Daily Management

Julie Fry

October 2014

Today’s Objectives

• (Minor) Understand how Daily Management

fits in with VM organizational management

framework

• (Major) Identify the 5 elements of Daily

Management

• (Major) Understand how Daily Management

principles can support your leaders and team

members

2

The Virginia Mason Production System

We adopted the Toyota Production System

philosophies and practices and applied them to

health care because health care was so lacking in

an effective management approach that would

produce:

• Customer first

• Highest quality

• Obsession with safety

• Highest staff engagement

• A successful economic enterprise

Traditional Health Care Management System?

World-Class Management

The World-Class Management System is a leadership

system that provides focus, direction, alignment, and a

method of management for daily work

This Or This

5

World-Class Management

Management

by Policy

Provides focus and direction

Daily

Management

Manages daily work

Cross-Functional

Management

Aligns across the organization

toward full customer satisfaction

World-Class

Management

System

The World-Class Management System is a leadership

system that provides focus, direction, alignment, and a

method of management for daily work

Annual Goals

Long Term Vision

KPO Priorities

Clinic Priorities

Section Priorities

• Develop and impl ement a "know you" template in our electro nic

medical record (EMR)

• Standard touch point behavi or (Milks hake) TBD

• Contribute to my team's excell ent phone service performa nce

• Work to resol ve patients needs i n one call

• Measure and i mprove message l ead time

• Simpli fy scheduli ng "rules", s hare best sc heduling pra ctices, a nd

reduce appoi ntment types

• Design and test innovative c are delivery model s

• Increas e patient enroll ment in MyVirgini aMaso n

• Pilot pa tient direct sc heduling

• Identify new ways to engage pa tients to use the portal

• Know and expla in how Virgi nia Ma son is present for pati ents

within my communi ty

• Schedule pati ents for foll ow-up appointments before they lea ve my

cli nic

• Successfu lly i mplement our ambulator y computerized provid er

order entry (ACPOE) sys tem

• Give patients the s pecific i nformation they need to navigate next

steps in their care

SHARE

PREPARE

• Implement new workflows using ou r electronic

medical recor d (EMR)

• Help us gro w! Champion our lo cations, services

and qualit y to prov ide our patien ts what they n eed

How do I contribute to

these goals?

• Treat every call, every message as ou r patient

Clinic Focus Areas:

Our Work in 2014

BE THERE

• Be present w ith our pat ients; demonstrate tha t

we know t hem and care

• Engage p atients in using MyVirginiaMason to

improve t heir health and well-being

• Just say yes! Offer p atients care when, w here and

how it is desired

Management by Policy

Aligning Vision with Resources

5 year Plans

Adapted from elements of World Class Management, Management by Policy

Reflection

•Environmental

Scanning

•SWOT

•Review 5 Year

Plans

•A3

Deployment

Production plan

Understanding/ awareness

Develop strategies for

entire organization

departments

individuals

Check and

Review

Compare performance to

plan

Occurs at all company

levels

“Catchball”

Idea exchange

Feedback, engagement

Identify resources / roles

Set measurement criteria

Management By Policy, or Hoshin Kanri

PLAN

DO

STUDY

ACT

ENGAGEME

NT

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Check and Review Cycle

•regular checks and reviews are critical

•determines current status of goal achievement

•conducted regularly (e.g., daily, monthly, quarterly)

•includes intensive, objective study of data

•joint problem-solving, planning, and follow-up may be

required

Cross-Functional Management

A management system for implementing

breakthrough improvements that is always

focused on the elements of full customer

satisfaction

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• Achieving full customer satisfaction requires

integrated cross-functional management, teams

working together, not at cross purposes

• Top leadership must integrate the organization

into a close-working system

• All functions must work together to achieve

optimum quality, delivery, cost and service

(QDCS)

• “The ‘horizontal weave’ must be stronger than

the ‘vertical weave’” Kaoru Ishikawa

Cross-Functional Management

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Cross Functional Management

Periop

Flow

Clinic

Experience

Inpatient

Care

Follow Up

Care

Orthopedic Value Stream

Daily

Management

13

Daily

Management

Repetitive daily activities and behaviors that leaders

engage in to ensure customer demand is met and

identify abnormal conditions:

• Know at a glance status of daily work

• Completing planned work

• Understand status of upstream and downstream

processes

• Standard work being followed

• Know when to take action and what action to take

• Engaging Staff

Daily Management

As a leader you have 2 jobs:

