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What is the problem????
Jack Billi, [email protected]/jbilliMichigan Quality System:med.umich.edu/mqs
Terry Platchek, MD
Hospitalist, Lucile Packard Children’s
Stanford University Medical [email protected]
Adapted from John Shook and Dave LaHote, with permission
Michigan Quality System:
• Quality
• Safety
• Efficiency
• Appropriateness
• Service
Engaging Physicians in Improvement
Standard Actual
PROBLEM!!
ADJUST
CHECK
PLAN
DO
Modified from Dave LaHote, with permission
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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
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Physician Engagement in Improvement
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
Title: What we are talking about.Background
Current Situation
Goal
Analysis
Recommendations
Plan
Follow - up
Of all our problems, why this one? The “ugly story”…
Where do we stand?
Problem Statement:
What is the specific change we want to accomplish now?
-What are the root causes, requirements, constraints?
What are your proposed countermeasures, strategies, alternatives?
What activities will be required?
What , Who, When?
How we will know?
What remaining issues?
Modified -Verble/Shook
Date: Owner:
An A3 Template
Title: What we are talking about.Background
Current Situation
Goal
Analysis
Recommendations
Plan
Follow - up
Of all our problems, why this one? The “ugly story”…
Where do we stand?
What is the specific change we want to accomplish now?
-What are the root causes ,requirements, constraints?
What are your proposed countermeasures, strategies, alternatives?
What activities will be required?
What , Who, When?
How we will know?
What remaining issues?
Modified -Verble/Shook
Date: Owner:
A3 - A Template For Structured Problem Solving……Does this sound familiar??
Name of Patient:
History
Physical Exam
Impression - Diagnoses
Plans
Follow - up
Date: Clinician:New Patient H&P
Chief Complaint
History of Present Illness
Past Medical & Surgical History
Medications and Allergies
Family and Social History
Review of Systems
General Appearance, Vital Signs
HEENT
Heart & Lungs
Abdomen
Extremities
Neuro
1.
2.
3.
Diagnostic:
1, 2, 3,
Treatment:
1, 2, 3,
Monitor x, y, z
Return visit:
Title: What we are talking about.Background
Current Situation
Goal
Analysis
Recommendations
Plan
Follow - up
Of all our problems, why this one? The “ugly story”…
Where do we stand?
Problem Statement:
What is the specific change we want to accomplish now?
-What are the root causes, requirements, constraints?
What are your proposed countermeasures, strategies, alternatives?
What activities will be required?
What , Who, When?
How we will know?
What remaining issues?
Modified -Verble/Shook
Date: Owner:
Where would “Increase Physician Engagement” fit on the A3?
Title: What we are talking about.Background
Current Situation
Goal
Analysis
Recommendations
Plan
Follow - up
Of all our problems, why this one? The “ugly story”…
Where do we stand?
Problem Statement:
What is the specific change we want to accomplish now?
-What are the root causes, requirements, constraints?
What are your proposed countermeasures, strategies, alternatives?
Increase Physician Engagement with Improvement
What activities will be required?
What , Who, When?
How we will know?
What remaining issues?
Modified -Verble/Shook
Date: Owner:
Work alone, then in groups to fill out the left side of the A3
1. Why engage physicians in improvement?
2. What are the barriers to engaging physicians? Are the causes in:
– Motive? – Means?– Opportunity?
Before addressing the upper right3. What strategies might help?
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Physician Engagement in
Improvement = Countermeasure
Title: Physician Engagement in QIBackground
Current Situation
Goal
Analysis: barriers
Recommendations
Plan
Follow - up
Why engage physicians in improvement?
Where do we stand?
Problem Statement:
What is the specific change we want to accomplish now?
-What are the root causes?
-Motive?
-Means
-Opportunity?
Proposed countermeasures Increase Physician Engagement with Improvement1. 2.3.
What activities will be required?
What , Who, When?
How we will know?
