– [Justin] Excuse me everyone, thank you for your patience in holding. We now have your speakers in conference. Please be aware that each of your lines is in a listen-only mode. You may ask questions at
any time using the chat box. I would now turn the conference
over to Miss Jen Braun. You may begin. – [Jen] Thanks Justin. Hello everyone and thank you for joining our monthly webinar series
on Integrating Quality Improvement Methods to Improve
Teamwork and Patient Safety. My name is Jen Braun and I’m with the Health Research and Educational Trust. We’re the research and
educational arm of the American Hospital Association, and we manage the national
implementation of TeamSTEPPS. Just a few rules of
engagement before we begin, so you can access audio
through two different ways. One is through your phone,
which is in a listen-only mode, and if you dial in and Sangita
just sent the dial-in number and passcode there in the
chat box as a reminder. If you dial in with your
phone you want to mute your computer speakers just
so you don’t get double sound. So if you don’t listen through your phone, then you can listen through
your computer speakers. We’ll use that chat box
on the right hand side of your screen to field any
questions that you might have. So please feel free to chat them in throughout the presentation. If they’re more logistical
we’ll answer them in real time but if they’re content
based we’ll save them for the end to ask our speakers directly. If we don’t get to all the
questions that you asked we’ll do our best to follow
up with the speakers after and get those answers to you. I just wanted to flag some upcoming TeamSTEPPS events that we offer. We have this monthly webinar
series that takes place on the second Wednesday of each
month at noon central time. And we have registration
available for next month’s webinar which is on TeamSTEPPS and the
role of leaders in the NICU. In addition to our
monthly webinars we offer TeamSTEPPS master training courses, and registration’s currently
available for courses starting in January through April of 2016. Registration for courses in the summer will open at the end of next month. And then finally our
annual national conference will take place in June in Washington, DC which we’re very excited about. Registration is filling
up rather fast for that so if you’re interested in going you can learn more on our website. And our website is listed right there it’s TeamSTEPPSportal.org. In addition if you’re not able to travel to one of our in-person
master training courses, an online course is
available so you can register at that website listed there. But again, our website
TeamSTEPPSportal.org contains a lot of information
including registration. As always we are available by phone or you can email us at that email there. [email protected] if you
have any questions any time. And then with that, I
promise I’ll keep this brief, I would like to officially
welcome our presenters today from UCLA, where
they service faculty. They’re one of our eight
regional training centers that provides master training courses. Today you’ll hear from Dr. Randy Steadman, Bob Martin, and Ken Miller. Unfortunately Yue Ming
Huang is stuck in jury duty, but you have three very competent
and great speakers today. And with that, I will turn
it over to Dr. Steadman. Randy, the floor is yours. – [Randy] Okay, thank you Jen. These are the objectives for today’s talk, we’re gonna compare two
quality improvement models. Those models being TeamSTEPPS and Lean. Both of which are designed
to improve patient safety. We’re gonna discuss how to reconcile the principles of these models. They are shockingly similar, and we wanna point that out to you. We’re gonna demonstrate three Lean tools that can be incorporated
into TeamSTEPPS courses and TeamSTEPPS implementation exercises. And we’re gonna give you
examples of a project that was done here by Ken,
that utilizes these tools. This slide shows on the left hand column a number of TeamSTEPPS tools
that will be familiar to you, and in the right hand
column are Lean concepts that overlap the TeamSTEPPS tools. Now these mapping of
one concept to another doesn’t work completely
down the list but indeed, many of the tools are very very similar. And we’re going to illustrate tools though that are different for you today, so that they will add to the diversity of your TeamSTEPPS courses. Bob? – [Bob] Hi, this is Bob Martin. So of course we need to talk
first about what is Lean? When we talk about the principles first. By the way when we talk
to people and we ask them what their opinion about what Lean is, a lot of times people say reducing waste, improving efficiency, and
while those are accurate Lean is really a management
system and a culture. And it’s focused around, designed as the way we
work by adding value for our customers and eliminating waste. Where every employee is
empowered to solve problems and to continuously
improve their processes. So really Lean is an empowerment
and engagement methodology and it’s similar in
many ways to TeamSTEPPS. The next question is,
well who’s doing that? As you can see, on the
upper left hand side we get our origins, well it actually goes much
further back than Toyota, but Toyota production
system is where we get our modern understanding of Lean. Companies like Porsche, GM, GE but it’s not just electronics
and manufacturing. There’s also aerospace
companies, you’ve got Starbucks, you can go to Monster.com and
you’ll see job applications forming for Starbucks Lean positions. 3M, Amazon, and on the bottom
left hand side you see, some of you are probably from
