1. Organizational Excellence and Culture Transformation
The Problem: One of the large hospitals in Ontario was formed through the amalgamation of a general hospital and a regional mental health hospital. Some of the key challenges included:
Disparate cultural differences, varying management styles, inadequate measurement system, lack of accountability & role clarity at all levels, departmental silo work ethic, culture of blame, fear of failure, resource skill underutilization and over allocation.
There was an urgent need to develop and implement a contemporary management approach that will support a massive change endeavor, such as this, and manage challenges and push back at all levels.
Approach: Best practice business excellence models for transformational change such as Malcolm Baldrige, Shingo and European model for excellence investigated. Organization readiness assessment conducted in-house. Findings and recommendations from the organization’s operational assessment report analyzed. Site visits arranged for all Vice Presidents, Directors, Managers, Physicians and CEO to observe and learn best practices being followed by other hospitals in Canada and the USA.
Senior Leadership workshops conducted to develop guiding principles of the quality journey, and finalize organization and governance structure to facilitate change. New job descriptions created, some positions eliminated, department of Academics and Quality created, and functions of quality, risk, project management office, education and performance management centralized.
New business model created that included 5 major categories namely, Patients, Leadership and Strategy, Process, People, and Measurement and Information System, in that order. Right mix of lead and lag indicators for tracking performance of key processes established in clinical, mental health and corporate support departments. 22 new management system elements implemented.
Result: Through the design and implementation of a unique and innovative plan comprised of a robust set of 26 Foundational and 22 Management System elements, the hospital has not only overcome these challenges on an accelerated timeline but has also propelled the organization further ahead on their quality journey compared to other organizations that started much earlier.
The quality excellence journey integrated continuous quality into hospital operations using LEAN principles, tools and practices and helped optimize systems and processes. Standard work ensured reliability on processes and continues to support sustainability.
Culture Change: The hospital has transformed into an organization that empowers people at all levels to optimize their work processes to free up time for care, and partner with patients to improve patient experience. Staff share and celebrate their learnings and experiments both formally and informally. Excitement around quality and measurement has been generated and continues to result in positive corporate change
The hospital was invited to present the approach and share learnings at several national and international conferences.
- CSQ 7th Canadian Quality Congress, Edmonton, Alberta (Sept 2015)
- Quality and Process Improvement in Nashville, Tennessee (May 2015)
- Lean and Six Sigma World Conference, Houston, Texas (March 2015)
- Health Systems Process Improvement , Orlando, Florida (Feb 2015)
2. Operational Excellence
The Problem: Six hospitals under a provincial health authority in British Columbia have inpatient psychiatry bed utilization varying from 83% to 110%. This implied under-utilization of beds at some hospitals while creating ED congestion in others. Patient had to wait in ED until an inpatient psychiatry bed became available. It also put tremendous pressure on the care delivery system to discharge patients in order to make beds available for new patient.
Approach: During early stages of the project, three full day Regional Kaizen sessions and additional working group sessions at each hospital sites occurred. More than 80 staff participated throughout these workshops. A regional project team, comprised of 18 representatives from the six hospitals, was tasked with executing the project. This cross-functional team included psychiatrists, nurses, operational leaders and frontline staff. A core team was formed to lead the steering committee that met every two weeks.
Literature Search conducted to understand best practices implemented by other healthcare providers in Australia, New Zealand and UK for maintaining bed inventory and inter-hospital transfers. The team also looked to the retail industry its approaches to manage and communicate inventory at retail outlets. Series of workshops conducted to map the current state and future state processes. The regional team was split into four working groups based on areas of expertise to develop standardized forms to support the new approach for transferring patients. Issues Resolutions Process established for evaluation and sustenance.
The Solution: The triage call will be replaced with a free web based tool to allow staff to access data in real-time. The patient would be medically cleared according to a standardized checklist before being presented to psychiatry. Psychiatrists at each hospital will be designated to affect inter-hospital transfers of patients. Care teams and psychiatrists would agree to standard regional criteria, SBAR, for accepting or declining transfers if beds are available. SBAR (situation, background, assessment, recommendation) is a technique for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action.
Instead of faxing all patient records, information will only be transmitted if the patient is deemed a good candidate based on the SBAR outcome. To ensure proper handoffs to transportation, a checklist will be used regionally. B.C. ambulances would be reserved for transferring “involuntary” patients. “Voluntary” patients would be transported by a family member, or the authorized private service provider, SN Transport. Two identifiers would be used to ensure the correct patient was transferred. Responsibilities and process steps will be identified for owners to avoid communication gaps. Buffer beds (beds retained by each hospital which they were not obligated to share with other hospitals) allocated to manage unexpected admissions at the local level.