1. RUN your business

2. IMPROVE your business

Daily management

is HOW you do

this…

15

The Leader’s Primary Mission

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The FIVE Principle Elements of Daily Management

Visual Controls

Create linked

visual systems

that drive action

Daily

Accountability

Process

Establish rounding

process at all

levels

Leader

Standard Work

Leaders routinely

complete key

activities necessary

to run and improve

their business

Root Cause

Analysis

Asking “why” and

using data and

analysis to attack

problems

Discipline

Leaders

consistently

verify the health

of processes

and systems

In order to run your business, you have to

KNOW your business.

Start with understanding your demand

• A metric that reflects your departmental objective – one that tells you

whether you’re meeting your day-to-day customer requirements.

(e.g., 22 patients per day per MD, or Ortho surgery schedule

= 5 total hips on Tue, L9 requires 5 empty beds. etc)

• A metric that reflects the health of your departmental processes.

(e.g. 48 hour post discharge phone call for all medical patients)

NOTE: Be sure you are looking at process measures versus outcome

measures (e.g. how is your staff currently handling the demand of phone calls

versus what do the phone stats show on the analytics report retrospectively?)

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Demand

Now that you have identified your demand, what is your

supply (what resources do you need to meet demand)?

Hospital example:

• Daily staffing and types of staffing needs (RNs, PCTs,

MAs, MDs, RTs, etc)

• Room availability?

• Special equipment?

18

Supply

Production Boards

Understand your business

• Key business function to meet customer demand

• Daily/weekly demand (plan). (Pts., files, checks, etc.)

• Capacity (FTEs, rooms, machines)

Make it visual

• Determine best metric-should be process not outcome

• Frequency to measure (daily, weekly)

• Visual display of plan versus actual

• Communicates key expectations with simple visual displays

Make it easy (at a glance)

• Standards are clear (quantifiable activity)

• Abnormal conditions are visible

• Improvement opportunities are apparent

Visual Control

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Visual Control Starting Point

20

Visual Control

Number of patients

being seen today,

should have this many

charge slips

Production Boards

• Cardiology

• CTS

21

Phlebotomy

AM Draw Production Board –

team assignments and team

leaders

Daily schedule

Daily Management

TRANSFO

RMATION

VMPS

TWI

Daily

Management

Respect for People

Quick and Dirty

24

Patients can see status

Visual Controls

Visual signal for help

Staff member can see

& re-assign to help

Here’s an example of how insurance

payment closure understands their business daily

Responding to abnormalities

27

Daily Accountability

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1. Visual

Controls

Create linked

visual systems

that drive action

2. Daily

Accountability

Process

Establish

rounding process

at all levels

3. Leader

Standard

Work

Leaders routinely

complete key

activities

necessary to run

and improve their

business

4. Root Cause

Analysis

Asking “why”

and using data

and analysis to

attack

problems

5. Discipline

Leaders

consistently

verify the

health of

processes

and systems

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• “Go see. Ask why. Show respect.” (Mr. Cho,

Chairman TMC)

• Regular checks on the production boards

• Process to follow up on the stories told by the visual

controls

• Leaders hold people accountable for completing

their assigned tasks

Genba Rounds

Visibility of all levels of leadership involvement

Huddles

Daily Accountability Concepts

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Huddles with Standard Agenda

• Demand: expected vs. current

• Capacity: availability of staff, beds, appointments, etc.

• Identify and trend abnormalities/assign improvement work

as needed

• Develop plan to address any variances

• Performance from the previous day to be recognized or

addressed/improved (e.g., quality measure such as phone

stats, outstanding WIP, etc.)

Huddle

Agenda

*Staffing

*Demand

*Capacity

*Yesterday’s Performance

*New Issues

Daily Accountability Process

Build the foundation with genba walks and a routine for huddles.

• Team leader huddle with team at start of shift at a minimum

once per day

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Team Huddle

RUN my business:

- Standard agenda/checklist

- Staffing and rotation

- Updates regarding performance from the previous day

- Takes place at the production board

- Review today’s plan – note issues

- No longer than 15 minutes; standing up

• Team leader huddle with team

• Supervisor huddle on genba with team leaders (daily)

32

Genba Round

RUN my business:

Review production boards

Safety, Service, Quality, Cost

IMPROVE my business:

Review issues from previous day – trend

abnormalities

Task assignment (red dot, green dot)

From the trending of production issues, visual board depicts

who is assigned, due date, and on task (green) or off (red).

