Laguna Honda Lean Transformation Laguna Honda Strategic Performance Management November 2017
Background MAKE IT BETTER 1. 4. Identify Performance Improvement Do the work problem and and make it value Quality Assurance happen Remove wastes Create SEE IT FIX IT standard work Respect people 2. 3. Map out all Create best steps in the work flow process SAY IT 2
2017 Staff Satisfaction Survey Responses “Create a culture to “Improve communication “Offer more between depts … value the input of line opportunities for staff for problem solving continuous improvement professional by increasing by way of lean development.” participation.” methodology.” “Balance the changes “Better communication “Involve frontline staff in from lean culture. between lean staff improvement Everybody is talking (Administration) and projects/work.” about it but we don’t frontline staff. Get more know what it is.” input.” “Continue with lean transformation as this “Spreading lean “Continue w/ lean gives structure and continuous improvement transformation.” organization to enhance principles.” good working environment.” 3
Objectives Support strategic goals by aligning initiatives, projects and Align metrics at all levels Facilitate Lean initiatives that Improve focus on improving flow, quality, safety, resident experience & setting standards Provide training, coaching, Enable and support for Lean systems & tools. Develop lean leaders around data driven performance As an organization, we need to move from a culture of compliance , to a culture of improvement. 4
Challenges Developing a Lean culture is a slow process Exposure of Lean initiatives Teaching Lean methods and tools to all departments and shifts Engagement at all levels Sustaining improvement efforts 5
Our Tools Value Stream Mapping(VSM) • A technique used to illustrate, analyze and improve the steps required to deliver a product or service Kaizen Workshops • Workshop attended by owners & operators with intent of improving a specific process Gemba Walks • Personal observation of the work A3 Thinking • Root cause analysis; a systematic approach to problem solving 5S Workplace Management • Standardize workspaces to eliminate unnecessary items and improve organization 6
Our Lean Journey Jun-17 Sep-17 Feb-17 Apr-17 VSM #1- Kaizen 3: VSM #2- Kaizen 1: VSM #1-Kaizen 1: VSM #1- Kaizen 2: Room Readiness Care Planning Jul-16 Nov-16 Pre-Admission Clinical Assessments Jul-17 Intro to Lean Rollout VSM #1- New Admissions VSM #2: Discharge Oct 2016 Jan 2017 Apr 2017 Jul 2017 Jul 2016 Oct 2017 Nov-16 Aug-16 Sep-16 Mar-17 Sep-17 Intro to LHH Leadership & Rona Jun-17 Jan-17 3-Day Executive Pharmacy 5S Lean EHR Prep A3 Thinking Plan Lean Transformation Apr-17 Monthly DMS Start of A3 Education Workshop- Cohort 1 Training Nursing 5S- Phase 1 Workshops Jul-17 Nursing 5S- Phase 2 Aug-17 Nursing 5S- Training & Coaching Kaizen Workshops Hospital Wide Rollout VSM’s & Hoshin Kanri 5S 7
The Start of Our Lean Journey • Strategic Performance Management Team developed a plan to introduce lean methodologies to all departments at Laguna Honda June 2016 • Laguna Honda leadership received formal introductory training on the basic principles of lean July 2016 • LHH Executive Team met with Rona Consulting to discuss approach for the organization’s lean transformation August • Projects were selected based on the needs of the San Francisco Health Network 2016 • 3-Day Executive Education September 2016 Oct 2016 Jan 2017 Apr 2017 Jul 2017 Jul 2016 Oct 2017 8
Value Stream Map (VSM) #1: New Admissions Problem • The existing admission process was flawed causing many delays and creating a long waitlist for approved patients. Actions • Improved Resident Care Team notification & communication • Mapped new PASRR workflow to eliminate waste • Set standards for timely completion of H&P documentation for coding Results • 3 Kaizen/Rapid Improvements: (1) Preadmission, (2) Clinical Assessments and, (3) Room Readiness Oct 2016 Jan 2017 Apr 2017 Jul 2017 Jul 2016 Oct 2017 9
VSM #1 – Kaizen Workshop 1: Pre-Admission Problem • The pre-admission and screening process was very inefficient and community partners had expressed their concerns to our organization. Actions • Developed guidelines for SNF requirements in the new standard Laguna Honda admission application • Developed standard work for screening, reviewing and responding to applications. Results # of Apps. reviewed by # of Incomplete Time for Clinical Screening Committee Applications Received Decision of New Apps. per Month per month 5.5 days to 2.6 days 134 to 27 71% to 3.3% Oct 2016 Jan 2017 Apr 2017 Jul 2017 Jul 2016 Oct 2017 10
