1. DEPLOYING A LEAN Approach to Quality Management
COST + QUALITY + SERVICE OUTCOME = CONSUMER VALUE
Learning to see, making problems visible, creating problem-solvers.
NCAHRMM Spring Conference – May 1, 2018

2. Today’s Objective
LEAN Basics – a formalized process improvement framework using practical tools and principles to achieve Operational Excellence
LEAN Management – applying lean tools in daily operations, building trust, showing respect, and empowering the frontline staff to solve problems
LEAN Leadership: a commitment to using A3 Thinking (standard problem solving methods) for sponsoring continuous improvement
LEAN Discipline: Managing Daily Improvement (MDI) at all levels of the organization for making problems visible and developing teams to tell the story of the numbers

3. practicing TEAM ACTIVITY…
1st  Learn to SEE… then, SEEK to Understand… and most important, develop others to problem-solve.

4. Our Mission: To improve the health of the people in our communities.
“Quality is doing the right thing, at the right time, in the most effective way to get the results you want.” –CEO, Chuck Elliott
Founded in 1951 as Johnston Memorial Hospital, the hospital has deep roots in Johnston County, NC.
Campuses in Smithfield and Clayton, Johnston Health is licensed for 179 medical/surgical beds and 20 behavioral health beds.
In 2014, Johnston Memorial became Johnston Health/UNC Health Care. Affiliation with UNC Health Care, ensures working together to enhance and add quality services and the latest technology to better serve our patients

5. Operational Excellence through lean leadership…
Improving daily performance to create and sustain value.

6. Operational Excellence is….
People
Quality
Growth
Value
Innovation
Operational Excellence is….
… our commitment to a disciplined management methodology and framework for problem-solving , collaborative teamwork and leadership that leads to excellence. (LEAN MANAGEMENT) ... our organization's focus on delivering value to our patients (co-workers). …our intentional continuous improvement work which based on “voice of customer” to ensure efficient, effective, timely, safe and quality results. … our passion for creating visibility and shared knowledge about our daily process flows. It requires measuring and understanding how processes are performing against  our GOALS. … supporting consistency and reliability in running our business. … serving our mission.
Sound Strategy (GOALS)
Operational Excellence
Outstanding Performance
Our mission is to improve the health of the people in our communities.

7. Lean Basics

8. Understanding your processes….
“The processes you have in place at your facilities are designed perfectly –
perfectly to achieve the outcomes you are obtaining.
If you want to change the outcome, you have to change your process.”
We manage processes; we watch outcomes
By ROBERT PEAR
Published: February 2, 2007
The New York Times WASHINGTON, Feb. 1 — President Bush will ask Congress in his budget next week to squeeze more than $70 billion of savings from Medicare and Medicaid over the next five years, administration officials and health care lobbyists said Thursday.
Donald Berwick, MD, at the time of the statement he was President and CEO, Institute for Healthcare Improvement 8

9. Developing people, solving problems, and improving processes… a journey.
Think about this statement…
“A minimum of 10% of my daily work is spent working ON the business versus IN the business…”
Is 10% improvement enough?
Who owns improvement?

10. Appreciation of Systems Understanding Variation
The Science of Improvement
Profound Knowledge
Appreciation of Systems
Human Side of Change
Understanding Variation
Building Knowledge
Deep insight into how to make changes that will result in improvement
William Edwards Deming, PhD
(October 14, 1900 – December 20, 1993)

11. “LEAN Defined” An organizational management system.
A disciplined set of practices (tools/techniques) for managing daily operations.
An appreciation of “systems” and “processes” versus task only.
A VISIONARY approach for bringing value based on the customer perspective, thus eliminating waste or non-value activities.
A culture (mindset) for collaborative teamwork where “value” is created – meeting the customers expectation of services delivered.
VISIBILITY and FOCUS on continuous improvement.

12. Lean IS…. Lean IS NOT… Cutting people PUNATIVE A one-time event
Transforming culture… DNA. Respect, trust and bringing VALUE to the customer
Optimizing resources
A journey.. A commitment to a disciplined, sustainable standard work (processes/systems)
WORLD KNOWLEDGE: Visibility
What/Why: Story of the numbers (Process Metrics linked to OUTCOMES)
Cutting people
PUNATIVE
A one-time event
Siloed thinking
OFAT (changing one factor at a time)
Quick RESULTS

13. 5 Lean Principles
The five-step thought process for guiding the implementation of lean techniques is easy to remember, but not always easy to achieve:
CREATE VALUE: Specify value from the standpoint of the end customer by product family.
UNDERSTAND VALUE STREAM: Identify all the steps in the value stream for each product family, eliminating whenever possible those steps that do not create value.
CREATE FLOW: Make the value-creating steps occur in tight sequence so the product will flow smoothly toward the customer.
GENERATE PULL: As flow is introduced, let customers pull value from the next upstream activity.
SEEK PERFECTION: As value is specified, value streams are identified, wasted steps are removed, and flow and pull are introduced, begin the process again and continue it until a state of perfection is reached in which perfect value is created with no waste. 