• Team leader huddle with team

• Supervisor huddle on genba with team leaders (daily)

• Supervisor huddle on genba with manager (weekly)

33

Genba Round

Leadership

Review issues, trends, abnormalities

Conducts Root Cause Analysis

Create/review action plans

• Team leader huddle with team

• Supervisor huddle on genba with team leaders (daily)

• Supervisor huddle on genba with manager (weekly)

• Manager genba walk with directors/executives (monthly/quarterly)

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Genba Round

RUN/IMPROVE my business:

- Starts at production board

- Review issues, abnormalities, trends

- Opportunity to discuss and make a plan for issues that cannot be solved locally.

Barriers to daily huddles include:

• 24/7 operation

• Phone work (can’t remove everyone at same time)

• Staggered start times

• Staff work from home

Some ideas our staff have leveraged:

• Videotape

• Sharing of huddle leadership

• Cascading huddles

35

Daily Huddle Barriers

Leader Standard Work

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1. Visual

Controls

Create linked

visual systems

that drive action

2. Daily

Accountability

Process

Establish

rounding process

at all levels

3. Leader

Standard

Work

Leaders routinely

complete key

activities

necessary to run

and improve their

business

4. Root Cause

Analysis

Asking “why”

and using data

and analysis to

attack

problems

5. Discipline

Leaders

consistently

verify the

health of

processes

and systems

Clinic Supervisor Daily List Director Daily List

Standard work for leaders specifies the actions to be

taken each day to focus on the processes in each

leader’s area of responsibility.

Standard Work for Leaders

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Frequency

Daily

Weekly

Monthly

Review Financials & Report Variances (information/report

specific)

x

Document & Follow Up on Issues/Concerns

x

Document & Follow Up on

Patient Alerts & Defects x

Review and Updated Kaizen Plan

x

Operational Rounding (Leader rounding, Service rounding,

etc.)

x

Conduct Purposeful Genba Observations supported by VMPS

tools

x

Applause Recognition

x

Sweep Staff Readiness: Performance Evals, FFD, etc.

x

Review Press Ganey

x

Essential Assigned Work for Each Site Leader

Critical Elements

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Essential Assigned Work for one leader at each site

Leader Standard Work Checklist Frequency

Essential "Assigned" standard work for at least one Leader

Daily

Weekly

Monthly

Conduct Daily Huddle with Standard Work

x

Review & Sign Genba Production Board (throughout the day)

x

Sweep Work Environment/Facility

x

Sweep for WIP (electronic systems for urgent messages i.e., Outlook, Cerner,

etc.)

x

Review

Kronos (Overtime, no breaks, etc.) x

Plan & Schedule Staffing

x

Perform Required Safety Audits & Checks

x

Review VMPS for Leader Status

x

Track & Trend Production Board Defects/Issues

x

Update

PeopleLink x

Critical Elements

1. Keep standard work with you all the time

• Clipboard, card, daily planner

• Sequence of tasks

• Visual

2. Note completion of tasks

• Note if not completed in sequence

• Checklist

3. Record daily notes

• Review for opportunities at standard times

• Update standard work for leaders tool after

solutions implemented or kaizen

40

Suggestions for Leader

Keeps these on

a clipboard for

rounding (Daily)

Kept on

clipboard for

both leaders to

use (Weekly)

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Examples

“

“The purpose of a lean system is

to make problems glaringly

obvious.”

Robert W. Hall, Editor in Chief

Target, Association for Manufacturing

Excellence

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1. Visual

Controls

Create linked

visual systems

that drive

action

2. Daily

Accountabili

ty Process

Establish

rounding

process at all

levels

3. Leader

Standard

Work

Leaders routinely

complete key

activities

necessary to run

and improve their

business

5. Discipline

Leaders

consistently

verify the

health of

processes and

systems

4. Root

Cause

Analysis

Asking “why”

and using data

and analysis to

attack

problems

Root Cause Analysis

Root cause

– “The basic source from which a problem

grows” David Mann, Creating a Lean Culture

Analysis

– A structured process of breaking a topic into

smaller parts to gain a better understanding

Improve Your Business

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1) Identify and define the problem.

