Accountability and Transparency:

LEANing on your data

2

Outline

• Background• What is Lean?• Lean at MSH• Data VSA• Results of LEAN events• Questions?

Fast Facts •Community Hospital •2 sites• 1800+ staff and physicians• 700+ volunteers• 230 beds• 14972 Admissions • 68365 ER visits• 16721 Day Surgeries• 204227 Outpatient visits• Embarking on redevelopment

4

What is Lean?

• Definition: Lean is a process improvement methodology based on the Toyota Production System (TPS) that identifies value added vs. non-value added activities.

• Key: Looking at healthcare through the eyes of the patient

• Goal: To more effectively and efficiently use healthcare resources to provide better patient care by eliminating non-value added activities.

5

MSH Values

•• CompassionCompassion•• Leadership & Leadership &

ResponsibilityResponsibility•• CollaborationCollaboration•• Creativity & InnovationCreativity & Innovation

Lean Supports MSH Values!

6

Central LHIN ISHP

Integration

Patient Centred

Accessibility

Appropriately Resourced

Effective/Efficient

Equitable

Safe

Population Based

Priorities

Integrated Health Service Plan (IHSP)2010-2013

Quality at a system level is defined as a high performing health system as described by the following performance dimension:

7

Supporting the LHIN’s IHSP

• Integrated Approach» Working closely with CCAC, CCO, CIHI, MOHLTC

participating in LEAN events

• Patient Centred» Valued added for the patient» Data accurately reflect and support patient care

• Accessibility» Right information to the right person at the right time

in the right format» One-stop shopping concept

8

Supporting the LHIN’s IHSP

• Appropriately Resourced» Most appropriate person performing the function» Standard work» Built in coverage

• Effective/Efficient» Accurate, timely data» Metrics for evaluating outcomes

• Safe» Key Patient Safety Indicators a LEAN event

9

Lean at MSH

• Started in the Emergency Department• Engage people that do the work – ‘experts’• Uses Lean tools such as the Value Stream

Analysis (VSA) and Kaizen or Rapid Improvement Events (RIEs) to implement change

• Standardize work to improve processes and provide better patient care

• The patient defines value

10

Core of Lean processes

• A large majority of the work we do is non value added in the eyes of the customer/patient

95% 5%

Value Added

Non value added!

Opportunity for Improvement!

Value added: Any activity that directly contributes to satisfying the needs of the patient

Non-value added: Any activity that consumes time/resources but does not directly add value

Patient Arrives

Patient is Discharged

11

So how LEAN was our data?

12

Reason for Action

• Lack of confidence in externally reported data resulting in poor decision making

• Data is becoming increasingly linked to funding and there is a general lack of accountability

• Errors in data lead to negative perceptions and tainted reputation of this hospital

• We don’t have a bigger picture understanding of what data is going out from the organization and being used to reflect our services externally

• Increasing demand from the Ministry for data transparency and accountability

13

Initial State

~ 115 key external reports

identified!

Metric Baseline# of Reports available (standard + custom) 13, 669# of External Reports Run/Submitted (approx) 400# of Internal Reports run (including scheduled) 1778% of databases with process oriented data validation 20%

# of total databases 25

TAT for Ad Hoc Data Requests 5 min - 5 weeksErrors detected and corrected (DAD & NACRS)/year 600

14

Initial State

•Rated and prioritized 115 key data sources

•Followed a theoretical patient through the continuum and identified data flows and key data submissions

•No method to measure data quality

15

Gap Analysis

Current data systems exist in silos

Data is not error proof

Data definitions are unclear and not standardized

Lack of standard work for data extraction

Lack of communication between those collecting, reporting and accountable for metrics

Lack of clear accountability re: who is responsible for data integrity

Decreased awareness of the importance of data within the organization

Lack of standard data validation process

Lack of clear structure re: data capture

Where do you go to get information?

Registration clerks responsible for input of data, decentralized reporting structure, is this appropriate?

Very complex data management system

16

Solution Approach• Streamline and error proof data collection and reporting for key metrics • Eliminate data errors at the source• Maximize functionality of current tools for data capture, presentation

and validation• Single seamless synchronized source – one stop shop for key metrics• Purge non value added reports/duplicates• Develop process/filter for new reports and data requests• Standardize registration process and accountability • Develop database of definitions, reports and accountabilities • Harmonize data systems• Automate manual data entry• Create key performance indicator dashboard that is transparent and

shared – recognize importance of electronic dashboard• Train and educate leaders and staff throughout the organization to

understand dashboard and use of existing data management tools (performance management)

• Establish Business Intelligence Group (BIG) for follow through (go BIG or go home!)

