WIXLIB

Lean Leadership Practices toAchieve Business ResultsCraig T. Albanese, M.D., M.B.A.Vice President, Quality and Performance ImprovementJohn A. and Cynthia Fry Gunn Director of Surgical ServicesStanford Children’s HealthProfessor of Surgery and PediatricsStanford School of MedicineStanford, California1

Learning Goals Understand that a lean leader’s primary job is align theorganization Understand the four lean leadership practices necessaryto achieve long term business results Be able to describe the “ascension paradox” of the leanoperating system Review a 3 year journey to decrease preventable harmin one hospital

Healthcare “challenges” Patient is customerPatient is the product—complex mixed product linesSecondary “products” are traineesEmotional connection requiredMedical/Nursing training teaches disease management not processmanagementDeeper than usual silos in an academic hospital; disconnectedreporting structuresUnusually powerful position of MDs, outside of managementhierarchiesThe mindset that MDs are the internal customers of many processesConservative, evidence-based nature of attitude to changeTruly 24/7 nature of a hospital

Why Lean?ClinicalOutcomes*Experienceof CareValueCostHealthcare reform and consumers demanding:Cheaper, faster, better, safer, kinder for individuals and populations*Patient and Staff Experience

QCDSE Business Results orEnterprise “True North” metricsQ -- QualityC -- CostD -- Delivery (Access)S -- SafetyE -- Engagement/Experience (Patient & Staff)

A lean leader’s primary job is to luesActivitiesLeanBehaviorsProcessesOutcomes QualityCostDeliverySafetyEngagement/Experience

ExtraordinaryPatient CareHighest Quality, Safety and Empathy;Easiest and Timely Access and Lowest CostManagement System/ People Development Refine leadership’s& workforce’sPDCA skills Refine strategydeploymentNo WaitingLevel 5 (optimize)Level 4 (taktenvironment) Innovation toimprove access,cost, empathySet staff cycle timesStaff StandardizedWorkClinical standardizedwork Detail patient flow& lead timesLevelloading Workflow control Control process variationLevel 2(Stability) Establish flow Initiate clinical std workQuality &service stds.Visual managementand problem solvingLeader engagement Customer patientInnovation toimprove quality /safetyVerify at the source Manage tostandardized work &level flowImmediate andonresponseLevel 3 (matchcapacity to demand)Level 1(Foundation)Quality FirstUse andon forprocess stop to meetthe standardSuccessive check Staff todemandSuccessmetricsShared valuesUnderstandcadence (takt)Methods, Equipment, Staffing,Supplies (MESS) 5SValue stream thinking

Frontline feedback that can be addressedwith lean leadership practices “I don’t ever see the senior leadership team members”“Senior leadership doesn’t understand our issues”“We are being asked to change and we don’t know how”“I am overwhelmed by the number of problems we have”“We are overwhelmed by the number of “initiatives” to beworked on” “I ask for help and I rarely get it in time” “The leadership team is always in meetings” “Leadership says they are supportive but I don’t seeevidence of it except they are supporting all of these highpriced consultants”

Leadership Practice One:Goal Alignment/Deployment

CatchballTop Down Themes: Process looks easy –hard to get true alignment Deprioritize work! Room for LODO activitiesCatchball: Negotiation Takes time Better buy-in bettergoalsDevelop the enterprisevision and missionDefine Strategic InitiativesDefine the Core Goalsfor next yearCascade goals to all levelsand functionsExecute monthly process,review, and adjustExecute yearly processreviewsCatchball

Goal Alignment for StanfordChildren’s Health

Core Goals – FY16CategoryQualityServiceAffordabilityInnovation &EducationRespect for PeopleExecutiveOwnersAlbaneseMcCune,RobertsFY16 Core GoalAchieve 2 Quality Metrics in HAC (Healthcare Acquired Condition) aggregate and SSE’s(Serious Safety Events)SSE’s 1 per month, HAC’s 8Ambulatory Care: LTR across specialties to equal 92.3 or above or 80% of specialties(with more than 25 responses) above 92.3Inpatient Pediatrics, OB and Ambulatory Surgery achieve or exceed their FY 15Likelihood to Recommend mean score.HaeringAchieve FY 16 Operating Expense & Capital Budget (where applicable) in each DivisionSandborgImprove manager, physician, and employee effectiveness by developing leaders ascoaches.In FY 16, 200 people managers (including managers, directors, VPs, executives, medicaldirectors and service chiefs) will attend Coaches’ Academy and lead, co-lead orotherwise participate in Quality, Affordability and/or Service improvements in theirrespective areas of responsibility throughout the enterprise.Souza Increase Grand Mean Engagement score by 0.1 point.Reduce the Rate of Injury for all employees to 5.3 per 100 FTE’sImplement 3000 staff/provider generated improvements (STP’s)Situation Target Proposal

Strategic Initiatives –FY16FY 16 Strategic InitiativesExecutiveOwnersInitiative StatementHospital Expansion, Transition andActivationTo deliver a facility that optimizes the hospital’s services andinfrastructure, supports innovation, enhances the patient and familyMcCuneexperience and enables extraordinary care as a top-tier children’shospital.Strategic Partnerships – current,expanded and newRoberts, Be the indispensable pediatric (specialty) partner for leadingLund healthcare systems.Physician network/practices - includesRoberts, Be the ‘must have’ pediatric and obstetric physician practice [orEnterprise Wide Scheduling, EpicLund network].Optimization, TelehealthVision 2025 clinical program initiatives– Centers Of Excellence, othersDevelop programs and services, leveraging our preeminent faculty andstaff, to advance our capability to provide care, create leading researchMcCuneand innovation, and to achieve unparalleled quality, outcomes, serviceand access.Prepare Stanford Children’s Health to participate successfully inAccountable Care – Infrastructure andBrown, current and future accountable care and population healthcapability development for populationSandborg management contracts with commercial payers, large employers, andhealth, complex care managementstate agencies.

