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Continuous Performance ImprovementContinuous Performance
Improvement
Continuous Performance Improvement
Continuous Performance Improvement
Agenda
• CPI at Children’s
• Waste & Value
• Just in Time
• Built in Quality
• Results
Continuous Performance Improvement
Our Vision
We will be the best children’s
hospital.
Continuous Performance Improvement
• Safety concerns– Serious safety events
• Service deficiencies – Access– Communication
• Healthcare finance reform
• Declining staff engagement
To achieve our vision
we needed a new management philosophy
Our Reality in the Late 1990s…
Continuous Performance Improvement
A Benchmark: Toyota
• High quality and reliability
• Safety record that exceeds others in the industry
• Cost effective with a short response time to customers
• High levels of employee engagement and morale
• Organization-wide philosophy and management system
Continuous Performance Improvement
Our CPI Philosophy: Benchmarking Lean
• Focus on the patient and family: involve them in our improvement work; listen!
• Engage staff at all levels: those that do the work, can improve the work; use the scientific method
• Leaders provide guidance and commitment: this is our management system and we support staff in their improvement work
• Long term view: this is a generational effort without an end point, that utilizes P-D-C-A
Continuous Performance Improvement
Our CPI House
Continuous Performance Improvement
What Does That Mean?
Balance the Work
Standard Work
Continuous Flow: Pull vs. Push
5S and Visual Control
Value Stream Improvement Through Waste Reduction
“Just In Time”
Right service in the right amount at the right time
in the right place
Eliminate batches
Rapid Changeover
“Built-In Quality”
Make problems visible
Never let a defect pass along to the
next step
Error Proof
Stop when there is a quality problem
Engage Everyone in a Patient-Focused Philosophy
No Waiting
No Harm
Waste & Value
Continuous Performance Improvement
1) Understand value for the customer: • Identify who is your customer• Identify what product or service the customer wants
How do we do this?
Value Stream Improvement Through Waste Reduction
2) Focus on Flow • Identify the process of how the value is created (The Value Stream)• Eliminate steps that do not create value (The Waste)
Continuous Performance Improvement
Value Stream Improvement Through Waste Reduction
Point Improvement Approach
Value Stream Approach
Admission EvaluationAncillaryService Discharge Billing
Admission EvaluationAncillaryService
Discharge Billing
Continuous Performance Improvement
The Basic Strategy
• Most processes are 95 – 99% non-value-added. • Everything we do in a work process either adds value or is waste• We want to design systems that provide value with as little waste as possible
Value-Added
Necessary Non-Value- Added
WasteEliminate Reduce
Continuous Performance Improvement
Non-Value Added Activity (8 Wastes)
Over-processing DefectsOverproduction
Transportation
Unused Creativity
WaitingInventory Motion
Google Image Photos; some rights reserved
“Activity that consumes resources but adds no value to the product/service”
Continuous Performance Improvement
5S - What are the 5S’s?
1. Sort – separate unneeded from needed
2. Straighten – a place for everything and everything in its place
3. Scrub – visual and physical inspection
4. Standardize – everyone doing the same thing
5. Sustain – hold the gains through audits and accountability
Was 5S used in our airplane factory?
Continuous Performance Improvement
Workplace Organization Helps Eliminate Waste
How does the setup of the fire truck and code cart impact the ability to do the jobs they were designed for?
Continuous Performance Improvement
What needs to be re-stocked?
Visual Workplace (cont’d.)
BLANKETSWASHCLOTHS
GOWNSTOWELS
Re-stocking Rule
Do not re-stock until level falls below red line.
Re-stock only up to green line.
© 2005v.2 Joan Wellman and Associates, Inc.
Continuous Performance Improvement
Visual Workplace
Visual workplaces use visual devices to:
• Tell us at a glance how we are doing
• Allow us to see abnormal conditions as they occur
• Understand the status of an area in 5 minutes or less by simple observation, without use of computers or speaking to anyone
Google Image Photo; some rights reserved
© 2005v.2 Joan Wellman and Associates, Inc.
Continuous Performance Improvement
5S is More Than Tidying Up
5S is a visually oriented system for organizing the workplace to…
• Wasted time• Training time• Errors• Maintenance• Inventory• Hazards• Barriers to success
• Teamwork• Quality• Safety• Cleanliness• Discipline• Consistency• Culture
© 2005v.2 Joan Wellman and Associates, Inc.
