Continuous Improvement Model

There is little doubt that there are many opportunities for Continuous Improvement in the US Healthcare System, but we need a Continuous Improvement Model that reliably sustains change.  There is, however, significant resistance to achieving Continuous Improvement using a model of multiple employee involvement.  In this blog I want to share one experience of using a team Continuous Improvement Model in healthcare.

Straw Man in Continuous Improvement Model

Continuous Improvement Model in Cardiovascular Surgery

In a recent engagement, KCOE coaches and mentors taught a Cardiovascular Surgery Intensive Care Unit the principles of team problem solving using the KCOE continuous improvement model. The specific problem that had been documented was that patients arriving in the unit from cardiac surgery experienced highly variable processes during the admission phase to the unit.   Differences in time to complete the admission, staff duplicating elements of work, crossed walking paths, team members bumping in to each other, loud noisy verbal exchanges and frequent confusion were just some of the variables.  Observers documented that there were times when all monitoring of the patient was unavailable for up to 30 seconds as lines and leads were changed in a haphazard manner.   Total lead time from entry into the patient room to patient admitted with all lines, tubes and leads in place, patient monitoring stabilized and patient in the bed varied widely, sometimes requiring up to 45 minutes.  Literature clearly supports the use of standardized processes to minimize variation in outcomes, but achieving agreement and sustaining the changes within a Cardiovascular Intensive Care Unit may be problematic.  The Continuous Improvement Model coached by KCOE involves engaging all unit personnel in designing standardized processes based on PDCA (Plan, Do, Check, Act).

Continuous Improvement Model Using a Straw Man

In this example the team first identified what an ideal admission process to the unit from surgery would look like.  This involved brainstorming over a one week period using the KCOE continuous improvement model by all members on all shifts via flip chart documentation.  The Team leader (Head nurse) then used this input to design a “Straw Man”  of the perfect admission process.  The Straw Man was shared over the following week with the team through a similar input and comment process.  Comments and suggestions were then formatted into a highly visual graphic documenting all activities, team member “locations” and team member actions in sequence.  A goal lead time of 15 minutes was chosen based on team experience.  With this plan in place the team was trained and implemented a “DO” phase in which every admission was audited against the “straw man”.  The team used video recording as a part of the continuous improvement model to document the process and to evaluate compliance to the “Straw man” during the “check” phase.  Opportunities for improvement were often noted during the reviews of the tapes.  Outcomes were compared with expected and opportunities captured.   Any problem that arose generated a problem solving sheet.  From the root cause analysis new methods and suggestions were developed by team members.  Suggestions were shared with the team and the activities proscribed by the “Straw Man” modified as the PDCA cycle continued onward.

This Continuous Improvement model process continued for approximately 3 months before the team was convinced that they in fact had the ideal process reasonably well defined.  At that time a visual standard graphic tool comprised of a flip chart showing locations of all individuals present for the admission process was created.  A second flip chart showing the sequential work of each team member was created.  These two charts constitute the standard visual admission process.  The outcome is that the lead time is consistently 15 minutes or less, patients experience no periods in which they are not monitored via at least one modality and the entire process is consistent, repeatable, quiet and organized.  Any variation or opportunity for an improvement generates a problem solving sheet and root cause analysis determines if the standardized process will be modified and implemented as the new standard.  This Continuous Improvement Model has given the unit a methodology to continuously improve a critical sequence of events involving a cross-functional team of providers in a process defined by the front line team to which they all comply and defend because they “own” the process.  There is in fact no “Buy in”—we created it and we own it so no one has to buy-in!  The KCOE continuous improvement model has functioned well for this unit.

MEDRAD Problem Solving Story

Here’s a note about Ken and how daily meetings are raising problems less than 24 hours later versus over a month from the time of the problem.

When do you know about problems? Do you find out about quality errors days or weeks after the produce has come through your team?

Check out the story about MEDRAD and Problem Solving below . . .

So we’ve been coaching daily meeting and problem solving on a production floor near Pittsburgh for sometime now, and another light bulb went off for the team. How familiar does this situation sound:

Ken was receiving reports, that a problem happened . . . 4 to 6 weeks ago. Part of his responsibilities was to approach his team member and do “problem-solving” around the error/mistake.

How successful can anyone be around solving a problem that happened over a month ago? Unless the problem was rather major – chances are low any one will even remember the problem, let alone the possible causes.

Ken then noted that his team members know within a day or so that there was an error on the product. This is when the product is brought from inspection back to the process for rework. Ken then added: “Shouldn’t problem solving be done at that point by the team members?”

Ken’s  from MEDRAD “light bulb” about Problem Solving

. . .“Shouldn’t problem solving be done at that point by the team members?” . . .

The answer, of course, is yes! All problem reporting does is tell you about problems. Coach your team members to not only identify problems but to solve problems by capturing the root cause and eliminating it. After all, problems are blessings, i.e. opportunities for your team to improve.

What Ken did was and is in the process of doing is reducing monthly problem recognition in the form of a report to a daily cycle by having his team report on problems via the daily meeting. Reducing problem recognition and the beginning of problem solving from 6 weeks to 24 hours (or less) greatly increases the chance of actually finding the root cause of the problem and eliminating it!

The Lesson about MEDRAD and Problem Solving

Remember, problems are blessings. The way to get your team to have this mindset is to ask them what their problems were the day before (via the daily meeting) and coach them to do problem solving (via the problem solving sheet). Reporting systems are just that – they report out. People are problem-solvers, the daily meeting and the problem solving process begin to unlock that creativity by bringing problems to the surface so those same people can see and solve problems in order to continuously improve. We’ll keep you updated on Ken’s team as they continue to learn with KCOE.

Keep up the good problem solving work at Medrad, Ken!

Today at Phoenix Sintered Metals, I coached the team on some basic problem solving level II. Once you are able to identify your top 3 problems, chances are those top problems have multiple causes. Use a fishbone diagram and the 4M’s (man/woman, machine, material, method) to identify ALL possible causes.

If your team has a good sense of what the top cause is (or a top cause that is more easily solved), start your problem solving sheet there! If you’re still in the dark after identifying all the potential causes, go ahead and use a pareto diagram to keep track of the causes. Once some time has lapsed, you should have a better sense of what the top cause is. Then, you can lead your team through a problem solving sheet.