Tools to Achieve Performance Excellence

Winona Health’s Continuous

Systems Improvement (CSI)
Lean 2.0 -Activities to Results!

Linda Wadewitz
Director of Continuous Systems
Improvement
Winona Health
 Activity to Results
• Strategy not aligned
• Sustainment issues
• Lack of Standard Work
• Discipline/Accountability
• Leaders Std Work
• RCA-Frontline
• ……thus LEAN 2.0
 CSI as a Strategy
• Focus on Principles of:

• Belief this strategy is key to a successful future for

transforming our culture at Winona Health
Winona Health Golden Circle
 CSI Goals
• Deployment of Lean 2.0

• Integration of the LMS enterprise wide

• A3 (PDCA) Thinking

• Strategy cascaded to Frontline

• Patient focused – outcomes and results

• Coaching and Mentoring

 What is Lean 2.0?
• Strategy Deployment/Enterprise Obeya
• Visual Management/PDCA/FB
• Cascading metrics
• Daily Management – Leadership Discipline
• Standard Work - 80/20
• Leaders Standard Work
• Frontline A3 Problem Solving
• Coaching and Mentoring
• Results Driven – Course Corrections
• Thus…Activity to RESULTS with lean 2.0
WH’s Lean Management System
 Customer Value
• Patient/Resident Satisfaction - True North
– Principle 1
– True North drives - Hoshin
– Value Stream mapping – starts with patient flow
– Process mapping – Kaizen, CIP’s
– A3 Problem solving
– Visual Management
• FOCUS Boards
• PDCA Boards
Hoshin Management = Strategy Deployment
Hoshin Kanri

Direction/Needle Management

•• Statement
Hoshin Kanri – Leadership Driven
is the
– Level 1- Organization
CONSTANT GUIDE for– True North/3 year Strategic Goals
– Level
the Team 2 – Service Line or Support
– Level 3 – Value Streams/Departments
– Linkage from Level 1 to Level 2 to Level 3
– Catchball between all levels
Hoshin Kanri
Hoshin Kanri Cascade
 “Catchball” Process
• CEO/Service Line Leaders/Directors

• Discussions between Leadership levels

– Need to limit the “How”/# of Tactics

• Level 3 catchball includes frontline

• Improves ownership/engagement at all levels

• Integrated goals cascade from Level 1 - Level 3

• Alignment and focus

Level-1

#1 lags everything
#2 is leading to #1 but lagging to #3
#3 is leading to #2 but lagging to #4
#4 is leads everything
2

1
Level-2
Metrics

Proposal Level-3

A3’s
4
Rotation in Hoshin
Linkage Validation
Value Stream Mapping
Evaluate Map
and Current
Improve State

Std Work Review

Sustaining Inputs SFP/
Results Patient

Kaizen CIP
Determine
3P A3’s
Ideal State
JDI’s

Prioritize Map
Gaps and Future
Events State
RCA and
Identify
Barriers
 Forecasting –
Ties to Level 1 Hoshin
Forecasting - What We Did
• Eliminated Annual Budget Process
• Implemented Quarterly Forecasting
–Designed overall process
–Operationalize software
–Initiated Quarterly Senior Leader
meeting
Forecasting - Why We Did It
• Agility – annual
budget process is out
of synch
– Pace of change in
the industry
– Winona Health
management
system
– Lead Time too long
– 17 months
 Forecasting - Why We Did It
• Noise – Budget becomes noise that gets
in the way of real-time continuous
performance improvement
Forecasting – Why We Did It

• Waste –
time and resources
Observations/Impact/Lessons Learned
• Start with Long-Term Financial Forecast to
determine targets
• Use Quarterly Forecasting to evaluate
progress on Long-Term targets
• Close the Loop on gaps between Quarterly
Forecast and LT Targets
• This is primarily a top-down exercise, resist
creating a quarterly budget process
Observations/Impact/Lessons Learned
• Quarterly Forecasting meeting has created
enhanced dialogue among Senior Leaders
• Preparation for the quarterly meeting has
triggered a more meaningful interaction
between finance and operations
• Operating leaders are asking more and better
questions
• You have to learn to walk again
 Observations/Impact/Lessons
Learned
• Quarterly Forecasting:
– Is about performance improvement
– Is not about precision or paper clips

• The point of forecasting is not creating

numbers to “hit”. It’s about designing
operations to deliver better performance.
Box Scores – Tie to Hoshin
 Boxscore Graphs/Charts

PCC Pt Sat Raw Score PCC % Use of CPOE

Actual Goal Linear (Actual)
Goal Actual Linear (Actual)