these health care systems. UCLA Health really has started our journey just a few years ago. So we’re very very early on
and we’re trying to catch up to some of our friends across the country and other academic
medical centers as well. And you even see some universities now and airlines that are
trying to implement Lean. You can get certificates and learning from a lot of universities
but there’s very few that are actually trying to implement it. So today, one of the main tools
we’re gonna be talking about even though Lean is about
management fundamentals, and engagement, and things like that it’s also about methodology. And a lot of times when
you take a Lean course, you’ll focus on that. So we’ll do a small focus on that but keep those other principles in mind as well. So we are going to be
simulating a problem solving, what’s called a PDCA,
plan, do, check, act. It’s basically used in
the scientific method for Lean, using a tool called an A3. Now Toyota used a tool called A3 it only means the size
of the paper, 11 by 17. And they figured that it
was a good size of paper to communicate anything
which was a complex problem you needed to gain
consensus with managing the quality improvement
project to use if any time that the root causes that
you’re trying to determine are really unknown at first. So it really requires a data analysis and starting to look into things. So keep this model in mind,
PDCA as we’re going through. We’re actually going to be going through, focusing primarily on
steps one through four, on the left, talking a
little bit about step five, and then look at check and act. But the way this works, PDCA, we’re supposed to be spending
a lot of time planning. So steps one through four is planning, and then step five is doing. So you plan before you do, and
then you check what you did, and then you make
adjustments, you act upon it. And that’s what PDCA
methodology is all about. But as you’re implementing PDCA, I’m gonna fast forward on my clips here, but as you’re implementing PDCA, as your implementing the solutions you also have mini PDCA
activity which occurs in here. So UCLA our culture right now typically, we’ll do workshops what we
call Rapid Improvement events, and other things where we
generate many solutions and we kind of implement them all at once. But we’re working towards
a system that you implement one solution at a time
using a more scientific, rigorous approach called mini PDCA. So you have the big PDCA, and then you have mini
PDCA and the solutions. And the reason we’re using this document, because the rest of the
presentation you’re gonna see us talking about the problem statement, some current state tools,
formation of a goal and root cause analysis. Ken? – [Ken] Hi, this is Ken Miller, I am the simulation education
program coordinator. And I also have a background in critical care and critical care transport. When I started TeamSTEPPS I was actually the manager of critical care transport. And through normal QA
we found that transport, our throughput process was
very delayed for some reason. When we did the QA we found
that it took 55 minutes for a patient to get from
our medical outpatient plaza to the ER or to a direct
admit to the floor. It’s on the same campus. So this was a huge problem that we found and we needed to solve this
problem or find a solution. So when I first looked at this I needed to come up with the actual problem, what is going on here? And I needed to look at the process. So in Lean we have this
tool called Process Mapping. And what it is is a visual representative of steps in the process. And what it really shows is a good, clear understanding of
what the process is. And it really helps us look at the value and the waste that is going on. There are several computer
programs out there that really can help you
with these process mapping. One is Visio which is
what we use here at UCLA. But each symbol represents a
certain part of the process. Like all the circles usually
are the start and the end. Rectangles are the task or
activity, arrows are the flow. The yield sign is either
a question or a decision. So you want to look at your process to really get that clear
understanding of what’s going on. When I did ours, this is what
we would call a spaghetti map. And I really tried to honestly
find out what was going on it was a little difficult. So I did the best I could
with the current process but I found a lot of
problems and a lot of waste, and a lot of things that I
could improve the value on. But I really wanted to take
this back to the group, to the whole transport
group to really show them, hey this is how we’re
doing this right now. Because everybody kind
of did their own thing. And what I like about these
current state process maps is, it’s puts everybody on
that shared mental vision. Because it’s like all of a sudden, oh do you do that, or do I do that. So a lot of value comes out of this and just creating that map. So when we got together, and this where TeamSTEPPS
simplification tools come in, we got to change team going, we talked about how could we improve this, we offered several solutions, which I’ll talk about in a little bit, but the bottom line is we
came up with interjecting the SBAR into our dispatch
system to help improve the time. Then we did a process
map that really showed that Lean process, that simplified process to get from point A to point B. And we actually did decrease
our times by 22 minutes. So it was very successful. One of the tools that we also use in Lean is the time observation tool, and this actually measures
what actually happens. So what I did is I did a
simulation of a transport and I documented the times
