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

Michigan Quality System & Lean References Books: Womack, Jones. Lean Thinking. (An overview) Liker. Toyota Way. Liker, Meier. Toyota Way Fieldbook. Liker, Hoseus. Toyota Culture. Shook. Managing to Learn. (Best book on leadership in a lean organization and A3 use) Sobek, Smalley. Understanding A3 Thinking. (Problem solving and A3 use) Dennis. Getting the Right Things Done. (Strategy deployment or hoshin kanri) Rother, Shook. Learning to See. (Value stream mapping) Baker, Taylor. Making Hospitals Work (From Lean Enterprise Academy, UK) Graban. Lean Hospitals. (Applies Lean principles to health examples) Articles: Kim, Spahlinger, Kin, Billi. Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med. 2006;1:191. Kim, Hayman, Billi, Lash, Lawrence. The Application of Lean Thinking to the Care of Patients With Bone and Brain Metastasis With Radiation Therapy. J Oncology Practice. 2007;3:189. Kim, Spahlinger, Kin, Coffey, Billi. Implementation of Lean Thinking: One Health System's Journey. Joint Commission J Quality and Safety 2009;35:406. Bush. Reducing Waste in the US Healthcare System. JAMA 2007;297:871. Spear. (all Harvard Business Review) Fixing Health Care from the Inside, Today (9/05); Learning to Lead at Toyota. (4/04); Decoding the DNA of Toyota Production System. (9/99) IHI. Going Lean in Health Care Web: Michigan Quality System at UMHS: med.umich.edu/mqsmed.umich.edu/mqs Lean Enterprise Institute: webinars, books, meetings… Lean Healthcare Value Leaders Network Lean Enterprise Academy (UK): Ideal Patient Care Experience at UMHS 1/11/10

Lean Thinking in Health Care at UMHS Summary A3 J Billi 2/15/10 Background –UM has problems in quality, safety, efficiency, service –Problems harm patients, raise costs, frustrate workers –Economy: short & long term Current state –>20,000 faculty, staff, trainees –>100,000 processes, all have problems –Great workers trying to do a good job Goals –Ideal Pt Care Experience –Ideal Clinician/Staff Experience –Ideal Research/Trainee Experience –Safest health system in US –Financial stability Analysis –Workers/mgrs: +/- trained in problem solving; little std work –Problems complex, cross 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 lessons from Lean Thinking –20,000 problem solvers –Michigan Quality System Plan: (UMHS workers help build it)

UMHS in a Slide Integrated Academic Health System, within major public research university: UM Hospitals and Health Centers –1000 beds –1.6 million outpatient visits UM Medical School –1600 faculty physicians –1000 resident physicians –690 medical students Total: >20,000 employees

Burning Platform for Change?

Gaps at UMHS (and most health systems): Quality: Not all coronary patients get statin, aspirin Safety: Medication errors (10x infusion pump dose) Labs labeled with wrong patient name Results sent to wrong clinician Efficiency: Nurse, doctor searching for equipment, forms, pts… Weeks waiting for appointment to the right physician Higher LOS: fewer admissions, less $$, lay-offs Appropriateness: Antibiotics for resp. infection; MRI for low back pain Service: Patients lost, staff look too busy to help

Gaps at UMHS (and most health systems): A different perspective using lean thinking: Waste: waiting, motion, errors -Muda Uneven workload, variability -Mura - Busy Monday, light Friday - ORs, inpatient beds Stress of overburden -Muri - Physicians, nurses, clerks, managers running faster - Nurse and physician shortage

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

The Ideal Patient Care Experience The IOM “Chasm” Report gives us a vision of where to go Lean Thinking gives us the holistic approach and business system to get there

The IOM “Chasm” Report gives us a vision of where to go Lean Thinking gives us the holistic approach and business system to get there The Ideal Patient Care Experience

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

Womack’s 5 Steps of Lean Thinking Applied to Healthcare 1.Specify value from customer’s perspective 2.Identify the value stream for each 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

The Customer’s Perspective: Your 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. 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?