Operational Initiatives –FY16FY 16 Strategic InitiativesExecutiveOwnersInitiative StatementBetter patient flow for patients, staff and the organization; today andfor the future.Better Patient FlowAlbanesePCARES PlusPCARES Plus is an enterprise-wide learning platform that governsrespectful, empathic, nurturing and meaningful interactions across theMcCuneentire human experience spectrum to include all staff and physicians,their interactions with each other and with families and patients.

Enterprise Strategic InitiativesVisibility Wall Cross-functional communication Cross-functional accountability Biweekly 30 minute huddle run by CEO, COO ordelegate Invited attendance by C-level, VPs, applicable Directors Initiative owner provides brief status update ( 5 minutes) Focus on reds, with appropriate countermeasures Annual planning process starts & ends with the wallcontents

Leadership Practice Two:Promote ContinuousImprovement

Value stream flow Patient ansport

Focus on the X’s not the YY is the outcomewe wantX’s are the processes/drivers thatneed to be controlled to get the zed WorkStd work and DMS are how to control the X’sDaily Management

Using standards as problemsolving tools Make issues (abnormalities) visible by implementingstandards and measuring the actual output against theexpected output Then do PDCA to solve the issues at their root (incontrast to quick countermeasures) so that they don’tcontinue to reduce efficiency This approach requires leaders to be very tenaciousabout continuously applying the PDCA cycle

A Daily Management SystemSustains the Improvements

Components of Daily ManagementDMS PrincipleDefinitionReliable Method/Standardized WorkA documented procedure (i.e. how to) with sequence, supplies and quality toll gates,owned by a named individual, used by everyone. When the element of time is added, itis deemed Standardized Work.Reliable Method or StandardWork Audit/CheckA structured check of the process to ensure Reliable Method is followedAbnormality & AndonA system to immediately notify appropriate management, maintenance, providers andother team members of a safety, quality, process or problem requiring acountermeasure. May involve abruptly stopping a process.Continuous improvement process generated and implemented by the frontline, withassistance and coaching from leadership. STP Situation, Target, Proposal.A strategy for creating, supporting, and sustaining process stability through the use ofvisual cues.Problem Solving:Improvement Ideas (STPs)Visual ManagementTiered HuddlesAndon ResponseBrief, structured, stand-up meetings used to review area readiness and identifyproblems.A tiered system to immediately respond to an andon. Involves team leads and a varietyof managers. Quick countermeasure and root cause problem solving requiredLeader Standardized Work:Responsibilities for LeadersA working document (checklist) for leaders specifying the actions to be taken each dayto focus on the processes in that leader’s area of responsibility.Leader Gemba WalkEach level leader above the work unit routinely observes the workplace with thedepartment leader/student for the purpose of supporting the work processes

Leadership Practice Three:Develop Self

Servant Leadership Practices Communicate vision: what is ideal future state, createdissatisfaction with current stateAppeal to head (intellect) and heart (emotions) Walk the Talk—go see reality at least once a week Humble inquiry Listen more than talk Engage the frontline workers: What is getting in your wayof doing your job? Review metrics with area management Foster value stream thinking: build span of supportversus span of control (authority v responsibility) Celebrate the wins

Leader Standardized Work Calendar gemba time: used for time with direct reportsand observing the real work in the hospital/clinic. Nocross-functional meetings Debrief gemba walks at team meetings Attend weekly improvement report outs Attend daily Ops huddle Sponsor improvement event Participate improvement event Construct and own an A3 Complete STPs (Situation, Target, Proposal)

Traditional ManagementLean ManagementFocus on outcome (“get results”)Focus on standardized processes that get the desiredoutcomeAttaining goals trumps all elseDeveloping people has equal weight to goal attainmentManage to industry benchmarksManage to customer requirementsMetrics visible to fewMetrics visible to allBatch and retrospectively review resultsReal time and prospective view of data/resultsManagement tells staff what to doManagement questions, challenges, coaches and offershelp to staffManage from officeManage in gembaProblems are badProblems are treasuresWho produced the error?What suboptimal work process(es) or system producederrorAutocratic, top-down problem solvingGuided, distributed, participative problem solvingAutocratic, top-down goal creationGuided, distributed, participative goal creationOrganizational success attained by time-intensiveanalysis and design of “perfect fix”Success through continuous, rapid, small, incrementalimprovements

Leadership Practice Four:Develop Others

Creating a strong air campaign1. Pit the vision of where you want to be against the realityof the current state to the organization2. Educate and engage the workforce through:1. Point improvements2. Lean pedagogy3. End of week improvement report outs4. Plethora of varied communication methods5. Lean learning trips and networking