The Result: Bed inventories shared across each hospital in an excel spreadsheet on a free web tool called Google Docs. Information on new admissions and expected discharges updated twice daily including weekends. No patient information included to ensure patient confidentiality. The project allowed 6 hospitals to move to a model of regional delivery of care and enabled timely access to acute care beds, reduced ED congestion, provided regional access standards, and resulted in highest standard of evidence based patient care. The new model provided single care approach across all 6 hospitals and increased average bed utilization to 94%. Zero capital ($0) was invested in the solution.
The approach has been presented at several National and International Conferences.
- Lean Six Sigma World Conference, San Diego, CA, USA, Feb 2013
- BC Patient Safety and Quality Council, Vancouver, Canada, Feb 2013
- Lean and Six Sigma Conference, Phoenix, AZ, USA, March 2013
- Keynote Speech at American Society for Quality (ASQ), Vancouver, Canada, May 2012
Case study published by ASQ URL: http://rube.asq.org/ 2012/11/lean/ emergency-department-congestion.pdf
3. Strategy and Operations Alignment
The Problem: Over 600 initiatives/projects under work-in progress at departmental level in a large hospital in Ontario. All deemed important, no resources to take them to completion, all departments overwhelmed with the sheer volume of projects.
Approach: Leadership workshop conducted. Big dot metrics identified at the organization level for key strategic objectives and developed the hospital report card based on the same. Three Management workshops conducted. Hospital report Card cascaded to department levels to develop performance scorecards in all areas across the hospital using Balanced Scorecard approach.
Separate session conducted for the physician group to identify issues concerning them across primary care, department of Medicine & Surgery, ED, and Mental Health & Addictions. Initiatives and projects mapped to department metrics. MOHLTC directed mandatory projects under Quality Based Procedures (QBP) and Quality Improvement Plan (QIP) listed. Additional projects to meet Accreditation Canada’s Required Organizational Practices and projects that received special funding, identified. Strategic project prioritization filters identified. Weightage assigned to each filter. All projects prioritized and integrated using the above filters.
QBPs, QIPs, and other projects focused on improving quality and safety in patient care integrated as a part of hospital report card. Strategy room created with visual walls that represent all projects (implementation period greater than 4 weeks) under-way, charters developed and resources assigned. Short duration projects put on the visual huddle boards and managed by frontline staff. Senior Team and Management teams review progress of organization wide, complex projects, every quarter. The managers review progress of their department projects locally on their performance scorecard huddle boards on a daily/weekly basis.
- 600 projects reduced to 45 with clear focus and deliverables.
- Dependencies of resources visible and budget allocation streamlined.
- All major clinical and non-clinical programs integrated and projects mapped to these programs.
- Visual Performance Management used in all areas
4. Managing Stakeholder Expectations
Project: Protect the rights of a mentally incapable venerable adult needing support from Public Guardian and Trustee (PGT) to act as Committee of Estate and/or Health Authority to manage his/her legal and/or financial affairs
Stakeholders: Public Guardian and Trustee of British Columbia, Ombudsperson, Acute care psychiatrists, primary care psychiatrists, Senior Executive Teams and Community Teams across eight hospitals in British Columbia.
Before the workshop: Identified stakeholders and undertook stakeholder analysis. Plotted key stakeholders on a ‘Power Interest’ grid to get a visual representation of the influence they have on the initiative/project. Met key stakeholders one-on-one for understanding their perspectives. Requested and gained acceptance from the stakeholders in the ‘High Power High Interest’ category to play a part in facilitating the workshop/meeting. Defined their role and expectations. Researched best practices and understood if a similar challenge has been addressed elsewhere in any country across the globe.
During the workshop: Clearly articulated purpose and intended outcome. Mapped and validated the current state. Created Issues log. Identified root cause factors contributing to top 80% of issues. Engaged the group in creative problem solving to integrate efforts and make system level improvement.
Shared best practices identified from research. Led the group in evaluating alternative solutions and plotted ‘Impact Effort’ grid. Identified High Impact Low Effort quick win solutions and High Impact High Effort longer terms projects. Confirmed whether these identified projects when implemented will help achieve our purpose and intended outcome. Agreed upon responsibilities and timelines for implementing quick wins and assigned resources to pilot the High Impact High Effort project. Project sponsor for pilot project identified. Summarized action plan. Informed next steps for developing communication and implementing the pilot.
After the workshop: Series of working group sessions conducted to develop the standard operating process (SOP) with inputs from all key stakeholders for issuing/tracking Certificate of Incapability issued/declined to clients. Engaged and managed expectations of all stakeholders. Once developed, SOP was piloted and education sessions were conducted to support implementation.
