Leading Continuous Improvement Why do we need continuous - - PowerPoint PPT Presentation
Leading Continuous Improvement Why do we need continuous improvement in healthcare? Instances of poor safety and quality, Capacity constraints and queues, Cash-flow crises, Low levels of efficiency Low levels of staff
To provide training and real-life practice to successfully implement an Improvement Project. To create a set of individuals who can think about continuous improvement, ask the right question at the right time and then select the right tool to use in a particular situation.
From : To :
Fire fighting symptoms Eliminating Root Causes Ad Hoc improvement Controlled and disciplined approach Unclear Priorities Data Driven Priorities Function/Dept Focus Customer/Patient Focus
What side are you on ?
Lean & Six Sigma PDSA Project Management Management of Change
DMAIC
Focused Approach for Continuous Improvement
Change Behaviour Experience Results Change Culture
Define, develop and communicate the Quality Improvement Approach. Start using the good behaviour this method defines in key initiatives. We can change our behaviour quickly. Communicate the results from the Changes in Behaviour resulting in the use of the Quality Improvement
Quick wins can help confidence and help the rollout of good behaviour. Longer term Culture changes come from the proliferation of good practices and behaviours throughout the company building a Quality approach into day to day life.
How do we create a Culture focused on the Patient and Quality ?
Not Overnight but it starts here
Define Measure
Analyse Improve Control
Create a shared need Leading Change Set up for success Overcoming resistance Mobilising Commitment Making Change last
Process Change People Change
CURRENT STATE TRANSITION STATE IMPROVED STATE
A single approach combining process and people change tools to help you through the transition required for successful results.
Define
Measure Analyse Improve Control
What are we trying to achieve? What’s important? What does success look like? What steps can we take? Who needs to be involved & when?
improvement activity, include deliverables & benefits.
(patients directly or other internal customers) and their goals.
processes and performance.
timelines.
Approved PID Action Plan Critical Customer Requirements Process Maps Quick Win Opportunities Prepared Team
Activities Tools Outcomes
What would happen without a PID?
statement)
improvement? (What does success look like? The
measures of success)
and tests you can attempt.)
Answers the 3 Critical Questions;
In & Out of the Frame Scoping
Draw large “picture frame” on flip-chart. Use this to help team identify what falls inside and outside the picture of their
customers etc.
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in in in in in
Before the project
During the project
After the project
Being an Effective Leader of Change
and stakeholders
an intrusion on their real jobs
meetings
Are you setup for success?
A person who has
a vested interest in the outcome of your project
Change Targets Change Leaders Change Advocates
The people who will need to change The people with the authority and position to make the change happen The people who can influence the change
Change Agents
The people who will help implement the change
Stakeholders
Stakeholder Analysis
have a vested interest in the project
project
sure all major "forces" are supporting the project
the stakeholders in the picture
Major Stakeholders Criteria
Stakeholder Analysis Template
Stakeholder Interest Involvement Influence Concerns
Role/Name of Stakeholder Enter Current Value Enter Current Value Enter Current Value Indicate if the stakeholder scores need to change to assist your project
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High interest + high involvement + low influence Do we need to increase their influence? High interest + low involvement Is it useful to increase their involvement? If yes, how? If yes, is their influence high enough? Low interest + high involvement Do we increase interest or reduce involvement? What if influence is high and involvement remains as it is?
Low interest + low involvement + high influence How do we make sure that influence is used in a proper and positive way? High negative interest + high influence Can we make interest more positive and how? Do we need to reduce the influence and how? High negative interest + low influence How can we prevent that their influence becomes higher? Low negative interest + high influence How can we prevent that interest becomes even more negative? Identifying Problem Areas
Stakeholder Analysis Communication Strategy Engagement Strategy Continuous Assessment
Communication Plan
Project Title:
Status Key : Blue = Action agreed by team as CompletedCommunications Plan
Amber = Action Pending - Not started yet, requires attention. Green = Action in Progress and on Plan. Red = Roadblock or Showstopper , requires immediate escalation.Comms Title Audience Objectives Message How By Who When Where Content Status Comments
1 Give the Comms a title easy to understand and refer to that distinguishes it from other comms. Who are the primiary recipients of the comms What are the key objectives24
Communication Strategy
do?
a project?
Your examples?
