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  1. Engaging Physicians in Improvement What is the problem???? Jack Billi, M.D. jbilli@umich.edu sitemaker.umich.edu/jbilli Michigan Quality System: med.umich.edu/mqs Terry Platchek, MD Hospitalist, Lucile Packard Children’s Stanford University Medical Centerplatchek@stanford.edu Adapted from John Shook and Dave LaHote, with permission • Michigan Quality System: • Quality • Safety • Efficiency • Appropriateness • Service

  2. ADJUST PLAN CHECK DO PROBLEM!! Standard Actual Modified from Dave LaHote, with permission

  3. Lean Thinking: Troubleshooting Guide • What is the problem? • Who owns the problem? • What is the plan? • What is the current status of the plan? How will it be monitored? • What worker training is needed? • How does this problem relate to the organization’s most important goals?* • What leader development is needed? Adapted from John Shook. Ask questions in order. *As a variation, 6 may be asked second. J Billi

  4. Physician Engagement in Improvement • What is the problem? • Who owns the problem? • What is the plan? • What is the current status of the plan? How will it be monitored? • What worker training is needed? • How does this problem relate to the organization’s most important goals?* • What leader development is needed? Adapted from John Shook. Ask questions in order. *As a variation, 6 may be asked second. J Billi

  5. An A3 Template Title: What we are talking about. Date: Owner: Background Recommendations Of all our problems, why this one? The “ugly story”… What are your proposed countermeasures, strategies, alternatives? Current Situation Where do we stand? Problem Statement: Plan What activities will be required? What , Who, When? Goal What is the specific change we want to accomplish now? Analysis -What are the root causes, requirements, constraints? Follow - up How we will know? What remaining issues? Modified -Verble/Shook

  6. A3 - A Template For Structured Problem Solving… …Does this sound familiar?? Title: What we are talking about. Date: Owner: Background Recommendations Of all our problems, why this one? The “ugly story”… What are your proposed countermeasures, strategies, alternatives? Current Situation Where do we stand? Plan Goal What activities will be required? What , Who, When? What is the specific change we want to accomplish now? Analysis Follow - up -What are the root causes ,requirements, constraints? How we will know? What remaining issues? Modified -Verble/Shook

  7. New Patient H&P Name of Patient: Date: Clinician: History Impression - Diagnoses Chief Complaint History of Present Illness Past Medical & Surgical History Medications and Allergies Family and Social History Review of Systems 1. 2. 3. Plans Diagnostic: 1, 2, 3, Treatment: 1, 2, 3, Physical Exam General Appearance, Vital Signs HEENT Heart & Lungs Abdomen Extremities Neuro Follow - up Monitor x, y, z Return visit:

  8. Where would “Increase Physician Engagement” fit on the A3? Title: What we are talking about. Date: Owner: Background Recommendations Of all our problems, why this one? The “ugly story”… What are your proposed countermeasures, strategies, alternatives? Current Situation Where do we stand? Problem Statement: Plan What activities will be required? What , Who, When? Goal What is the specific change we want to accomplish now? Analysis -What are the root causes, requirements, constraints? Follow - up How we will know? What remaining issues? Modified -Verble/Shook

  9. Title: What we are talking about. Date: Owner: Background Recommendations Of all our problems, why this one? The “ugly story”… What are your proposed countermeasures, strategies, alternatives? Increase Physician Engagement with Improvement Current Situation Where do we stand? Problem Statement: Plan What activities will be required? What , Who, When? Goal What is the specific change we want to accomplish now? Analysis -What are the root causes, requirements, constraints? Follow - up How we will know? What remaining issues? Modified -Verble/Shook

  10. Physician Engagement in Improvement = Countermeasure Work alone, then in groups to fill out the left side of the A3 1. Why engage physicians in improvement? 2. What are the barriers to engaging physicians? Are the causes in: • Motive? • Means? • Opportunity? Before addressing the upper right 3. What strategies might help?