that everything was done. Cause I really wanted to give the staff a benefit of the doubt that this didn’t take really 55 minutes, but actually this time
observation tool validated that. Which was helpful for the staff as well to see that this really was occurring. It helped streamline the
process and identified waste. We identified a lot of things
with multiple phone calls, duplication of information
being transferred, you are able to describe
each task in detail, look at the running line and calculate the times and averages. So that really gave us a lot of value. – [Bob] Hey Jen, would you
like us to answer the question that we put in there or should we wait? – [Jen] No sure, you can
go ahead and answer that. About the PDCA and PDSA, sure. – [Bob] Deming brought PDCA to Japan, or PDSA, plan, do, study,
act, and in Japan with the, it’s a group of engineers, I
can’t remember the society name they adopted and adapted
it for manufacturing and they called it PDCA. And since then, they kind of
evolved down different paths. And so the short answer is, yes they are pretty much the same but if you talk to some PDCA
and PDSA zealots or advocates they’re going to tell you that they’re probably totally different. But realistically the
principles and concepts are very very similar. So if you see PDCA you can
generally swap it with PDSA. PDSA means plan, do, study, act. Go ahead Randy. – [Randy] So we’re gonna walk you through the second Lean tool, which
is the time observation. The first one was the process map. So on the screen you see an
example of a time observation that Ken did for his transport. And you see in the red
box the work element. So you can see nine different
steps that are listed here. – [Ken] From the request for
the transport, to getting ETAs, to giving report, to getting
multiple calls from the CCTRN, which is critical care transport RN, up to the time that they
arrive at the patient bedside. – [Randy] And now we’ve
highlighted the clock time, so this is looking at the
watch and noting the time that each of these nine steps started. And the column next to it, Time in Step, illustrates that for the first
step it took five minutes. And then there’s a further
column on the right in which notes can be added. – [Ken] And so notes that we
noticed in this observation was about our estimated time of arrival. There just wasn’t one given, which can cause some anxiousness with the person requesting the transport. And it really identified
a couple of issues that we weren’t doing like
bedside report for example. A lot of the nurses were
getting report over the phone, or through EMR, and
really Joint Commission does command that report
is given at the bedside. – [Randy] So this is an acronym DOWNTIME, that is one of the Lean
tools to identify waste. The acronym stands for as
you see in the text box. Defects, which would be errors, mistakes. Overproduction, getting
things ready too soon, excessive setup. Waiting, which would be actual downtime. N is for not utilizing talent. T transport, moving
things around excessively. I inventory, either too much, too little. M motion, that would be
moving people around. And E is extra-processing,
meaning unnecessary steps. So on the next slide, we’ll
see these illustrated. So again this is DOWNTIME, the acronym. Defects, overproduction,
waiting, not utilizing talent, transport, inventory,
motion, and extra-processing. And on the next slide we see that the DOWNTIME analysis has been expanded. And we see that the defects are added and have their own column. So here you see step number
two which is waiting, for the estimated time of arrival, that is a waiting step so that’s waste and it would come under
the waiting column. So you see seven minutes added there, in the waiting column. So you can see that
following the Clock Time, or the Time in Step column
down to the very bottom, you see that it was a 55 minute process. But if you go to the right
most column called Path Time, you see that the time in each
step was really 18 minutes. So subtracting 18 from 55, 37 of the minutes were wasted time. So this is really drilling down
and identifying the process. – [Ken] And this gave then me,
as the manager of transport a chance to look at our process, and how much time we could
shave off that response time. The national standard for
transport is a on-scene time for 9-1-1 calls is 30 minutes. So I identified 37 minutes that are wasted so this was a big help because
not only did we surpass our national standard
goal but we were able to cut down 22 minutes
right away off the time. The process maps and
time observations really help us as group define
what our goals were. And our goal was to
decrease that time from 55 to at least that national
standard of 30 minutes within the first six
months of implementation of this TeamSTEPPS project. The Lean process helped
us with those maps, the time observations and really gave us that definite clear goal
that we wanted to go to. – [Bob] Understanding the current state, this is Bob by the way, as your going through that
process what you’re trying to do, and this is step four if you were following along from that A3, is work towards trying to understand what the root causes are. The root cause analysis, this should be a familiar
tool to most of you hopefully, if we have adverse events in healthcare, hopefully that’s not too familiar, or sentinel events or if you have M&M or peer reviews at
PBE, things like that. A lot of times we do have
mistakes in health care, we try to investigate it as part of Joint Commission requirements. We use root cause analysis methodology and we all have different