17

Rapid Experiments

18

Confirmed State

• 100% accuracy rate for key external reports

• Confidence in internal data collection• No loss of funding opportunities as a

result of poor data quality• Restored community confidence in MSH • 25% reduction in non-value added

custom reports• Improved transparency, access and

accountability for key performance indicators

19

Completion Plan (LW)A c t io n P la n

x S tre a m lin e K e y S a fe ty In d ic a to r R e p o r t in g M a yx S tre a m lin e K e y F in a n c ia l In d ic a to r R e p o r t in g J u n ex S tre a m lin e K e y C IH I In d ic a to r R e p o r t in g J u lyx S tre a m lin e K e y W a it t im e In d ic a to r R e p o r t in g A u gx S tre a m lin e K e y E D R S In d ic a to r R e p o r t in g S e p tx N e w D a ta R e q u e s t P ro c e s s O c tx S ta n d a rd iz e R e g is tra t io n N o v

x P u rg e e x c e s s iv e / N V A re p o r ts in s y s te m L y n n T . M a y 3 1 s t

x E x p lo re & m a x im iz e u s e o f th e to o ls w e a lre a d y h a v e D ia n a & C h r is t in a J u n e 3 0 th

x A u to m a te D a ta E n try R ic k A u g 3 1 s t

x S y n c h ro n iz e d a ta b a s e fo r K e y M e tr ic s S h a ro n T . & J e a n n ie A u g 3 1 s t

x S y n c h ro n iz e d a ta b a s e fo r A ll o th e r In d ic a to rs K im O c t 3 1 s tx D e v e lo p P e r fo rm a n c e M a n a g e m e n t S y s te m D a s h b o a rd A n th o n y N o v 3 0 th

x B u ild b u s in e s s c a s e fo r C o g n o s 8 .x A n th o n y M a y 1 5 th

x E s ta b lis h B .I .G . te a m fo r fo llo w th ro u g h S h a ro n T . & R o b M a y 3 1 s t

x D e te rm in e d e f in it io n s & s o u rc e fo r K e y M e tr ic s J o a n n e , A n th o n y M a y 3 1 s t S H C N in d ic a to rs d e f in e d b e fo re 1 s t

K a ize n E v e n t

x D e v e lo p o n - lin e d a ta b a s e o f d e f in it io n s fo r k e y in d ic a to rsJ o a n n e , A n th o n y , L y n n W .

J u n e 3 0 th

x T ra in in g & E d u c a t io n fo r c a s c a d in g "s tra te g y d e p lo y m e n t" f ro m B o a rd to U n its V ic k y O c t 3 1 s t

E x te r n a l In fo r m a t io n V S A E x e c u t iv e S p o n s o r : N e i l W a lk e r D a te U p d a te d : 4 /8 /0 9

Even

t

Proj

ect

Do-

It

D e s c r ip t io n W h o D u e D a te C o m m e n ts

D e liv e r a b le s

20

Data Management

Spread & Sustainability

Implementing a standard approach to request, manage, mine and report data. Targeted the main external reporting data sets.

ScheduleApril 2009: Data Management VSAMay 2009: Key Patient Safety IndicatorsJune 2009: External Data RequestsJuly 2009: Wait Time ReportingSept 2009: ERNINov 2009: ALCFeb 2010: MIS/Financial

Aim Statement:To improve data management process by ensuring that the right information gets to the right people at the right time to facilitate accurate external reporting and critical decision making.

21

Key Patient Safety Indicators

• Reason for Action:• Key Patient Safety Indicators reflect

Markham Stouffville Hospital Corporation’s clinical practices and impact our funding and public reputation. Lack of standard processes for capturing, validating and submitting this data has led to confusion and decreased accuracy in reported metrics.

22

Initial State

•Multiple reports going to various external organizations

•Lack of clarity around accountability for externally reported key patient safety indicators

•Multiple data locations with multiple touch points and handoffs

23

One Stop Shop for KPSI

• Created a ‘Corporate Indicators’ link on the Intranet to house all key patient safety indicators

• Clearly defined accountability, definitions, frequency of reporting and targets as appropriate

• Developed standard work

24

External Data Requests

• Reason for Action:• No formal process for external data

requests has sometimes resulted in submission of inaccurate data which has not been appropriately validated.

