Stock Keister, Mary, MD

Taus, Karen A, PMP

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of Family MedicineUtilizing LEAN Tools to Develop and TestStandardized Work in a Residency ClinicMary Stock Keister MDLehigh Valley Health Network, Mary_C.Stockkeister@lvhn.orgKaren A. Taus PMPLehigh Valley Health Network, Karen.Taus@lvhn.orgFollow this and additional works at: https://scholarlyworks.lvhn.org/family-medicineThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtStock Keister, M. Taus, K. (2018, December 6-9). Utilizing LEAN Tools to Develop and Test Standardized Work in a Residency Clinic.Poster Presented at: Conference on Practice Improvement Society for Teachers in Family Medicine (STFM), Tampa, FL.LVHN.org© 2018 Lehigh Valley Health NetworkUtilizing LEAN Tools to Develop and Test Standardized Work in a Residency ClinicMary Stock Keister, MD Karen Taus, PMPLehigh Valley Health Network, Allentown, Pa.RESULTS•  By the second week of PDCA in the first teamlet, previsit planning was done on 100% of daily charts•  Forms were prepped for physician in 78% on sessions•  Co-located teams members felt positive about the change on several satisfaction measures (performed weekly)DISCUSSION•  Teamlets prefer the post-PDCA state•  Teams took greater ownership of their schedules, their forms and their patients. •  Patients are starting to notice and request teamlet staff•  Staff awaiting team assignment are starting to engage with their daily clinician more effectively, asking for huddles, because they see teams doing it•  When the process seems too big to tackle, the driver diagram helped identify areas of focus and achievable interventions. CONCLUSIONKeys to success:•  Avoid analysis paralysis•  Don’t wait for perfect team or  perfect plan•  Start small•  Encourage teammates to try their own things•  Address tribal leaders and water cooler conversationUse the change process to create standard work•  Becomes onboarding material for new hires•  Creates sustainability Figure 3: Planning ProcessFigure 4: PDCA and  Implementation DocumentsAIMBring highly effective care teams to the Family Health CenterINTERVENTIONWalkie-talkiesFloor supervisors – "Air traffic controllers"Defined flow stations with co-locationDefine time spent in direct versus non-direct patient carePSR to 2nd floorIn room checkoutPSR assigned to teamCCT/GWEP/CDE wrap-aroundForms flowPre-visit planningAll staff knows FHC processesHuddles: teamlet and practiceSECONDARY DRIVER2 floors - barriersDefined spacesSupport staffClinicalClericalExtendedLVPG protocolsLocal flowResident trainingWork environmentPRIMARY DRIVERPhysical StructureRolesProcessesNormsFigure 2: Driver DiagramBACKGROUND / INTRODUCTION•  High functioning primary care residency clinics share characteristics including engaged leadership, team-based care and meaningful, data-driven quality improvement.1 •  During leadership vacuums (medical, clinical, operational), residency practices are especially vulnerable to breakdowns in standardized work, performance measurement and improvement activities.SETTING•  Urban family medicine residency program clinic within a large multi-hospital health network •  8800 patient empanelmentMETHODSUtilizing a LEAN A3 problem solving approach, a multi-level team of faculty, clinical and clerical staff, and non-practice colleagues conducted:•  Identification of gaps and breakdowns•  Root Cause Analysis•  Countermeasure intervention  design•  Evaluation design•  Pilots (forms, care team  alignment, and pre-visit  planning)•  It became apparent that using the LEAN A3 outline was confusing the team, as they were concentrating on process rather than problem solving.  A driver diagram was introduced to clarify the primary issues the team wanted to address.ACT• What barriers impacted implementation?• What issues haven’t been resolved?PLAN• Develop/refine interventions• Strategize implementation DO• Roll-out to cohort(s) of practice staff• Intentional use of intervention featuresCHECK• Review tracking sheets• Staff feedbackPDCA FHC- Care Teams Pilot- Colocation- 9/28/18 msk   Project:  Care Teams to the FHC Cycle #: 1 Date:  October 1, 2018 Lead Person: Mary, Myra Objective:  (Outcome + the Purpose)   Co-locate Clincian and MA in consistent team and learn basic skills of being in a care team PLAN Questions/Changes “If we do X, Predictions (can be + and -) we expect Y” 1.  