systems to do that. But we also do the same
thing at TeamSTEPPS and we do the same thing in Lean as well. And I’ll give you an example
of why root cause is important. For this example right here, you have to think way back to the 1990s. There was actually two memorials, the Lincoln and the Jefferson Memorial even though it just
says Jefferson on there, where the granite was
increasing at a crumbling rate. And people were trying to understand why, there was a lot of theories,
is it acid rain, is it traffic, and so if you start looking at actually what happened
it’s pretty insightful. For example, and you might
investigate acid rain, you might investigate everything else, all this granite and everything else came from the same quarry, so when you look at all the
rest of different things, they discovered that these two memorials were actually being
washed more frequently. So you would ask yourself why? Root cause analysis is
about using the five whys. Well maybe it needed to
be cleaned more often. But why does it need to
be cleaned more often? Well because they had a lot of birds that were increasing waste. Now this is a different type of waste than I was talking about
last time of course. So, the idea is should
we eliminate the birds? And usually when I’m with
a little group of people, people will laugh at that but we don’t have the opportunity here. But I’ll give ya a small story, before I worked at UCLA I
worked at Boeing for 14 years and my last assignment was
helping out a supplier in Italy, Alenia Aermacchi implement
a Lean production system, little town called Cortale
and this Italian guy would drive up every
week in a little truck, and he’d have a falcon on his shoulder, and he would launch the falcon, and the falcon would take out the pigeons that were always in these very tall, gigantic aerospace airplane hangars. So they were trying to
figure out that way. But that’s not just
how it’s done in Italy. In America, when I was
a production manager on the 787 program and this
is back in the late 90s, they used to poison the birds. And we had these open bullpins
so we’d go out every morning and we’d lay out our keyboards and you can imagine what mess
was all over our keyboards, I mean we’re washing
them out in the bathroom it was pretty disgusting. Because the birds would ingest the poison and it would go through them. But that wasn’t the root
cause of the problem. Why are the birds there? Well they had a large
number of spiders to eat. But why all the spiders, should we kill all the spiders, right. If we did that the other insects
would overrule the Earth. But the spiders are there of
course also for a food source. And they weren’t actually eating midges, they were crawling up on the wall because these midges would swarm, and the ones that had these
protein larva egg sacs, would hit the walls and
the spiders would crawl up and eat those and then the
birds would tell their friends, hey we’ve got a lot of food over here. And suddenly we have
granite which is crumbling. But why was that happening? We still had all of these
different memorials. Well midges are attracted to lights, and at these two particular memorials the lights were turned on
about an hour before dusk. All of the other memorials
the lights were turned on five minutes before dusk. So you can imagine what the solution was. It didn’t cost any money
to turn the lights off five minutes before dusk. And believe it or not we
have these types of things happen in health care all the time. And the metaphor of root cause analysis is literally thinking about a tree, if a tree looks like it’s sick or failing you can’t really tell by the branches. A lot of times the
problems are in the roots. And you have to literally dig down, and as you’re digging down
you’re discovering the problems. So the current state analysis in box two, points you out to where
the root causes are. Root cause analysis is actually
trying to find out why. So one of the tools we use to do it, well one of them I just
demonstrated to you it’s called five whys, but another one is
called Fishbone diagrams. This is also called Ishikawa diagrams, and it’s also called
cause and effect diagrams. And it’s a very, very,
very simple tool to use, Ken is going to illustrate
one in a moment. But all you do, just to let you know is you write down a problem
on the right hand side or left hand side of a document. You come up with several
different categories. And in this case you see Communication, Process and Environment. And then you start
brainstorming or doing five whys to find out where all the
different root causes are. Ken? – [Ken] So I use this
Fishbone to come up with, try to come up with some solutions. Again I really wanna emphasize, cause we are a nursing magnet facility, this was a group project of
the whole transport team, this just wasn’t me providing
this and developing this, this was a group effort. So we were able to put this Fishbone up, and we found it’s a problem of 55 minutes. So we broke it down into these groups of, is it a people problem, is
it a communication problem, is it a equipment problem, or
is it just a systems problem. So we all brainstormed what about people, did we identify were issues. One is the EMTs and the CCTRNs
were doing different things. Communication, the dispatcher
didn’t receive any kind of report which we looked
at as a waste of talent. They could pass on something to the CCTRN to give them more of a idea of
what’s going on at the time. The CCTRN sit there and read the EMR for at least 10 minutes. Investigating the whole
history of the patient. So then we looked at our
systems, our elevators were slow, the equipment, a lot of times