Stakeholders will support the project
Commitment to change
To be rewarded To know what it’s all about (be informed) To find it meaningful To be asked to play a role in it (participation) To feel supported in my role To see results and progress 1 2 3 4 5 6
Strategies
gatherings
validation sessions
workshop
to inform and consult others
decision-making
validation
Key Mechanisms
Main Purpose CONSULT COLLABORATE INFORM Strategies & Focus Communication Strategies Engagement Strategies
What strategies can you use to engage your stakeholders? Add them to your Stakeholder Analysis.
determine your communication and engagement strategies towards your stakeholder
and listening), not out of one-way communication
achieve consensus
direction is set
people who can move the change through the
immediately when starting up the project – however this does not mean that you involve everybody immediately
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The purpose of Process Maps is to:
– Identify the complexity of the process – Communicate the focus for problem solving – Provide a big picture context to all those involved – Consensus
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Process Maps are living documents and must be changed as the process is changed
– They represent what is currently happening, not what you think is happening or what you would like to happen. – They should be created with the people who are closest to the process, the “Process Experts”.
improvement/change.
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Standard symbols for process mapping (available in Microsoft
Office™ PowerPoint & Visio™) A RECTANGLE indicates an activity/task. Statements within the rectangle should begin with a verb A DIAMOND signifies a decision point. Only two paths emerge from a decision point: No and Yes, Pass or Fail etc.. An ELLIPSE shows the start and end of the process An ARROW shows the connection and direction of flow
Step 1 Start Check ? Step 2 Step 3 End Pass Fail
Process Map
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Process needing Mapped
Available ?
Process Experts
everyone in a room
Start & End points first Re-arrange until all available
No Yes
all steps & decisions. (Warts & All)
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Blood Donor Flowchart example
interviewe d and fills
1. Donor Arrives 4. Veins OK?
veins are checked in waiting room 5. Doctor’s evaluation
drawn from Donor. No Yes Donor Rejected 6. Health OK? Donor Rejected No
goes to Donor room Yes 8. Phlebotomist checks veins 9. Veins OK? No Yes Donor Rejected
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Blood Donor Flowchart example
interview and fills
1. Donor Arrives 4. Veins OK?
veins are checked in waiting room 5. Doctor’s evaluation
drawn from Donor. No Yes Donor Rejected 6. Health OK? Donor Rejected No
goes to Donor room Yes 8. Phlebotomist checks veins 9. Veins OK? No Yes Donor Rejected
DUPLICATION
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Blood Donor “Improved” Process
Arrives
interviewed and fills
evaluation
phlebotomist checks veins
goes to donor room
& Veins ok? Yes No
Drawn from the donor
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Donor Rejected
Patient Receives Appointment Patient seen at home Is Patient Housebound ? Patient attends Clinic Patient receives 1st treatment Patient Discharged Outcome Details Recorded Is Care Package prescribed ? Is Care Package Long Term ? Patient given return appointment Short Term Care Patient Transferred to Podiatry Assistant Clinic Long Term Care Patient given return appointment Long term care process Details sent back to referral source
“Podiatry Patient Treatment Flowchart”
Yes Yes Yes No No No
Podiatry Example of a Patient Flowchart:
Flowchart
Swimlane Process map
When multiple departments or functional groups are involved in a complex process it is often useful to use Cross Functional Process Maps or Swim
Lane Map. This clearly shows ownership.
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Clinic Call Centre Podiatrist Patient GP
Call
Referral
Patient
Patient Details
Patient Appointment
card / Letter
to Podiatry Clinic
Patient Details
Appointment
Patient & Inform GP
Informed
“Referral to Discharged” Foot care Process
1.Patient Referral
Patient Records
System Records
Swim lane Process Flowchart
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techniques in Analyse stage.
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Summary page
PM Tools used in the cycle:
Task Who
Status
Define
Measure
Analyse Improve Control
How do we measures our problem? Where does the data come from? What is the performance now? How will we demonstrate before & after ?
current process.
current performance.
to help monitor progress towards the goals stated in the “Define” stage.
measure project success.
need Measures/KPI Definitions Data Collection Plans Baseline Performance Metrics & Goals Shared vision
Activities Tools Outcomes
Data = Facts Information = Answers to questions ‘Information’ includes ‘data’ ‘Data’ does not necessarily include ‘information’
Questions Communication Data Analysis
question
the answer to the question
Check sheet - Form has been designed so that results can be readily interpreted from the form itself Data sheet – data is recorded in tabular format – additional processing is required. Checklist – Contain items which are important
General purpose is for guiding operations rather than collecting data. Any examples?
with minimum effort and chance of error?
Why Display Data ? A Visual display of data is the best way to understand what the data is telling you. Benefits:
identified.
performance to all.
Tool : What it does : When to use it :
Run Chart
Show how a chosen measurable varies with respect to time. Allows trend and pattern analysis. When Gathering data in Stages D &
performance after Improvement
improvement and sustainability in Control stage.
