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ENA15_CWalker_PPT 9-2015
- 2. Breaking down cultural walls preventing superior ED performance Christopher Walker, MS, RN, NP, CNS, CCRN, CEN Director Emergency Services Sharp Memorial Hospital San Diego, CA christopher.walker@sharp.com
- 3. Faculty Disclosure Session goal: Empower ED leaders and staff to drive a cultural revolution in their departments. Conflicts of interest: None Employer: Sharp Healthcare Sponsorship / commercial support: None
- 4. The Emergency Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.
- 5. Reflection There are three constants in life. CHANGE CHOICE, and PRINCIPLES - Steven Covey
- 6. Sharp Memorial Hospital Community Hospital Level II Trauma Center Base Station (Radio Room) 400 operational beds 48 ICU Beds (+10 overflow) 44 Short-Stay/Observation Private Inpatient Rooms 49 Bed ED 40 ED 4 Trauma 2 Decon 3 Quick Care
- 7. Sharp Healthcares Vision Sharp Healthcares vision is to be the best health system in the universe. The best place to work The best place to practice medicine The best place to receive care
- 8. Why must we change? Regulation Overcrowding Patient Satisfaction Tradition
- 9. Regulatory Scrutiny Mandates to provide care (EMTALA, CMMS) Fear of retribution and litigation Refusal to pay (Medicare and Private) $$$ tied to patient experience $$$ tied to quality (readmissions, mortality) = Higher Cost of Care
- 10. Overcrowding Full lobbies have become the norm, not the exception Its a daily phenomenon More patients than beds Bypass overutilization
- 11. Patient Dissatisfaction Its the typical expectation for ED care High ER wait times and long length of stays Patients leaving without being seen or treated Perception of poor quality of care Dissatisfaction continued for admitted patients
- 12. Tradition Rarely patient centric Bad, old, or no science behind practices Unable to adapt with healthcare evolution Divides a unit across generational lines Settling for Good Enough Its the way we have always done it
- 13. No Change, No Change Sharp Experience starts in 2001 2009 moved into beautiful new building No Change in Experience Deep divide between staff and leadership Stuck in daily survival mode
- 14. The Lean Intervention Focus on the patient experience and improve ED patient satisfaction Increase efficiency through waste reduction Reduce ED patient LOS & lobby wait times Improve staff satisfaction and morale Education, team development, standard work Improve Physician Satisfaction Growth in volume and income
- 15. What is Lean? A methodology that focuses on Improving Workflow Eliminating Waste Delivering Value
- 16. The Toyota House from Graban, M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction, New York, NY: Productivity Press, 2009, p74. The Toyota House
- 17. The Toyota Way Leadership Model True North Values Challenge Kaizen Mind Go and See Teamwork Respect for Humanity Commit to Self Development Coach and Develop Others Support Daily Kaizen Create Vision and Align Goals
- 18. True North Values Challenge Kaizen Mind Go and See Teamwork Respect for Humanity
- 19. Commit to Self Development I am always doing that which I can not do, in order that I may learn how to do it. -- Pablo Picasso
- 20. The Self Developer Personal motivation and initiative Commitment to lifelong learning Emotional intelligence Seeks out mentorship Works through the novice to expert cycles Shu Ha Ri
- 21. Domains of Self-Development Attitude Know Why Knowledge Know What Skills Know How Commitment Process Purpose ABILITY
- 22. Leader and Team Study
- 23. Coach and Develop Others
- 24. Building New Leadership Habits Coaching Self-Development Role Model True North Values Avoid office and boardroom management Respect your staff by engaging them See and ask, dont tell or demand Nurture and Severely Challenge your high performers
- 25. Change Readiness
- 26. Change Management Support Lean Six Sigma Master Black Belt Green Belt Training on-site Lean Leader Development Frequent Mentorship Meetings Break work into components for easy wins Change Management Education Leader visibility and rounding with focus
- 27. Information Sharing What are the challenges? What is working well? RNs and MDs given feedback on change initiatives. People Engagement
- 28. Internal ER Top Pod Leader Top Team Member External ER First Attempt Report (given by ER RN) Top Charge RN LeanER Reward and Recognition
