The Impact of Job Instruction To Standardize Patient C Care: "If You Are Dreaming About It You Can Do It."

5/7/2010
The Impact of Job
Instruction to
Standardize Patient
Care Martha Purrier
Alenka Rudolph
Virginia Mason Medical Center
May 12, 2010
Copyright 2010 Virginia Mason Medical Center All Rights Reserved. Any further use of these materials is prohibited.
“If you are dreaming about it…
you can do it.”
Chihiro Nakao, Chairman and CEO
Shingijutsu International
November 4, 2003
1
5/7/2010
Our Strategic Plan
Virginia Mason Medical Center
• An integrated healthcare system
• 501(c)3 Not for Profit
501(c)3 Not for Profit
• 336 bed hospital
• 8 locations (main campus and regional centers)
• 400 employed physicians
• 5000 employees
• Graduate Medical Education Program
• Research center
• Foundation
• $650,000,000 Net Revenues
2
5/7/2010
We looked outside our industry, and found a model that we
were sure could work in health care—the lean thinking
philosophy, which we now call the Virginia Mason Production
System (VMPS).
Virginia Mason
Production System
To Make things in the Right Way
JUST IN TIME Jidoka

People Standard Takt Time
Work Production
One--by
One by--one confirmation to
Operate with the minimum detect abnormalities.
resource required to Standard Work in One Piece Flow Stop and respond to every
consistently deliver Production
• Just what is needed.
Materials Process
Supermarket
abnormality.
• In just the required amount.

Kanban System Separate machine work from
human work.
• Just where it is needed.
• Just when it is needed.
needed Enable machines to detect
abnormalities and stop
autonomously.
Andon
Pull System
Machines Operational Production
Availability
Leveled Production ((Heijunka)

j )
Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)
VMPS is modeled on the Toyota Production
System, a management method with over a
half‐century track record of success.
Improvements Education Activities Other

Executives 395 Staff Involved 18 Patient Safety Alerts
2002 Point to Japan
47 RPIWs
1 3Ps
Certify Execs and 833 Staff Involved 125 Patient Safety Alerts

2003 Department Japan Training
108 RPIWs 7 Staff in Single KPO
5 3Ps Report Outs
787 Staff Involved 204 Patient Safety Alerts
2004 Cross‐Department Certify Directors 110 RPIWs 7 Staff in Single KPO
4 3Ps Comp‐VMPS link
573 Staff Involved 2450 Patient Safety Alerts
2005 Cross‐Department Kaizen Fellowship 51 RPIWs 22 Staff in 3 KPO Divisions
Divisional Goals
Collaboration with 601 Staff Involved 3315 Patient Safety Alerts

2006 Outside Vendors Manager Training 44 RPIWs 1 3Ps 22 Staff in 3 KPO Divisions
51 Kaizen Events Divisional Goals
683 Staff Involved
683 S ff I l d 2855 Safety Alerts
2855 Safet Alerts
Experiential
2007 Model Line Work Supervisor Training
46 RPIWs 5 3Ps 20 Staff in 3 KPO Divisions
65 Kaizen Events
Education Team 820 Staff Involved* 2710 Patient Safety Alerts

Large Integrated
2008 Value Streams 3P Training/Cert
53 RPIWs 4 3Ps 31 Staff in 4 KPO Divisions
64 Kaizen Events Central KPO and VM Institute
Further Curriculum 65 RPIWs* 2879 Patient Safety Alerts*

Model Lines and
2009 Superflow RPIWs Development
8 3Ps* 27 Staff in 4 KPO Divisions
115 Kaizen Events*
3
5/7/2010
Visual Control for Safety
5S Anesthesia “Shadow Board” - Before

Visual Control for Safety
5S Anesthesia Shadow Board - After

4
5/7/2010
Building in Speed of Delivery:

Just In Time Exam Flu shot by
Make Drive/ Register
appt Wait park Wait Wait room Wait immunized staff
Wait on phone
PREVIOUS
STATE
TIME
CURRENT
STATE
Waits and delays
Non value-
value-added
Drive
Flu shot Evidence--based value
Evidence
FP Margin 2003 - 2007