Pareto
Enables you to identify the most significant category within your data. Focuses your team on what’s important. When Analysing data. When Selecting the major problem areas from multiple areas. Displaying clearly the 20% of causes contributing to 80% of the problem.
Bar Chart
Allows you to compare several items at the same point in time and show the frequency distribution across several items. Gathering & Analysing data. When assessing the capability of a process. To answer if the process meets the customer requirements.
Issues Category Pareto 50 100 150 200 250 300 350 400 450 500 HES Installation Content Sat Functionality Patch Install Internet on TV Media Internet Laptop choose one Others 1.85 beta ver PO card PMS App 1st level Question Double Billing Wrong Op Network HUB Demo System C ategory N u mb er o f even ts 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0% C u mmu l ati ve % C ategory Q ty C um m ulativ e % 20 40 60 80 100 120 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr CPU1 CPU17 Issue R esolution D istribution 20 40 60 80 100 120 140 160 180 Hints & Tips for Stakeholder Interviews
and project – what will be done with the information received
roles, activities, you & others
to start
the details
understanding – reflective listening Ask about:
negative
end of interview)
Stakeholder Interview Example
work groups
S U P P L I E R S C U S T O M E R S FINANCIAL PEOPLE PROCESS & OPERATIONAL PERFORMANCE PRODUCT / SERVICE QUALITY
Task Who
Status
across the business
Define
How does the process really work? What does our knowledge about the process say? What does the data tells us about the process? What are the root causes of our process problem?
identify ways of eliminating the gap between current and desired performance.
just symptoms.
focus and id resources required to help.
risks to success.
change Process & Data Analysis Validated Root Causes Potential Solutions Prioritised focus areas Identifying and overcoming barriers to change
Activities Tools Outcomes
Measure
Analyse
Improve Control
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Value Added Activity
Any activity that satisfies customer/patient requirements
Unnecessary Waste
Any activity that does not support customer/patient needs in any way.
Necessary Waste/Value Enabling
Supports the delivery of value but is not directly value add. It’s value if your customer/patient experiences hands on treatment/help/support/assistance improving their situation
can be wasteful.
Protect & Increase
What’s Valuable or Wasteful?
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Attacking Waste !!
Waste > 90% Value time < 10% The Average Process :
Waste Reduction but the Value remains.
Waste impacts all Processes
Cycle Time
Before
Step 1 Start Check ? Step 2 Step 3 End Pass Fail
All processes have their own proportions of Value and
After
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The unnecessary movement of a materials / information from one
different depts.
Build up, queue or backlog of Work-In-Process (WIP) at any particular step in the process. Sometimes an indication of a bottleneck in the process. Patients queuing for clinic, lab samples for testing, stocks on wards, dictation awaiting typing.
Motion that requires extra steps to accommodate an inefficient work layout. Typically hunting and searching for. Working across multiple sites, storage of consumables in disparate places
Periods of inactivity in a downstream process due to the late delivery of an upstream process, lack of information or instruction, etc. Inpatients waiting in ED, patients waiting for discharge, physicians waiting for test results
The 8 Wastes in any Process
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Extra work / Duplication - Rework, reprocessing, special handling &
Doing more than required. Producing ahead of demand or a process that continues after the customer requirement has been met. . Excessive reporting, unnecessary tests, Irrelevant information sent out.
Processing of any product or service that does not meet customer requirements. Needle stick injury, missing patient information, wrong information communicated
a) Using wrong staff for tasks. Mismatching skills & tasks. Medics transporting patients, not fully using skill mix of staff. b) Untapped Human Potential (Hidden Value). Not involving staff in changes.
The 8 Wastes in any Process
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to review wastes in the process map from Video 1.Define stage.
the process with process experts identifying waste and possible solutions.
methods
responsibilities
scheduling
selection
Causes of Waste
process
to remove waste
your process.
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Discovering the Root Causes of Process Wastes
What is it ?
How to use it :
root causes. Only factual answers accepted.
“Because I said so” or favourite theories / urban myths.
enough times that there will be no lower level explanation.
The 5 Why’s
Why? Why? Why?
process.
Why? Why?
Porters busy transferring Blood Tests manually Patients waiting for transfer
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No Porters available Jnr Docs not using Automated Blood test System Info not in their training Jnr Docs never told
Why? Why? Why? Why? Why? ROOT CAUSE WASTE
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Why? Why? Why? Why? Why? ROOT CAUSE 1 WASTE Why? ROOT CAUSE 2
If your Why chain splits this means multiple Root Causes and therefore multiple solutions required to eliminate the waste. Now use the 5 Why’s tool within a Cause & Effect Diagram.
