Hoshin Kanri for Patient Safety - Institute for Healthcare Improvement

12/10/2013
Session C26
This presenter has
nothing to disclose
Hoshin Kanri for
Patient Safety
CARLOS FREDERICO PINTO
Tuesday Dec 10
1:30 PM – 2:45 PM
P2
Session Objectives
Use both Hoshin Kanri to align organizational goals and
outcomes and the standard methods for organizational
alignment, such as Trigger/Tracer tools, daily huddles, and
leadership huddles.
VSM-HFMEA
How to use standard work for organizational alignment: daily huddles,
Trigger/Tracer tools.
Describe the key attributes of a strategic planning and
deployment process that embraces continuous improvement
principles and puts patients first.
Identify ways in which Hoshin Kanri planning can be used to
build a shared narrative and facilitate health system
transformation, particularly with respect to patient safety.
1
12/10/2013
Chemo&RT units at
Regional Hospital: Public
300 bed complex care
HRVP Taubaté
•
•
•
•
IOV SJC
Private
Practice
Ch&RT
•
Who are we?
Outpatient Cancer Care Group;
Chemo and Radiotherapy Centers:
• 6 chemo units;
• 3 radiation units (4 LINACs);
• ~180 employees/partners;
45,000 medical appointments/year;
~500 patients under treatment daily:
• 250 radiation (*);
• 160 IV chemo;
• 100 PO chemo;
Covering cancer treatment for ~70% of
our Metro Area (not exclusively);
Mercy Hospital 100 bed
secondary care - Pinda
IOV Taubaté
Private Practice
Where
are we?
2,4 million inhabitants
Metro Area in
Sao Paulo State
2
12/10/2013
What is hoshin kanri?
Policy deployment method based on “up stream” and
“down stream” agreements (A3s) and – for us – with
Focus on Safety
We aligned our Policy Deployment to the 8 steps for
patient safety.
Why Lean?
The Promise of Lean in Healthcare
2
Continuous
Improvement
Lean is:
6
Flexible
Regimentation
3
Unity of
Purpose
1
Create
Value
4
Respect
for People
5
Visual
6
Toussaint J, Berry L. The Promise of Lean in Health Care.
Mayo Clin Proc 88(1):74-82, 2013
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12/10/2013
Hoshin Kanri IOV 2010 – 2013
Directive 1:
Directive 2:
LEAN THINKING
PATIENT SAFETY
8 Steps to Achieving Patient Safety
and High Reliability
(Leadership Guide to Patient Safety)
CONVERGENCE OF FOCUS:
2010-13 working projects (Action Plans)
8 Steps to Achieving Patient Safety
and High Reliability (guidelines for safety)
Step 1:
Address Strategic Priorities, Culture, and Infrastructure
Step 2:
Engage Key Stakeholders
Step 3:
Communicate and Build Awareness
Step 4:
Establish, Oversee, and Communicate System-Level Aims
Step 5:
Track/Measure Performance Over Time, Strengthen Analysis
Step 6:
Support Staff and Patients/Families Impacted by Medical
Errors
Step 7:
Align System-Wide Activities and Incentives
Step 8:
Redesign Systems and Improve Reliability
Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper.
Cambridge, MA: Institute for Healthcare Improvement; 2006.
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12/10/2013
Key Challenges
Commitment to change
Safety is a System Property (IOM 2001).
Get everyone in the same platform AND looking at the same
direction;
Respect for people.
Future Shock is “too much change in too short a period of time”;
People don’t fear change, they fear the unknown;
Understand hidden patterns and hidden values.
Agree on new standards
Make it visible: If you can see you can deal with...
Everything is about agreements…
9
Major Outcomes
Safety:
Predicted risk reduction of patient journey from 40 to 60%;
Reduction in 70% of Sentinel Events (never events) in 24 months;
Patient harm (TRIGGER TOOL) in the lower quadrant:
~ 7/1000 procedures (outpatient facility);
Other outcomes:
Timely, “3rd 1st appointment” :
At IOV 99% in less than 7 days;
At IOV-HRVP (public hospital) 80% in less than 14 days.
