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Laguna Honda Lean Transformation

Laguna Honda Strategic Performance Management November 2017

Background

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SEE IT

Remove wastes Create standard work Respect people

SAY IT MAKE IT BETTER FIX IT

1. Identify problem and value 2. Map out all steps in the process 3. Create best work flow 4. Do the work and make it happen

Performance Improvement Quality Assurance

2017 Staff Satisfaction Survey Responses

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“Offer more

• pportunities for

professional development.” “Create a culture to value the input of line staff for problem solving by increasing participation.” “Improve communication between depts… continuous improvement by way of lean methodology.” “Involve frontline staff in improvement projects/work.” “Balance the changes from lean culture. Everybody is talking about it but we don’t know what it is.” “Better communication between lean staff (Administration) and frontline staff. Get more input.” “Continue w/ lean transformation.” “Continue with lean transformation as this gives structure and

• rganization to enhance

good working environment.” “Spreading lean continuous improvement principles.”

Objectives

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Improve Enable Align

Support strategic goals by aligning initiatives, projects and metrics at all levels Facilitate Lean initiatives that focus on improving flow, quality, safety, resident experience & setting standards Provide training, coaching, and support for Lean systems & tools. Develop lean leaders around data driven performance

As an organization, we need to move from a culture of compliance, to a culture of improvement.

Challenges

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Developing a Lean culture is a slow process Exposure of Lean initiatives Teaching Lean methods and tools to all departments and shifts Engagement at all levels Sustaining improvement efforts

Our Tools

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Value Stream Mapping(VSM)

• A technique used to illustrate, analyze and

improve the steps required to deliver a product

• r service

Kaizen Workshops

• Workshop attended by owners & operators with

intent of improving a specific process

Gemba Walks

• Personal observation of the work

A3 Thinking

• Root cause analysis; a systematic approach to

problem solving

5S Workplace Management

• Standardize workspaces to eliminate

unnecessary items and improve organization

Our Lean Journey

7 Training & Coaching VSM’s & Hoshin Kanri Kaizen Workshops 5S

Jul 2016 Oct 2017 Oct 2016 Jan 2017 Apr 2017 Jul 2017

Jul-16 Intro to Lean Rollout Feb-17 VSM #1-Kaizen 1: Pre-Admission Mar-17 Pharmacy 5S Apr-17 Nursing 5S- Phase 1 Apr-17 VSM #1- Kaizen 2: Clinical Assessments Jun-17 VSM #1- Kaizen 3: Room Readiness Jul-17 Nursing 5S- Phase 2 Jul-17 VSM #2: Discharge Aug-17 Nursing 5S- Hospital Wide Rollout Sep-17 Lean EHR Prep Workshop- Cohort 1 Aug-16 LHH Leadership & Rona Plan Lean Transformation Sep-17 VSM #2- Kaizen 1: Care Planning Jun-17 Monthly DMS Training Nov-16 VSM #1- New Admissions Sep-16 3-Day Executive Education Nov-16 Intro to A3 Thinking Jan-17 Start of A3 Workshops

The Start of Our Lean Journey

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Jul 2016 Oct 2017 Oct 2016 Jan 2017 Apr 2017 Jul 2017

June 2016

• Strategic Performance Management Team developed a plan

to introduce lean methodologies to all departments at Laguna Honda

July 2016

• Laguna Honda leadership received formal introductory training
• n the basic principles of lean

August 2016

• LHH Executive Team met with Rona Consulting to discuss approach for the
• rganization’s lean transformation
• Projects were selected based on the needs of the San Francisco Health Network

September 2016

• 3-Day Executive Education

Value Stream Map (VSM) #1: New Admissions

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Jul 2016 Oct 2017 Oct 2016 Jan 2017 Apr 2017 Jul 2017

Problem

• The existing admission process was flawed causing many

delays and creating a long waitlist for approved patients.

Actions

• Improved Resident Care Team notification &

communication

• Mapped new PASRR workflow to eliminate waste
• Set standards for timely completion of H&P

documentation for coding

Results

• 3 Kaizen/Rapid Improvements: (1) Preadmission,

(2) Clinical Assessments and, (3) Room Readiness

VSM #1 – Kaizen Workshop 1: Pre-Admission

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Jul 2016 Oct 2017 Oct 2016 Jan 2017 Apr 2017 Jul 2017

Problem

• The pre-admission and screening process was very inefficient and community

partners had expressed their concerns to our organization.

Actions

• Developed guidelines for SNF requirements in the new standard Laguna Honda

admission application

• Developed standard work for screening, reviewing and responding to

applications.

Results

# of Incomplete Applications Received per month Time for Clinical Decision of New Apps. # of Apps. reviewed by Screening Committee per Month

71% to 3.3% 5.5 days to 2.6 days 134 to 27

VSM #1 – Kaizen Workshop 2: Clinical Assessments

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Jul 2016 Oct 2017 Oct 2016 Jan 2017 Apr 2017 Jul 2017

Problem

• The length of time for all Resident Care Team members to complete their initial

clinical assessments could take 7 to 14 days.

