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Strategies for Rapidly Improving Performance with Systems Thinking

Strategies for Rapidly Improving Performance with Systems Thinking. Bethany Rogers, MSML, BSN, RN, LSSMBB, CPHQ, CPHRM St. Luke’s Health System Director, Performance Improvement. APIC Intermountain Region 19 th Annual Educational Conference October 25, 2018.

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Strategies for Rapidly Improving Performance with Systems Thinking

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  1. Strategies for Rapidly Improving Performance with Systems Thinking Bethany Rogers, MSML, BSN, RN, LSSMBB, CPHQ, CPHRM St. Luke’s Health System Director, Performance Improvement APIC Intermountain Region 19th Annual Educational Conference October 25, 2018

  2. What’s Your Favorite Pixar Movie?

  3. My Job as a Pixar Movie… Once upon a time…

  4. Every day…

  5. But one day…

  6. Because of that…

  7. Because of that…

  8. Until finally…

  9. The Imperative Public sector organizations are increasingly compelled to transform into high-performing organizations • What a health system produces is largely dependent upon the quality of the processes and workflows it is made of: QP1 + QP2 +QP3 +…QPn = QOHS • Poorly-designed processes will make the right thing to do inconvenient or difficult • Well-designed processes will make the right thing to do the easy thing to do In order to achieve our respective Missions and Visions, we must redesign our broken processes and workflows

  10. Improvement Science A methodicalchange to a process that seeks to improve process outputs:

  11. The Industrial Revolution Transition from hand production to machine production • Horse power  Steam power • Wood fuel  Coal • Wood machine parts  Metal machine parts • Cottage industry  Factories Sustained job growth First meaningful increase in standard of living in centuries • Eli Whitney – 1798 • Henry Ford – 1913 1760s to 1840s

  12. Modern Improvement Influences General quality inspection processes (pre-1920s) • Responsibility of the manufacturing supervisor or foreman Quality improvement pioneers • Walter Shewhart • W. Edwards Deming • Joseph Juran Official quality standards (1950s to present) • Military Standard (MIL-STD-105A) • International Organization for Standardization (ISO) • Malcolm Baldridge National Quality Award • Healthcare-specific (NIAHO, TJC, DNV, etc.)

  13. The Evolution of Improvement Science PI strategies and approaches have evolved into a science over the past 150 years Four distinct methodologies stand out • FOCUS PDSA • Lean Production • Six Sigma • Clinical Microsystems Industrial Revolution to the Present Day

  14. What is the difference between a Process Improvement TOOL and a Process Improvement METHODOLOGY?

  15. Plan-Do-Study-Act TOOL used to TEST and IMPLEMENT changes in real work settings • Assess real-worldapplication of a proposed change concept Based on the Scientific Method • Hypothesize, Experiment, Evaluate, Replicate PDSA Process: • PLAN the change • what will happen, by whom, by when, for how long? • DO the change • carry out a test and collect data • STUDYthe effect of the change • analyze data, assess practical application challenges • ACT on the findings • as applicable, make changes to the plan or implement the change

  16. Plan-Do-Study-Act • PDSA is an EXPERIMENTATION STRUCTURE: • Test only one variable at a time - resist the urge to change more than one variable at once • Cause-and-effect will be unclear; run the risk of “analysis paralysis” • Conduct smalltests of change • Only as many data points as are needed to learn about what parts of practical application need to be tweaked • It is NOT the goal of a PDSA cycle to get statistically significant data • Plan to conduct manysmall tests of change • Go into it intending to make small, frequent tweaks and start another test

  17. The Model for Improvement Developed by the Associates in Process Improvement (API) and adopted by the Institute for Healthcare Improvement (IHI) as its preferred PI model • Defines three fundamental questions that must precede each PDSA cycle • Designed to sharpen the focus of a PDSA cycle so that each cycle is purposeful and clearly articulated • Is NOT intended to be a comprehensive improvement methodology