that the equipment was gone because there was a
simultaneous transport, and equipment was really
stored in three areas. So this really highlighted a
lot of issues that we needed to look at to help decrease
this response time. – [Bob] So Marci, reading your comments about five whys being messy, and it can take root causes
in different directions, absolutely true. If you do root cause analysis properly, it can take some time,
and generally speaking you will find several,
several root causes. I saw a consulting firm once
do a root cause analysis on why the Titanic sunk, and they found 17 isolated root causes. The thing is is that if you
have to look under the surface, just like with the iceberg, it didn’t hit the top of the iceberg it hit the side of an iceberg which was underneath the water. And if you don’t do the digging or drain the water to try to understand that, which is very messy, takes a lot of time, but think about our patients. We don’t jump to solutions
with our patients, right, we try to understand the root causes with our patients as well. So the idea is that we should
also try to understand the root causes of our problems
before we make decisions. – [Ken] And do can do 10 whys, the five is just a general guideline. You can keep asking if the
response can reply to a why, you can ask another why. – [Bob] Yep. And it might
tree out into four or five different branches, so on and so forth. It’s a lot of work. – [Ken] Like your two
year old, why, why, why. So this is our example of our A3. At the top, we put our
what our project name was. And that was Improving Patient
Throughput Through Decreasing Response Times in Critical Care Transport. This is all the staff
that was involved with it, the project team and when
we implemented it in 2014. We came up with our problem statement. Again this is the Lean tools that we used to get to these boxes on the left, we came up with our current
state, what our goal was, our root cause analysis. And it’s very important to
show that root cause analysis to everybody because they can look at it. And they can even add
stuff that you possibly might not even have known. Other staff or other people walking by. It’s very important to show that. The right side of the
paper is more the PDCA. The solutions, which we came up with really two basic solutions. One was to streamline the process, so we did the process map. The second thing was doing
a TeamSTEPPS intervention of applying SBAR to our dispatch. So what we did was we realized
that the talent of the EMT wasn’t being as utilized as it should be, so when they would request a transport the EMT would get a simple SBAR report, and I put air quotes on that because it was just a transfer
of clear communication. We needed to know why that
patient needed to be transported. That was the issue so the
SBAR was designed to really look at why they needed to be transported, what problems we could be anticipating, equipment issues, and staffing issues. Those are the big three
complications of transport. And that SBAR addressed all three of them. Then that SBAR was given
to the transport nurse who looked at that SBAR,
they got that information, and decided what equipment they needed and what personnel they needed and then they were
dispatched to the bedside. Then the transport nurse
showed up at the bedside. And even if they were delayed
once they get to the bedside, it’s still the patient satisfaction which was something we really
had to consider as well. The patient satisfaction is better because at least they know they’re there. It’s when they’re waiting for
an hour for nobody to show up is really an issue with
patient satisfaction. So we did our checks, we did monthly audits
of our response times, we did audits of the SBAR intake, and then we did the initiation of discussing SBARs in our daily huddles. At UCLA at the beginning of each shift, the nursing staff and
I we do a daily huddle to talk about things that are going on, and this was a great
TeamSTEPPS intervention again, using these huddles because
it did help us talk about the SBAR and what problems we were having. And then the action, we
looked at this and did change a couple things on the information sheet that nurses felt they
needed but it really, the act part is so important
because if you don’t, things just aren’t stagnant
if you can find other things and other issues that
you can take care of, that’s where the act comes in and it just keeps getting better. We are continue doing
audits of the SBAR format, our times now are still about the same. There are some improvement
issues we’re going to look at, and we’re actually changing
over to an electronic version, with our Care Connect issue. Which is gonna really
impact this whole project. – [Justin] There’s a question
about the sample size. – [Ken] The sample size of the audits, I wanna say was 55 transports. – [Bob] So you were
actually able to do all? – [Ken] Ya. It was 100%. So the outcome, by using
these Lean tools and SBAR, we improved that response
time from 55 to 22 minutes, which was even better than we thought. And actually the first
time we implemented this, the response time was 16 minutes. Now with that said you
always have to watch for that Hawthorne effect because they knew that we were implementing this. So you had to take that in consideration. Now our response times
are a little bit longer than 22 minutes but they’re
definitely not 55 minutes which is really was our goal. But again, this is a continual project, it’s a continual improvement project which our goal is just to keep
getting better and better. – [Randy] So in summary we think that TeamSTEPPS and Lean tools are complementary, they