The Cause & Effect Diagram helps to:
possible causes related to a problem
Main Cause Categories Issue or Problem
Cause & Effect Diagram – How to
Patients waiting on transfer
Process People Systems Equipment
arrow pointing to the box
problem description inside the box
main categories
causes
Why? Why? Why? Why? Why?
5 why’s on each sub cause.
Porters Nurses
wastes and issues.
reduce your process wastes and improve performance.
stage.
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B C
High Low Low High
D
Benefit
(Increased Revenue, Decreased Costs
Effort
(Resources: Time, Money, People)
A
Zones: A – Just Do It! B – Plan to do? C, D – Later…
Prioritising Opportunities
Value Analysis Prioritisation Tool (VAP)
Be practical – scope what is achievable
1 2 3 4 5 6 7 8
Task Who
Status
Define
What are all the possible solutions? Which ones are best? How can we try it out? Has it worked as we expected? Which ones will we keep?
ways to do things, quicker, cheaper & better.
to implement changes.
to validate improvement/
changes.
to change. Tried & tested Solutions Process Maps and Documentation Cost/Benefit Analyses Improvement Impacts and Benefits Pilot and Solution Results Storyboard Staff engagement
Activities Tools Outcomes
Measure
Improve
Control Analyse
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Making Improvements with the Plan,Do,Study,Act Model (PDSA)
small scale.
impact before implementing it widely.
evidence gained during small scale tests.
and less money.
have been involved and seen it work on a smaller scale.
Study Act Do Plan
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perfect first time.
what works better
evidence of the best solution
and maximum benefit.
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PDSA cycles form part of a framework for implementing changes leading to improvement. The framework includes three key questions which need to be answered before the PDSA cycle begins:
(The aims statement)
(The measures of success.)
improvement? (The tests to try.)
Study Act Do Plan
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the cycle
data.
Plan
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planned
unexpected observations
Do
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data
learned.
Study
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aims?
are to be made?
cycle?
Action was rationally based on what was learned
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What is 5S ?
workplace through better organisation.
what is needed, when it is needed and where it is needed.
activities.
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where it is needed.
detected.
activities.
process
SAFETY – IN EVERYTHING
Eliminate all unnecessary and seldom used items & equipment from the workplace.
Organise the way that necessary items are kept, making it easier to find, use and return to the proper location.
Maintain a Clean and Tidy work area for the already sorted and set-in-order items
Establish Standards to ensure sort, set-in-
by all users all the time.
Create an environment to maintain and improve the first Four S’s and make it a natural everyday way of working.
“A place for everything and everything in its place”
Stop slips & trips, reduce wasted time searching, improve efficiency and productivity, better quality, better environment to work in, feel pride in the work place, impress your customers.
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Before After
What does yours look like?
After >
No clutter – ease of access Only necessary items stored & clearly labelled Items easily accessible with minimum movement More space & time to do the job Clean and tidy area
<Before
X Corridors cluttered impeding access X Unnecessary equipment stored in corridors X Undefined layout of space X Searching for equipment
5S Examples
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After >
Only necessary items stored & clearly labelled Items easily accessible with minimum movement More space & time to do the job Clean and tidy area Item maps visible
<Before
X Storage disorganised with unnecessary items mixed with the vital items X Unclear labelling and layout, floor being used impeding access. X Searching for items time consuming X Lack of space because its not used correctly
5S Examples
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After >
Space cleared for utilisation as training/study room Only necessary equipment in place for training & study. Access controlled Library area designated Improved staff morale
<Before
X No staff training/study room available X Rooms used as dumping grounds X Space available but not utilised X Staff demoralisation
5S Examples
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for current work
–What do we need? –What do we not need? –What can we remove? –What can we throw away? –What can I reorganize?
Distinguish the necessary from the Unnecessary
Arrange items so they are:
Methods:
A Place for Everything and Everything in its Place
Methods Clean and Ready to Use As Is
Standard Systems need to be put in place:
how it happens
again – SOPs , training, audits etc..
and Storyboards
Tools:
5S every day
Self Discipline and Motivation
establishing and maintaining the 5S process.
Walk the Talk ! LEADERSHIP RESPONSIBILITY “We are what we repeatedly do: Excellence then, is not an act, but a habit”
MS Word
Desired State Current State
Transition State
Unfreezing
Refreezing
Unfreezing Techniques
Refreezing Techniques
People adapt to change in 3 levels
Physical This is the time it takes for a person to
comply with the behavioral requirement of the
Intellectual This is the time it takes for a person to comprehend why a change has taken place or is necessary. Emotional This is the time it takes for a person to feel comfortable with the results of the change, the new state.
