Patient Flow Improving the Patient Experience

1. 5 year Transformation Journey in 3 Phases 5 year Transformation Journey in 3 Phases

2. The province of Ontario The People 35% of population of Canada 49% Ontarians born outside of Canada 50% with post-secondary education Economics 41% GDP 60% Canadian exports Toronto/Greater Toronto Area The People 50% of population of Ontario 56% speak English as their first language � 100+ languages spoken Large homeless population: in 1996 26,000 used the shelter system The Economics 17% of Canada�s jobs 14% of Canada�s retail salesThe province of Ontario The People 35% of population of Canada 49% Ontarians born outside of Canada 50% with post-secondary education Economics 41% GDP 60% Canadian exports Toronto/Greater Toronto Area The People 50% of population of Ontario 56% speak English as their first language � 100+ languages spoken Large homeless population: in 1996 26,000 used the shelter system The Economics 17% of Canada�s jobs 14% of Canada�s retail sales

4. A Case Study of Success Dynamic Evaluation - managing for daily improvement Coupling of Quantitative and qualitative measures - human capital survey results ( moving in the right direction) Alignment and integration of organizational and ED/ GIM metrics Identifying new �proxy� measures - intuition in decision-making Dynamic Evaluation - managing for daily improvement Coupling of Quantitative and qualitative measures - human capital survey results ( moving in the right direction) Alignment and integration of organizational and ED/ GIM metrics Identifying new �proxy� measures - intuition in decision-making

5. The NYGH Leadership Culture Transformation

6. ORGANIZATIONAL CULTURE/LEADERSHIP TRANSFORMATION

7. Phase 1: Creating Momentum for Change

9. Strategic Alignment Model

10. Phase 2:Implementation of Multiple Changes The focus in the ED/GIM project has been: Improve patient flow by reducing non value added activities first Then concentrating on reducing variation Bringing culture transformation to life for staff (demonstration of new world). Hypothesis: That ED/GIM change will be sustained because of cultural leadership transformation foundation We tried for many decades but it never sticks. The focus in the ED/GIM project has been: Improve patient flow by reducing non value added activities first Then concentrating on reducing variation Bringing culture transformation to life for staff (demonstration of new world). Hypothesis: That ED/GIM change will be sustained because of cultural leadership transformation foundation We tried for many decades but it never sticks.

11. The ED / GIM Story 1. Initial transformation efforts met with moderate success and were difficult if not impossible to sustain over time. Turning point when at a Leadership/management session, CEO stood up and appointed herself as executive sponsor for Patient FLOW in order to reduce all barriers across the organization for success. LEAN � Is a management philosophy based on the pillars of continuous improvement and respect for people. Lean is about identifying the value added steps, reducing non-value added activities, reducing variation. Staff are engaged to own the changes and all was accomplished via a patient safety lens. Expanding Across the organization � ED/GIM � 6 value streams, 13 kaizen events, 2 vertical value streams and 3 cause and effect analyses CCAC � 1 value stream, 4 kaizen events 2 additional Kaizen events in other areas of the hospital 1. Initial transformation efforts met with moderate success and were difficult if not impossible to sustain over time. Turning point when at a Leadership/management session, CEO stood up and appointed herself as executive sponsor for Patient FLOW in order to reduce all barriers across the organization for success. LEAN � Is a management philosophy based on the pillars of continuous improvement and respect for people. Lean is about identifying the value added steps, reducing non-value added activities, reducing variation. Staff are engaged to own the changes and all was accomplished via a patient safety lens. Expanding Across the organization � ED/GIM � 6 value streams, 13 kaizen events, 2 vertical value streams and 3 cause and effect analyses CCAC � 1 value stream, 4 kaizen events 2 additional Kaizen events in other areas of the hospital

12. Just a few of the events to note from the ED GIM ...Just a few of the events to note from the ED GIM ...

13. The ED / GIM Story Vs. One kaizen event between the ED and multiple units. Rational was the synergy of multiple changes form multiple Kaizens can create system change between the ED and one medical unit Then bundle the kaizen and implement the bundle on other medical units� spread. The Kaizens were focused on : ED Medicine AND between both. Vs. One kaizen event between the ED and multiple units. Rational was the synergy of multiple changes form multiple Kaizens can create system change between the ED and one medical unit Then bundle the kaizen and implement the bundle on other medical units� spread. The Kaizens were focused on : ED Medicine AND between both.