supplement each other. We think that Lean
tools can be implemented within TeamSTEPPS and vice versa. And just to review the Lean
tools that we discussed, PDCA and the A3 form we illustrated, we showed a process map, we
showed a time observation sheet, we illustrated the DOWNTIME analysis within the time observation sheet, and we showed a root cause analysis in a Fishbone diagrammed format. And then we used the example
of the transport team response times and transport times illustrating these various tools. So we see a number of questions. – [Bob] And I’m scrolling
up to the PDCA tools. I’m not sure if everybody can see, you may have it in screen mode. So there is a question from
Norris about the PDCA tools usually include a check cycle, or if that’s what we do on the project management slide in which you describe the A3 there’s no
mention of a repeat check cycle. Ya it’s definitely a
continuous process for us, we normally do is we integrate
these into our daily, weekly and monthly upbringing cycles. We’ll use the PDCA to get us started and then it goes into a project in that way. So ya, we definitely use it. And by that point we will
typically keep a focus on all of the metrics
and supporting metrics which are critical to
make sure that the process is going to continuously
maintain, sustain and improve. – [Ken] This is directed to Marianne. Why is your target only 20% for completion of the SBAR form on intake? We specifically targeted a specific area. We do other transports just
not from the outpatient area, so this made up about
20% of our transports. And then we want to disseminating
to other transports. Cause we picked up patients
from other hospitals, we picked up patients
from our sister hospital and transport back and forth. We really wanted to focus
on this medical plaza, because that was where
we’re getting a majority of complaints so that’s
why it was the 20%. – [Bob] So Lisa, I’ll take your question about what part of this
is available to use. Of course the presentation is available. We can make the tools available. Everything that you see is
pretty much non-proprietary. If you go to Toyota, GE, Boeing, it doesn’t matter where you
go the tools are 90 or 95% the same and they’ve been that way since the industrial revolution pretty much. Except for the A3. Ya they’re available to use but if you like the ones that you saw, we particularly like our A3 PDCA format because it directly links
in the root cause analysis to test actual root
causes in the solutions but we can send that link out as well. And by the way, we didn’t even
talk about A4 methodology. A4 would be like a daily type PDCA. But the link that we send out
will have both forms on there. – [Justin] Debra has a question. – [Ken] So who’s tracks the action items? That you have to determine
within your group. That wasn’t my job as the coordinator I was looking at how they doing this and was the forms being
filled out correctly. You have to prioritize your action items. And really see what you’re
gonna get the full value out of. We knew that SBAR was gonna
give us the full value of decreasing that time. Because the big issue
when we did our Fishbone, was the communication. What we did, ya you can’t
have a lot of action items, but you have to prioritize and look at what’s gonna
give you the most value. – [Bob] Ya and a lot of
times we use a two axis, this is Bob, prioritization matrix, that some people call it the PICK method, you can probably Google
that but it’s a great tool that you can use with the team to actually prioritize what you can do. You might want to phase
out your action items. A lot of teams make a
mistake by identifying 30 or 40 action items and
just trying to do them, but really you should
probably focus on doing 5 or 10 at a time or so on and so forth. Or reduce the scope of your project so that you can get them all done. – [Ken] So there’s a
question about what about using SBAR as an abbreviated A3? I don’t quite understand that question. – [Bob] I’ll take this one. I guess there’s a possibility
you could use the SBAR. What I would do is encourage you to do some searching on A4 methodology. So the basic idea is if you
know what the root causes are, like if you’ve got a group of employees and you want to encourage
them to submit ideas, you would probably not use
A3 for very simple projects you would use what’s called A4 methodology and it’s very very similar to SBAR and I really hadn’t made the connection until you asked the question. But A4 methodology would be the one. It’s basically four steps of
the seven step A3 methodology. – [Ken] This is why we
have the expert here for the Lean process. How long does it take to
complete the process map? That’s a great question. After we did the time
observation I went back and kind of sketched it out myself but then we took it to the staff meeting and had the staff look at it
and continue that process map. Because everybody was doing something a little bit different. When we did the time
observation that nurse did something different than another nurse that was on the next shift. So it’s so important again to
get everybody’s input on this because it’s gonna identify more problems with that process map. So it took at least
minimally of four times meeting with everybody and all
the staff that are involved because we had separate EMT meetings, we had separate nursing meetings and we also posted the process
map up in our wait room where we would wait for the calls so everybody could also add their process. We would put up is, also
think about improvements, what could we make here. We used little Post-It notes and people would write on