Stage 1 Stage 2 Stage 3 Stage 4
Recognising and Supporting
Key Reactions to Change
Shock/Denial/Anger Resistance Exploration Acceptance
Divide categories among groups and go to exercise
change curve
behaviours what would / could you do as an individual to move the employee forward
you agree with the responses ? Add any additional input as required.
flipchart.
Reaction Employee & Team Needs Caution Provide facts and continually articulate the reality of
Recognize the feelings and help get the emotions out Help focus the individual on the priorities Shock, Denial, Anger Clues Expressed anger, constant complaining, withdrawing and refusing to accept changes Avoid taking personal responsibility for the individual’s reactions
Reaction
Employee & Team Needs Caution Continue to articulate the reality of the change Listen actively Assist the person to reconcile personal frame of reference to the new reality Resistance Clues Performance drops, errors, refusing assignments related to the change, negative, complaining, withdrawing Understand that you will have questions as well Do not speculate or ‘make-up’ reality as you go along
Reaction Employee & Team Needs Caution
Provide resources, time and support to help individuals try new and realistic alternatives Give appropriate recognition, appreciation and feedback on new ideas Exploration Clues Ready to change, confused about what to do, loss of confidence in skills and asking others what to do Be sure to discuss realistic options for the future Do not mistake ‘searching’ for liking the change
Reaction
Employee & Team Needs Caution Reward the team and individual for focusing on implementing the change. Encourage risk taking that supports change. Stay involved, look ahead Acceptance Clues Initiates problem solving on his/her own. Positive about what needs to happen, suggests ideas, supports the change Be sure to discuss realistic options for the future
Change will occur when:- D x V x F > R D = dissatisfaction with status quo V = desirable vision of future F = first small practical steps towards the vision R = resistance to change
that we should change
months that we should change
rather left us standing
lives
D x V x F > R
change
are seen as achievable, if challenging
change goals and their own jobs
D x V x F > R
processes have been well planned
key aspect of the change process to date
achievable
D x V x F > R
will experience difficulties during this change
changes in their approach
D x V x F > R
Use the change equation to analyse a change that you are; currently dealing with or have experienced in the past
Details/Actions What has been done? What needs to be done Dissatisfaction with status quo Clarifying and communicating the future vision Identifying and communicating the first steps/plan What will be the impact of the change? What resistance do you anticipate?
Applying Gleicher’s Change Formula D x V x F > R
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Task Who
Status
Define
How do we makes our changes normal operation? How can we sustain our improvements & benefits? How will we measure in future? Have we met the goals we set and can we close the project?
processes.
into everyday routines and systems.
reports.
Sustain the benefits.
Standards and Procedures Standardization Trained staff & training Plans Project & Team Review Success Stories Replication
Activities Tools Outcomes
RACI matrix
Measure
Control
Analyse Improve
What steps can you take to control and ensure the sustainability of your project? Use the Control Plan.
What training is required for staff to implement new or revised processes and procedures? Think about both existing and new starts, Who will write the training material? What will the training comprise
Review your Comms plan from the Define stage as there may be new requirements at this stage.
Revise your Stakeholder Analysis at this stage also as new Stakeholders may be involved since the changes have been implemented and their impact has spread.
Carefully define the new Roles & Responsibilities within the new or improved process. Clarity at this stage is critical to the process being sustained. Use the RACI Chart to Identify who will be Accountable for the process tasks being carried out, who is Responsible for performing the tasks, who will need to be Consulted and when and also who will need to be informed at what point within the new process.
Documentation is necessary to ensure that what has been learned from the project is shared and institutionalized: Used to aid implementation of solutions, Used for on-going training. Documents need to be kept current to be useful with help from the Documentation Plan.
Allowing people to change their behaviours permanently means implementing goals, measures, job descriptions, incentives etc.. Which align with the new process approach and will motivate them to sustain the changes & benefits.
Lessons Learned can be started from the beginning of the project and maintained throughout making this step at the end a summarising activity. The main question to be addressed here is “What could we have done better and how?” using the Lessons learned matrix.
Single page overview of the improvement project to Share Learning's, Document Case Study, Communicate Success, Evidence of Improvement & Convince others to try
Task Who
Status
Pitfalls:
Teams can potentially derail when they:
change.
(“Flavour of the Month”)
business.
Define Measure
Analyse Improve Control
Create a shared need Leading Change Set up for success Overcoming resistance Mobilising Commitment Making Change last
Process Change People Change
CURRENT STATE TRANSITION STATE IMPROVED STATE
Analysis & Q’s
TEMPLATES
Update
formula
Learned
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