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Rapid Improvement Events (RIEs), A3 Problem Solving, and Voice of the CustomerJudy Krempin, MS, CPHQManagerQuality, Safety, Performance Improvement
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RAPID IMPROVEMENT EVENTS (RIES)
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Objectives
State when a Rapid Improvement Event (RIE) should be used
Name the people (roles) who should be involved in an RIE
process
Describe the timeline for an RIE cycle
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Why use an RIE?
Rapid improvement events enable you to:
Learn and implement continuous improvement practices (i.e.,
Lean Tools)
Work as representative team
Focus on a targeted process/ area and patient population
Improvement work is completed within a specific time
period
Reduce variation, improve flow, improve value for the patient
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Who is involved?
The hospital-wide Quality Improvement Committee, a high level steering committee commissions the team
RIE team (project team) will be responsible for planning and implementing the Lean tools
Note: All employees should do their own Kaizen (continuous improvement) daily – they do not have to wait for a rapid improvement event to think about reducing waste.
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Wednesday-Friday:
Implement changes
Three-week preparation
period
Monday:Discuss current
process flow
Tuesday:Redesign flow and remove
waste
Three-week post-event sustainment
3 weeks 1 week3 weeks
Create Team
Team Charter
Approval of Charter/ A3
Communicate To Staff
Voice of the Customer
Observation & Data Collection Current State Flow Chart/ Value Stream Map Identify Barriers Spaghetti Diagram COPQ 5S Brainstorm Improvements Future State Flow Chart/ Value Stream Map Benchmarks and Measures Mistake Proofing Leveling Standard Work Specific Task List & Timeline
Report Results
Teach Standard Protocols
Update Policies
Monitor Results
Targeted Gemba Walks
Huddle at the PI Board
Source: Advisory Board interview, December 2006.
Rapid Improvement Event
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RIE Supports the Mission, Vision, Strategy of the Organization
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Rapid Improvement Events
Will accomplish the following:
Quickly implement Lean tools to eliminate waste and non-value added work
Train staff in Lean tools and application
Improve work flow
Improve productivity
Reduce stress
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Summary of Key Points for RIEs Must have all three phases - The planning
phase and follow-up phase are just as important as the workshop (“hot week”) phase.
These events can be focused on one area or process, or on multiple areas.
Only successful if management (champion) is in support and there is cooperation from the staff.
Keep events manageable with focused projects. Expand as you experience success.
Always keep 5S as the initial part of any event.
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A3 & PROBLEM SOLVING
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Objectives
State the principles of A3 thinking
Describe the benefits of the A3 process
Articulate how to use tools to document the A3 process
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A3 Thinking
A3 is structured problem solving
Helps us to truly grasp the root of the problem before we determine a solution
Transparency of thought and analysis
Develop A3 for all RIEs hospital-wide and all department specific
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Three Pillars of A3 Thinking
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A3 Elements
Project Title Executive Sponsor Background Current State
(Compelling Reason for Action)
Goals/Measures Analysis/Root Causes
Interventions / Future State Map
Observations Results / Conclusions Follow up(Has this change resulted in improvement?)
Plan to Sustain
PlanDo
StudyAct
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Title: What you are talking about?
Background
Current Situation
Goal
Analysis
Recommendations
Actions
Follow Up
Why are you talking about it?Cost of poor quality?
Where do we stand today?
What’s the problem?
Where do we need to be?
What is the specific change you want to accomplish now?
What are the root causes of the problem?
What are your proposed interventions/ countermeasures?
What activities will be required for implementation and who will be responsible for what and when?
How we will know if the actions have the impact needed? What remaining issues can be anticipated?
Authors: John Shook and David Verble. Lean Enterprise Institute. www.lean.org
A3
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A3 Background & Scope
Why are we forming this team?
How does the work of this group support the overall goals of the organization?
Which patients?
Which settings of care?
Which process?
What are the start and end points of the process?
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A3 Background &Cost of Poor Quality (COPQ)
What are the dollars at risk?
Quantify the value of wasted staff time for non-value added activities
What are the additional days in length of stay when patient harm events occur or care coordination activities fail?
What are the risks to the organization if publicly reported data reflect poor performance?
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A3 Current Condition (and Compelling Reason for Action)
Problem Statement: One sentence stating the compelling reason for action
Problem Description: Patterns, frequency, nature of problem
Facts: Show graph or process map that describes problem
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A3 Goals
High level statement describing what we will improve? How? By When?
Aim Statement
How will we know a change is an improvement?
Process Goal?Outcome Goal?Note Benchmarks
Measures
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A3 Analysis/ Root Causes
5 Whys: Ask “why” multiple times to identify the root cause
1 Why did the problem happen?
2 Why did that happen?
3 Why did that happen?
4 Why did that happen?
5 Why did that happen?
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A3 Analysis/ Root Causes
Process
Effect
People
Place Policies
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A3 Interventions / Future State Map
Identify the most effective solution that can be implemented, considering time and cost
Obtain approval from project sponsor
If steps in a process will change, show flow diagram
Consider standard work and visual controls
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A3 Observations
Assign tasks to specific people and set target date:
Communicate plan to people affected by change
Implement interventions (pilot)
Collect data
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A3 Results/ Conclusions
Team meets to discuss results of the trial/ implementation
Discuss unintended consequences
Decide what input, sequence, or step needs adjustment
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A3 Follow Up
Tasks Target
Date
Responsible
Person(s)
Decide if new PDSA is needed
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Why?
‘A3 Thinking’ The A3 Report
Background of the problemContext required for full
understanding Importance of the problem
Diagram of current situation (or process)Highlight problem(s) with storm burstsWhat about the system is not IDEALExtent of the problem(s), i.e.,
measures
List problem(s)Most likely direct (or root) cause:
Why?Why?