there during that process, what either they did or what
they felt would be different. And that was very helpful. So my advice is this,
make sure its thorough, and that everybody has
a chance to put into it and it’s just not kind of a one time shot. It can take several weeks to
really get a solid process map. – [Bob] So now I’ll take your question about triaging projects. I’ll let you know how
we do it at UCLA Health. This is Bob again. I work in a group called
Performance Excellence. We spend probably a little
more than a 1/2 to 2/3 of our time getting directions
from our suite on health. And we focus, we’re like
a SWAT team we go out and we try resolve health
system level problems. But what we also did was
we formed a collaboration between nursing, medicine,
and operations through an institute called the
Healthcare Improvement Institute. And through that we
developed a Lean academy. And what we do is we have
a course where right now it’s just internal employees
but they go through a certification program so
that managers and directors and so on and so forth can
send people to our class. We will train them, and then as they’re doing their projects, then what we do is we
coach them and mentor them for at least an hour a week. You know because Lean shouldn’t be focused just on improving the bottom line or just the top-level problems. Really it should be an all
out whole cultural change. So really my ideal for me is
that you just let everybody do the projects as they want. Go ahead Ken. – [Ken] In the case of nursing, we allow the bedside nurse
to go to the Lean academy and learn these things. Cause they’re the ones
who identify the problems. They’ll come up to us, to
management and administration and say hey this is going on. And they’re able to apply
this Lean methodology which really kind of
validates their issues too. And it gives them some good tools to use to help solve these patient
care problems and issues. – [Randy] This is Randy Steadman again. The hospital has a committee, the Performance Improvement committee that also triages projects
so to get the physician, attending physician by in, we definitely try to
avoid too many projects going on at once. So that would also look at
more institution wide projects. So there’s a number of
ways we might do that. I’ll also take the question
about Care Connect. Sorry that’s our UCLA term for our electronic medical records system. – [Bob] And that’s based on epic. – [Randy] And Dan thank
you for pointing out that Lean.org has templates. And do you Bob do you wanna
take Laura’s question? – [Bob] Laura how long do you keep a focus at what point can you stop
monitored results and say good? I’ll tell you a story when
I was a production manager many many many years ago, and we did this simple
improvement production system. I’m trying to line these brackets on overhead cabinetry in an airplane. And after we implemented the project about six months later one of
the Shingijutsu consultants that we learned Lean from came and said hey let’s go ahead and do
that same project again and I looked at him
like he was nuts I said you know, what are you talking
about we already improved it. And this is when I was
still learning of course in the mid 90s and at that
point I didn’t realize that this was really about
continuous improvement and you never really stop monitoring. When you stop monitoring,
that’s when you’re done. And you’re not going to improve anymore. So you actually have to completely change the way your culture works
and it’s extremely difficult if you’re not there already
to try to get there. But remember this is culture change and it can take five years, 10 years. Toyota said that they’ve
been working on this for 50 years and they
still haven’t perfected it. – [Randy] Do you wanna scroll down? – [Justin] Ya, so, (mumbles)
this says how does the subset of transports that you were. – [Ken] Marianne in
response to your question. The goal was 100% of
the subset of transport that we were having trouble. We wanted to improve those times. So that was our 100%. In the problem statement, what we should have done is
really said in the medical plaza transports to make it a
little bit more specific. But that’s our 100%. See now I’ll go back and look
at my project and reevaluate. But I agree with Bob 100%,
these are never over. And we can always improve, and keep improving, and keep improving. Because we want those outcomes
to affect our patients and that’s the overall goal
of using both these processes. – [Bob] And we’ve spent a lot of time, and people tend to spend a lot
of time on the P for planning and then the doing, and they spend very little time
on the checking and acting. So a lot of people are
good at PD but not CA. And including us, we do that a lot here so we’re still working on that as well. But you definitely have to
institutionalize it over time. – [Randy] Cynthia’s
question about collecting the process times data, I think that’s really the time
observation that does that. The time observation can be done either by an outside observer, who is
devoted strictly to that task, and that can take a day
or two, or even a week. It can also be done by
the employees themselves, but then their recording of the times will interfere with the accuracy. So an outside observer is
probably the best way to do that. But then the project
lead which in this case for the transport team
example that we gave was Ken, needs to assemble that
data into the process map. Which as Ken illustrated,
started out as a spaghetti map, and then was streamlined
into a much smoother process. – [Bob] Good, thank you Kathy. So Chris Anderson, you