14. GEMBA: “Learning to see…”
FROM THE Chief Medical Officer: “Our patients just assume our processes will work smoothly.” -- Go to GEMBA and observe.
Go to Gemba (現場 ?, also romanized as genba) is a Japanese term meaning "the real place."
Japanese detectives call the crime scene gemba, and Japanese TV reporters may refer to themselves as reporting from gemba.
In business, gemba refers to the place where value is created; in manufacturing the gemba is the factory floor.
Within a LEAN context, Gemba simply refers to the location where value is created, while Kaizen relates to improvements.

15. Time to drive to facility
Thinking Like A Customer (Create VALUE)
How does the customer experience our process?
What does the customer look at to measure our performance?
Patient’s View
of Registration
Lobby Time
Time to Park Car
Registration
Walk to Procedure Area
Procedure Time
Time to drive to facility
Points to Highlight:
Introduce example as seque to thinking like a customer.
Example: When we go to the restaurant, what do we care about? Fast delivery of food, food is tasty, fast, friendly service. Do we care about the fact that 2 servers called in sick, or the produce delivery truck was late, etc. etc.?
Introduce example in the slide to review the process from each of patient’s and each of the operator’s perspective.
Let’s look at this customer coming to our facility for a procedure. As a registrar talking to the patient during a pre-registration call, do you know what the patient’s experience will be when you say—just go to the lobby and check in w/ registration?
They are considering/experiencing the time to drive to the facility, time to park, time in lobby, time to walk to the procedure area and time in the procedure room.
As the registrar, my view of registration is the registration process, as the nurse in cardiac cath, my view is the procedure time. The patient’s perspective is much broader. We need to start thinking like our customers, viewing the process from their perspective.
Hospital’s View
of Registration

16. Understand the value stream (GEMBA Observations)
VALUE-ADD + NON VALUE-ADD = Total Process Cycle-times
(How much is time is spent on VALUE-ADD?)

17. Consistent Processes Yield Quality Results (Create Flow: Standardize)
Inconsistent
Process
Results
Traditional = staff doing whatever they can to get results
Consistent
Process
Desired
Results
Improvement Science = using a standard process to get consistent results

18. Benefits of Lean (seek perfection)
Lean…..The relentless pursuit of the perfect process through waste elimination
Before
. . . Any process or value stream
After
Wait/Waste . . .
Non Value Add Time
Lean attacks waste here
Work . . .
Value Add Time
Lead Time/Cycle Time
Higher customer satisfaction
Reduced cycles
Better delivery
More capacity
Better quality
Productivity

19. Defects Overproduction Waiting Non-utilized Talent Transportation
The Eight Types Wastes (Muda)
Defects
Overproduction
Waiting
Non-utilized Talent
Transportation
Inventory
Motion
Extra-Processing
The 8 waste categories
Go through each and define
When brought from Japan was only 7 but when can back to US had to be specific and add non-utilized talent – make sure wking at scope of license and practice

20. QUICK ROI WINS: DO a 5s?
Goal everything has a place and there is a place for everything – many companies begin their lean transformation with 5S due to its visible illustrations of waste. We’ll dig into each of these categories to learn more about their meaning and application
Review Steps

21. LEAN MANAGEMENT SYSTEM
Creating a LEAN CULTURE

22. Essentials for a successful Lean Management System
Alignment of goals:  Whether you use traditional hoshin planning or another form of strategic planning, the critical element is alignment of all improvement activities to the organization’s strategic goals.
Disciplined adherence to process:  Managers who keep their eye on the process, knowing how well the process is meeting patient and customer expectations and how well staff are adhering to standard work of the process are essential in real time.  Retrospective reports from the last quarter or last month or even from last week’s performance are all too late.  Measurement of performance must move to the daily or hourly level of review to identify problems and make improvements as close to the work as possible.
Standard Work:  In order to ensure disciplined adherence to process, standard work must be defined both for the front line staff meeting the patient’s needs as well as leaders at every level of the organization who are monitoring and improving standard work.
Visual Management:  Getting everyone on the same page is much easier when the goals are displayed in a manner that is accessible and understandable to all.  In order to be understandable to all, process and outcome indicators need to be connected to the work done in each area.  As a staff member, if I cannot see how I can contribute, it is unlikely that the metrics posted will have much meaning to me, and I will not change my behavior to help move the metrics.
Coaching for Continuous Improvement:  Lean tools are often described as easy to understand, but not necessarily easy to apply.  Managers and leaders at all levels of a Lean healthcare  organization should move improvement activities out of a conference room and coach others in applying the tools in the GEMBA!
Johnston Health Operational Excellence