• Lack of process and accountability has resulted in duplication of efforts throughout the organization.

25

Initial State (DG)

• ‘Spray ‘N Pray’ approach• No Standard ‘place’ requests

come to and no tracking process

• Lack of clear accountability for external data requests

• Last minute data requests challenge our ability to provide accurate data

• Lack of ownership and responsibility for data validation

• May be a number of people processing the same request and don’t know it!

26

External Data Requests

Dianna / Anthony

5-Jun-09x Follow-up on auto-response from data@omaha.on.ca

Bobbijo 26-Jun-09

x Present at LeadershipSharon /

Anthony / Erin17-Jun-09

x Complete validation process for sick/overtime

Lynn W / Ali / Anthony

12-Jun-09

X Follow-up with Neil re: sign-off of ALC Data Erin 8-Jun-09

X Finalize std work / tracking form

Set timelines and roll out plan for education Sharon / Bobbijo

12-Jun-09 Including upload to intranet - OD?

X

X

Complete Education plan package Sharon 12-Jun-09

Eve

nt

Pro

ject

Do

It Deliverables

What Who When Comments

CompleteComplete

CompleteComplete

CompleteComplete

CompleteComplete

MIS LEANMIS LEAN

In progressIn progress

In progressIn progress

Action Plan:

• Review the template for tracking external request

• Education and communication

27

Wait Time Event

Reason for Action:Lack of standardization in the OR booking process and validation of data has created excessive rework, touches and has the potential for creating inaccurate publicly reported data (WTIS). An improved process will allow for an easier transition as hospital grows and when the new Meditech Focus system is installed.

28

Initial State

• Hybrid booking approach

• Confusion on ownership/ accountability of data

• OR Scheduling Office correcting and validating data

• Frustration with online booking process in some surgeon offices

29

MetricsMetric Before After

External WTIS Errors (Surgery) 19% <5%

Cases with Internal Errors 75% <5%

% surgeries requiring change (Any) 75% 10%Sr. Mgnmt Confidence in data (1-low to 5-high scale) 3 5Difficulty of current OR Booking process (1-easy to 5-difficult scale) 4 1

% of offices booking cases online 56% 100%

# of Case Carts picked incorrectly 2.5/week 1/weekIn – progress for surveys/audits to measure results

30

Wait Time

Action Plan:

• Survey Physician offices

•Survey Senior Team

In ProgressSharonIdentify backup for Lynn and HeidiX

July 30Magda4pm daily volunteer run to get

packages to OR BookingX

September 15Clay, LynnNew Report for Special RequestsX

December 31Heidi, LynnSecretary Cheat Sheet rollout for

remaining Dr. OfficesX

In ProgressSharon Moore

Talk to Dr. Arnold regarding gynephysician involvement to input key dataX

End of JulySharon Moore

Talk to Dr. Whelan regarding physician involvement to input key dataX

CommentsWhenWhoWhat

Deliverables

Do ItProjectEvent

In ProgressSharonIdentify backup for Lynn and HeidiX

July 30Magda4pm daily volunteer run to get

packages to OR BookingX

September 15Clay, LynnNew Report for Special RequestsX

December 31Heidi, LynnSecretary Cheat Sheet rollout for

remaining Dr. OfficesX

In ProgressSharon Moore

Talk to Dr. Arnold regarding gynephysician involvement to input key dataX

End of JulySharon Moore

Talk to Dr. Whelan regarding physician involvement to input key dataX

CommentsWhenWhoWhat

Deliverables

Do ItProjectEvent

CompleteComplete

CompleteComplete

CompleteComplete

CompleteComplete

CompleteCompleteCompleteComplete

31

ERNI Event

• Reason for Action:• MSH does not have data that is complete and

accurate at the source• With transition to ERNI, Ministry requires

current 60 day facility submission turnaround time to be reduced to 3 days

• This data is used for our funding allocations and performance metrics which will be reported publicly

• Cannot submit data to CIHI from Meditech

32

Initial State

• At least 4 data quality checks performed prior to submission

• Upon submission 6-9% of data still incorrect• Lack of ownership and accountability• 75% of patients from ER with incomplete,

incorrect, or missing data elements

"Quality @ Source" Index (at Time of Pt Disposition)