100 100 100 100 100 100 100

90 90 90 90 90 90 90 90 90

80 80 80
89.3
65.5
88.5 88.4 88.4 88.4
88.1

1-Jun 1-Jul 1-Aug 1-Sep 1-Oct 1-Nov 1-Dec

 Proposal A3’s
• Proposal A3’s-all levels of Hoshin – “HOW”
– What tactics we use to accomplish breakthrough
objectives and how do you measure for success

– Started by leader /
finished by area

– Burning platform

– Also used for CPR’s

presented to CEO/CFO
 Proposal A3

Future State
Business Case

Action Plan
Current State/Gap
Measurement/Results
Visual Management Enterprise
• PDCA Enterprise Level
– Plan wall
• Hoshin Level 1 and Level 2’s
• Proposal A3’s from level 1 Hoshin
• Long term goals and forecast
– Do wall
• Proposal A3’s from all level 2 Hoshin
– Check wall
• Std Boxscores from every Service/Support Line
• Charts/Graphs not meeting target
• Results tracking to forecasting
– Act wall
• Follow-up – Course Corrections
Enterprise Obeya
Visual Management-PDCA Boards
PDCA Boards – Level 2 and 3 (SL/Dept)
–New format with Standard Work

–Box Score – Vital few – Level 2 and 3

–Reviewed weekly, monthly and

quarterly
PDCA Board Weekly/Monthly
Visual Management FOCUS Boards
• FOCUS Boards- Daily- every dept

–New format with Standard Work

–A3 Problem solving at frontline

–More meaningful than old version

FOCUS Boards - DAILY
 Standard Work
• Standard work at the frontline-goal 20%
– Based on risk and volume
– Critical to quality steps on a scorecard audit
– Improves outcomes and quality
– Process stable prior to improvement
– Decreases variability
• Standard work for Leadership
– Standard set of tasks all leaders or managers perform
– Same expectations/outcomes-quality
– Accountability
– Staff see the same process in all leaders
 Leaders Standard Work
• Leaders Standard Work cascaded up from
frontline to the CEO
• Daily, weekly and monthly audits
• Done with a score card
• Gemba walks/Rounding
• Coaching and Mentoring- 4-Patterns
• Visual Board Rounding
Standard Work / LSW
Scorecard Requirements
• Cascaded frontline to CEO
• Vital few – one on/one off
• Discipline at all levels
• Reviewed at 1:1 leaders mtg
• Follow-up to issues and
commitment from either party
• 4- Patterns guides actions
• Live tool-changes as needed
Frontline Daily Problem Solving
• 22 Coaches trained
• 75 Frontline Problem Solvers trained
• 6 additional groups trained
• > 200 A3’s since January 2013
• > 140 A3’s closed out of the 200
• New A3 Format
• Healthcare sensei December 2012
• In addition to FB and JDI’s
 Problem Solving A3

Problem Statement

Background Target Condition

Current State Countermeasures

Implementation Plan

Problem Analysis Follow-up Actions and Metrics

Gap
Cost Benefit Analysis
 Recognition Program
• New-previously not done well, if at all

• Access Data Base to track results

–Hard dollars saved
–Revenue enhancement
–Hours saved
–Satisfaction – lagging
–Reports
 Recognition Reports
• Executive Summary – Financial and time

• Weekly Recognition-report detailing

closed A3’s
–teams are recognized at the FOCUS
Boards by the Service Line Leaders.

• Monthly Recognition – CEO highlights

monthly and tells the story….
Executive Summary Report
A3 Revenue Enhancement and Hard Dollar Savings
 Value Realization
Hours saved
Reassigned to “new” work
A3 Problem solvers/Coaches
Have a “no lay off” policy related to “CSI”
Attrition
Forecasting adjusted if appropriate
Hard Dollar Savings
75% adjustment in forecasting
Validation required in intervals
Forecasting adjusted if appropriate
Leadership Academy
Why Leadership Academy?
• Developing out people
• Respect for our people
• Use of talent
• Grown your bench
• Staff Satisfaction = Increased
Patient Satisfaction
 Results
• Strategy patient focused, aligned and integrated
from Hoshin to the frontline
• Sustainment with Results using Std Wk/LSW
• Improved visual management
• Engagement at all levels with A3 problem solving
(critical thinking) and FOCUS/PDCA boards
• Enterprise results monitored and addressed by
the CEO and Senior Leadership Team with course
correction and follow-up when needed
• Results reflected in measurement and metrics
 Questions?

• is the CONSTANT GUIDE for the Team