  11. Title: Physician Engagement in QI Date: Owner: Background Recommendations Why engage physicians in improvement? Proposed countermeasures Increase Physician Engagement with Improvement 1. 2. 3. Current Situation Where do we stand? Problem Statement: Plan What activities will be required? What , Who, When? Goal What is the specific change we want to accomplish now? Analysis: barriers -What are the root causes? -Motive? -Means -Opportunity? Follow - up How we will know? What remaining issues? Modified -Verble/Shook

  12. Physician Engagement in Improvement • What is the problem? • Who owns the problem? • What is the plan? • What is the current status of the plan? How will it be monitored? • What worker training is needed? • How does this problem relate to the organization’s most important goals?* • What leader development is needed? Adapted from John Shook. Ask questions in order. *As a variation, 6 may be asked second. J Billi

  13. The next 2 slides are photos of the results of the group discussions, written on white boards.

  14. A3 References Books with Focus on A3 Use: • Shook. Managing to Learn. (Best book on leadership in a lean organization and A3 use) • Sobek, Smalley. Understanding A3 Thinking. (Problem solving and A3 use) • Dennis. Getting the Right Things Done. (Strategy deployment or hoshin kanri) • Liker, Meier. Toyota Way Fieldbook. (Practical lean tools) • Baker, Taylor. Making Hospitals Work. (Workbook from Lean Enterprise Academy, UK) • Graban. Lean Hospitals. (General lean healthcare reference) Lean Web Resources: • Michigan Quality System at UMHS: med.umich.edu/mqs • Lean Enterprise Institute: www.lean.org webinars, books, meetings… • Lean Healthcare Value Leaders Network www.healthcarevalueleaders.org • Lean Enterprise Academy (UK): www.leanuk.org 05.17.10

  15. Michigan Quality System & Lean References Books: • Womack J, Jones D. Lean Thinking. • Liker J. The Toyota Way; Liker J, Meier D. The Toyota Way Fieldbook. • Shook J. Managing to Learn. • Dennis P. Getting the Right Things Done. • Rother M, Shook J. Learning to See. • Womack J, Jones D, Roos D. The Machine That Changed The World. • Sobek D, Smalley A. Understanding A3 Thinking. • Marchwinski C, Shook J, eds. Lean Lexicon. Articles: • Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med. 2006;1:191. • Bush R. Reducing Waste in the US Healthcare System. JAMA 2007;297:871. • Spear S. Fixing Health Care from the Inside, Today. HBR. 9/05. • Spear S. Learning to Lead at Toyota. HBR 4/04 • Spear S. Decoding the DNA of Toyota Production System. HBR 9/99 • IHI Whitepaper: “Going Lean in Health Care” www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm Web: • Michigan Quality System at UMHS: med.umich.edu/mqs • Lean Enterprise Institute: www.lean.org webinars, books, meetings… • Ideal Patient Care Experience at UMHS www.med.umich.edu/i/acs/ipe.htm • Crossing the Quality Chasm (IOM): newton.nap.edu/catalog/10027.html • Lean Enterprise Academy (UK): www.leanuk.org • National Health Service (UK): www.networks.nhs.uk/networks.php?pid=211 • Wikipedia: en.wikipedia.org/wiki/Lean_manufacturing

  16. Appendix

  17. Problem and PDCA Tools for different levels PDCA tool: (HK) Strategy deployment Role Problem: MURI, MURA Impact MUST PROVIDE VISION AND INCENTIVE Likes the results SENIOR MANAGEMENT PDCA tool: A3 or VSM Problem: MURA, MURI MUST LEAD THE ACTUAL OPERATIONAL CHANGE MIDDLE MANAGEMENT Requires tools and support to lead PDCA tool: Standardized Work Problem: MUDA Likes the involvement FRONT LINES MUST “DO” Key to success: The Mid-management and First Line Supervisory Level HK – hoshin kanri (strategy deployment) Muri – overburden Mura – uneven workload Muda – waste Shook

  18. MQS Michigan Quality System Quality – Safety – Efficiency – Appropriateness – Service Built-in Quality Just-in-Time • Error Proof • Surface Problems • Stop and Respond to Abnormalities • Solve Problems at Root Cause • Pacing by Demand • Continuous Flow • Pull Systems Customer DefinesValue LeveledWorkload Continuous Improvement (P-D-C-A) and Learning Standardized Work Make Value Flow by Eliminating Errors and Waste

  19. An A3 Template Title: What we are talking about. Date: Owner: Background Recommendations Of all our problems, why this one? The “ugly story”… What are your proposed countermeasures, strategies, alternatives? Current Situation Where do we stand? Problem Statement: Plan What activities will be required? What , Who, When? Goal What is the specific change we want to accomplish now? Analysis -What are the root causes, requirements, constraints? Follow - up How we will know? What remaining issues? Modified -Verble/Shook