“Just in Time”-No Waiting
Continuous Performance Improvement
Continuous Flow = Steady Velocity
Batch Processing Continuous Flow Processing
Right service, right amount, right place, right time
“Just in Time” – No Waiting
Continuous Performance Improvement
Batch Processing vs Continuous Flow Processing
Batch Processing Continuous Flow Processing
Large batches Batch of 1 (one-piece flow)
Process silos(operate independently)
Connected processes(dependent on each other)
Layout of space designed to optimize silo (promotes batching)
Layout of facility/space based on sequence of work
Schedule each process and push to the next
Entire process linked with no inventory or waiting between steps
Equipment & supplies are stored in “warehouses”
Equipment & supplies (including meds) are stored at the point of use
Problems remain hidden in buffers of inventory
Problems become visible (stop the line)
Continuous Performance Improvement
Continuous Flow Enables “Just in Time” Services
Physical layout eliminates transportation and movement
Product or service is provided on customer request
The customer and value is identified
Service is produced one-at-a-time to meet demand
Right Service
Right Amount
Right Place
Right Time
If… Then it’s Just the…
= No Waiting
Continuous Performance Improvement
Definition:• A signal for communication that allows the customer to say, “I am ready for
more” or “I need more”• Signal can be a card, empty space, cart, etc.• Used to create flow between disconnected processes often due to physical
layout
Purpose:• Paces the work to prevent batching• Authorizes work to begin• Authorizes supplies or equipment to be moved
Creating Flow with Signals: Kanban
Was kanban used in our airplane factory?
“Built in Quality”- No Harm
Continuous Performance Improvement
The Importance of Built in Quality
Errors become “defects” when work moves beyond where the error occurred.
Process Step Where Defect is FoundError
Occurs
Start
What are the effects of later detection?
Customer
A
B
E
C
D
Continuous Performance Improvement
1. DETECT the Abnormality
Need to rely on memory or look up acceptable level
Quick glance enabled by simple visual indicators
Knowledge in the World
Knowledge in the Head
Continuous Performance Improvement
1. DETECT the Abnormality
Continuous Performance Improvement
2. STOP
Give Stop-the-line authority to everyone and prevent defects from being passed on
= STOP
= Need Help
= Normal
STAR:Stop; Think; Act; Review
Stop and Resolve when uncertain
Andon
Continuous Performance Improvement
3. FIX or Correct the Immediate Condition
Respond immediately to the abnormality
ARCC:Ask a question; Request a change; voice a Concern; and Chain of Command
Stop and Resolve when uncertain
Continuous Performance Improvement
4. INVESTIGATE root cause…
Solve the problem to prevent recurrence
SBAR: Situation, Background, Assessment, Recommendation
A3
Continuous Performance Improvement
5S & Visual Standards
Standardized Processes
Visual Alerts
Audible Alerts
Error Proofing
4. …and INSTALL Countermeasure
Build quality into the process with…
Management System
Continuous Performance Improvement
Daily Management
7 am – Supply Chain Night/Day Shift Team Huddles
8:15am – Supply Chain Division Leadership Huddle
3 pm - Day/Evening Shift Team Huddles
7:30 am - OR Huddles7:45 am – Nursing Flow Huddle
1pm - OR Huddles
11 pm – Supply Chain Evening/Night Shift Team Huddles
3pm- Nursing Huddles
8am – Supply Chain Team Huddles
8:50 am – Daily Safety Briefing
9:30am – VP/Supply Chain Issues Communication
10:00am – Executive Leadership Team Huddle
Continuous Performance Improvement
Daily Huddles Agenda
Director • Shares Organizational Message to Team • Discusses Outstanding Issues/Projects• Discusses Patient Safety Issues
Manager • Updates Performance Metrics • Shares Barriers and Potential Counter Measures • Shares Barriers From Team Huddles • Shares Barriers from Nursing Huddles
Continuous Performance Improvement
Supply Chain Daily Management
Continuous Performance Improvement
Our CPI Management System
Continuous Performance Improvement
Present: Strategy Deployment
Continuous Performance ImprovementContinuous Performance
Improvement
ResultsOur Results
Our Results
Continuous Performance Improvement
Engagement: Gallup Q12® Results Over Time
Ratio of Engaged to Actively Disengaged:
1.32:1 2.92:1 3.42:1 4.20:1 3.75:1 5.56:1 5.56:1 6.25:1 5.67:1 6.50:1 6.00:1
Copyright © 2011 Gallup Inc.,. All rights reserved.