14. ED Ambulatory Care

15. ED Sub-acute Care

16. 16 bed zone for intermediate acuity patients (~ CTAS 3s)16 bed zone for intermediate acuity patients (~ CTAS 3s)

17. Team members ED UA & Chief - Team Leads Program Director ED Clinical Coordinator 4 ED RNs & RN Educator 2 ED MDs ~ full attendance 2 members of NYGH Quality Team 1 Unit Secretary ED Supply Tech Lean Consultant

18. created the �Yellow Zone� (rapid cycle assessment rooms) developed patient criteria dedicated YZ nurses renovated & reorganized work area YZ = 6 of 16 Sub-Acute (SA) rooms + waiting areaYZ = 6 of 16 Sub-Acute (SA) rooms + waiting area

19. patients transfer themselves to YZ with clear visual cues new chart management system �Yellow Brick Road��Yellow Brick Road�

20. Team worked hard, had fun new leaders emerged safe environment, open to new ideas lost sleep � creative juices were flowing! support from partners from other departments was effective and appreciated ~ doubled throughput of Sub-Acute Zone, while improving LOS and Time to see MD major, sustained positive impact on the Waiting Room

21. Subacute Care volumes have nearly doubled Subacute Care volumes have nearly doubled

23. So a decrease of 1.9 hr (or 114 minutes) per patient means a savings of 124 patient hours per day At ~ 65 patients/day - translates to increasing the functional capacity of the Subacute Zone by 5 exam rooms per daySo a decrease of 1.9 hr (or 114 minutes) per patient means a savings of 124 patient hours per day At ~ 65 patients/day - translates to increasing the functional capacity of the Subacute Zone by 5 exam rooms per day

24. Has had positive effects on flow in the highest acuity areas of the EDHas had positive effects on flow in the highest acuity areas of the ED

25. built on lessons learned from previous Kaizens successes fuel interest in future events physician engagement is key Kaizens support team learning, team functioning change is good!

26. Bed Placement

27. ED Bed Assignment to Inpatient Bed

28. Improving the Hospitalist Resource

29. Equipment Availability

30. Collaborative ED / GIM Results These are the cumulative results of four events from October 2006 � April 2007. These results have been sustained since April 2007. These are the cumulative results of four events from October 2006 � April 2007. These results have been sustained since April 2007.

31. Care Map Example One example is the vertical value stream that was completed for our patient plans for community acquired pneumonia and AMI. The OLD was, had already taken over 1 year of monthly meetings, initial momentum for change waned over time and the paths were not moving ahead. The key members of the team were brought together to complete a vertical value stream event. Vertical value streams are the development of a project plan that uses LEAN tools to identify, anticipate, and eliminate non value added activities in the planning process. Key was having the right people at the table at the right time (people came and went as needed ). Builds on other Kaizen projects. One example is the vertical value stream that was completed for our patient plans for community acquired pneumonia and AMI. The OLD was, had already taken over 1 year of monthly meetings, initial momentum for change waned over time and the paths were not moving ahead. The key members of the team were brought together to complete a vertical value stream event. Vertical value streams are the development of a project plan that uses LEAN tools to identify, anticipate, and eliminate non value added activities in the planning process. Key was having the right people at the table at the right time (people came and went as needed ). Builds on other Kaizen projects.

33. NYGH After Kaizens

34. Empowerment

35. Collective Wisdom

36. Mindfulness This reflects mindfulness from high reliability literature. Most frequent comment from staff at Friday morning report outs.This reflects mindfulness from high reliability literature. Most frequent comment from staff at Friday morning report outs.

