1. Daily Continuous Improvement Program Trey Coffey MD FAAP FRCPC Medical Safety Officer, SickKids Associate Director, University of Toronto Centre for Quality Improvement and Patient Safety

2. Disclosures I have no conflicts of interest to disclose

3. Lean Concepts Origins in Toyota Production System c. 1930s Term coined and applied to western manufacturing c. 1980s Processes analyzed from the point of view of customer value Focus on eliminating waste of all kinds in the system Deference to expertise – executives on the factory floor (“Gemba”)

4. Getting to know you Your prior experience with LEAN is best described as: A. I am not very familiar with LEAN. B. My healthcare organization is doing some LEAN things and my reaction is… “meah.” C. My healthcare organization (or other organizations I am familiar with) did some LEAN and it was an unmitigated disaster. D. My healthcare organization is completely LEAN

5. Different Levels of Process Improvement Adapted from: “The Toyota Way Fieldbook” by Liker and Meier Very few Large issues Few Medium issues Many Small issues

6. Objective To tell a genuinely enthusiastic firsthand account of a unique Lean Management System, which: is new to SickKids is not yet fully realized nor perfected might be revolutionary…

8. New Job Paediatric Medicine Quality Committee c. 2005

9. 2011: Emergency Department Performance Improvement Program We used Lean to improve Door-to-Floor times!

10. Reality sets in… Again.

11. ThedaCare group of hospitals and clinics in Appleton, Wisconsin. Early adopter of Lean methods 8 years ago ThedaCare Business Performance System to address sustainability and to develop a culture of daily continuous improvement Impact 32% improvement in patient satisfaction 21% reduction in hospital cost per case Feb 2012: Learning Partnership with ThedaCare

12. Awaiting my invitation… Rapid process improvement workshop? Kaizen event?

13. Manager Daily Status Sheet

15. A few weeks later this appears

16. Daily Improvement huddle: M,W,F 1:15-1:30

17. Daily Improvement Board Just do its More challenging problem solving (PDSA 3 ) Collect Improvement Cards Prioritize Issues Completed

18. Daily Improvement Huddle Board

19. Early signs of success: Engagement of frontline nurses on 7B raised hand hygiene compliance

20. Daily CIP’s Goal: Develop people to solve problems and improve performance

21. Different Levels of Process Improvement Adapted from: “The Toyota Way Fieldbook” by Liker and Meier Very few Large issues Few Medium issues Many Small issues Large Projects Lean Event Focus of Daily CIP Six Sigma

22. Status Sheet: Manager, Director and VP DAILY Manager Status Sheet WEEKLY Director Status Sheet EVERY 2 WEEKS VP Status Sheet Manager Charge Nurse DirectorVP

23. Status Sheet: Links Between Levels DAILY Manager Status Sheet WEEKLY Director Status Sheet Manager Charge Nurse Director

24. A wise man once told me: “Behavior drives culture” 24 Competing priorities for improvement Improvement accountability with a few people Project teams solve problems periodically Ad-hoc use of improvement tools and approaches Frequent review of improvement priorities Improvement accountability at all levels Front line staff solve problems daily Staff trained in adopting tailored toolkit and approach for problem solving From:To:

25. New and Improved Paediatric Medicine Quality Leadership Team We still meet monthly to discuss trends in performance and to prioritize which metrics to improve upon Except now… I had to get a much bigger room! I am currently looking for an even bigger room! Staff come in on their OFF DAYS! I look forward to it instead of dreading it

26. Monthly Score Card: Driver and Watch indicators This scorecard dictates the unit focus for the month

27. Falls, Entrapment, Strangulation, Entanglement documentation scores

28. Three day Equipment Improvement Event Situation Overview Finding supplies is difficult Approach Impact a place for everything everything in its place Sort Set-in-order Shine Standardize Sustain 5S

30. RESULTS Staff-driven problem solving: Over 65 improvement ideas identified and executed since April 2012 Median of 19% Improvement in Engagement Scores

31. Key ingredients 1. INTRINSIC MOTIVATION Provide opportunity for self-leadership Provide choices Help members acquire skills and knowledge Assign tasks but make connections Coach 2. DISCIPLINE Simple behaviors repeated over and over Autonomy Relatedness Competence Self-Determination Theory

32. Enterprise wide picture 12/22 units doing Daily CIP 20 yellow belts trained 178 green belts trained Larger projects/value streams: Ambulatory, Surgical, Procurement, Pharmacy, Administrative. ~20 Rapid Improvement Events completed to date

33. How much does this cost? “Lean Promotion Office” Office of Process Improvement Director, five staff, and an assistant hired from industry and consulting firms $1 million/year (approx)

34. The Hand Hygiene graph continued….

35. Questions for consideration 1.Are we going to be able to tackle the big stuff? 2.How is this experience going to vary across units? 3.How are we going to substantively engage physicians?

36. Acknowledgments SickKids nursing and operational leaders: Kate Langrish, RN, Lynn Mack, RN, Linette Margallo, RN, Dinarte Viveiros, RN SickKids Office of Process Improvement: Shiraz Bhajwa, MBA, Travis Beamish, MBA Ali Shahzada, MBA Executive sponsor: Jeff Mainland, EVP Strategy, Performance, Quality and Communication