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Outline
1.
2.
3. 4. 5.
Process mapping exercise Quantitative analysis, facilitated discussion Quantitative analysis, group work
stem 3
6. 7.
Root cause analysis didactic session Facilitated discussion: leading change what went wrong
stem 4
8. 9.
Didactic session: key success factors for implementing and monitoring change Conclusion
Disclosures
Dr Richard Bowry
No disclosure
Dr Antoine Pronovost
Has received funding from the government of Ontario to study and improve Pre-admission facility processes.
Objectives
You will understand how to apply Quality Improvement techniques to the complex problem of redesigning a PAF You will become familiar with the five stages of DMAIC You will become familiar with the key principles of successful change management
June 18, 2012
We will not be providing you with a cookbook answer for fixing problems in your own PAF
Solutions take teamwork, planning and local insights to work
The case study is loosely based on actual experience, but has been heavily adapted for the purpose of this session
June 18, 2012
Introduction to DMAIC
DMAIC - Define
Reasons for action? What are our targets? What is within our control? All members need to agree on the problem Create a purpose statement rationale, scope and targets Start an A3 style grid to monitor progress
June 18, 2012
Define - A3
DMAIC - Measure
What is our baseline? Acknowledge our own variation / trends? What happens 80% of the time? Root cause analysis Prioritization matrix Cause Effect Diagram
June 18, 2012
Prioritization Grid
Cause-Effect Diagram
DMAIC - Analyze
What does our current state look like? Are there any wasted steps in what we do? How would a patient experience this? What are the root causes?
Process mapping to identify NVA steps Holistic approach looking at all aspects Spaghetti Charts
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DMAIC - Improve
How should the future state look? Use rapid process improvement cycles Pilot and observe Remove unnecessary steps and create a future state No need to get it perfect first time Implement pilots to assess impact
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DMAIC - Control
Re-evaluate and make ongoing changes Monitor the new performance Repeat the cycle as require to further improve Reevaluate the changes and re-design as needed Repeat evaluation of process to assess impact Ongoing performance monitoring
June 18, 2012
Tool Matrix
You have been asked to review your preadmission facility by your CMO because:
Patients are unsatisfied with long wait times Surgeons offices are frustrated they cannot access short-notice appointments
These are necessary to fill time released by lastminute patient cancellations
Anne M Breen, Tracey Burton-Houle, David C Aron,Applying the theory of constraints in health care: Part 1-- the philosophy, Quality Management in Health Care; Spring 2002; 10, 3;pg 40.
A.
Average (13)
B.
C. D.
20
Identify the bottleneck Elevate the bottleneck Design the process around the bottleneck
Unload the bottleneck Keep the bottleneck busy all the time
This means non-bottleneck resources MUST sometimes be IDLE.
Batching refers to the processing of many units in a single group, for example:
I change all the ceiling light bulbs at the same time because I need a stepladder (hard to get) Painting all similar colours together (trim, then walls, then contrast wall) Porters delivering multiple samples to the lab
Pro
Cons
Lather
Repeat
Rinse
What if I dont get it right the first time? How do I keep people focused?
How do I frame the hypothesis?
How much technical stuff do I need to know to participate or lead this discussion?
What if I dont get it right the first time? Dont worry you wont get it right the first time Thats part of the plan Its an iterative process, and youll likely need a few drafts. Its a group process, and much benefit comes from team discussion:
Oh so thats what happens when the patient leaves my care
June 18, 2012
Activity
Decision Flow Line
Please use this time to develop a process map in small group settings Use the data from case study stem 2 (next slide) as a starting point for your process map
60 patients are seen daily; Patients are registered, then seen by a nurse, then by a family doctor; 50 % of patients seen by an anaesthesiologist; Subgroups (orthopaedic and cardiac surgery) patients also receive group teaching;
Other patients receive DVD-based teaching;
Most patients receive bloodwork, and EKG +/- xray investigations while in clinic.
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Three groups Map the current state Brief Presentation of processes found
Initial Thoughts
Lessons Learned
Conventions in mapping Importance to map out whole process
Measure
Quantitative Data to be provided in the following slides/handouts. Please review and discuss implications of quantitative data.