Efficiency:
Over 30% capacity improvement between 2010 and 2012;
Same facilities, minimal layout redesign;
40% reduction in overtime with the same number of employees.
(Major layout redesign in 2013)
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Thumbs up!
Daily Huddles (up and down stream)
Safety Alert System + Kaizen Board
Culture Survey MSI 2007 and other surveys
VSM-HFMEA
11
Not so well...
Sustaining team design
For information
For people development
5S (but 5S is ok...)
Leveling all activities
We are growing faster than we can manage
Sustaining Safety Alert System in a fast growing environment.
Common Root cause (?):
standard work missing parts...
12
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12/10/2013
* Step by Step
Address Strategic
Priorities, Culture,
and Infrastructure
Lean thinking
Engage Key
Stakeholders
Communicate and
Build Awareness
Team work and DAILY HUDDLES
“model” and project
alignment
flow REDESIGN to
CONNECT FLOWS
Board Approval
“A3 shake hands”
4 DAYS KAIZEN
EVENT (~ RIE)
Framework
approved:
“IHI 8 steps paper”
Information team
Patient flow team
Environment team
People team
SBARs
Establish, Oversee,
and Communicate
System-Level Aims
IHI-WSM adapted to
our needs
DAILY  WEEKLY  MONTHLY HUDDLES
Huddles STANDARD WORK
* Step by Step
Track/Measure
Performance Over
Time, Strengthen
Analysis
Support Staff and
Patients/Families
Impacted by Medical
Errors
Align System-Wide
Activities and
Incentives
IHI WSM
Tracer – Trigger tools
Root Cause Analysis
(London Protocol)
Lean and safety
training program
HUDDLES
STANDARD WORK
Respect for
People
Lean thinking valued
For carreer
progression
(no blame culture)
2013 ASCO-QOPI
Survey
Redesign Systems
and Improve
Reliability
VSM - HFMEA
Training program 2009-10 and:
MSI-2007 survey
Lean tools survey
(2013) LESAT survey
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12/10/2013
Agreement “Kaizen Event”
Four day “Kaizen Event” in 2 units:
Hoshin Kanri for Patient Safety ;
10 weeks preparation and 4 days
event (feb/2011);
Around 50 action plans developed
to be executed in 2011-13;
Agreements were made and
working teams designed to specific
projects (A3s);
Interim reviews planned every
45 – 90 days;
Major adjustments would require
new agreements.
Model  Engage
Patient
Value
Stream
WSM
project
Human
Develop.
Team
Information
Team
project ...
project G
project F
project E
project D
project C
project A
Backgrounds:
Project
Yellow & Green
Belt 2009-10:
Internal
Lean training
for 2010-2013
project B
Hoshin Kanri IOV “style”: teamwork design
Environment
team
Catchball
Leadership Team (Project Coordination Team)
Executive Director
BOD
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12/10/2013
Policy Deployment and
Daily Management:
Daily Huddles STANDARD WORK:
Refers to the six dimensions of care, specially focused on safety as of:
Kaizen Boards (continuous improvement)
Root Cause Analysis of Sentinel Events
(The London Protocol Adapted)
Safety Alert System
Adverse and Never Events Forms
Catchball for further alignment
(similar to Thedacare)
Weekly Huddle for Safety at every
department /area board (16 in total)
Weekly Leadership Huddles at Q0
and “Boards on Board”
Monthly Huddle at WSM-IHI
board for all.