500,000 425,377
400 000
400,000
300,000 192,546
200,000 113,692
100,000 1,635
0
-100,000
-200,000
,
-300,000 -301,696
-400,000
-500,000
2003 2004 2005 2006 2007
5
5/7/2010
Rapid Response
Standard Work
6
5/7/2010
Need for standard work and training
“Without standards, there can be no improvement.” ‐
Without standards, there can be no improvement.
Ohno
Standards provide stability.
Stability provides visibility.
Visibility provides targets for kaizen.
(Purrier)
Job Breakdown: Hand Hygiene
7
5/7/2010
JI Class
List of 10 Practice Jobs

• Hand Hygiene • Remove a Saline
• Hand Washing Lock
• 6 Point Hourly • Donning and
Rounding Removal of Gown
and Gloves
• Collecting a
Specimen • Placement of Patient
ID Band
• Blood Glucose
Monitoring • Stool Occult Blood
Testing
• Emptying an Ostomy
Bag
8
5/7/2010
Job Breakdown: HH#2
Pilot Based on Kotter’s 8 Steps

1. Increase Urgency
2 B
2. Build
ild th
the Guiding
G idi T Team
3. Get the Vision Right
4. Communicate for Buy-In
5. Empower Action
6. Create Short-Term Wins
7. Don’t Let Up
8. Make Change Stick
9
5/7/2010
Kotter and JI
• Kotter s step one: Increase Urgency-

Kotter’s Urgency show others the
need for change with a compelling object that they
can actually see, touch, and feel.
• JI step one: Prepare the worker- get the person

interested in learning the job, find out what the person
already knows
knows.
Why Change?
10
5/7/2010
Right People, Right Vision

Guiding Team- think beyond the trainers…
TWI “Master
“M Trainers”
T i ”
KPO Leadership
“Patrons”
Vision- training is the missing link for

standard work implementation
“Just do it!”
Tips for Trainers
1. When you get to a unit, check in…..
2. There is a limit to how many staff you can train
in one setting…
3. When teaching Hourly Rounding...
Continued Production Updates
11
5/7/2010
Wins!
“ …Our transfusion safety officer took Metro #303
home a few days agoago. After she sat down on the
bus, took off her badge, and stored it in her
purse, she Purelled her hands. A woman was
watching her and remarked, “You must work at
VM.” When Melanie asked why the woman said
that,, the woman replied,
p , “That’s how theyy do it at
VM.”
Go the Distance
“ areas off the organization will be

“All
instructed in Hand Hygiene using the JI
Method of instruction…it is our way”
Sarah Patterson
COO VMMC
12
5/7/2010
Results and Learnings
Patients Notice Reliability

“ You know… you all must go through some kind
of special training because EVERYONE asked
me if I was comfortable, offered the bathroom,
made sure that I had my call light and phone, and
then asked if there was anything else I needed.
I’ve never seen such great customer service
while in a hospital.”
Conversation between discharging patient and his nurse on

the Telementry Unit.
13
5/7/2010
Safety/Quality Defect Falls
Customers inspecting:
Proper Hand Washing
“Recently I entered a patient's room on
L
Level
l 10
10. FFrom hher bbed,
d thi
this patient
ti t
watched me wash my hands. The patient
remarked, "That is so interesting!
EVERYBODY coming in here washes their
hands the exact same way! I've never
seen anything like it!"
Ellen Noel, Med-Surg CNS
14
5/7/2010
Culture Change
Continued Training
• Kelly Debbie Purrier Martha Verkler Arni Rudolph Alenka Kuykendall
Kelly LeBeau Andrew Kopf-Klakken Shirley Finley Christy Rhoades
Brittany Noel Ellen Crickman Rachael Westely Mike Russell
Katherine Anuradhika Anuradhika London Amy Sundet Allison
Ricardi Anthony Sarriugarte Jennifer Marotta Jill Ludgood Lisa
Tempel Rosemary Derheimer Celeste Eusek John Kudo Miwa
Jensen Elisha Honnold Kathryn Smith Donna Fuller Fariba Bishop
Robbi Penick Falon LeGore-Churchill Tonya Cyhan Tamara Haner
Mike Brown Laurel Hebish Linda Bickel Lara Haufe Susan Ching
Joanie Palmer LesleeAnn Luker Sam Knowles Brian Sausser Gail
Suko Jolynn Dolbey Suzanne Tufano Amy Rupp Steve Jachim
Jeannne Cutchin Debbie Phillips Jennifer King Rosemary Howie Jill
Graham Steve Perron Patti Kahn Dana Duscherer Linda
15
5/7/2010
Job Break Downs in Health Care

