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LEAN DAILY MANAGEMENT:LEADERSHIP IN THE GEMBAEduardo OsorioJamie KlimpProcess Management Consultants
WHO IS BRONSON?
System StatisticsWorkforce: 7,100 Employees (1,400 RNs) 1,000 Medical staff members 870 VolunteersLicensed bed count: 648 Acute care beds 115 Skilled nursing facility beds 49 Psychiatric/gero-psychiatric beds
Bronson’s Service Area
Bronson Healthcare Group Regional, not-for-profit health system Serving southwest Michigan since 1900 Bronson Methodist Hospital-Located inKalamazoo, Michigan 21,500 discharges and 103,000 ED visits
WHY GEMBA WALKS
Why Gemba WalksLeaders tell us they want to: Create a culture of problem solversAlign organizational goals withdepartment goalsIncrease employeeengagementBring executives tointeract with employees
Why Gemba WalksFront Line Employees tell us: “I don’t know how to ask for help” “My boss doesn’t know what I do” “The left hand doesn’t know what the right handis doing” “I’ve tried to implementchange but got frustrated”
WHAT AREGEMBA WALKS?
Bronson’s Improvement (EDI) Model
Lean Daily Management Daily HuddlesDaily Check InGemba Walks (The focus of thispresentation)
This is Gemba
This is NOT Gemba
Gemba Walks Daily (Monday-Friday)Along a Specified RouteAround a Standardized BoardBy an Executive and a DirectorStandard Scripts
Gemba Walk Video
What do they look like?Metric BarChartsPareto ChartAction Plan5 Whys
What do they look like?Metric BarCharts
What do they look like?Pareto Chart
What do they look like?Action Plan
What do they look like?5 Whys
Gemba WalksCurrent State3 Service Lines haveGemba Walks Cardiac (5 Boards)Neuro (5 Boards)Ortho (6 Boards)One Support Service Line(5 Boards) Patient Access/Environmental Services(Manager Led)(6 Boards)
HOW TO CREATEA GEMBA WALK
Preparation No Meeting Zone (10:00-12:00) Executive and Director Training CEO to do first walk
Gemba Walk Standard ScriptGemba Walkers1.The Executive Rounding Team is led by aspokesperson.Board Presenters2. Say “Good morning” to the leader of the Gemba &state your name and role.Note: Get right to the report out. You are reporting on the last24 hours of activity with some exception for weekend items.3. The spokesperson warmly greets the presenter &introduces others (including their department/role).5. Verify a cause been found (Pareto / 5 Whys) andthere is a strategy in place (Action Plan). Reviewthese on the board and further discuss, if necessary.Provide guidance and help to remove barriers. This isthe critical part that the Leadership team plays in theGemba to7. To conclude, the spokesperson asks: “Do you havewhat you need to meet your goals today?”4. Present from left to right on all the metrics.Example: Our Safety Metric is Patient Falls; Our target iszero; We are green for our safety metric. We didn’t meet ourQuality Metric, which is Mislabeled Specimens, for the last 24hours. Our target was “X” and our actual was “Y”. We had anissue with “Z” (Pareto). We have completed a 5 Why and theRoot Cause is “A”. We have identified action item on ourAction Plan.6. When this process is complete, ask “Do you haveany questions for me or the team?” If you do notknow the answer (and no one is available) put it on the actionplan to follow up on and available for them to view on the nextGemba Walk.8. Thank them for coming!