Why? Why?
Diagram of proposed new processCountermeasures noted as fluffy
cloudsMeasureable targets (quantity, time)
What? Who?
Cost:
When? Where?
Actions to be taken
Responsible person
Times, Dates
How will you check the effects?When will you
check them?
In red ink/pencilDate check doneResults, compare
to predicted
Background
Current Condition
THEME: “WHAT ARE WE TRYING TO DO?”
Root Cause Analysis
Target Condition
Implementation Plan
Follow-Up
Plan Actual Results
To:By:Date:
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First Step: Hand Drawn A3
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Electronic A3 (eVSM)
www.evsm.com
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A3 with Photos
Source: http://www.shmula.com/wordpress/wp-content/images/shmula-5s-fishbone.png
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A3 Templates
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Format A3 for Easy Uptake of Information
Goal is to tell a story
Strive to make the story visual
Address all A3 elements
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A3 Plan to Sustain
How will these improvements be sustained?
Monthly A3 Reports with Data
Real Time Feedback/ Huddles
Visual Management
Go See
Standard Work
Leadership Rounds
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Summary of Key Points The goal of an A3 is to tell a visual story
and communicate our problem solving approach.
The left side of the A3 represents the “Plan” of the Plan-Do-Study-Act methodology.
The value of spending time planning is that we understand the root causes of the problem before selecting an intervention or solution.
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VOICE OF THE CUSTOMER (VOC)
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Objectives
Define the Voice of the Customer (VOC)
Identify who the customer IS for a process
Describe how the needs of the customer are defined
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What is a Customer?
A customer is:
Anyone who interacts with a product or service, from its design, development, transformation, and every step along the way to the end-user
Anyone whose perception of the value offered can affect whether or how an organization continues to deliver those offerings (American Society for Quality)
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Primary Customer
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What is VOC?
The “voice of the customer” is a process used to capture the requirements/feedback from the customer (internal or external) to provide the customers with the best in class service/product quality
This process is all about being proactive and constantly innovative to capture the changing requirements of the customers with time
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How do we obtain VOC?
The stated and unstated needs of the customer can be captured in a variety of ways:
o direct discussion or interviews
o surveys
o focus groups
o customer specifications
o observation
o warranty data
o field reports
o complaint logs
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Who are the Customers?
External customers Those not employed by the organization who interact with a product or
service
Often the person who pays for the service
Person who receives the output of the process
End user
Patient (sometimes called the “primary customer” in healthcare)
Internal customers Those in the organization who participate in the development/ delivery of the
product/ service People who need the output of the previous “step” to do their job Employees
Organization/ Stakeholders The stakeholders or leaders of the organization who want the
process to operate efficiently
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Defining Customer Requirements
To adequately determine customer requirements, practitioners need to conduct discussions with the customer
Through these conversations, practitioners typically gather generic customer needs
Practitioners must go on to translate these generic needs into specific items called critical-to-quality requirements (CTQs)
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Transitioning from VOC to Critical to Quality
To begin the translation to specific CTQs, consider the typical generic needs of the customer:
Cost: How efficient is the process operating from the perspective of the business? What costs are involved for the patient?
Timeliness: Delivery to customers when they want it
Quality: Did the customers get the what they wanted? (e.g. well-explained, helpful, done right the first time)
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Obtain Voice of the Customer (VOC)
Identify the stakeholders in the process List all customers/receivers throughout this process
Talk to people! This is the beginning of our communication strategy.
Answer these questions: What are your customers saying?
What needs to be improved and why?
What does the process look like?
What is happening in the environment?
o National, regional, local, internal
Can we validate the perceived need for improvement using data?
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VOC
1) Who is the customer of this process 2) What do they say about this process, what do they need? 3) What is the key issue for improvement?
Customer Voice of Customer Key Issue
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VOC for Patients/ Family – Timely Care
1) Who is the customer of this process 2) What do they say about this process, what do they need? 3) What is the key issue for improvement?
Customer Voice of Customer Key Issue
Patient I was stressed upon arrival but relieved when the doctor showed me pictures
Patient uncertainty about process/ outcome
Patient Would help to have more explanation if surgery is delayed for ½ hour or more
OR case delays/ Explain delays
Patient/ Family My mom didn’t know why it took so long. OR case delays/ Explain delays
Patient There seemed to be a lot of duplication in the questions they asked me
Cumbersome Pre-op process/ Duplication
Patient The nurses made sure I was comfortable Patient comfort
Family More information about what is going on after a few hours. I thought my wife would be done by 3pm.
OR case delays/ Explain delays
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Example “Critical to Quality”: OR Cases Start On Time
Driver 1
Driver 3
Driver 4
Requirement 1
Requirement 4
Requirement 5Requirement 6
Customer Need (CTQ)
Driver 2Requirement 3Requirement 2
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Example “Critical to Quality”: OR Cases Start On Time
Doctor has adequate information to select procedure(s)
Level load schedule
Separate emergent and elective case flow
Patient is on timeDoctor and staff are on timeEveryone involved knows the plan for the day
Standardized room set up
Supplies replenished on pull system (kanban)
Separate internal and external set up
Standard work
Contingency plan for increased patient demand (staff, rooms, communication)
Performance management – goal, visual management, threshold for action
Case Starts on Time
Consistently
Duration of surgery is appropriate for case
Schedule is blocked when surgeons are unavailable
Correct Surgery Scheduled
Schedule Reflects Demand for Services
On Time Staff
Supplies in Reach When Needed
Consistent Process to Clean and Set Up
Flow Management
Surgery Scheduling Guidelines
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Summary of Key Points
Voice of the customer requires communication and current data.
Customer needs must be translated into specific items called critical-to-quality (CTQ) requirements.
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