ADMISSION
PHARMACY
17
Huddles down stream:
Daily for
Safety
Monthly:
Whole
System
Measures
Weekly
for teams
“Boards on board”
weekly
18
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12/10/2013
Align: Whole System Measures – IHI
SIX DIMENSIONS OF CARE at IOV
Safety:
Triggers (harms)
Personnel safety
Events (Alerts and “never”)
Effectivity
CLINICAL OUTCOME QOPI-ASCO
(2013 ASCO-Pilot)
CLINICAL AUDIT- QOPI (Tracer)
FHS-6
Efficiency
Productivity (FTEs)
Chemo in the last six months*
Hospital days in the last six months*
Timely
Third first appointment
Patient Centered
Surveys, FHS-6
VSMs
QOPI
Equitative
FHS-6 compared
Clinical Outcome
compared
LEAN ENTERPRISE
Martin LA, Nelson EC, Lloyd RC, Nolan TW. Whole System Measures. IHI Innovation Series white paper.
Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007.
Daily Huddle and Variation Sheet Samples
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12/10/2013
Kaizen Board, Alert System and
Daily Huddles Board
Safety Alert
System
21
Kaizen board: Respect for People
22
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Sentinel Event: No blame on RCA
Colored Sectors:
improved safety
and services.
Chair Poka-yoke:
base enlargement
Sample MSI 2007 Survey Analysis
P er g unt a
1. A s pessoas se ajudam mut uament e nest a
unidade.
2. Quando muit o t rabalho t em que ser f eit o
rapidament e nós t rabalhamos junt os como um t ime
para que o t rabalho seja concluí do.
3. Nest a unidade o t rat ament o ent re os
prof issionais é f eit o com respeit o.
4. Quando uma unidade f ica muit o at aref ada exist e
a cooperação de out ras unidades da inst it uição.
IOV
g er al
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S JC j un/
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1. . M eu lí der considera seriament e as sugest ões
da equipe para melhoria da segurança do pacient e.
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2. M eu lí der elogia quando vê um t rabalho f eit o de
acordo com as normas de segurança do pacient e
3. Sempre que as pressões aument am, meu lí der
quer que t rabalhemos mais rápido, mesmo que ist o
signif ique t omar at alhos.
4. M eu lí der ignora problemas de segurança do
pacient e que ocorram repet idament e.
Scope
Totally
Agree
1. A direção provê um clima de t rabalho que
promove a segurança dos pacient es.
2. A s ações da direção most ram que a segurança
do pacient e é uma prioridade.
3. A direção parece int eressada na segurança dos
Agree
Totally
Disagree
Team Work
People do help each
other in this unit.
When a lot of work
has to be done quickly,
we work as a team to
get the job done.
pacient es a pe na s apó s a o co rrência de um
evento sentinela.
Disagree
1. Nós est amos at ivament e f azendo coisas para
melhorar a segurança dos pacient es.
2. Os event os t em levado a mudanças posit ivas
para a unidade de t rabalho.
3. A pós t ermos f eit o mudanças para assegurar a
segurança do pacient e, avaliamos sua ef et ividade.
2.É por sort e que erros e event os sent inelas não
t êm acont ecido nest a unidade.
2. Sempre há mais t rabalho a ser f eit o para a
segurança do pacient e
3. Nós t emos problemas com a segurança de
pacient es nest a unidade.
4. Nossos prot ocolos e processos são adequados
para prevenir a ocorrência de event os.
1. Somos inf ormados sobre mudanças que são
f eit as com base nos relat órios de análise dos
event os sent inelas.
2. Somos sempre inf ormados sobre os event os
que acont ecem nest a unidade.
3. Nest a unidade, nós discut imos f ormas de
prevenir que event os se repit am.
1. A equipe f ala livrement e se percebe alguma coisa
que possa af et ar negat ivament e o cuidado dos
pacient es.
2. A equipe se sent e livre para quest ionar as
decisões ou ações def inidas com os superiores.
3. A equipe t em medo de f azer pergunt as quando
alguma coisa não parece cert a.
1. Quando um erro é comet ido, mas é int ercept ado
e corrigido ant es de af et ar o pacient e, com
f reqüência é not if icado.
2. Quando um erro é comet ido, mas não t em
pot encial para causar dano ao pacient e, com
f reqüência é not if icado.
