Changing the Culture: GME-Streamlining and Standardizing for Cost Savings and Efficiencies

1. Changing the Culture: GME-Streamlining and Standardizing for Cost Savings and Efficiencies Ann M. Dohn, M.A. Stanford DIO Nancy A. Piro, Ph.D. Program Manager/ Education Specialist

2. Disclaimer • No Conflicts of Interest to Report

3. Session Core Competency Focus • This presentation addresses the GME Leader Core Competencies of: • Developing and Supporting Residency Program Directors & Coordinators • Managing the Institution’s GME Operations.

4. Three Key Session Objectives • Provide a foundation for the understanding and application of lean philosophies and practices to GME. • Describe specific process improvement measures that can result in increased efficiency and cost savings in a graduate medical education (GME) setting. • Provide a Toolkit • Forms • Templates • Examples to streamline and standardize GME processes at their respective institutions.

5. Thinking Out of the Box?

6. Thinking Outside the Box – Looking to Industry and Corporations • What does industry have that we can use? • Conveyor belt to move patients in and out of OR’s?

7. No…. • But they do use a “Lean Philosophy” • Respect for People • Total Elimination of Waste • And they use “Lean Tools” such as • Kaizen • 5S’s • 3 M’s

8. Lean – Toyota Production System (TPS) • TPS system managed to get by with “half of everything”! • Physical space • Personnel • Capital Investment • Inventory • Resulted in far fewer than half the defects and safety incidents

9. NUMMI

10. Lean Culture Shift • Make problems visible – not hide them or “not talk about mistakes/problems” • Fix problems permanently – get to the “root cause” and eliminate it. • Focus on the value and respect for people.

11. Lean Tools --- A Sample • Kaizen • Elimination of WASTE - 3Ms • Problem Solving • 5 Whys • Fishbone Diagrams (Ishikawa Charts) 4 Ms • 4 Ps

12. Lean Tools: Kaizen What is ‘Kaizen’? • Gradual, unending continuous improvement of processes • Processes must be improved to get improved results • By improving and standardizing activities and processes, Kaizen aims to eliminate waste

13. Kaizen Basics • Focus is on small, incremental change (not necessarily huge leaps, innovation) • Quality Control = quality of people • “A company that is able to build quality into its people is halfway to building quality outcomes” • Respect for People • “Only people produce improvements”

14. Lean Tools: 3M’s • All about Waste- Identifying it and Removing it • MUDA = Waste of using resources without creating added value • MURI = Waste of overburdening people or equipment/resources • MURA= Waste of unevenness, variability in processes

15. Five Why’s Problem Solving Method • Keep asking ‘Why’ until you discover the root cause of the problem • No magic in 5 – • might be 3, or 7, or 10 • Why do we? (conduct orientation in person, fill out multiple forms, take on line training for non MDs)

16. Lean Tools: – Fishbone Charts using the 4Ms – 4 Ps • Manpower/Personnel • Materials • Method(s) • Machines / Equipment • People • Process • Policy • Principles

17. Ishikawa Diagram of ER Prolonged Wait Times Materials Methods/Process WHY? WHY? xxx hr wait time in ER WHY? WHY? Manpower/People Machine\Equipment

18. 5Ss - Mnemonics Retained • Sorting • Simplifying • Sweeping • Standardizing • Self Discipline = Seiri = Seiton = Seiso = Seiketsu = Shitsuke QUICK EXERCISE

19. 5Ss in Action

20. AFTER BEFORE ER Rooms

21. Now ---How Can this be Applied to GME? • Have read the books • Know the materials • Understand the tools • Have stolen former Toyota Manager … • So what do we do

22. Putting Philosophy into Practice • Flowchart the processes • Ask- “Why are we doing this?” • Fishbone the problem • Huddle to discuss with the team • Look for the 3Ms • Apply the 5Ss

23. Start with the Current State • CURRENT CULTURE • Paper driven registration (forms, forms, and more forms)

24. CURRENT CULTURE • 87 programs (87 fiefdoms all doing their own thing….but having common requirements)

25. Current Culture • Lack of standardization/inconsistencies (MURA) • Overburden (MURI) • Waste (MUDA) of both materials and time • Lots of files • Time to file personnel folders or ACGME letters • Time-consuming institutional oversight of programs (MUDA, MURI)

26. Streamlining a GME Process Example • What GME Processes would be the best targets to streamline and improve eliminating waste and redundancies?