Actions

• Implemented Pharmacy chart preparation process
• Improved Resident Care Team communication
• Created standard work with expectations to complete initial clinical assessments

w/in 48hrs of admission

• Created Admission Kits for clinical assessments and ADLs kits for residents

Results

Social Services Assessments, n=82 Rx Chart Prep Process

82% compliance rate process time & did not decrease med rec errors

Clinical Nutrition Assessments, n=82

72% compliance rate

Activity Therapy Assessments, n=82

4% compliance rate

VSM #1 – Kaizen Workshop 3: Room Readiness

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Jul 2016 Oct 2017 Oct 2016 Jan 2017 Apr 2017 Jul 2017

Problem

• Vacant rooms are scheduled for a new admission within 24 hours of discharge.

However, the process of cleaning & repairing a room can take several days.

Actions

• Facilities, Nursing, and EVS collaborated to create a “Room Readiness Checklist”
• Implemented new method to send notifications when discharges are confirmed
• Created standard work & mapped new workflow with sequencing and time

requirements

Results

July 2017 – Aug 2017 Vacant Rooms Prepared w/in 24hrs, n = 24

50% Compliance Rate

Sep 2017 – Oct 2017 Vacant Rooms Prepared w/in 24hrs, n = 30

77% Compliance Rate

Return on Kaizen for VSM #1

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Category Kaizen Measure Data % Change

Motion Pre Admission # of steps taken to transfer the Admission Application to the clinical screener Baseline: 500 steps by Admission Cord. ↓ 100% Result: 0 steps by Admission Cord. Clinical Assessments # of steps taken during Nsg Assessment Baseline: 308 steps by Nsg ↓ 100% Result: 0 steps by Nsg Cost Savings Pre Admission Salary spent per month on non-value added time for unnecessary screenings & incomplete application follow up Baseline: $3,515 ↓ 100% Result: $0 Time Savings Pre Admission Turn around time from receiving application to admission decision Baseline: 5.5 days ↓ 44% Result: 2.9 days Room Readiness Turn around time to prepare a room after discharge Baseline: 48 hrs ↓ 75% Result: 12 hrs Defects Pre Admission Admission Application missing clinical information Baseline: 71% (n = 52) ↓ 68% Result: 3% (n = 30) Clinical Assessments Initial clinical assessments completed w/in 48 hrs Baseline: 100% (n = 22) ↓ 52% Result: 48% (n = 82) Room Readiness Rooms prepared w/in 24 hrs of discharge Baseline: 100% (n= 70) ↓ 77% Result: 23% (n = 54)

Pharmacy 5S – Workplace Management

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Jul 2016 Oct 2017 Oct 2016 Jan 2017 Apr 2017 Jul 2017

14 San Francisco Health Network

• 1. Sort
• 3. Shine
• 5. Sustain
• 2. Set in Order
• 4. Standardize

Nursing 5S – Workplace Management

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Jul 2016 Oct 2017 Oct 2016 Jan 2017 Apr 2017 Jul 2017

Nursing 5S- Phase 1 Nursing 5S- Phase 2

Before After

Value Stream Map #2: Discharge

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Problem

• Some short stay residents who have housing remain at Laguna Honda

beyond their skilled nursing need, which contributes to a waitlist and backup in the network.

Actions

• Created a script for A&E and each discipline to acknowledge short stay
• Documented reason resident not present in RCC note
• Discussion with referring sources re: start discharge plan.

Results

• 3 Kaizen/Rapid Improvements: (1) care planning, (2) discharge preparation

and, (3) discharge day

Jul 2016 Oct 2017 Oct 2016 Jan 2017 Apr 2017 Jul 2017

VSM #2 – Kaizen Workshop 1 Care Planning

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Jul 2016 Oct 2017 Oct 2016 Jan 2017 Apr 2017 Jul 2017

Problem

• There are no estimated discharge dates for Short Stay

residents due to unclear ownership in care planning

Actions

• Revised the Resident Care Team meeting notes form
• Standardized physician work flow for Short Stay referrals to LHH’s

specialty clinics

• Created an educational program for staff on short stay goals

Results

• Process Owners will evaluate the outcomes at 30, 60 and 90 days

Moving Forward

18 Training & Coaching VSM’s & Hoshin Kanri Kaizen Workshops 5S Lean Certification

Oct 2017 Jun 2018 Jan 2018 Apr 2018

Oct-17 Lean EHR Prep Workshop- Cohort 2 Oct-17 Monthly DMS Training Nov-17 VSM #2-Kaizen 2: Discharge Prep Oct-17 Lean Certification Training Jan-18 VSM #2-Kaizen 3: Day of Discharge Nov-17 Lean EHR Prep Workshop- Cohort 3 Nov-17 Nursing 5S- Hospital Wide Rollout Dec-17 Lean Certification Training Jan-18 Lean Certification Training Jan-18 Hoshin Kanri Mar-18 VSM #3: TBD May-18 VSM #3- Kaizen 1: TBD Nov-17 Lean Certification Training

Strategic Performance Management Team/ Kaizen Promotion Office

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• Health Program Planner

Elizabeth Schindler

• Administrative Analyst

Vincent Lee

• Jr Administrative Analyst

Olivia Thanh