3. Quando um erro é comet ido, o qual poderia
causar danos ao pacient e, mas não causou, ele é
sempre not if icado.
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Neutral
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Not
Applicable
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1. A s dif erent es áreas assist enciais nã o se
co o rdenam adequadamente.
2. Há boa cooperação ent re as áreas quando
precisam t rabalhar junt as.
3. É de s a gra dá v e l trabalhar co m equipes
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de o utras áreas .
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4. A s unidades t rabalham junt as para prover o
melhor cuidado aos pacient es.
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1. A s inf ormações NÃ O são claras quando da
t ransf erência de um pacient e de uma área para
out ra.
2. Inf ormações import ant es sobre os cuidados do
pacient e são perdidas durant e as t rocas de t urnos.
3. Problemas f reqüent ement e ocorrem na t roca de
inf ormações ent re as áreas do hospit al.
4 .A s t rocas de t urno são problemát icas para o
pacient e nest e serviço
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N ão se ap l i ca
http://www.yorku.ca/patientsafety/psculture/questionnaire/MSI%20version%202007_FINAL.pdf
12
12/10/2013
Process Redesign
Value Stream Mapping
Above:
Partial View
Left:
Complete
Schema of
Chemo VSM
VSM
VALUE
STREAM
MAP
FUTURE STATE
DESIGN
(countermeasures)
ACTION PLAN FOR
THE FUTURE STATE
(VALUE DELIVERY)
CURRENT
STATE
PROBLEM
ANALYSIS
Rother M, and Shook J. Learning to See, LEI, CAmbridge, 2002
EXECUTE
FUTURE
STATE PLAN
CHECK / ADOPT
13
12/10/2013
FUTURE STATE
DESIGN
(countermeasures)
VSM - HFMEA
VALUE
STREAM
MAP
CURRENT
STATE
ACTION PLAN FOR
THE FUTURE STATE
(VALUE DELIVERY)
FUTURE
STATE
HFMEA
PROBLEM
ANALYSIS
EXECUTE
FUTURE
STATE PLAN
CHECK / ADOPT
http://www.engres.org/ojs/index.php/engres/article/view/29
VSM Future State Sample (~25%)
NEW ACTIONS FOR
THE FUTURE STATE
One “step” (Box) has 8
possible failure modes
FUTURE
STATE RISK
NEW SCORES
FOR THE
FUTURE STATE
28
14
12/10/2013
VSM Patient Flow & HFMEA
HFMEA Patient Flow (#1) at IOV
May 2011:
Review Jan 2012:
points
5,098 points
2,074
~60% REDUCTION OF
IDENTIFIED RISKS
“ Care Path HFMEA” at IOV-HRVP Unit:
March 2011:
points
Review March 2012:
27,261
17,085 points
~38% REDUCTION OF
IDENTIFIED RISKS
VSM-HFMEA on SAFETY:
Never Events per Procedures (by month)
2010-2012
less 70% events
2012
2011-2012
less 83% events
Better safety
awareness in
2011 raised
notification?
2011
2010
0
0.001
dez
0.002
nov
out
set
0.003
ago
jul
jun
0.004
mai
abr
mar
0.005
fev
0.006
jan
15
12/10/2013
Trigger/Tracer Standard Work
Trigger/Tracer Audits as check
points for medical records:
Fall Prevention Protocol
Visits to Emergency
Hospitalizations
Surgery or other
Drug Reconciliation
Pain and Opioid use
Constipation
ECOG
Side bar containing
trigger and tracer
checkpoints
http://www.ihi.org/knowledge/Pages/Tools/IHIGlobalTriggerToolforMeasuringAEs.aspx
IOV Lean Journey so far:
HOW WE ARE CREATING VALUE
SAFETY (“never” events)
Waste elimination in km
(transportation and movement)
Waste elimination in working hours
(eliminated tasks, movement)
Productivity annual gain per employee
Overtime from 2010 to 2012
Power Saved (% reduction in billing)
Inventory
Capacity Improvement (IOV unit)
32
- 75 % (2010-2012)
18,000 km (accumulated)
13,000 hours (per year)
6.25 FTEs
12 days (per year) (5.4%)
- 40 %
- 16 % (2013)
- 70 % (total)
~ 170 % in six years
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12/10/2013
http://misseytwisted.wordpress.com/lessons-from-jedi-master-yoda/
Thanks
Additional Material:
My IHI  Enrollments  Session  Handouts
Daily Huddles (with subtitles)
Video: http://www.youtube.com/watch?v=JFL6Rk74mmk&feature=relmfu
Routine Management for Strategy Deployment (with subtitles)
video: http://www.youtube.com/watch?v=cvoz1OrURjw&feature=relmfu
[email protected]
www.iov.com.br
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12/10/2013
Extra: How we used the HFMEA
1.