23. Understanding LEAN MANAGEMENT SYSTEMS
LEAN Leadership
Understanding LEAN MANAGEMENT SYSTEMS

24. LEAN success factors…
1. Willingness and Desire to Lead: motivate and inspire people to achieve great things
2. Job Knowledge: a subject matter expert w/business acumen
3. Job Responsibilities: role clarity (accountability v responsibility)
4. Continuous Improvement Ability: encourage people to develop improvement in thinking and action.  It is more important to have many small daily improvements than to have few major improvements
5. Visible Leadership: able to “translate” the overall company objectives into specific activities that their team must perform in order to be successful.  Develop the game plan and assist the team in how to carry it out.  Provide support, training and coaching
6. Teaching/Coaching: Primary duty is to teach others.  If skill and knowledge is not passed on to others, the organization will not grow and prosper

25. Mindsets…Leaders must understand

26. Adopting your LEAN leadership identity
Role Clarity:
Strategy: purposeful commitment to adopt lean
Make time for improvement on the calendar
Practice Lean Tools (A3: PDSA)
Teach Lean Philosophy (Socialize: WHAT with WHY)
Get out of the way – trust others/develop others
Bring me a problem requires: validation “what/why/how do you know?” AND recommended solutions
Continuous Lean Learning
Model the Way:
Assure alignment with GOALS re: Lean thinking (you, your team)
Set performance expectations (STANDARD WORK)
Make lean visible (COMMUNICATE)
Use LEAN language (How do you if we’re RUNNING GOOD TODAY?)

27. Introducing… A3 thinking
A management “process.”
An effective problem-solving process.
A3 thinking socializes a problem by telling a story – the thinking behind the “WHAT/WHY/HOW” to solve a problem.
Kaizen

28. Developing a culture of PROBLEM-SOLVERS at all levels of the organization!
Thinking
PROBLEM TYPE:
MACRO (Organizational)
MESO (Dept)
MICRO (Local)
Senior Leadership
Middle Management
Front Line
Customer
Tactics
Strategy
Problem-Solving
Delivering value to our customers
OUR PATIENTS (each other)

29. A3 Thinking: A Problem-Solving Framework
Problem-Solving Teams thrive when using common tool to gain a shared vision.
A3 THINKING promoted a common language to problem solve. Following the steps of an A3 using “9-Boxes” (or steps) ensures teams problem-solve together using a discipline method.
All A3s start with “GRASPING THE SITUATION” – defining the PROBLEM first!!

30. Managing Daily Improvement (MDI Visual Boards)
Learning to see problems, not just correct them.
Deploying a Lean Management System at Johnston Health

31. MDI: managing Daily Improvement
Implementing a lean management systems to making things visible.
MDI teaches us to “look” for problems and solutions (learning to see)
MDI promote “We do our DAILY WORK and we “improve DAILY WORK.”
MDI promotes going to GEMBA as the center of process improvement.
MDI demands making things visible to one other.
MDI provides a “pulse” for how the business is running… real-time.
MDI promotes teamwork, trust, story of the numbers…
MDI MAKES the what with why re: a process visible…
MDI develops team/relationship – focus on patient (customers)
Johnston Health Operational Excellence