2) Quarantine the problem and take immediate REMEDIAL

actions.

3) Involve the appropriate, knowledgeable people.

4) Conduct RCA (Root Cause Analysis).

5) Identify root cause solutions, assess them and test

preferred alternative.

6) Implement root cause solution(s).

7) Monitor and revise the solution(s) as indicated by

performance data.

Steps from Identification to Solution

Your production board, daily rounding and

tracking, value stream map, defect metrics, etc.,

will show you where to start.

This is knowing your business.

This can be MUCH harder than it sounds…

Step 1: Identify and define the problem

This allows the workers to stop the line,

identify the issue and correct immediate

defects

A structured process solves the problem

and changes the culture from creating a

work around

Step 2: Quarantine the problem and take immediate

remedial actions

• Upstream

• Midstream

• Downstream

• Sidestream

• This list may expand and contract as you get to

real root cause.

Step 3: Involve the appropriate, knowledgeable

people

RCA is more than fixing the current problem, it’s

about preventing it from occurring again

– 5 Whys

– Affinity Diagrams

– Fishbone Diagrams

Step 4: Conduct Root Cause Analysis

Root Cause: Looking at Data 3 Ways

Defect by

product grouping

Defect by root

cause (process

accountable)

Defect by risk to

the patient (Red,

Orange, Yellow)

Example of Fishbone for RCA

You can only improve your business if you now take action.

VMPS as management methodology enables us

to:

– Understand the current state-Standard Operations

– Solutions to test-Idea generation

– Improve-VMPS Methods

– Continual Improvement-Kaizen Action Plan (multiple

roots?)

Step 5: Identify root cause solutions, assess

them and test preferred alternative

• Change Management

• Training

• Communication

Step 6: Implement root cause solution

• Production board tracking

• Assess if multiple roots exist for the same

problem

• Kaizen action plan lets you have a structured

plan for addressing ALL identified roots.

Step 7: Monitor and revise the solution as

indicated by performance data

1. Visual

Controls

Create linked

visual systems

that drive

action

2. Daily

Accountabili

ty Process

Establish

rounding

process at all

levels

3. Leader

Standard

Work

Leaders routinely

complete key

activities

necessary to run

and improve their

business

5. Discipline

Leaders

consistently

verify the

health of

processes and

systems

4. Root

Cause

Analysis

Asking “why”

and using data

and analysis to

attack

problems

Discipline

• The adherence to a defined process

• Lack of follow through/rigor (discipline) is the leading

cause of ‘failure’ in a lean culture

• This is the at a minimum Genba walk in action

How do you build accountability into your work?

What leader behaviors exhibit commitment, relationship,

reliability and inspiration?

Discipline

56

Discipline on the Genba

Our team members tell us Daily

Management…

• Enables quicker correction of problems

• Provides staff with regular, predictable

communication channels

• Makes leaders & their work more visible to staff

• Builds trust & transparency

– More constructive problem-solving, less blaming

• Boosts quantity/quality of ideas

• Gives leaders more predictability in their day

ED Results

5274

5305

5651

86.6 %

87.9 %

90.8 %

5000

5100

5200

5300

5400

5500

5600

5700

5800

5900

6000

186

188

190

192

194

196

198

200

202

204

206

208

QTR 1 QTR 2 QTR 3

2013 ED Length of Stay, Census and Patient Satisfaction

Score

ED ALOS mINUTES Census PG Patient Satisfaction Score

0

5

10

15

20

25

30

35

PACE ED

2011

2012

2013

Voluntary Turnover % VMPS Leaders

ED Results

Phlebotomy - Teamwork

Members of my work

group treat one another

with dignity and respect

2012: 77.5

2013: 82.9

Virginia Mason Lessons So Far

The rituals are critical

Leader attitudes and approaches really matter

Boards are only a tool; they can’t be static

Expect it to take time & lots of experimentation

Focus on building trusting relationships that can

weather change

Staff idea processes have to be hassle-free

“The intangible benefits of visual controls

are remarkable.

The development of teamwork by

increasing the level of involvement of the

operators in observing, analyzing,

improving the process, and understanding

the whole and not just their individual

work.”

David Mann, Creating a Lean Culture

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Daily Management Resource

• What is your business?

• What are you producing?

• How are you running your

business?

• How do you identify issues?

• How do you assess root cause?

• How are you improving your

business?

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