- 29. Support Daily Kaizen Build local capability for continuous improvement
- 30. Philosophy of Continuous Improvement Over Time S K S K S K S K S K K = Kaizen (good change in Japanese) S = Sustain through Standardization Lean Implementation Process No Sustain = No Gain
- 31. Managing to Learn with the Kaizen Events, Try-storms, and A3 Kaizen Event Full day(s) documented the current, ideal, and target states. Used these to take big process steps Trystorms Rapid Cycle Improvement Model team, area that would test new processes and measure outcomes Nimble enough to change midstream A3 Individual/Small Group PI Used on smaller process issues within the value stream
- 32. All hands, hands on, all stakeholders. 1. Walk the process 2. Brainstorm Wastes 3. Sensing with coworkers 4. Integrate Lean philosophy 5. Test the new process 6. Create Standard Work 7. Seek feedback (Muda Board) 8. Reanalyze data Solutions Through Kaizen Events
- 33. Communication flow Patient flow 13% value added activities Value Stream Mapping
- 34. Intra-department Improvement Team Development (Developing People) Team structure by pod* Team member responsibilities (Standard Work) Team leadership Team accountability Physician accountability * A Pod is the functional unit of our department. There are 5 pods within our department
- 35. Intra-Department Improvement Targeted Solutions Team Leaders with Self-Sufficient Teams Top of the Hour Huddles Co-assessment/Co-discharge Bedside Triage Work Station Re-Configuration ED Patient Room Standardization Diagnostic Turn Around Time
- 36. Hospital Wide Improvement Admission Throughput Started as service recovery Alignment with strategic plan and organizational goals Nurse Transport & Bedside Hand-off Rapid Cycle Improvement 100 day campaign to 60 minutes (order to bed)
- 37. Sustaining Strategic Planning and Priorities Ongoing Learning Frontline Engagement Lean Meetings Every 2-4 weeks 2-4 Projects per year Town Halls Monthly with Lean report out Muda Boards Ongoing
- 38. Current Efforts Growth opportunity is the discharged population Longer lobby waits for the lowest acuity, but Patient satisfaction surveys Risk of deterioration Experience suffers Utilization of Observation Unit Trauma Obs Psych Boarding
- 39. Create Vision and Align Goals Alignment of goals vertically and horizontally
- 40. Target Selection Criteria Reduce ED LOS to < 3hours Identified the relationship between a patient experiences less than 3 hours and satisfaction scores reaching our goal of 90th percentile performance. 2009 Overall > 3hr <3hr Overall ED Patient Satisfaction Rank 57th 40th 95th Mean Score 84.3 82.8 89.1 N 3936 2883 1053
- 41. Targets Sharp Memorial All Nursing CNO to ED Clerk Admission Throughput Order to Occupy < 60min Hospital-wide Patient Satisfaction > 90th Emergency Services Total ED LOS Door to Exit < 3 hours Total LOS for Quick Care Door to Car < 90 (2015) ED Patient Satisfaction > 90th
- 42. Admission Throughput 216 128 77 60 55 61 57 0 20 40 60 80 100 120 140 160 180 200 220 240 FY2009 FY2010 FY2011 FY 2012 FY2013 FY2014 FY2015 Minutes SMH Emergency Department Admission Throughput Goal is < 60 minutes Admit Order to In Bed Goal 60"
- 43. LOS and Patient Satisfaction 5.6 4.90 4.70 3.80 3.30 3.30 3.5 3.2 27 69 88 97 99 99 96 88 0 10 20 30 40 50 60 70 80 90 100 0 1 2 3 4 5 6 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY to date 2015 PercentileHours SMH Emergency Department Length of Stay and Patient Satisfaction Percentile Rank LOS Pt Sat
- 44. LOS and Census 5.6 4.90 4.70 3.80 3.30 3.30 3.35 3.20 47,137 52,173 57,605 63,290 69,799 73,670 78,318 87,680 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000 0 1 2 3 4 5 6 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 Hours SMH Emergency Department Length of Stay and Total Census LOS FY Census Annualized total
- 45. Changing Culture Align your goals and behavior with your principles Structure yourself and your team for continuous change Engage the early adopters and enlist the frontline to drive the change Manage the CAVEMEN with < 10% of your time Coach yourself and your staff to be experts in performance improvement Innovation and Adaptability leads to happy patients, physicians, and nurses
- 46. Thank you for your attention christopher.walker@sharp.com