If we do Previsit planning 1. we will identify reason for visit and gaps in care/ HM items for action  2.  If the teamlet huddles early in each session 2. teamlet communication and planning for each session will improve 3.  If the clinical support brings clinician forms to each session 3.  forms will be completed more quickly and get lost less often 4. If we outreach to chronic disease returns, new patients and well child patients 4. we can identify patients likely to no-show, get more immunization records and advise on guardian presence for well-child visits.  What data will be collected during this time? Daily questions on tasks, weekly questions on satisfaction Where: FHC               DO the Action Plan Who (individual/team) will perform the test? Marlene Gonzalez, MD; Bianca Veliz, MA, PSR TBA  How long will the test be run? (2 weeks, 1 month): 10/12/18  CHECK Complete analysis of data.  Summarize what was learned include results of predictions. What happened that you didn’t expect, (both + and -)?  Lots of clinical schedule changes and same day sessions make PVP and huddles less effective.  These sessions also tend to end later.  Neither clinician nor MA would go back to previous model (no alignment)  What went wrong?  What happened that was not part of the plan?  Loss of Bianca for 1 week unexpectedly.   Unable to add PSR as they are shorthanded and unable to identify any tasks to remove to allow even a single PSR to make outreach calls ACT What decisions were made from what was learned? PVP needs to be better defined and standard work done  What will be the next cycle? 10/22/18-11/2/18  version 111/26/18Macintosh HD:Users:paulayoo:InProgress:LVHN:POSTERS:N06985 MaryKeister_Poster:PVP-Clinical-Standard Work.xls STANDARD PROCESS STEPWho?How/Where?Why?1Go to daily session in EpicFlow ManagerSchedule tabIdentify patients appropriate for today's PVP session2Go to chart reviewFlow ManagerHighlight pt name, click on chart reviewGet into individual patient's chart for review3Go to Health Maintenance moduleFlow ManagerClick on "Health Maintenance" in patient chart banner.  It is yellow if there are overdue itemsPart of HAM, 4Identify: Is patient diabetic?Flow ManagerDo they have diabetic metrics in HMDiabetics have more recommended testing and referrals and this needs to be tracked.5Does patient have undone labs?Flow Manager Anything listed as "Ordered" in lab tab which was ordered by FHC clinician Do they need labs before they are seen?6Does patient have undone imaging studies?Flow Manager Anything listed as "Ordered" in imaging tab which was ordered by FHC clinicianDo they need that study done before they are seen?7Does patient have undone cardiac studies?Flow Manager Anything listed as "Ordered" in cardiac tab which was ordered by FHC clinicianDo they need that cardiac study before they are seen?8Does patient have pending referrals?Flow Manager Anything listed as "Ordered" in referrals tab which was ordered by FHC clinicianDo they need the referral completed before they are seen?9 Review last FHC office visit note and/or PCP visit noteFlow ManagerUnder Encounters tabWill help answer the above questions10Review any interval notes from other officesFlow ManagerUnder Encounters tabWill help FHC clinician put the story together and not miss importance care items11 Is this a procedure visit?Flow ManagerReason for appointmentEnsure needed equipment availableApproval Date:Implementation Date:STANDARD WORK FOR: ___Previst Planning- Clinical- FHC_____________________________ Approval Signature(s):Figure 1: PDCA CycleREFERENCES1.  Gupta, R, Barnes K and Bodenheimer, T. (2016) Clinic First: 6 Actions to Transform Ambulatory Residency Training. Journal of Graduate Medical Education: October 2016, Vol. 8, No. 4, pp. 500-5032.  Feld, William M. (2001). Lean manufacturing : tools, techniques, and how to use them. Boca Raton, FL : Alexandria, VA :St. Lucie Press ; APICS.3.  Provost L, Bennett B.  What’s Your Theory? Driver diagram serves as a tool for building and testing theories for improvement. Quality Progress.  2015 Jul: 36-43.

Utilizing LEAN Tools to Develop and Test Standardized Work in a Residency Clinic

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Utilizing LEAN Tools to Develop and Test Standardized Work in a Residency Clinic

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