38.

39. Patient Flow: Lean Focus

40. Phase 4:

42. Have Tenacity & Courage Have the Tenacity & Courage to lead the organization thru change and endure the inevitable resistance that will result at all levels of the organizationHave the Tenacity & Courage to lead the organization thru change and endure the inevitable resistance that will result at all levels of the organization

43. It�s always more than you think. It�s always more than you think. Rome was not built in a day�.There is not a silver bullet approach. Local level improvements are seen over days while system levels improvements are seen over years. This is a critical point worth highlighting. You must be patient� There are many layers to problems regardless of how big or small. One major point worth noting is to allow initiatives to flourish in their due time�you don�t want to push to hard or pull back to far. You must recognize the initiatives natural disposition to take to culture�it�s different for every organization. You must find the sweet spot�. It�s always more than you think. Rome was not built in a day�.There is not a silver bullet approach. Local level improvements are seen over days while system levels improvements are seen over years. This is a critical point worth highlighting. You must be patient� There are many layers to problems regardless of how big or small. One major point worth noting is to allow initiatives to flourish in their due time�you don�t want to push to hard or pull back to far. You must recognize the initiatives natural disposition to take to culture�it�s different for every organization. You must find the sweet spot�.

44. Using the tools will only get you so far. Soon after you demonstrate the value the tools, you will need to begin to develop the management system to sustain it. Performance measurement: Managing for daily improvement, teams have weekly meeting to ensure that trends and progress are tracked and momentum is high. Monthly with executive sponsors, monthly to the steering committee which is a direct link to the CEO. Using the tools will only get you so far. Soon after you demonstrate the value the tools, you will need to begin to develop the management system to sustain it. Performance measurement: Managing for daily improvement, teams have weekly meeting to ensure that trends and progress are tracked and momentum is high. Monthly with executive sponsors, monthly to the steering committee which is a direct link to the CEO.