What remaining issues?
Modified -Verble/Shook
Date: Owner:
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Physician Engagement in Improvement
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
The next 2 slides are photos of the results of the group discussions,
written on white boards.
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A3 References
Books with Focus on A3 Use:• 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)
• Liker, Meier. Toyota Way Fieldbook. (Practical lean tools)
• Baker, Taylor. Making Hospitals Work. (Workbook from Lean Enterprise Academy, UK)
• Graban. Lean Hospitals. (General lean healthcare reference)
Lean Web Resources: • Michigan Quality System at UMHS: med.umich.edu/mqs
• Lean Enterprise Institute: www.lean.org webinars, books, meetings…
• Lean Healthcare Value Leaders Network www.healthcarevalueleaders.org
• Lean Enterprise Academy (UK): www.leanuk.org
05.17.10
Michigan Quality System & Lean References Books:• Womack J, Jones D. Lean Thinking.• Liker J. The Toyota Way; Liker J, Meier D. The Toyota Way Fieldbook.• Shook J. Managing to Learn.• Dennis P. Getting the Right Things Done.• Rother M, Shook J. Learning to See.• Womack J, Jones D, Roos D. The Machine That Changed The World.• Sobek D, Smalley A. Understanding A3 Thinking.• Marchwinski C, Shook J, eds. Lean Lexicon.Articles:• Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: what can hospitals learn from a
world-class automaker? J Hosp Med. 2006;1:191.• Bush R. Reducing Waste in the US Healthcare System. JAMA 2007;297:871.• Spear S. Fixing Health Care from the Inside, Today. HBR. 9/05.• Spear S. Learning to Lead at Toyota. HBR 4/04 • Spear S. Decoding the DNA of Toyota Production System. HBR 9/99• IHI Whitepaper: “Going Lean in Health Care”
www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm Web: • Michigan Quality System at UMHS: med.umich.edu/mqs• Lean Enterprise Institute: www.lean.org webinars, books, meetings…• Ideal Patient Care Experience at UMHS www.med.umich.edu/i/acs/ipe.htm • Crossing the Quality Chasm (IOM): newton.nap.edu/catalog/10027.html • Lean Enterprise Academy (UK): www.leanuk.org • National Health Service (UK): www.networks.nhs.uk/networks.php?pid=211 • Wikipedia: en.wikipedia.org/wiki/Lean_manufacturing
Appendix
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Problem and PDCA Tools for different levels
Key to success: The Mid-managementand First Line Supervisory Level
FRONT LINES
SENIORMANAGEMENT
MIDDLEMANAGEMENT
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
Role Impact
Problem:MUDA
PDCA tool: (HK)Strategy deployment
PDCA tool:A3 or VSM
PDCA tool:Standardized Work
Problem:MURA, MURI
Problem:MURI, MURA
ShookMuri – overburdenMura – uneven workloadMuda – waste
HK – hoshin kanri (strategy deployment)
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• Pacing by Demand
• Continuous Flow
• Pull Systems
Just-in-Time Built-in Quality
• Error Proof
• Surface Problems
• Stop and Respond to Abnormalities
• Solve Problems at Root Cause
MQS
Make Value Flow by Eliminating Errors and Waste
LeveledWorkload
Continuous Improvement (P-D-C-A) and Learning
Standardized Work
Michigan Quality SystemQuality – Safety – Efficiency – Appropriateness – Service
Customer Defines
Value
Title: What we are talking about.Background
Current Situation
Goal
Analysis
Recommendations
Plan
Follow - up
Of all our problems, why this one? The “ugly story”…
Where do we stand?
Problem Statement:
What is the specific change we want to accomplish now?
-What are the root causes, requirements, constraints?
What are your proposed countermeasures, strategies, alternatives?
What activities will be required?
What , Who, When?
How we will know?
What remaining issues?
Modified -Verble/Shook
Date: Owner:
An A3 Template
