSES Common CauseSpecial Cause Commuting Time (mins) Days UCL Mean LCL Commuting Time (mins) Days UCL Mean LCL Special Cause Variation

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 16 M AINTAINING THE GAINS Now that we have reviewed tools monitor our processes… Lets discuss maintaining our gains.

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 17 H OW C AN I INTEGRATE P ROCESS M ANAGEMENT INTO MY WORK ? The goal is to hardwire process management into our daily work Review measures Focus on closing your largest performance gaps First, reduce routine variation by finding and eliminating root causes Next, work on improving the mean Process Management may start with: The control phase of a Performance Improvement project Key indicators that you need to improve for your area Sustain the gains, pursue perfection Show me the data Action plans Specific Recommendations for action based on analysis

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 18 PROCESS VARIATION QUESTIONS FORLEADERSHIP Leadership Questions to ask…Reviewing process performance… Q: Is the new process being followed? Q: Have the key leading and lagging indicators for your process been identified? Q: Is the process stable? (free of special cause variation) Q: Is the process capable? (able to meet requirements) Q: Is your process stability and capability being monitored on an ongoing, regular basis? Q: Is there a mechanism to monitor feedback from Those We Serve for changes in expectations? Q : What progress has the team made in implementation of solutions and achieving performance targets? Q: What are the lessons learned? Q: What milestones have been reached? Not reached? Q: What obstacles have been identified? Are anticipated? Q: What is the action plan to overcome the obstacles and place the team back on schedule or to improve the process? Q: What support or resources do you need? Q: What actions needs to be taken and by when?

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 19 Q UOTES : “Confusion between common causes and special causes leads to frustration of everyone, and leads to greater variability and to higher costs, exactly contrary to what is needed.” “I should estimate that in my experience, most troubles and most possibilities for improvement add up to proportions something like this: 94% belong to the system (responsibility of management), 6% special.” – W. Edwards Deming

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 20 S USTAINING GAINS THROUGH COMMUNICATION Communicating the performance and action plans locally  Unit/Department/Division/Regional meetings – Standing agenda item “Takeaway” information  Performance Improvement Display Boards: Include: What was the baseline data, current performance and the target?  Utilize existing structures: Professional Committees or Councils Local communication pathways Portals

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 21 C OMMUNICATION TACTICS Leverage all current processes, vehicles, and resources Management structure & processes Employee newsletters Internal communication boards etc Provide consistent key messages that are easy to remember Use a variety of methods & media Tailor messages to meet the needs of the specific audience Uses appropriate language and detail Addresses audience specific concerns (What’s in it for them or WIFM)

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 22 T AKEAWAYS All key elements of process management must be in place to sustain gains Control charts show performance trends over time and focus analysis efforts Leadership engagement and involvement is essential to success. Effective communication is a critical function for successful implementation and sustaining change Remember - a mature process is: owned and managed, documented, known, standardized, produces consistent quality outputs, is measured and evaluated’ and is improved in a disciplined way Process management is the first step in process maturity

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 23 PMCS: PROCESS MANAGEMENT CONTROL SYSTEM

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 24 W HO IS PART OF THE P ROCESS M ANAGEMENT T EAM ? Business Leaders Directors/Project Sponsors Managers/Supervisors Process Owners PI Coach/MBB PI Facilitator/BB

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 25 P ROCESS M ANAGEMENT C ONTROL S YSTEM A measurement plan to assist the Process Owner to implement change and to manage performance of key processes Illustrates the relationship between process performance and outcomes Focuses on the key process variables that have significant impact on the quality of the process outputs Defines process priorities Establishes performance targets and accountabilities necessary to drive change and continuously improving performance Provides process owners with all the information needed to evaluate how well the process is meeting its customer’s requirements

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 26 PMCS E XAMPLE

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 27 Process Description: Reflects a key process, job, or group of work tasks Uses simple and general terms Must be understandable for owners, customers, and users Process Description: Reflects a key process, job, or group of work tasks Uses simple and general terms Must be understandable for owners, customers, and users PMCS Process Description

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 28 CCRs of “Those we serve”: Identified measurable expectations in regard to service product or experience Includes the “Voice of the Business” CCRs of “Those we serve”: Identified measurable expectations in regard to service product or experience Includes the “Voice of the Business” PMCS CCRs of Those We Serve

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 29 Outcome Indicator (Y): Measures how well the requirements of “Those we serve” are being met” Outcome Indicator (Y): Measures how well the requirements of “Those we serve” are being met” PMCS Outcome Indicators