Walker Key Points Red is Okay– Make sure presentersunderstand that red shows good problemselectionBoard purpose “Problem Solving Tool”NOT “Report Card”Make focus and questions about “ActionPlan” items
Format 4 Day Kaizen Event Format was Used toImplement Gemba Boards
Steps to Create aGemba WalkLearn ProblemSolvingBuild BoardsDevelop MetricsTrain StaffPractice RunFinal Run
Develop MetricsLearn ProblemSolvingBuild BoardsDevelop MetricsTrain StaffPractice RunFinal Run
Develop Metrics Staff are given some time to think aboutmetrics before the event Staff are coached in the event to come upwith the original 4 metrics Staff are coached after the event whenit’s time to change the metricsStaff Choose the Metrics
What are Metrics?They are grouped into five basic categories:Safety - Falls, Employee Injuries, PPEQuality - Documentation, Errors, Right the first timeDelivery - Timely Responses, Correct InformationProductivity - Man hours, Overtime, Idle timeCost - Delays, Inventory on Hand, Over-processing
What is moreimportant?SafetyPatient/Customer and EmployeefocusedQualityPatient focusedDeliveryProductivityBusiness FocusedCost
Sample MetricsCardiac Value Stream AreaCall CenterAreaAdvancedCardiacSafetyQualityDeliverynone at this time 5 orders with problemsper day0 call center schedulingerrorsSafetyZero Patient FallsCardiology90% of patients will havetheir sheaths DC'd within30 minutes of normal ACTSafety100% Document Contrastusage in EPICCath Lab& PRUAreaCardioVascularServices(CVS)100% appropriate TimeOut for All proceduresSafetyPre-Stress Check Listreceived prior to test 90%of the timeCostnone at this time0 accident yDiagnostic TurnaroundPatient Wait Time 30Order reconciliation ofabnormal nuclear or echoZero occurrences of MIminutes from sched. ApptTesting Procedures andwithin 24 hours to MACalldown to non-scheduledto Provider Contact at leastEKG's to be marked done100% of the timeprovider50% of the timeECIS 80% of the timeAreaAreaProductivity5 days ahead of preregistration.none at this timeQualityDeliveryProductivityCost100% Documentation ofPatient I & O per shift80% of Dischargedpatients leave unit within 1hour of order QualityZero Incorrect StressOrders received100% of Patients arrivewith appropriate attire80% First Case On Time inNo PRU Staff misseseach lablunches between 12 & 2noneDeliveryProductivityCost70% of Stress Tests arestarted within 15 minutes ofscheduled timenonenone
Learn Problem SolvingLearn ProblemSolvingBuild BoardsDevelop MetricsTrain StaffPractice RunFinal Run
Learn Problem Solving Training includes: 5–WhyChoosing the right problemsBrainstorming CountermeasuresManageable experiments
Pareto Analysis
2/17/145 Why’s Worksheet Date:Completed by: John, Stephanie R, & BobDefine the Problem:The car won’t start because the battery is dead.Why is this happening?1. The alternator did not charge it correctly.Caution: Don’tjump toWhy isConclusionsthat?2. The alternator is not rotating.Why isthat?3. The belt driving the alternator from thecrankshaft pulley is broken.Why isthat?4. The belt was not changed at correctmileage interval.Caution: Focus onthe Why’s NOT theWho’s5. The owner did not follow therecommended maintenance schedule.Why isthat?
5 Why’s
2/17/145 Why’s Worksheet Date:Completed by: John, Stephanie R, & BobDefine the Problem:The stone on the Jefferson Memorial was crumblingWhy is this happening?1. The stone was crumbling because it waswashed too frequently.Caution: Don’tjump toWhy isConclusionsthat?2. It was washed regularly to remove the birddroppings.Why isthat?3. The birds flock to the building due to theabundant food supply of little fat spiders.Why isthat?4. There are so many spiders because theyare attracted to all of the midges.Caution: Focus onthe Why’s NOT theWho’s5. The midges are attracted to light andemerge in a mating frenzy when the ParkService turns on the spotlights at dusk.Why isthat?
Solution:Delay the daily lighting to one hour aftersunset. Midge population went down 90%,they have broken the food chain and thereare less frequent washings.
Build BoardsLearn ProblemSolvingBuild BoardsDevelop MetricsTrain StaffPractice RunFinal Run
Build Boards
Build BoardsYou will need: Post-it packages (2)Sign Holders (12)Screwdrivers (1)Screws (27)
Train StaffLearn ProblemSolvingBuild BoardsDevelop MetricsTrain StaffPractice RunFinal Run
Train Staff Staff Training Staff Employee Roster ensures100% Completion Different Levels ofTraining Observer Apprentice Expert
Practice GembaWalkLearn ProblemSolvingBuild BoardsDevelop MetricsTrain StaffPractice WalkFinal Run
PracticeGemba Walk
Final RunLearn ProblemSolvingBuild BoardsDevelop MetricsTrain StaffPractice WalkFinal Run
Final Run
PDSA(PLAN DO STUDY ACT)
PDSA(Plan Do Study Act) SharePoint Gemba Board Owners Action Plans moved underMetrics Week-long commitments Process Management Supporton Mondays Maps available inthe meeting area Manager led walksare successful!
Upcoming Thoughts/Changes Incorporating BronsonPractices Develop devoted teamproblem solving time More coaching throughmanagers Identifying organizationalmetrics related to theboards Including Patients andFamily Advisors on thewalk
Sample Results
Orthopedic Gemba Walk
Thank You!bronsonhealth.com
Gemba Walk Standard Script 1. 2. Sayspokesperson. “Good morning” to the leader of the Gemba & state your name and role. Note: Get right to the report out. You are reporting on the last 24 hours of activity with some exception for weekend items. 4. Present from left to right on all the metrics. Example: Our Safety Metric is Patient Falls; Our target is zero; We are green for our safety .