  18. FOCUS PDSA Designed as an answer to the shortcomings of PDSA as a comprehensive improvement methodology • Rapid-cycle improvement with defined discovery & planning phases FOCUS • FIND an opportunity to improve • select the process of interest, define boundaries • ORGANIZE the improvement effort • identify the team, agree on the aim • CLARIFY current knowledge • flowchart the process, collect baseline data • UNDERSTAND process variation • analyze baseline data (SPC, data subsets) • SELECT the strategy • identify ways to reduce process variation • …and then conduct PDSAcycles to test the change strategies

  19. Lean Production Manufacturing / business strategies developed in Japan the 1970s, under the guidance of Dr. Deming • “Lean” coined by MIT researchers visiting Toyota in 1988 Improve quality (as defined by the customer) by eliminating waste • Supply just what the customer needs, • when they need it, • in just the right amount, • for the right price, • using minimum materials, equipment, workspace, labor resource, and time

  20. Lean Production Three forms of Waste: • Mura– unevenness in work demand or work flow; stopping and starting or variable volume (vs. smooth and constant) • Muri– greater demand than capacity or overburdening; pushing to perform above capacity and burning out machines or people • Muda – waste that is necessary but non-value-added (e.g. regulatory requirements); waste that is unnecessary (irrational) • Value Rules: (all three must be met for an activity to be value-added) • It must be something the customer is willing to pay for • It must transform the product or service in some way • It must be done right the first time • DOWNTIME:Defects, Overprocessing, Waiting, (Non)-Used Talent, Transportation, Inventory, Motion, Excess Inventory

  21. Lean Production

  22. Lean Production

  23. Lean Production

  24. Six Sigma (6σ) Designed by Bill Smith (Motorola) in 1986 • Any business process can be measured, analyzed, and improved upon… then controlled • Reduce variation • Increase output • Meet the desires of the customer Goal: Decrease variation in the processto make the outcomesmore predictable

  25. Six Sigma (6σ) You cannot improve what you do not measure • Consistent production of high quality services, products, or processes • Improved process performance • Increased customer satisfaction Structure: Define-Measure-Analyze-Improve-Control (DMAIC) • Definethe problem, agree on the goals, listen to the Customer • Measurekey performance indicators (KPIs) • Analyzethe problem using root cause analysis and statistical analysis • Improveby developing and deploying possible solutions (PDSA) • Controlnew processes by monitoring and reacting to signal

  26. Clinical Microsystems Created by Dartmouth-Hitchcock Medical Center • First unique improvement methodology created for healthcare rather than business Focuses on the functionality of the “microsystem” (the place where patients, families, and caregivers meet) • Every microsystem has a mission, vision, or purpose • Every microsystem serves a discrete subpopulation of patients • Every microsystem is staffed by a capable group of professionals • Every microsystem has its own routines and processes • Every microsystem has consistent behaviors, sentiments, and results that emerge from its patterns “5Ps”

  27. Clinical Microsystems Strategy: • It is through understanding the microsystem’s 5Ps that it identifies its values, its problems, and its solutions • Improvements are driven by grassroots peer leadership within each microsystem • For each problem, the microsystem identifies a Theme, a Global Aim, and several Specific(measurable) Aims

  28. Clinical Microsystems 3 Global Aim 2 1 PDSA Improvement Ramp Cause & Effect Diagrams Measures Change Ideas Flowcharts Specific Aim Global Aim The Dartmouth Microsystem Improvement Curriculum (DMIC) Ramp Theme 5P Assessment

  29. Comparing Methodologies* *PDSAand The Model for Improvement are not included in this comparison, as they are not independent improvement methodologies

  30. Jumping to Solution Can you identify this upside-down celebrity?

  31. Jumping to Solution Our minds are very powerful at assimilating information… …but not infallible. What we SEE or THINK is not always right.