2.
3.
4.
5.
Using each Future State
“box”, identify most relevant
failure mode and possible
effects.
Use the score table to
calculate this “box” score
Sum all scores.
This is your Future State
Before HFMEA score.
Now work on these failure
modes: propose new
improvements and go further
on safety.
Each of these failure modes
are scored for:
Chance (probability of
happening),
higher the value, higher the
risk;
Consequences (event
possible outcome),
higher the value, higher the
risk;
“Preventability”(current ways
to avoid risk),
higher the value, less
avoidable risk.
Chance X Consequences X Prevention = SCORE
Extra: Triggers for outpatient care
T1 – New Cancer diagnosis
T2 – Home Care
T3 – Hospital
Admission/discharge
T4 – More than 2 doctors in
one year
T5 – Surgical procedure
T6 – Emergency Visit
T7 – More than 5 drugs in
use
T8 – Ask for new doctor
assistance
T9 – Letter of complaint
T10 – More than 3 nurse
calls at the same week
T11 – Abnormal blood
sample
T12 – Sudden medication
stop
T13 – Sudden treatment
plan change
T14 – Emergency call or
CR arrest
http://www.ihi.org/knowledge/Pages/Tools/IHIGlobalTriggerToolforMeasuringAEs.aspx
18
12/10/2013
Medical appointments / Med Oncologists
FTE
Extra: Practice
Benchmarks
37
1st chemo infusion / chemo staff FTE
All Staff FTE / Med Oncologist FTE
National Oncology Practice Benchmark,
2012 Report on 2011 Data
By Elaine L. Towle, CMPE, Thomas R. Barr, MBA, and
James L. Senese, MS, RPh
Journal of Oncology Practice Publish Ahead of Print,
published on October 2, 2012 as
doi:10.1200/JOP.2012.000735
Extra: Align for the future (2013-16):
2013 LESAT
2013-16 Drivers:
1.1 Liderança (PR)
5.0
8.3 Facilitar Infraestrutura (PF)
1.2 Governança (PR)
4.5
8.2 Ciclo de Porcessos no serviço
2.1 Desenvolvimento Estratégia
de saúde (PF)
(PR)
4.0
3.5
2.2 Implementação Estratégia
8.1 Transformação Lean (PF)
3.0
(PR)
2.5
2.0
7.5 Resultado financeiro e
3.1 Voz do Cliente (PR)
1.5
Mercado (PF)
1.0
0.5
7.4 Resultado Liderança e
3.2 Engajamento dos Clientes
0.0
Governança (PF)
(PR)
7.3 Resultado Força de Trabalho
(PF)
7.2 Resultado Focado no Cliente
(PF)
4.1 Medição e Melhoria (PR)
4.2 Gestão em TI (PR)
7.1 Resultado Processo de Saude
(PF)
5.1 Ambiente RH (PR)
5.2 Engajamento Força de
6.2 Processo de Trabalho (PR)
Trabalho (PR)
6.1 Sistema de Trabalho (PR)
http://lean.mit.edu/downloads/cat_view/94-products/204-lesat/595-lesat-2-0
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