Medical Staff Engagement & Lean Management

Diane Bissenden

Director, Population and Family Health Vancouver Coastal Health – Richmond

Dr. Brenda Wagner

Chair, Richmond Medical Advisory Committee Clinical Associate Professor, Obstetrics & Gynaecology University of British Columbia

Laura Sato

Coordinator, Lean Transformation Services Vancouver Coastal Health February 28 th , 2013

Burning Platform

How do you engage medical staff in yet

another

administrative process to drive patient safety and quality improvement?

How do you ensure sustained medical staff engagement in system redesign that is based on Lean principles?

Medical Staff Engagement: Current State

Initial State

: • Medical staff disengagement as have lived through multiple administrative change efforts • Improvements have been ‘tried before’ and not sustainable • Long standing issues that have not been resolved and people didn’t believe the issues could be changed

Feedback from Medical Staff

• “There is lack of physician engagement” • “Management should make the changes and leave us alone” • “Everyone else around the table is paid for being here except for physicians”

Medical Staff Engagement: Ideal State

Ideal State

: • Medical staff engagement in Lean as a unique and successful change management process • Improvements are sustainable • Long standing issues are resolved and medical staff believe they are part of the change

Target State

: • One medical staff member from each relevant discipline will engage in the process i.e. family practice, midwifery, obstetrics, paediatrics, and anaesthesia • Process inspires ongoing engagement

Birth Centre Initiative: Goals and Area of Focus

Provide quality family centred care for women and their families Promote people first Enhance capacity of the interdisciplinary team to use their talents to its full potential Embed Lean thinking at all levels to fulfill objectives and to deliver quality outcomes

Birth Centre Initiative: Deliverables

• Increase capacity to do Caesarean Births and recovery in the Birth Centre • Build processes to manage surges • Provide timely outpatient services – Triage, assessment, non-stress tests & inductions of labour, etc.

• Standardize processes from decision to Caesarean Birth

Birth Centre Initiative: Engagement of People

• Medical Staff – Obstetricians – Family Physicians – Paediatricians – Midwives – Anaesthesiologists • Nursing Staff – OR/ PACU/ Birth Centre/ NICU/ Staff Support Coordinators • Allied Health Staff – Respiratory Therapists, Social Work, Laboratory Services • Support Services – Housekeeping, Unit Aides, Sterile Processing Aides, Unit Clerks, Medical Office Assistants

Medical Staff Engagement Strategies

• Physician co-sponsor on the team • Funding for medical staff time spent in Lean initiatives • Off site obstetrician & anaesthesiologist meeting on Code Pink & Skin to Skin in Operating Room • Ad-hoc meetings during down times with on-call medical staff (end of the day) • Hallway conversations (1:1) • Feedback obtained during observations (1:1)

Medical Staff Engagement Strategies

• Arrange Working Group Meetings around medical staff schedules: – Lunch times & end of the day – Organize meeting agendas so physicians can attend at times when their key issues will be highlighted • Mixture of 2 hour, full day & ½ day workshops • Piggyback on existing medical staff meetings • Provide ample notice for meeting invitations • Invite medical staff in person • Invite on-call medical staff

Medical Staff Engagement in Lean Management

• Process improvements occurring in tandem with Lean Management – Using Lean Management approach based on ThedaCare Model – Three physicians attended Lean Management education • Applying Lean principles to clinical office setting • Organization investing in physician education in order to support improved patient care • Physicians feel part of the team

Lean in Action: What is Code Pink ?

Obstetrical emergency requiring imminent delivery of baby Better response time Better outcome for patient Better team

Code Pink: Standard Work

OB (co-pilot)

-Provides direction to the team -Verbal consent & explanation -Primary RN gives report -Site mark?

Anaesthesiologist (co-pilot)

-Greets pt -?who can get the meds the quickest -Check equipment -Receive report from OB

Paediatrician

-Prep for baby resuscitation -Double check ICC -Primary RN gives report

Birth Centre Initiative: Code Pink Mock Session

Initial Mock

Noisy – lots of talking Repeating questions multiple times Lots of double checking Too many people in the room

Post - Actual Code Pink

Calm & quiet Staff know what to do Duplicated work- # of people doing the same thing Roles and responsibility clarity Trusting environment

Medical Staff Testimonials

Keeping mothers and babies together after birth encouraged me to participate Best thing was seeing the capacity we have within our frontline staff to make changes happen. This is the power I see Lean harnessing that I have never seen harnessed before.

Doctors see the satisfaction their patients and babies are kept together. This satisfaction is encouraging the doctors.

“…..If you want to show us this is different, fix the problem no one has been able to fix in 20 years emergency caesareans”. This physician now states with enthusiasm that LEAN is making a big difference and we are being successful.

Sessional payments are helpful and meaningful I have been “blown away” by the improvements during the past year

Birth Centre Outcomes

Indicator Baseline % Target ∆ Outcome ∆

Reduce the Birth Centre OR Turnaround time % of Caesarean Births done in BC OR 3:30 h 27% ↓ by 50% ↑ by 50% Code Pink Response Time (Decision to Baby born) Medical Staff Engagement 30~ minutes 4 per engagement opportunity ↑by 200% *30 day data 1:30 h (138%↓) 75% (185% ↑) 18 minutes* (↓ 40%) 400%

Reasons for Success

• Strong physician, director & manager leadership • Strong relationship between medical staff and clinical resource nurse (over 20 yrs) • Operational and medical staff leadership “Walk the Talk” • Engaged and stable team (low turnover) • Project leadership share successes • Organizational commitment in form of individuals with expertise in lean thinking

Operational Sponsor’s Experience

• Setting the stage at the beginning of every session, no matter where you are in the process • Simple is usually complex • Don’t get discouraged when things get “messy” – trust the process • Medical staff participation in all aspects of the Birth Centre quality improvement initiative adds value and strengthens team relationships • Deeper level of engagement and pride in the change, through doing together • Continuous improvement is embedded in the culture of the Birth Centre

Physician Sponsor’s Experience

• Be flexible with meeting times • Invite people personally • Sometimes a different venue can overcome obstacles • Projects identified by frontline staff as “unfixable” will convert the hard of heart • Practice, Practice, Practice …embed, embed, embed