27. Where to start? • Low hanging fruit vs. most impact on residents/faculty/GME staff • Actually you can do both!!!

28. Drivers: Where to start? • Areas of largest number of ACGME citations? • Questionnaire data? • Program Directors’ Needs Analysis • Incoming House Staff survey data • Annual GME resident survey data • Program Coordinator requests

29. Where to start? • Huddle-need team involvement • Respect for people • Respect can lead to elimination of unnecessary work

30. Real Time Examples of What We Standardizing We Have Done • Project One: Program evaluation standardization • Project Two: Orientation standardization/streamlining • Project Three: Policy standardization • Project Four: Summative evaluation standardization • Project Five: Paperless Office/Registration

31. Project One: Standardize Program Evaluations • Factors driving decision to standardize: • Largest number of program citations from ACGME • Lack of consistent data on program evaluation for APRs (MURA) • Huge amount of paper generated to produce suboptimal evaluations (MUDA) • Burden of work on the coordinators (MURI)

32. Standardized Program Evaluations What did we do? • Developed standardized comprehensive core competency-based Program Evaluations – by Faculty and Trainees • Presented the draft templates to the Program Directors who edited and approved them.

33. Standardized Program Evaluations – Process Implementation • Annually the GME office: • Delivers --via our Residency Management System (RMS)--176+ evaluations • Aggregates each program’s data after the evals have been completed • ‘Prints’ (electronically to pdfs) their aggregate Program evaluation reports • Posts the Program Eval Reports (pdfs) on their APR site (in the RMS)

34. Program Evaluation Standardization “Toolkit” Example

35. Standardization of Program Evaluations • Benefits • Fewer citations • Can be input to our Institutional Report Card • Easy oversight by DIO/GMEC • Early warning system

36. Results of Project One • Less paper wasted (none used) • Program evaluations sent out centrally by GME using standard evaluation forms • Compliance with program evaluation can be easily monitored by GME • Reduction in ACGME citations • Less concern about confidentiality from house staff

37. Project Two: OrientationStandardization/Streamlining • 360+ incoming residents/fellows attending one day orientation sessions • Completion of various mandated training • Issuance of computer codes, pagers, ID badges, parking permits, etc. • How do we cope with residents unable to attend orientation?

38. CURRENT CULTURE • Face to face orientation • great to know what we look like but big differential in quality of some presentations • inability to really control content of each presentation and test knowledge of materials

39. Project Two: OrientationStandardization/Streamlining • Wasted both incoming trainee time and staff time - MUDA • 20+ speakers • Long lines waiting for such stations as photo ID - MURI • Lack of standardization of presentations - MURA • Loss of the one auditorium large enough to hold group • Difficulty in keeping the attention of the trainees (material overload vs. shopping at Nordstrom's) - MURI

40. Project Two: Web-based Orientation • Based on the input from resident orientation questionnaires: • All mandatory modules became Web-based • Offered in advance of orientation • Many have post tests • Can verify completion of training • Can be done from home/Starbucks

41. Unintended Outcome • Have we gone too far?

42. Project Three: Standardization of Policies • Design a policy template for common program requirement policies to reduce redundancies (MURA, MURI, and MUDA) • Supervision • Moonlighting • PLAs • Recruiting • Duty Hours • Work Environment • Beyond Duty Hours • etc.

43. Policy Development

44. Teaching the Use of Policy Templates • Program director noon conferences • Policy writing workshop

45. Monitoring Implementation of the Policies • Verify in our residency management database (system which cannot be named)

46. Easy Online Policy Verification for each program - Example

47. Project Four: Summative Evaluations – The Drivers • ACGME Citations • Incoming and Outgoing!! • Multiple / variable forms (MURA) • Redundant wasted paper (MUDA) • Overburden PCs and PDs (MURI)

48. How Do We Do This Efficiently and Effectively? Fill in the blank? Multiple Choice?? Can my coordinator help me out here?

49. Project Four: Summative Evaluations – What did we do? • Developed Standard Evaluation Template for Summative Evaluations Comprehensive over program training years Core-competency based User friendly word document • Held Program Director and Program Coordinator Teaching Sessions / Workshops Taught the use of the template and how to pair it with aggregated evaluation data from our RMS

50. Use of Resident Evaluations from RMS: • Programs could select the evaluations to use – • We recommended: • Evaluations Competencies by Resident • Resident/Faculty Ranking Report (aggregate) • Aggregate Comments Report • Evaluation Competencies Report