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Continuous Performance Improvement
2013Seattle
Children's
4.38
Performance Difference:
NationalChildren'sHealthcare
Average
+.09
WorkforceCommitment
Percentile Ranking
95th
NationalHealthcare
Average
+.22
Overall Workforce Commitment
Note – GREEN/RED notes a statistically significant difference.
•National Children's Healthcare Average +/- .04
•National Healthcare Average +/- .04
4.37 +.06 94th+.21
2012
FY13 Goals: Baseline = 4.37; Target = 4.39; Stretch = 4.41
Engagement: Morehead Associates
Continuous Performance Improvement
Quality: Family Experience Survey
A: Accountability – Nurses answered questions understandably. R: Respect – Involvement in decision making. T: Teamwork – Staff worked as team to care for child.
58.354.6
49.9 47.3 47.443.7
40.234.6
0
10
20
30
40
50
60
70Pr
oble
m S
core
ART
(FES Year)
2004 2005 2006 2007 2008 2009 2010 2011
Continuous Performance Improvement
Quality: Family Experience Survey
FY 2012 FY 2013 FY2014 YTD70.0%
72.0%
74.0%
76.0%
78.0%
80.0%
77.0%77.6%
79.4%
76.6%
78.4%
80.4%
Goal Cumulative Hospital Score
Using any number from 0 to 10, where 0 is the worst possible and 10 is the best possible, what number would you use to
rate Seattle Children’s Hospital?
Continuous Performance Improvement
Delivery: New Patient Wait Times
FY07 FY08 FY09 FY10 FY11 FY12 FY130
5
10
15
20
25
30
35
-
20,000
40,000
60,000
80,000
100,000
120,000
21 20 19 20 20 15 15
38,033 43,989
67,635 72,377 80,581
90,245 96,248
Wait Times for New Patient AppointmentsTrend by Year and Visit Volume Days
Me
dia
n D
ay
s
** FY13 Median Wait Times ex-clude PSY **
Continuous Performance Improvement
Safety:
FY HAI Rate Discharges # of Infections
FY 2008 14.2 13514 192FY 2009 11.9 14144 168FY 2010 10.1 14321 145FY 2011 8.6 14107 121
FY 2012 8.1 14594 116
FY 2013 8.35 14374 120
Continuous Performance Improvement
Cost: Supply Chain
• Two-bin kanban system: “Demand Flow” • $2 million reduction in excess supplies
• $539,000 (50%) reduction of Central Service Main Supply Area
• $410,000/year reduction of returned supplies cost
• 48,000 hours/year returned to staff (projected)
• Reduced off-contract supply orders (~$2 million per year)
• Eliminated ~20,000 stat/rush calls per year
Continuous Performance Improvement
Cost: Supply Chain
2008 2009 2010 2011 2012 2013 20140
10
20
30
40
50
60
70
80
90
$0.00
$2,000,000.00
$4,000,000.00
$6,000,000.00
$8,000,000.00
$10,000,000.00
$12,000,000.00
$14,000,000.00
$16,000,000.00
$18,000,000.00
$20,000,000.00
60.2 62.258.95 60.25 60.75 63.55 63.55
88 12
1619
21 21
$6,296,231$6,908,111
$8,132,662
$10,618,306
$12,701,182
$15,755,478
$18,359,540
Supply Chain Staff Supply Chain Quality Staff Supply Chain Managed Spend
FTE per Managed Supply $$
Quality Staff:*Increased Leadership*Strategic Sourcing Managers*Project & Quality Mgmt*Demand Flow*Value Analysis
Continuous Performance Improvement
Our Approach: Wins and Challenges
• Wins:• Early successes allowed us to prove the methods worked • Early leadership buy-in and enthusiasm provided a basis for
engagement throughout the organization• Executive leadership and Board support afforded a strong
foundation
• Challenges: • Value stream approach earlier on would have allowed us to see
the system-wide impacts • Early focus on the tools and event-based – RPIWs, 5S, etc.;
management systems approach did not start soon enough to support sustainment of work (audits, leader standard work, etc.)
Continuous Performance Improvement
Lessons Learned
• Requires a long term view
• Requires substantial leadership and financial investment
• This is hard work!
• Learn to fish – external consultants can get you started, but you have to develop leaders within your organization