  32. Jumping to Solution The easiest solutions to jump to are Person-Oriented solutions intended to make people less fallible: • telling people to do it right / better / faster / more carefully, • sending an e-mail, • sending out a Single-Point Lesson / Tip Sheet, • creating a new form, • holding a staff meeting, • providing more training / classes, • writing or revising a policy, etc. Plan Workaround

  33. The PI Advantage What We Don’t Have Right Now That We Need What We Have Right Now What We May or May Not Have Right Now • A general idea of what the problem is • A general idea of what we’re here to do • Thoughts on what is contributing to or creating the problem • Ideas on how to fix it • Assurancethat our assumptions are right • Evidencethat our solutions willwork • Confidencethat our solutions willstick Bridge this gap using improvement science

  34. The PI Advantage In contrast, System-Oriented strategies attempt to safeguard against the impact of errorsor to reduce the ability of the error to occur • Error-proofing, • Automation, • Redundancies, • Checklists, • Usability testing, • Visual management, • Alerts, • Standardization, etc. Can we eliminate human error or fully control human behavior? No; we have to design our systems anticipating error / deviation and protect against it before and after

  35. The PI Advantage Two Schools • School A: Private College in Intermountain West • School B: Private University in New England Same Problem • New grass in Quad being damaged by foot traffic Different Problem-Solving Strategies • Person-Oriented • System-Oriented

  36. School A’s Problem-Solving Strategy System-Oriented or Person-Oriented?

  37. School B’s Problem-Solving Strategy System-Oriented or Person-Oriented? Making observations of the foot traffic Analyzing the data: Most-traveled paths? Natural angles created?

  38. School B’s Problem-Solving Strategy

  39. Rapid Cycle Improvement PLAN / DO PDSA Cycles Goal: Assess the real-world application of a proposed change concept • Rapid– “What can we test by next Tuesday?” • 1 Day • 2 Nurses • 3 Shifts • Cycle – Expectation of repeating tests again and again • Improvement – Changing the test each time based on worker feedback • Hands-on, active, responsive process • Make changes; test again Shrink the change STUDY ACT

  40. How Do You Get It Done Fast? “Working meetings” • Preparatory work between each meeting • Produce something by the end of each meeting • Each meeting’s tasks move you closer to Rapid Cycle Testing • Kickoff  Problem Statement, Aim Statement, Workflow Overview (SIPOC-R) • Meetings 2-3 Review data / process to identify a high-impact workflow • Meeting 4  Test of Change (ToC) Plan, Specific Aim Statement • Meetings 5-8  Review ToC results, make revisions, test again • Meeting 9  Final ToC Plan • Meeting 10  Implementation Plan • Meeting 11  Evaluation and Celebration! Rapid Cycle Improvement

  41. How It All Fits Together 6σ Lean C O F U S FOCUS PDSA Clinical Micro-systems Planning and Testing Possible Future States Making Short Term Gains Long Term Understanding the Problem and the Scope Assessing Current State

  42. The Ball Game PDSA Practice

  43. Teams and Roles Break up into teams of at least 6 individuals: • Players (4+): Perform the exercise, conduct tests of change • Timekeeper (1): Times each test • Recorder (1): Documents test times, change concepts tested, and learnings from each PDSA cycle Each team needs: • 1 ball • 1 stopwatch (use smartphone timer function) • DMAIC/PDSA document to record test times, change concepts tested, and learnings from each PDSA cycle

  44. The Rules Every Player must participate in the cycle To complete a cycle, the ball must return to the person who started with it You cannot pass the ball to the person next to you The ball must travel through the air The ball cannot be rolled across surfaces (e.g. floors, walls, tables, chairs, etc.) The PDSA Simulation Exercise • Create a process for giving and receiving the ball in your group, adhering to The Rules above • Conduct a timed baseline test • Come up with change ideas to reduce your baseline time by half • (As time allows) Come up with change ideas to reduce your baseline time by half again Ready… Set… Go!

  45. Debrief Which team had the fastest cycle? • How did you do it? Would you have had the same kind of improvement if you had stayed with your original strategy and strongly encouraged people to do it the same way, but faster?

  46. Questions?

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