25%

75%100% Correct and TimelyErrors / Missing / Late

33

ERNI

Action Plan:

• Implement standard work for audit with ER Registration

• Update the baseline measures for ERNI and monitor

Sept 25, 2009GraceCreate Standard Definitionsx

Sept 25, 2009

Sharon, Elizabeth, Sandy, Elaine

Integrate Uxbridge into new processx

Oct 2009Sharon, ElizabethER Educationx

Oct 9, 2009Cassandra, SharonTransfer sheet formalized x

Sept 25, 2009JeannieApproval and final edits for

emerg face sheetx

Sept 30, 2009Magda, MariaGet 24 hour clocksx

Sept 24, 2009Elizabeth, Heidi, Sandy

Standard work for audit report runningx

CommentsDue DateWhoTask Description

Deliverables

Do-ItProjectEvent

Sept 25, 2009GraceCreate Standard Definitionsx

Sept 25, 2009

Sharon, Elizabeth, Sandy, Elaine

Integrate Uxbridge into new processx

Oct 2009Sharon, ElizabethER Educationx

Oct 9, 2009Cassandra, SharonTransfer sheet formalized x

Sept 25, 2009JeannieApproval and final edits for

emerg face sheetx

Sept 30, 2009Magda, MariaGet 24 hour clocksx

Sept 24, 2009Elizabeth, Heidi, Sandy

Standard work for audit report runningx

CommentsDue DateWhoTask Description

Deliverables

Do-ItProjectEvent

CompleteComplete

CompleteComplete

Complete/OngoingComplete/Ongoing

CompleteComplete

CompleteComplete

CompleteComplete

CompleteComplete

34

Metrics

4.85%9.7%Ambulance Transfer of Care

5%75%Error at Source(internal)

0%New Process

Rejected Records on submission to CIHI/CCO

5.4%

Current

2.7%Missing PIA

FutureIndicator

<5%<5%

15%

12-15%

35

ALC Event

• Reason for Action:• Ministry mandated changes to the ALC

definition and new data reporting requires MSH to redesign its ALC data collection processes.

• MSH is contractually obligated to submit timely and accurate data, failure to do so could result in financial penalties.

• Need for new processes set for November by Ministry and CCO

36

ALC External Submissions

CCO Interium Upload Tool OHA report

CCAC Daily Web Submision

CCAC Monthly Web CCAC Flo Central LHIN P4R EDRS ALC CIHI DAD

Submission

Who Collects the Data? Doc/PFC's Doc/PFC's Doc/PFC's Doc/PFC's Doc/PFC's Doc/PFC's Doc/PFC's Doctor/PFC

Who enters the data? Unit Sec/ Nurse/Pt Reg

Unit Sec/ Nurse/Pt Reg

Unit Sec/ Nurse/Pt Reg

Unit Sec/ Nurse/Pt Reg

Unit Sec/ Nurse/Pt Reg

Unit Sec/ Nurse/Pt Reg

Unit Sec/ Nurse/Pt Reg

Unit Sec/ Nurse/Pt Reg

Who Processes the data? ALC Site Lead ALC Site Lead PFC DS Analyst/ALC Site Lead Flo Manager DS Analyst DS Analyst Coders

Where does the data come from? -where is it stored/found

Meditech ADM & OE

Meditech ADM & OE

Meditech ADM & OE Meditech ADM & OE Meditech

ADM & OEMeditech ADM & WinRecs

Meditech ADM Census

Coders review the e-chart and enter the info into Winrecs abstract

- scope of ALC

All discharges with ALC days for the month; case count of open cases

Current ALC inpatients

Current ALC inpatients

2 parts - discharged ACUTE patients only; all current ALC inpatients

Current ALC inpatients - unit specific

All discharges with ALC days for the month

Current ALC inpatients

Acute inpatients only

- timeframe for data month month daily monthly/daily Tues/Thurs Monthly Monthly Monthly

Timeliness/Frequency of Reporting

7th initial submission; 15th final submission

15th of month daily 15th of month Weekly 30 days post month end

60 day post month end

30 days post month end

Who Requires the data? CCO OHA CCAC CCAC CCAC Central LHIN CCO CIHI

Who submits the report? ALC SPOC ALC Site Lead PFC ALC Site Lead Flo Manager DS Analyst DS Analyst DS Analyst