asked again about the tool that we use for prioritizing
either problems or solutions. The original tool is called
the PICK method, P-I-C-K. And it’s a two axis system, to evaluate two different
criteria for anything to see if something is possible, implement, I can’t remember what C is. Consider. Consider for later. Or the last one K was kill. Right but we can’t use kill in healthcare. The manufacturing term is PICK. So we call it a prioritization matrix. But if you type in prioritization matrix it might be difficult to find. That’s why I’m letting you
know look up PICK method so that you can find it online. We also don’t wanna kill people’s ideas. So as far as an example of
action items you wanna look back. – [Randy] So if you look
in the upper right box of solutions here Misty, you’ll see that tested
solution was complete a revised process map and do mock simulations to examine the process to
see whether it’s feasible. And then the second row is
have equipment available in one area to avoid having
three equipment storage sites. So those would be two
examples of action items. – [Bob] But I think the message though that we want to convey is that
when your doing solutions, what you wanna make sure
you do is tie in all the root causes that you
developed in step four. The ones that you can actually, after you’ve done prioritization
or whatever you did, that’s when you come up with a solution. A lot of people don’t directly tie in the root causes to solutions. So I think that’s probably
the more pertinent and powerful message. Ah, Debra. – [Ken] Oh example implement
a debriefing to a falling episode of behaviour. Ya that’s a great TeamSTEPPS intervention. And again using this
model, we just gave you, you’ll be able to change
that culture in your units of everybody doing a debriefing. One of the problems we
found with debriefing after events like this is the staff say they’re too busy or they don’t have time. Just a tidbit. Just really try to swoon them over, and really keep that debriefing short, so once they’ve lived that
debriefing they’re gonna be able to see okay ya this doesn’t take long and really emphasize the value
of what they get out of it. And then hopefully vicariously
everybody else will see that and you’ll be able to change your culture. (mumbles) Ya unfortunately I left the unit, I took another position
and so the follow up wasn’t as robust as I would like. It’s hard to leave a project, when especially you get good results, and it is definitely something that you do have to figure out. Of how much staff the are,
the staff was involved 100%, the EMTs were responsible
for getting the SBAR, documenting the times, and then we would review
this in staff meetings and then be able to get
everybody’s suggestions on what could be improved with it, or what we could do differently. – [Bob] Brett I think Ken
has a powerful message there. Like for example when I talk
about Performance Excellence or anybody else doing a
project at UCLA Health, we don’t go in and just do a project. We involve people. And there is research. You can do research on participation and decision making with quality improvement. If you do not, and the research
directly supports this, if you do not involve employees
throughout the process, especially when it comes to participating in the decision making,
you will reduce morale, you will reduce their
role breadth self-efficacy or engagement or empowerment. And you can actually
increase anxiety as well. So that’s something you have
to be very, very careful about when you’re doing quality improvement. A lot of quality improvement
and Lean improvement actually result in reduced outcomes if you don’t involve the employees. Where we at? – [Randy] I think there was
another powerful message too and that is that sustainment is many times the toughest piece. And as Ken illustrated,
when he transferred jobs, there was some drift in
the improved outcomes. They haven’t drifted
back to where they were, but it takes an ongoing commitment. And that relates to a question
that Bob addressed earlier and that is when do you stop monitoring when the results are good, and Bob’s answer was you never stop. Because there will be
a trition of personnel or culture changes that occur over time so that’s why the monitoring
needs to continue, albeit maybe not at
the original frequency. – [Bob] Ya but the more
you can embed these things into your management systems,
the more successful you’ll be. And does it look like we
don’t have any more questions? – [Jen] Correct. This is Jen I think you
guys got everything. I wanna be sure that we get
to your contact information there if that’s okay. So I think since there
aren’t anymore questions, thank you for covering all
those questions you guys, what we’ll do is we’ll make
sure that we email everyone some of the tools that Bob
and you guys mentioned, we’ll email that to
everyone who is registered. We will also email everyone once the recording has been posted. We recorded this so we will
post this on our website. So I think with that since
there aren’t any questions left, we won’t keep you all here any longer. So I wanna really extend my
thanks to the UCLA faculty they’re really great to work
with and I think the work that they’re doing is
really integral to the times in healthcare right now and I think this is
really useful and again, their presentation is available to be downloaded there in the box above. Or it’s on our website it’s
www.teamsteppsportal.org. So thank you everyone and
have a great rest of your day. – [Bob] Thank you. – [Randy] Thanks for joining us. – [Ken] Thanks. Happy holidays everybody.