45. Participating in events: To truly empathize and understand the cycle of improvement and the effort involved in making and sustaining change at the locale level it is absolutely important that we participate in events along side those who do the work. This is the best way to ensure we understand, thourouly, the methodology we are asking people to adopt. Assure accountability: Following events we have a structure to sustain the solutions. We have 3 to 5 follow-up meetings. In These meetings we talk about the performance of the new process and whether or not we are on track. If we are not on track the process owners are held accountable to strategizing and implementing a plan to achieve their targets. The results of the strategy are then analyzed prior to the next meeting�so the pressure is on to get it right. My time commitment is significant as I could have 3 to 5 meetings every couple of weeks. We are now utilizing a standard communication tool in our meetings to expedite the process (SBAR) Also, in every final report where we ask the organization to attend and listen to the Kaizen teams at the end of their long week we also have process owners from previous events report out on events that took place in their area and where they are in relation to their targets. This is a very transparent process as result you can exploit areas of opportunity both in leadership and process�accountability is formed on the basis of this. Create decision making body: In the beginning you may end up taking a grass roots approach to Lean but once you start seeing the results you�ll have people lined up for more and eventually you�ll need to create the management system to manage the approach and sustain the Lean transformation. Development of steering committee is critical to this management system. The mandate of this group is ensure that all Lean related initiatives align with corporate score card measures and that the events are both sufficient and necessary in order to move score card metrics we call value stream metrics. Also, part of that management system is creating leadership roles with in the Lean structure as it takes much time to build capacity, coach, select appropriate Lean related projects, do-it�s, and kaizen events. Ensure content expertise�. Critical to the deployment of lean is having the right expertise. You cannot short change this especially in the beginning as poor lean outcomes can result in the early derailment of the initiative with people chalking it up to another flavour of the month at best. Investment in consultants maybe necessary in the beginning depending on your in house expertise. If you go this way, you need clear understanding of how capacity will be created and determine when to move them into a holding pattern as you fly solo. If consultants are not willing to share the tools and methodology in away where your folks could understand and replicate �cut them loose now�good consultants give everything and explain and redefine themselves.. Empower: As a sponsor to Kaizen events my job is truly empower the teams in the event to generated LEAN solutions that work from the patient perspective. I am not there to tell them what is going to work or not work or steer the solution. Eliminate Barriers My role is to eliminate structural barriers that may impede the teams ability to implement key solutions. Participating in events: To truly empathize and understand the cycle of improvement and the effort involved in making and sustaining change at the locale level it is absolutely important that we participate in events along side those who do the work. This is the best way to ensure we understand, thourouly, the methodology we are asking people to adopt. Assure accountability: Following events we have a structure to sustain the solutions. We have 3 to 5 follow-up meetings. In These meetings we talk about the performance of the new process and whether or not we are on track. If we are not on track the process owners are held accountable to strategizing and implementing a plan to achieve their targets. The results of the strategy are then analyzed prior to the next meeting�so the pressure is on to get it right. My time commitment is significant as I could have 3 to 5 meetings every couple of weeks. We are now utilizing a standard communication tool in our meetings to expedite the process (SBAR) Also, in every final report where we ask the organization to attend and listen to the Kaizen teams at the end of their long week we also have process owners from previous events report out on events that took place in their area and where they are in relation to their targets. This is a very transparent process as result you can exploit areas of opportunity both in leadership and process�accountability is formed on the basis of this. Create decision making body: In the beginning you may end up taking a grass roots approach to Lean but once you start seeing the results you�ll have people lined up for more and eventually you�ll need to create the management system to manage the approach and sustain the Lean transformation. Development of steering committee is critical to this management system. The mandate of this group is ensure that all Lean related initiatives align with corporate score card measures and that the events are both sufficient and necessary in order to move score card metrics we call value stream metrics. Also, part of that management system is creating leadership roles with in the Lean structure as it takes much time to build capacity, coach, select appropriate Lean related projects, do-it�s, and kaizen events. Ensure content expertise�. Critical to the deployment of lean is having the right expertise. You cannot short change this especially in the beginning as poor lean outcomes can result in the early derailment of the initiative with people chalking it up to another flavour of the month at best. Investment in consultants maybe necessary in the beginning depending on your in house expertise. If you go this way, you need clear understanding of how capacity will be created and determine when to move them into a holding pattern as you fly solo. If consultants are not willing to share the tools and methodology in away where your folks could understand and replicate �cut them loose now�good consultants give everything and explain and redefine themselves.. Empower: As a sponsor to Kaizen events my job is truly empower the teams in the event to generated LEAN solutions that work from the patient perspective. I am not there to tell them what is going to work or not work or steer the solution. Eliminate Barriers My role is to eliminate structural barriers that may impede the teams ability to implement key solutions.

47. We party as hard as we work�.the act of celebrating success is probably one of the most important aspects. It is the catalyst that is shaping continuous improvement culture.We party as hard as we work�.the act of celebrating success is probably one of the most important aspects. It is the catalyst that is shaping continuous improvement culture.

48. Sustainable Lean Iceberg Model

49. �People will exceed targets they set themselves.� GORDON DRYDEN Out Of The Red The Truth About People:

50. �The challenge lies in creating a workplace in which people can be the best they can be.� FREDERICK W. SMITH The Book of Leadership Wisdom Challenge People:

51. �A skill that enables groups of people to reliably develop insights and wisdom that is greater than the sum of individual members� talents.� Peter Senge The Fifth Discipline Team Learning:

53. �The art of systems thinking lies in seeing through complexity to the underlying structure generating change. Systems thinking does not mean ignoring complexity. It means organizing complexity into a coherent story that illuminates the causes of problems and how they can be remedied in enduring ways.� Peter Senge The Fifth Discipline Systems Thinking:

54. It�s Always All About Leadership!! �We all need to become leaders if we are to transform.