Validation/Reconcilliation ALC Missing Data Report OHA report Census report CCAC Report Census

Report Winrecs report Census Report Winrecs/CCO reports

Specs for the report/submission

Data collection process

ALC Reports

37

Audit of ALC Orders

• December Discharges

Number of ALC Discharges 38 8 46Number of ALC Order Forms 25 65.79% 6 75.00% 31 67.39%Number of Start Orders only 24 63.16% 6 75.00% 30 65.22%Number of Complete Orders 1 2.63% 0 0.00% 1 2.17%

MSH site Uxb site Total

March Discharges

Number of ALC DischargesNumber of ALC Order Forms 49 76.6% 5 83.3% 54 77.1%Number of Start Orders only 47 95.9% 4 66.7% 51 94.4%Number of Complete Orders 2 4.3% 0 0.0% 2 3.9%

MSH site UXB site Total64 6 70

38

ALC

Nov 23-30, 09MelissaEducation on OEX

Nov 30, 09JulieAssign dedicated

Site LeadX

Dec 15, 09Sharon Tai Young

Modify reports for validation and submissionx

Dec 1, 09Julia Scott, Dave Austin

ALC Designation Role of PFC, SW,

D.Plannerx

Nov 30, 09ALC Site LeadDefinition Educationx

Dec 1, 09BarbaraGo Live on OExDec 15, 09OD

Team Building SW/PFCx

CommentsDue DateWhoTask Description

Deliverables

Do-ItProjectEvent

Nov 23-30, 09MelissaEducation on OEX

Nov 30, 09JulieAssign dedicated

Site LeadX

Dec 15, 09Sharon Tai Young

Modify reports for validation and submissionx

Dec 1, 09Julia Scott, Dave Austin

ALC Designation Role of PFC, SW,

D.Plannerx

Nov 30, 09ALC Site LeadDefinition Educationx

Dec 1, 09BarbaraGo Live on OExDec 15, 09OD

Team Building SW/PFCx

CommentsDue DateWhoTask Description

Deliverables

Do-ItProjectEvent

CompleteComplete

CompleteComplete

In progressIn progress

CompleteComplete

CompleteComplete

In progressIn progress

In progressIn progress

Action Plan:

• Ongoing Education with staff

3939

MIS LEAN

Reason for Action:• With the ministry and LHIN now

looking at MIS submitted statistical data to compare hospitals and determine funding levels, MSH needs to ensure processes of collecting data are fixed, and data reported is accurate and timely

4040

Initial State• MSH often put on the spot at ministry "data

blitzes" to explain data that appears to be erroneous

• Posting of statistical data in batches after close• Single resource chasing incomplete/incorrect data

elements• Data collected "after the fact"

Indicator Current

Missing data elements prior to Submission 62

Total Time on Submission 168 hours

# of corrections required for a successful Submission

118

41

Metrics

50%3162 Missing data elements prior to Submission

80%33.6 hours

168 hoursTotal Time on Submission

50%59 hours118# of corrections required for a successful Submission

TargetCurrent % ChangeIndicator

To be evaluated after next submission – May 2010

42

MIS

Agenda has been determined and will focus on roles, responsibilities and expectationsMarch 31

Jean Marie , Directors, Analysts

Role of Analysts & Team Building with DirectorsX Training presentation complete:

outcome is improved understanding of department’s business activitiesMarch 10

Jean-Marie, Keith

Education for Managers and Directors on MIS Trial

Balance and accountability of dataX

March 31Tim and Christina

Investigate integrating GL structure and mapping into

Meditech 6.0X

Result of this meeting is to assess development of indicators. If reasonable, then integrate Cognos methodology into our practice. Feb 10

Jeannie, Denis, Bobbijo

Cognos and statistical indicator developmentX

Creates standard reports for each department March 31Jean-Marie

Set clear guidelines for variance reports and develop

a standard templateX

Feb 28KeithEliminate unused Functional

Cost CentresX

If financially feasible Stats Reports will be updated/ redesigned and interim fixes will be evaluated -Week of Feb 15Christina

Initial meeting with Expert-Scope the feasibility of updating stat reportsX

CommentsDue DateWhoTask Description

Deliverables

Do-ItProjectEvent

In progressIn progress

In progressIn progressMar 15

Apr 30

todaytoday

In progressIn progress

In progressIn progressJun 30

In progressIn progressMay

Jun 30In progressIn progress

Questions?