VSM #1 – Kaizen Workshop 2: Clinical Assessments Problem • The length of time for all Resident Care Team members to complete their initial clinical assessments could take 7 to 14 days. Actions • Implemented Pharmacy chart preparation process • Improved Resident Care Team communication • Created standard work with expectations to complete initial clinical assessments w/in 48hrs of admission • Created Admission Kits for clinical assessments and ADLs kits for residents Results Rx Chart Prep Social Services Clinical Nutrition Activity Therapy Assessments, n=82 Process Assessments, n=82 Assessments, n=82 process time & did not 82% compliance 72% compliance 4% compliance decrease med rec errors rate rate rate Oct 2016 Jan 2017 Apr 2017 Jul 2017 Jul 2016 Oct 2017 11
VSM #1 – Kaizen Workshop 3: Room Readiness Problem • Vacant rooms are scheduled for a new admission within 24 hours of discharge. However, the process of cleaning & repairing a room can take several days. Actions • Facilities, Nursing, and EVS collaborated to create a “Room Readiness Checklist” • Implemented new method to send notifications when discharges are confirmed • Created standard work & mapped new workflow with sequencing and time requirements Results July 2017 – Aug 2017 Sep 2017 – Oct 2017 Vacant Rooms Prepared Vacant Rooms Prepared w/in 24hrs, n = 24 w/in 24hrs, n = 30 50% Compliance 77% Compliance Rate Rate Oct 2016 Jan 2017 Apr 2017 Jul 2017 Jul 2016 Oct 2017 12
Return on Kaizen for VSM #1 Category Kaizen Measure Data % Change Baseline: 500 steps by # of steps taken to transfer the Admission Cord. ↓ 100% Admission Application to the clinical Pre Admission Result: 0 steps by screener Motion Admission Cord. Baseline: 308 steps by Nsg Clinical # of steps taken during Nsg ↓ 100% Assessment Assessments Result: 0 steps by Nsg Salary spent per month on non-value Baseline: $3,515 added time for unnecessary Cost ↓ 100% Pre Admission Savings screenings & incomplete application Result: $0 follow up Baseline: 5.5 days Turn around time from receiving ↓ 44% Pre Admission application to admission decision Result: 2.9 days Time Savings Baseline: 48 hrs Room Turn around time to prepare a ↓ 75% room after discharge Readiness Result: 12 hrs Baseline: 71% (n = 52) Admission Application missing ↓ 68% Pre Admission clinical information Result: 3% (n = 30) Baseline: 100% (n = 22) Clinical Initial clinical assessments ↓ 52% Defects Assessments completed w/in 48 hrs Result: 48% (n = 82) Baseline: 100% (n= 70) Room Rooms prepared w/in 24 hrs of ↓ 77% discharge Readiness Result: 23% (n = 54) 13
Pharmacy 5S – Workplace Management 1. Sort 3. Shine 5. Sustain 2. Set in Order 4. Standardize Oct 2016 Jan 2017 Apr 2017 Jul 2017 Jul 2016 Oct 2017 14 14 San Francisco Health Network
Nursing 5S – Workplace Management Before After Nursing 5S- Phase 1 Nursing 5S- Phase 2 Oct 2016 Jan 2017 Apr 2017 Jul 2017 Jul 2016 Oct 2017 15
Value Stream Map #2: Discharge Problem • Some short stay residents who have housing remain at Laguna Honda beyond their skilled nursing need, which contributes to a waitlist and backup in the network. Actions • Created a script for A&E and each discipline to acknowledge short stay • Documented reason resident not present in RCC note • Discussion with referring sources re: start discharge plan. Results • 3 Kaizen/Rapid Improvements: (1) care planning, (2) discharge preparation and, (3) discharge day Oct 2016 Jan 2017 Apr 2017 Jul 2017 Jul 2016 Oct 2017 16
VSM #2 – Kaizen Workshop 1 Care Planning Problem • There are no estimated discharge dates for Short Stay residents due to unclear ownership in care planning Actions • Revised the Resident Care Team meeting notes form • Standardized physician work flow for Short Stay referrals to LHH’s specialty clinics • Created an educational program for staff on short stay goals Results • Process Owners will evaluate the outcomes at 30, 60 and 90 days Oct 2016 Jan 2017 Apr 2017 Jul 2017 Jul 2016 Oct 2017 17
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