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 30 Process Map or Process Steps: The set of sequential and parallel activities that must be completed to ensure the Customer requirement is met Shows individual as well as cross-functional accountability Process Map or Process Steps: The set of sequential and parallel activities that must be completed to ensure the Customer requirement is met Shows individual as well as cross-functional accountability PMCS: Key Process Steps

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 31 Outcome Indicators (Ys): A set of indicators identified during the project which measure key elements of performance Based on critical relationship between process variables and outcomes Y = f(x) Tied to the specific process activities Approved by Business Leader Team Outcome Indicators (Ys): A set of indicators identified during the project which measure key elements of performance Based on critical relationship between process variables and outcomes Y = f(x) Tied to the specific process activities Approved by Business Leader Team PMCS Outcome Indictors

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 32 Upstream Indicators (Xs): The description of the data type and operational definitions to be monitored based on CCRs Upstream Indicators (Xs): The description of the data type and operational definitions to be monitored based on CCRs PMCS Upstream Indicators

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 33 Capturing Data: Defines the measurement plan the Process Owner will implement Defines the frequency at which they should be checked Defines the individual accountable for checking Capturing Data: Defines the measurement plan the Process Owner will implement Defines the frequency at which they should be checked Defines the individual accountable for checking PMCS Capturing Data

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 34 Recovery Action: Defines the actions the Process Owner will take in response to certain identified events Recovery Action: Defines the actions the Process Owner will take in response to certain identified events PMCS Recovery Action

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 35 Next Steps Develop the turnover agreement Compile the turnover documents Sign the turnover documents

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 36 T URNOVER D OCUMENTS Standard documentation for project turnover includes all of the following: Charter MGPP CCRs/CBRs Root Cause Validation Matrix Communication Plan FMEA Implementation Plan PMCS Turnover Agreement Education & Materials

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 37 T URNOVER A GREEMENT Purpose: to formally transfer the project implementation responsibility and management to the process owner. Elements of a turnover agreement Define Roles and Responsibilities Agreed upon project success metrics Agreed upon time frame for Leadership Reviews Signatures of those taking ownership

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 38 T URNOVER A GREEMENT D OCUMENT We are presenting to you on August 24, 2012 a detailed Solution Implementation Plan for the Respiratory Protection Program for Employees Project that was approved on July 5, This document contains process design, process control management, communication/ education plan, and implementation plan. Upon review of this plan, it is agreed this project team’s work is complete and the process owner will complete the detail as written in the implementation work plan. Roles & Responsibilities Black Belt: Patty McMahill Provide detailed implementation plan to process owner. Coordinate quarterly leadership review. Global Process Owners: Director of Business and Community Health, Jo Garrison Occupational Health Manager, Peggy Grace Serve as Chair of the Environment of Care Safety Sub-Committee See EOC Safety Committee Charter in Turnover documents Track completion of employee medical evaluations.

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 39 T URNOVER A GREEMENT M ETRICS Measure Current Success Target Respiratory Protection Program Compliance 90% Hazard Assessment Completion Rate 100% Respiratory Protection Education Module Completion 90% PAPR Education Module Completion 90% Success Metrics & Review The solutions for this project were implemented on July 5, The following metrics and success criteria will be used to evaluate the success of this project starting July 1, Operational definitions and collection plans are documented in the Process Management Control plan provided at this meeting. Leadership review of performance will be scheduled as listed below.

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 40 T URNOVER A GREEMENT T EMPLATE Review DatesCoordinated by January, 2013Patty McMahill April, 2013Patty McMahill July, 2013Patty McMahill October, 2013Patty McMahill Leadership Reviews Leadership Sign Off We, agree with the above, assume the process owner(s) responsibilities and will complete the activities assigned to ensure successful implementation and process control. ____________________________________ __________________ Director of Business and Community Health, Jo GDate Process Owner Signature ____________________________________ __________________ Occupational Health Manager, Peggy GDate Process Owner Signature

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 41 T AKEAWAYS All key elements of process management must be in place to sustain. Key elements include clear responsibilities, measurement plan with targets, communication plan Clear recovery action if not meeting target. Clear line of sight of accountability. Provides process owners with all the information needed to evaluate how well the process is meeting its customer’s requirements

TRANSFORMING HEALTH CARE FOR THOSE WE SERVE Performance Improvement Tools and Methodologies 42 Q UESTIONS ? Thank you!