32. MDI (Managing Daily Improvement ) __________________________________
Expert care, close to home.
*TRUE NORTH METRICS: FY18
MONTHLY STATS PERFORMANCE
DAILY STATS PERFORMANCE
IMPROVEMENT (Work-in-Progress)
DAILY HUDDLE
“Today’s Performance”
DRIVER 1: Sepsis/Fluids
DRIVER 2: Hand Washing
DRIVER 3: C-Diff Infections
Pillar
Goal 1
Pillar Goal 2
Pillar Goal 3
OUR PILLAR GOALS
A3s (PDSA)
JDI
# New Ideas
# Ideas IN-PROGRESS
# Ideas COMPLETED
YTD DRIVER STATS Trends
YTD DRIVER STATS Trends
YTD DRIVERSTATS Trends
OVERALL #
Improvement Ideas
MONTHLY
DRIVER 1: Monthly Performance STATS
(Run Charts)
DRIVER 2: Monthly Performance STATS
(Run Charts)
DRIVER 3: Monthly Performance STATS
(Run Charts)
ACTION PLAN for TODAY
Xxx
xxx
Idea Tree
WHY?
DRIVER 1:
BARRIERS to GOOD
DRIVER 2: BARRIERS to GOOD
DRIVER 3: BARRIERS to GOOD
INFORMATION/CELEBRATION
ANNOUNCEMENTS
(NEW POLICY/DEPT NEWS)
Huddle
TEMPLATE

33. MDI : ED-Smithfield Initial Department MDI Metric:
STRATEGY/TRUE NORTH METRIC (DPT)
Metric: Improve Patient Satisfaction
Barrier: Communicate w/providers (Nurses)
DAILY STATS: ED Time to Disposition (from patient arrival to discharge/disposition <3hours)
DAILY STRATEGIES: (Plan for Today)
1) Initiate Protocols
2) Complete & Timely Orders
Approach Provider in timely manner
IMPROVEMENT
IDEAS SUBMITTED (evaluated)
Hourly patient rounding… PDSA
Johnston Health Operational Excellence

34. MDI : ED-Clayton Initial Department MDI Metric:
STRATEGY/TRUE NORTH METRIC (DPT)
Metric: Improve Patient Satisfaction
Barrier: Patient Pain Re-assessments
DAILY STATS: ED Time to Disposition (from patient arrival to discharge/disposition <3hours)
DAILY STRATEGIES: (Plan for Today)
Changes in Pain Response
1)Chart non-pharm methods of pain relief
2)Set patient pains goals
3) Education on narcotic medication management/safety
4) AT-RISK for addiction readmission
IMPROVEMENT
IDEAS SUBMITTED (evaluated)
Needle sharps containers… et.al.
Johnston Health Operational Excellence

35. MDI : ICU-Smithfield Initial Department MDI Metric:
STRATEGY/TRUE NORTH METRIC (DPT)
Metric: Decrease Foley Catheter Utilization
Barrier: In-dwelling Catheters
DAILY STATS: Timely Foley Catheter Removal
DAILY STRATEGIES: (Plan for Today)
Changes in Pain Response
1)How many patient w/Foleys are long-term in-dwelling Foley patients
2)How many patients admitted from ED have a Foley – was it necessary
3) Removal w/I 24 hours of admission.
IMPROVEMENT
IDEAS SUBMITTED (evaluated)
Johnston Health Operational Excellence

36. Leader GEMBA Walk process…
Establishing and Adopting Guiding Principles for MDI Leadership…
Assure a safe environment for transparency - storytelling
Develop people (Lead/Coach)
Empower and involve everyone in the process
Establish Leadership Visibility to BUILD RELATIONSHIPS, support and listen to staff and recognize LEAN Leadership at all levels of the organization.
Johnston Health Operational Excellence

37. INSIGHTS ABOUT LEAN at JOHNSTON FEEDBACK & sincere comments
Lean has been at Johnston for about 8 years. A journey… from rapid improvement events/projects (ROI) to daily improvement problem-solving
Senior leadership sponsors lean A3 project teams requiring an average of 3-5 months (improve/sustain) – engaging all levels of the organization to develop lean skills, leadership and relationships.
LEAN education (Operational Excellence Champion program)
LEAN Visual Management boards to bring lean learning to all work areas.
LEAN invites conversations focused on “Running and Business AND Improving the Business” across teams/departments
Front-line staff tell the story of the numbers. problems/solutions… from customer’s perspective
LEAN REFLECTIONS:
REMEMBER TRUE NORTH: HEAD + HEART – What with why…
LEAN LEADERSHIP – Focus on process, not people
LEARN BY DOING… DEFINING THE PROBLEM is the first step of SOLVING IT
LEAN THINKING – No problem, is a problem

38. A LEAN Approach to Quality Management … it takes all of us
Operational Excellence Champions
Front-line MDI Teams
MDI Boards active in departments
Weekly Leader GEMBA Walks
(Cost + Quality + Service = VALUE)

39. FOR MORE MDI Storytelling…
My contact information:
Deborah J. Katz, MBB, MBOE
Director of Operational Excellence
Johnston Health UNC Health Care e:
w: (919)