1. Creating the Michigan Quality System Jack Billi, M.D. jbilli@umich.edu Michigan Quality System: med.umich.edu/mqs Website with talks on A3 Thinking, Lean Leadership, and other topics: sitemaker.umich.edu/jbilli Michigan Quality System: Quality Safety Efficiency Appropriateness Service Lean Thinking to Health Care

2. 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 www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCarewww.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare 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 Lean Healthcare Value Leaders Network www.healthcarevalueleaders.orgwww.healthcarevalueleaders.org Lean Enterprise Academy (UK): www.leanuk.orgwww.leanuk.org Ideal Patient Care Experience at UMHS www.med.umich.edu/i/acs/ipe.htmwww.med.umich.edu/i/acs/ipe.htm 3/11/10

3. 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)

4. Burning Platform for Change?

5. Gaps at UMHS (and most health systems): Quality: Not all pts get right antibiotic timing, redosed Safety: Medication errors (10x infusion pump dose) Labs labeled with wrong patient name Retained foreign objects Hand sanitizing “in and out of bedside” less than 100% Efficiency: Nurse, doctor searching for equipment, forms, pts… Outdated DPCs, wrong instruments for case Higher OR case length: fewer cases, less $$, RIFs Appropriateness: Drugs ordered up, not used; imaging v. examining Service: Patients lost, staff look too busy to help

6. 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 - Busy afternoon, light morning - Service at a meeting all week - ORs, PACU, inpatient beds Stress of overburden -Muri - Physicians, nurses, clerks, managers running faster - Nurse and physician shortage

7. 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

8. 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

9. 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

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

11. 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

12. 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?

13. 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

14. 14 Psychiatry Referral Process Current State Map

15. The Broken Office Visit

16. 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!

17. 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

18. 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 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

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

20. 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

21. 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 Solving problems: –1. Go and See –2. Ask Why –3. Respect People Mr. Cho

22. “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

23. 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

24. 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.

25. 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

26. 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

27. VAS Supply Cart 5S

28. Drawer: Pre-5S

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

31. Engaged team: front line workers and managers

32. Problems, Problems, Problems… What was your most serious problem… –Your last shift in PACU? –In your last pre-op clinic? Could you do the 4 steps? –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! Could you do a good H&P on the problem, with Impressions, Plans and Follow up?

33. Questions and Discussion Tell us your “ugly story…”

34. Additional Materials Michigan Quality System “House” Womack 5 Step Process examples Lean is about empowerment Plans Appropriateness Michigan Quality System: –Why Lean Thinking? –Project Selection Process/Criteria –Results Waste Examples in Health Care The Ideal Patient Care Experience statements for UMHS

35. Just-In-Time Overview/MQS Philosophy (All Missions) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, Park-Nicollet /jmk 04.09.07 Michigan Quality System MQS UMHS Values: Respect, Compassion, Trust, Integrity, Collaboration, Leadership Built-in Quality

36. 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 04.09.07 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

37. 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 /jmk04.09.07 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

38. 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 04.09..07 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

39. “Act your way to a new way of thinking”. ---John Shook, Ph.D. Senior Advisor, Lean Enterprise Institute Author, Learning to See Lean system reinforces empowerment 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 can’t do this till we change the culture…”

40. 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

41. 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?

42. 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

43. 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

44. 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

45. MedSport Appointments Current State Map

46. 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

47. MedSport Appointments Future State Map

48. 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

49. 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

50. 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

51. We know half the plan is wrong, we don’t know which half. We have to watch it unfold, detect normal from abnormal 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)

52. Eight Forms of Waste (Muda) in Healthcare Overproduction and Production of Unwanted Products: Material Movement: Worker Motion: Waiting: Over-processing: Inventory: Correction of defects: Wasted creativity of employees:

53. 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

54. 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

55. 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

56. 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, Children's, 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

57. 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

58. 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

59. 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

60. 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

61. 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.

62. A Quick Summary of Lean Thinking 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 Solving problems: –1. Go and See –2. Ask why 5 times –3. Respect people Mr. Cho jbilli@umich.edu www.med.umich.edu/mqs www.lean.org

63. Lean Thinking is just… …simple and practical, consistently solving real problems in real time, at the source, at all levels. …not jumping to solutions. …fixing the problem now. …hard on the problem, easy on the people. …leader saying, “Follow me. Let’s look at it together”. …leading by being knowledgeable, fact-driven, expert negotiator, strong willed (for organization’s goals) yet flexible; leading by influence and persuasion. …not telling people exactly what to do. …having individual responsibility clear. John Shook

64. Lean Thinking: Troubleshooting Guide 1.What is the problem? 2.Who owns the problem? 3.What is the plan? 4.What is the current status of the plan? How will it be monitored? 5.What worker training is needed? 6.How does this problem relate to the organization’s most important goals?* 7.What leader development is needed? Adapted from John Shook. Ask questions in order. *As a variation, 6 may be asked second. J Billi

65. We know half the plan is wrong, we don’t know which half. We have to watch it unfold, detect normal from abnormal 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)

66. UMHS Chief Engineer System Med Surg Anes Nursing Pharm Med Surg Anes Nursing Pharm Modified from John Shook

67. Problem and PDCA Tools for different levels Key to success: The Mid-management and First Line Supervisory Level FRONT LINES SENIOR MANAGEMENT MIDDLE MANAGEMENT MUST PROVIDE VISION AND INCENTIVE MUST “DO” MUST LEAD THE ACTUAL OPERATIONAL CHANGE Likes the involvement Likes the results Requires tools and support to lead RoleImpact Problem: MUDA PDCA tool: (HK) Strategy deployment PDCA tool: A3 or VSM PDCA tool: Standardized Work Problem: MURA, MURI Problem: MURI, MURA Shook Muri – overburden Mura – uneven workload Muda – waste HK – hoshin kanri – strategy deployment – policy deployment