Re-Design of a
Mean Median Standard Dev. Resource Availability Throughput
RN Wait Time 13.7 min 10 min 9.9 min 8 Nurses 14.8 patients/hours
Pre-Admission Facility
Stem #3: Quantitative Data (Continuation) AN wait time by scheduled time of day
Patient Ready Time vs. AN Wait time
6:00
4:48
3:36
Wait time
2:24
1:12
0:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 Patient Ready Block
AN Throughput:
7. Facilitated discussion Case Study Stem #4: Le denouement Suggestions are implemented, but results are not anticipated
Wait times increase Throughput decreases
Engage in issues that matter Use Engagement to drive decisions Engage the right stakeholders Engage empowered representatives Seek shared values Agree on the rules of engagement Manage expectations provide adequate resources
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Establishing a Sense of Urgency Forming a Powerful Guiding Coalition Creating a Vision Communicating the Vision Empowering Others to Act on the Vision Planning for and Creating Short-Term Wins Consolidating Improvements and Producing Still More Change Institutionalizing New Approaches
Kotter, Leading Change 1996
June 18, 2012
Control - Sustainability
Balanced Scorecare
80 75 70 65 60 55
52 CTAS 1-3 CTAS 4-5 76
50
May-08 May-09 May-10 Nov-08 Nov-09 Feb-09 Mar-09 Feb-10 Aug-08 Sep-08 Aug-09 Sep-09 Mar-10 Dec-08 Dec-09 Aug-10 Apr-08 Apr-09 Apr-10 Jul-08 Jul-09 Jun-08 Jan-09 Jun-09 Jan-10 Jun-10 Oct-08 Oct-09 Jul-10
Conclusion
DMAIC Methodology Stakeholder Engagement Leading Change Measuring Success Importance of Value Add
Appendix
Theory of Constraints asserts that in the real world a balanced plant will self-destruct
Statistical variability: Throughput at each step varies around a mean + Dependent events: a downstream process cannot occur before its upstream precursor = Small gaps build up to infinity unless there is reserve capacity
Scouts are heading on a 5 mile hike They must walk single file
They cannot pass each other (dependent events)
SSSSSSSSSSSSSSSSSSSSSSS
After 1 hour
SS
S S
1. Over time, the scouts will continue to spread; 2. To keep the group compact, one must place the slowest hiker (bottleneck) at the front.
So how do you identify bottlenecks? In the hiker example, you look for a large gap in front of a scout In a plant, you might look for a large pile of inventory in front of a particular station In a hospital, you could look for a large number of (angry looking) patients in a waiting room
Batching refers to the processing of many units in a single group All units have the same start/finish times Batching is highly effective when setup costs/setup time are high
Batching cupcakes:
I mix one batch of batter, drop it into moulds, place in the oven, and Im done; I only have to run the oven once (lower energy costs ); This is a locally optimal solution.
As a cupcake-decorator, batching is terrible: At first, I have no work to do while the cupcakes are baking Then I suddenly have 20 cupcakes to decorate.
How does this come together? Assume baking a batch of 20 cakes takes
15 minutes prep + 45 minutes baking
Assume decorating takes 5 minutes per cake How long would it take to make a single batch of 20?
Answers:
This results in cupcake cycle time of 160/20 = 8 minutes per cake That doesnt seem so bad
60 + 5 = 65 minutes
60+100 = 160 minutes Time for 10th cupcake 60+(10x5) = 110 minutes
Why might this be a problem? Assume cupcakes are shipped from the kitchen in batches of 20:
What if a walk-in client wants to pickup 6 cupcakes:
It takes almost 3 hours for the first (and last) cake to be ready
What if the cupcakes sell best when they are fresh (< 45 minutes from the oven)
June 18, 2012
Baking 8 hours/batch x 20 cakes/batch = 160 cakes Decorating 7 hours (1 lost hour) x 12 cakes/hour = 84 cakes Total 84 finished cakes 76 waiting
June 18, 2012