As part of my work to support the Healthcare Value Network, I had the good fortune to visit two great organizations in Oregon last week. Here’s a brief summary.
I asked to learn about the current lean work that was going on at Oregon Health & Science University in Portland, OR. I was invited to see a series of daily huddles with the first one beginning in the OR at 7:00 am.
Here’s a picture of some of the OR staff with something they invented – a “huddle board on wheels”. This board helps to support the daily huddles in the OR. There are key items for tracking and communicating on each of the 4 sides. Each side is a white board, which can be updated quickly on the spot in real time. The huddles take 15 mins. The staff certainly have a sense of humor. One of the huddle boards (Neurosurgery) had this written on the top “Actually, it IS brain surgery!”
I saw a series of huddles that work together as a system to facilitate communication and coordinate activity up and down (and across) the organization. This diagram shows the current main huddle types and what is discussed.
Here’s another example of a visual management board used at one of the daily huddles. They are tracking and improving “readiness for surgeries”. This board shows where there are problems and accountability for studying and improving future readiness.
“Knowing how we’re doing” on key measures of importance to the organization and the OR’s performance on these measures. A combination of computer-supported and hand drawn graphs and charts. This board is also used in daily huddles.
A close-up example of how the graph helps tell the improvement story “getting information to the family”.
Another example is “improving surgery turnover time”. The sharp drops occurred after improvement “kaizen” events. The graph shows if the improvement has been maintained and if the standard work that was developed is being followed.
Another graph that shows how the staff is doing with “process audits”. This is a way to see how the standard work is being followed once it has been agreed to by the people who do the work.
An example of a team’s “kanban board”. There are lots of areas for improvement and ideas for improvement, but it is not possible to work on them all at once. Which one’s to start with? How many can we handle per week? This makes the process visible.
I saw an example of improvement being made in the oncology infusion unit. This list shows the 47 standing orders that had to be managed by a staff person for one patient. After the improvement work, the list was reduced to 9.
The latest data point shows what looks like substantial improvement in patient experience. What are the likely causes? The staff believe a lot of it has to do with a new system for matching and scheduling staff based on patient acuity. The next step is “level loading”.
Not all huddles are in person. This manager is leading a “virtual huddle” with remote departments. He’ll take the information that needs to be escalated to the next-level huddle.
This is what the daily administrative huddle looks like. It’s a “standing meeting” (no-one sits) and it takes about 15 minutes to understand the current state of the organization. This is not a meeting for problem-solving. That occurs during the remainder of the day, with updates at subsequent daily huddles.
By 9:00 am the information from various huddles will be discussed at the daily administrative huddle. This occurs in a “visual room” where current performance is posted. It was helpful to see this wall with performance on key measures (compared to other academic medical centers). Some things to note: data were plotted on control charts to tell if the performance was stable or not, and how the performance was against the goal. Those that are not yet at goal are coded “red”, those that are meeting goal are “green”. The colors help to determine where efforts need to be focused and what changes need to be made to study and adjust.
Another wall shows the major areas of improvement area by department and by month. There is no shortage of improvement needed, but it’s not possible to tackle everything right away. This helps to prioritize and plan.
Part 2 of my visit took me to Salem, Oregon.
Salem Health hosted a meeting of the “Oregon Healthcare Lean Community of Practice”. This is a grass roots, volunteer effort to help spread the understanding and application of lean thinking to healthcare organizations in Oregon.
The session was kicked off by CEO, Norm Gruber who offered a welcome message and history of the Salem Health lean effort. He described how they “did their homework” to really understand what a lean transformation is all about. “It won’t work unless top management understands this and is actively leading the work. This is not a set of tools.”
The visit featured short tours of various areas. This is a wall in the information services department. Salem health is not only a member of the Healthcare Value Network, but also the Clinical Business Intelligence Network. I blogged about this before. Here’s a link to that blog post, including a youtube video describing the connection between lean and information.
All departments have a board that links that department’s work with the key goals for the organization. Some of the boards are electronic, like this one in Environmental Services.
Here’s a close-up of the board. The EVS department has identified processes (and process measures) that connect to the key outcomes (outcomes measures) that connect to the related items at the organization level.
Once improvement has been made in a measure, it is not forgotten about. The measure is monitored for 30, 60 and 90 day updates to see that the improvement in that measure has been sustained.
The daily process measures that will go into the electronic board are gathered on this white board.
Some departments (like this nursing area) have a similar board that is paper on a magnetic board. The same approach is applied here.
The organization has created a giant fish-bone diagram that shows the current performance on the key measures that ultimately affect unintended outcomes for patients (mortality, infections, etc.)
Here’s a close-up of the hypothesis of how this fish-bone diagram works.
The lean support team has a nifty way of keeping track of the monetary savings from their lean efforts
The session closed with an overview of the Oregon Healthcare Lean Community of Practice and a “call for volunteers” to host the next meeting. Having been involved with multiple similar volunteer efforts in my career, I can personally attest to how difficult it is to sustain such an effort. It’s important work that requires a tremendous amount of tenacity and patience.