Result: On successful completion of the pilot it was rolled out across eight hospitals in British Columbia. Zero adverse comments received from the Ombudsperson audit evaluation. Since the SOP and policy developed was adequately robust, it was accepted by the PGT and implemented across all other provincial health authorities in British Columbia.
5. Service Portfolio Redesign
Problem: The department of Academics and Quality in a Health Centre, like many other programs/departments in the Health Centre, is in the bottom 25th percentile of budget performance as compared to peer health centres. There is an urgent need to undertake program evaluation and redesign to ensure financial viability of the health centre, while maintaining quality of care.
Approach: Participated in the hospital-wide benchmarking and budgeting process conducted to meet the funding requirement for a balanced budget. Peer hospitals contacted to understand the number of human resources in their setting, their roles and responsibility, manager span of control, their geographical reach, number of partner agencies in the community, budget, performance measures, etc.
In some cases site visits were conducted to see how others were set up and understand challenges faced by them with the current design of their program. The whole portfolio of Academics and Quality was redesigned with the revised job descriptions. Internal job postings done, interviews conducted and individuals hired in the new roles.
Result: Strategy Planning & Execution, Accreditation, Policies & Forms, Continuous Quality Improvement, Project Management, and Patient & Family Partnered Care functions centralized and brought under the same office. Reallocated 22% of the manpower cost of Quality & Academics, thereby establishing required benchmarks.
6. Business Turnaround
Problem: A large Indian Conglomerate had multiple businesses that included Paper, Yarn, Terry Towel, Chemical and Energy. However, the profitability statement and the balance sheet for the Paper and Chemical business units were combined. The CEO decided to separate Paper and Chemicals business into two separate entities. It is realized that the Chemical business was actually piggy‐backing on the profit making Paper business and after separation the profitability of Chemical Unit is in RED, (‐) $2.8 Million compared to the budget of $28.62 Million for the period Apr’07 to Sep’07.
Management is considering exiting from the loss making Chemical Business. This is leading to increased no. of disengaged employees, thereby affecting the overall business viability even further. The CEO gives a directive to the Business Head to turn around the loss making business within the next 12 months, failing which the business would be shut down.
The Approach: The Project team went around collecting data for 3 key elements namely, customers, employees and internal process capability of the different functions of the Chemical Business Unit. Data revealed that the overall Customer Score was a healthy 72%, however, People Score was low at 51% and the Overall Process Score was a dismal (‐) 13%.
Research studies from Fleming & Asplund and also from Gallup Organization, have suggested with data, worldwide, that that an engaged employee drives profitable business outcomes. Therefore, it was strategically decided that the primary area of focus in the Chemical Business Unit will be to improve the People Score that in‐turn would help improve efficiencies and hopefully recover the losses.
A 22 step roadmap to People Excellence under AQTE* (pronounced as Equity), which uses the concept of Self Directed Teams (SDT), was designed and implemented. The workforce was arranged into cross functional teams (named BU’s – Business Units), all along the entire value chain both in upstream as well as downstream operations.
The Function Based Structure (FBS) was revamped to create a new Process Based Structure (PBS). The supervisors at the shop floor were replaced by team‐elected leader, who was empowered to take all decisions in his BU in that shift. Members in each team were multi‐skilled to effectively manage all Cyclic, Planned/Routine work, Kaizen & 5S activities inside the BU. Activities in Maintenance, QC, HR, IT, Supply chain & Admin pertaining to BU identified and transferred inside BU.
Team operated, repaired, cleaned, tested, quality checked, logged and did paper work on their own. 90% of the jobs are done inside the BU without any assistance from supervisors. Preventive Maintenance / Overhauling Activities remained outside BU and were given to the Shared Services Unit. A team for Centre of Excellence (CoE) was constituted, which included one employee each, from the areas of Training & Development, SHE (Safety Health & Environment), Purchase and Strategy.
Access to information and data was earlier limited to the privileged few and communication channels were very weak. Training Programs on developing Soft‐skills, Mentor‐Mentee relationship, encouraged employees to be transparent with each other in sharing information and build trust in the system & also the Leadership. Teams formed were self sufficient, self managed and self directed to perform activities that helped them and the unit, realize the targeted gains.
Results: The initial results were not promising and the Business kept losing more money than before, since the processes were not stabilized, employees were not multi‐skilled and employee morale was still low. However, as things started stabilizing and trust on the system grew, the outlook appeared more promising by month 9.
Employee and Customer Engagement Surveys respectively indicated that the People Score jumped from 51% to 67% and the Customer Score increased marginally from 72% to 78%. However, the major breakthrough was in the Overall Process Score which went from negative 13% to positive 65%, resulting in a net margin of 8%, revenue increase by over 70% and delivering savings to the tune of $3.4 million.