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

The Broken Office Visit

MedSport Appointments Long term problem: Long delays to get an appointment Frustrated referring physicians, patients Frustrated MedSport staff, physicians Incomplete records, phone tag Physician review records prior to scheduling Lots of hidden processes, errors, rework Project scope: MedSport consult – from request to scheduling

Using the 5 Step Process on MedSport Appointments 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 Errors, time on hold, callbacks, physician reviews

MedSport Appointments Current State Map

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

MedSport Appointments Future State Map

Using the 5 Step Process on MedSport Consults 4. Let the customer pull value from the process Same day appointments Open 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

MedSport Project Results Goal: reduce time from request to scheduling –Pre project: process time = 27 min of work wait time = 23 days –Post project: 89% 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

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

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?

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

26 Psychiatry Referral Process Current State Map

Value Stream Mapping: Learning to See “Ah ha” 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!

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

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, 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

Lean Thinking: How To Get It “Right Every Time” Steven Spear, Institute for Healthcare Improvement Short on Time??? Can’t find time to fix the root cause??? Rather use a 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

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

How can we create (liberate) “20,000 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

“20,000 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

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

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 a skilled clinician.

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

The Goal of Analysis: To Implement a Plan 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

We know half the plan is wrong, we don’t know which half. We have to watch it unfold, find what’s not working right now, and fix it. Traditional companies think of a plan - as a prediction of what will happen. Lean companies think of a plan - as an experiment to be conducted - to tell us what we didn’t know about the work –Paraphrase of Steven Spear, Fixing Healthcare… HBR’05 Plans are useless, planning is essential. (Eisenhower)

39 Can You Find Waste in Your Area? How Do They Build On Each Other? Overproduction and Production of Unwanted Products: Material Movement: Worker Motion: Waiting: Over-processing: Inventory: Correction of defects: Wasted creativity of employees: Variable Workload? (mura) Waste? (muda) Overburden? (muri)

Not All Waste Is Equal Production of Goods, Services Not of Value to the Customer –Most important form of waste –Worsens all the others Appropriateness – key to quality health care! –Eliminate tests, treatments, steps, processes that do not add value Better to eliminate work than to improve how it’s done –Hard to beat the efficiency or safety of a cardiac cath that’s not done because it wasn’t needed! –If its not worth doing, its not worth doing well. -Donald O. Hebb

Role of the Leader in a Lean Organization Standardized Problem Solving 1.Go and see 2.Ask “why?” 5 times 3.Respect people - Fujio Cho, Chair of Toyota Leader’s role is to mentor by asking questions - John Shook, LEI

“Act your way to a new way of thinking”. ---John Shook, Ph.D. Author, Learning to See and Managing to Learn Lean system empowers by cascading responsibility: –Standard work created by workers –Stop the line (andon cord) for abnormalities –Standard workplace to do the job every time (5S) –Systems to replenish what’s needed (kanban) –Value stream mapping to see complex processes –Structured problem solving and idea presentation (A3) “But we don’t have the right culture to do this…”

Why UMHS Chose Lean Thinking? …to improve quality and efficiency, to reduce errors and stress It is a learning approach –Empowers workers to redesign their work –Uses “Work as Learning” It is the scientific method applied to all we do –Uses “Work as Discovery” of new knowledge

Is Lean Thinking just CQI/TQM in a new coat of paint? Builds on Traditional CQI: Frontline workers redesign the work Analyzes root causes of problems (5 whys) Expands on CQI: Starts with value defined by the customer Each step to produce only what is needed by the next one: Just-In-Time Uses “one piece flow” to surface problems now Focuses on overburden & uneven workload, not just waste and errors Value stream maps are very useful for invisible work of health care

MQS Learning Projects Why use them? To Learn! Goal of “Projects”: –Teach managers and workers that they can design their work to solve problems Why not train all managers and workers first? –We Learn Lean Thinking By Doing –“Learn-do-reflect-discuss” cycle of a learning organization

MQS Learning Project Results Radiation Oncology (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

MQS Learning Project Results Results Reporting ~ 13% lab results had no ordering physician, radiology requisitions lost, extensive rework Preprinted labels (12/06) Imaged requisitions increased by 880% (from 957 to 9380) Labs without ordering physician fell from 13% to 2%

48 Internal Results Reporting Goal Improve delivery of test results Accomplishments Enhanced & implemented Results Inbox Reduced lab requisitions with no ordering provider from 13% to 2%

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.

