Lessons learned through early application of Lean methods helping ensure current improvement efforts lead to better, safer patient care
What “size” of problem warrants a Rapid Process Improvement Workshop? What metrics should you track to determine if a change really is an improvement? And who needs to be part of an improvement team, if you want to find the best solution and make it stick?
Discovering the answers to these questions over the past two years, through trial and error, has been a big part of the learning process for managers, staff, and physicians in the Prince Albert Parkland Health Region.
“In the early days, we were very eager to get started, and to use the skills and tools we learned in Lean Leader Training,” said Pat Stuart, Vice-President Clinical Support and Quality Performance.
“We probably did not understand everything involved, such as how best to identify problems, gather relevant data, and make sure all team members are aware of responsibilities.”
Stuart said the Region, led by its Kaizen Promotion Office (KPO), has made many changes to ensure that the hard work that goes into Rapid Process Improvement Workshops (RPIWs), mistake proofing projects, and other improvement activities yields measurable benefits for patients and that those successes are sustained over time.
From figuring out what problems really require the intensity of an RPIW, to identifying target outcomes and audit measures, Prince Albert Parkland has made several changes to its own processes, according to Cynthia Leschyshyn, KPO Infrastructure Lead.
“Initially we were waiting until Week Minus 3 to begin the data collecting and identify what problem, if any, existed,” Leschyshyn said. “We were often finding out that what we thought was a major problem might only require a small fix or, for one RPIW, that a simple change had already been made to address the initial problem.”
She said this often left an improvement team’s leads, process owner and sponsor scrambling to find another problem to solve.
“We wanted to use the RPIW as a tool, but needed a better method for identifying where one was required, and what problems really needed a larger team to help implement solutions.”
“For one RPIW in primary care, we identified a couple of other needed improvements, but it placed unnecessary stress on the people involved in the event to do all of that work at the last minute,” said Leschyshyn.
Today, project forms are first drafted at kaizen planning sessions. They are then discussed at quarterly reviews, and the final draft (which evolves throughout the process) is completed 12 weeks prior to the team leads beginning to prepare for the event week.
Leschyshyn said this includes using data to validate the problem and appropriately scope the improvement work. Team composition is discussed at this point, in terms of specific roles required; however, actual membership may not be finalized until a few weeks prior to the event. If physicians are needed on the team, this request is brought to the Practitioner Advisory Committee three months prior to the event to ensure there’s plenty of lead time to free up doctors to participate.
Carol Gregoryk, Vice-President Integrated Health Services, said changes in how Prince Albert Parkland identifies and prepares for RPIWs is helping the region make and sustain improvements in patient care.
“Now we are selecting an RPIW based on pain points, or areas where we can’t seem to solve a flow issue, care issue, safety issue.”
“Initially there was very little preparation. We did the data gathering, value stream mapping, timings, etc., during Week Minus 3. Now we do this ahead of time and really have a better idea of the scope of the RPIW so that it can be successful,” said Gregoryk.
Doing a better job defining the problem, and spending more time preparing for the actual improvement work is also helping ensure that teams include all of the people required to help implement changes. Gregoryk said that successful events and sustainable improvements rely on having everyone from an area represented during the improvement week.
“The people doing the work need to be involved,” said Terry Fjeld, Regional Director of Environmental Services.
“It is a huge error to assume you know what’s best if you don’t include all perspectives. Having fresh eyes from other departments usually leads to questions being asked on why things are done certain ways. An RPIW team is exactly that, a team, with each team member contributing greatly to the outcome of the project.”
Another challenge for Prince Albert Parkland in their early improvement events was identifying audit metrics that accurately reflected the problem they were trying to solve, and that could actually be measured.
“As we have moved forward, we’ve become better at selecting audits that make sense and are measurable,” Gregoryk said. “In the past, we did not have measurements specific enough and used data that was not easy to gather on a regular basis. Now the audits are much clearer and focused on maintaining the gains from the RPIW.”
Leschyshyn said that audit measurements are now being discussed early in the planning process, and defined during the RPIW week. Audit leads and process owners also have work standards to better understand their role and expectations. While the audits are displayed in the program area, they are also shared with the senior management on a monthly basis, as well as with others involved in the process. That includes utilization committees for the emergency department, operating room and mental health.
Understanding the impact that RPIWs, Kanban, 5S, or mistake proofing projects can have on program areas and the staff working there, is also important, Fjeld said. Too much change too fast can be unsustainable.
“We need to ensure that one area is not overburdened with so many changes that it causes improvement efforts to fail. Staff members and physicians need time to adjust to new processes before more are introduced, if the gains are to be sustained.”
Support from the KPO and people who worked on the RPIW are critical to holding gains. “
Fjeld pointed to an early RPIW in an area that had a part-time nursing unit manager. Fjeld said there were two RPIWs conducted in the department at the same time. The event week at the end of June conflicted with a busy time for many staff members involved in the RPIW – including some whose children were graduating from high school.
“We delayed our RPIW report out by three weeks to accommodate the manager and staff members,” Fjeld said.
That small change appears to have had a big benefit over the longer term.
“After the RPIW, I continued to visit the area to answer questions for the staff or help resolve issues that arose,” said Fjeld. “One year later, two of the staff member told me that they had been discussing the RPIW and said that they couldn’t remember how they used to do things. They continue to use the new process we developed and are very happy with how the flow has improved.”
Photo: From left, RPIW Sponsor Carol Gregoryk (Vice-President Integrated Health Services), discusses the preparation for an upcoming RPIW (Decrease lead time for Long-Term Care assessment completion in Victoria Hospital) with co-leads Edward Harding and Tannice Thompson, along with Co-Process Owner Linda Sims (Director of Home Care) and KPO Support Cynthia Leschyshyn.