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%

MQS Learning Project Results Cardiovascular Center 32 projects and analyses over 3 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

MQS Learning Project Results CT scheduling and throughput In by 9, out by 5 for inpatients; no longer a weekend bottleneck 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

VAS Supply Cart 5S

Drawer: Pre-5S

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

Engaged team: front line workers and managers

Questions and Discussion

Additional Materials Michigan Quality System “House” MQS Project Selection Process/Criteria Waste Examples in Health Care The Ideal Patient Care Experience statements for UMHS

Just-In-Time Overview/MQS Philosophy (All Missions) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, Park-Nicollet /jmk Michigan Quality System MQS UMHS Values: Respect, Compassion, Trust, Integrity, Collaboration, Leadership Built-in Quality

Using the fewest resources to consistently deliver exactly what the customer needs Just-in-Time Built-in-Quality Error-Free Don’t Make, Accept, or Send on an Error MQS House – Master version (All Missions) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, J. Womack, Park-Nicollet /jmk MQS Make Value Flow by Eliminating Errors and Waste Leveled Workload Continuous Improvement (P-D-C-A) and Learning Standardized Work Michigan Quality System Quality – Safety – Efficiency – Appropriateness – Service Customer Defines Value

Using the fewest resources to consistently deliver appropriate care Right Care, Right Time, Right Setting Just-in-Time Built-in-Quality Error-Free Don’t Make, Accept, or Send on an Error! MQS House (Clinical Mission) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, J. Womack, Park-Nicollet /jmk Michigan Quality System Safe - Effective - Efficient - Patient-Centered - Timely - Equitable Health Care MQS Make Value Flow by Eliminating Errors and Waste Leveled Workload Continuous Improvement (P-D-C-A) and Learning Standardized Work Ideal Patient Care Experience

Just-in-TimeBuilt-in-Quality QUANTITY QUALITY MQS Error Proof Surface Problems Stop and Respond to Abnormalities Solve Problems at Root Cause Pacing by Demand Continuous Flow Pull Systems Work Force - Skilled, Capable, Flexible - Engaged, Motivated - Design Work, Solve Problems Technology and Equipment - Reliable, Tested - Serve People and Processes - Preventive Maintenance -TPM Materials - Materials Readiness - Supplier involvement Make Value Flow By Eliminating Errors and Waste STABILITY MQS Methods (All Mission) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, Park-Nicollet /jmk Methods - Robust Processes - Organized Workplace (5S) - Visual Control Leveled Workload Continuous Improvement (P-D-C-A) and Learning Standardized Work Customer Defines Value Michigan Quality System Quality – Safety – Efficiency – Appropriateness – Service

MQS Project Selection Criteria Critical UMHS priority Opportunity for improvement – large gaps between optimal and current practice Opportunity to expand upstream and downstream; and to translate sideways Existence of a clinical champion Visibility – potential for creating a model line Learning opportunity – for the workers and leaders Quality Safety Efficiency Appropriateness Service

Michigan Quality System Project Selection Process Select Areas: –Prioritization Committee (COO, CFO, CMO, CIO, Chief of Nursing, Group Practice Director, Director of Ambulatory Care) Project leads: –Process Owner, Corporate Sponsor –Determine scope, participants and timing Leadership panel: –All the leaders who need to approve the Future State Value Stream Map and the plan to get there –They support the implementation

Two Models of Project Support In the Michigan Quality System 1.Central coaches: –Assigned by central Prioritization Committee –Complex, cross silo projects –Majors: CV, OR, ED, 5B ward, supply chain, home care 2.Area coaches: –Assigned by their department –Within line management –Areas: Amb Care, Group Practice, Pathology, Medicine, Psych, Childrens, Radiology, Radiation Oncology … All coaches collaborate as a community of learners: –Share strategies and tactics –Build standard work for coaches: the MQS model –Mentor other coaches

TYPES OF WASTE I I C C O O M M W W P P M M CURRENT THINKING WASTE NOT DEFINED REACT TO LARGE EXAMPLES REACTIVE IMPROVEMENT REQUIRED THINKING CONTINUOUS IMPROVEMENT Correction Over Production Over Production Motion Material Movement Material Movement Waiting Inventory Processing WASTE IS "TANGIBLE" IDENTIFY MANY SMALL OPPORTUNITIES LEADS TO LARGE OVERALL CHANGE GM’s Categorization of Waste WASTE Unreasonable -ness Unevenness Source: GMS Training

Eight Types of Waste in Heath Care Waste Category DefinitionHeath Care Examples CorrectionRework because of defects, low quality, errors. Requisition form incomplete/inaccurate/illegible. Order entry error. OverproductionProducing more, sooner, or faster than required by the next process. Inappropriate production. Unused printed results/reports. Unnecessary labs/visit. MotionUnnecessary staff movement (travel, searching, walking). Walking to and from copier/office/ exam room. Searching for misplaced form/ equipment/chart. Material Movement Unnecessary patient or material movement. Multiple patient/paperwork transfers. Temporary locations for supplies. WaitingPeople, machine, and information idle time. Patient in waiting room. Wait for lab results. InventoryInformation, material, or patient in queue or stock. Patient waiting in exam room. Excess stored supplies. ProcessingRedundant or unnecessary processing.Reentry of patient demographics. Repeat collection of data. UnderutilizationUnderutilized abilities of people.Nurses refilling Rx or making appointments. Doctors doing simple patient education. From Elsa Mersereau

Eight Forms of Waste in Healthcare Overproduction and Production of Unwanted Products: The most important form of waste – worsens all the others. Any health care service that does not add value to the patient Antibiotics for respiratory infections CT screening for coronary disease with no symptoms Medication given early, testing and treatment done ahead of time to suit staff schedules and equipment use Appropriateness – key dimension of QI in health care! Material Movement: Moving patients, meds, specimens, samples, equipment Worker Motion: Searching for patients, meds, charts, supplies, paperwork Long clinic halls No printer in exam room for prescriptions, patient education Adapted From Long, Mersereau, Billi

Eight Forms of Waste of Healthcare Waiting: ER staff waiting for admission, can’t see next patient Waiting for test results, records, information Nurse waits for med, blood draw, transport, OR cleaning Over-processing: Bed moves, retesting, repeat paperwork, repeat registration, multiple consent forms, logging requests Inventory: Bed assignments, pharmacy stock, lab supplies, specimens awaiting analysis Patient waiting for anything – tests, visits, discharge, phone cues Correction of defects: Medication errors, wrong patient, wrong procedure, missing or incomplete information, blood re-draws, misdirected results, wrong bills Wasted creativity of employees: Resident trying to find a Livonia infusion center

Lean Thinking: 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

HEALTH AFFAIRS January/February 2001 – Volume 20, Number 1 Interview: A Founder of Quality Assessment Encounters A Troubled System Firsthand “ At the University of Michigan, the outpatient and inpatient teams are entirely separate…There are areas where no one takes responsibility, where planning is weak, where I am left on my own …The system is the problem…Things won’t improve until something is done about the design of the system…The system is the responsibility of the doctors and the leadership. ……. tell the committee that Donabedian said they have a problem.” By Fitzhugh Mullan, p “Every good improvement effort starts with an ugly story.” Don Genord, GM

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

Working to Cross the Chasm at UMHS: The Ideal Patient Care Experience A) Each patient will have an Advanced Medical Home continuity of care across INPT, OPT, ED, home, non-UM… B) We will use Patient and Family Cantered Care in design and operations. C) We use Evidence-based Standard Work. D) Safety will be a System Property. E) We deliver care in an Environment of Service Excellence. F) Care Coordinated Around the Patient’s Needs minimize and managing handoffs communicate effectively among providers, understand the patients' goals, needs, values, lifestyle, and make their health care work within that framework. G) We will provide Facilities and Amenities that Promote Health and Well-being.