• Donning Sterile Gloves • Application of SCD’s
• Blood Product • Obtaining
Obt i i ThThroatt
Verification
Culture
• Specimen Labeling
• Glucose Check • Sterile Field Setup
• IV Tubing Prime and • ECG Lead Placement
Load • Peripheral Lab Draw
• Skin Prep- Procedure • Pacemaker Testing
• Emptying an Ostomy
• Securing an
Bag
Indwelling Urinary
Catheter
Getting The Most Out Of Class
• Healthcare edits to training manual

• Identifying the right participants for class
• Cohort teams
• Homework before class
• Identifying “good jobs”
16
5/7/2010
Communicating With Trainers
• Consistent and specific scripting for how to

putt a job
j b across
• Visibility and accessibility of the timetable
for training
• Sharing training experiences, recognizing
patterns
After the Class…
More coaching and support is needed:

Job Break Downs
Practice with the method
Time Tables in Motion
Keeping up Momentum
17
5/7/2010
Our Next Move…
• Infrastructure support
• Continue to apply it to healthcare
Infrastructure
Targeting the right Jobs- Work to identify the
problem
bl that
th t a “S
“Supervisor”
i ” needs
d tto
solve. Using VMPS tools to identify current
state (Setting up for outcomes).
Targeting the right participants-

Administration or front line supervisors?
18
5/7/2010
Infrastructure
Trainer Capability Evaluation Sheet
Name:
Department:
Score Notes
Willingness to learn
Adaptability and flexibility
ersonal
eristics
Caring and concerns for others
Intuittive
Patience
character
ability/pe
Taking responsibility
Confidence
Questioning nature
Average for personal characteristics
Observation and analysis ability

learnable skills
Communication skills
Fundamental/
Attention to detail
Job knowledge
Respect of fellow employees
Average for fundamental skills

Scoring
0-1 = Intermittently Demonstrates 2-3 = Generally Demonstrates 4 = Consistently Demonstrates
Willing and Able to Learn- the true Master Trainer is a Master Student. A trainer must have the desire and ability to continually learn
and grow and to reinvest his or her own learning into the teaching. People with this trait make efforts to learn on their own initiative
and accept new challenges.
Adaptable and Flexible-

Flexible every training circumstance will be different: work conditions
conditions, ability of the student,
student time available,
available etc.
etc The
trainer must be adaptable and not rigid in their teaching methodology.
Genuine Caring and Concern for Others - trainers must want the student to become successful in the task and as a person overall.
They respect others and can be empathetic of a person’s situation as a student. They demonstrate genuine interest in the individual and
naturally make efforts to help others learn- without being asked to do so.
Patience – Conditions for the ideal training situation rarely occur, and challenges are plentiful. Some students will need lots of practice
to master the job. If the trainer is easily frustrated, they will not be able to put the learner at ease so that they can concentrate on the
task.
Persistence – a trainer must stick with the process until the outcome is achieved. They must be “ok” that everyone has a different
capacity for learning new skills and that not everyone will learn at the pace that they have mastered a skill. Persistence should not be
confused with belligerence or doggedness- relentless pestering of the student leads to resentment.
Taking Responsibility - The responsibility for a successful outcome rests with the trainer. If the student hasn’t learned, the trainer
hasn’t taught. They must continue to adapt the training plan until the desired outcome is reached.
Confidence and Leadership - Trainers should be confident and self-assured; viewed as the content expert. They must be able to handle
having their capability challenged, their rationale questioned and should come across as an authority without being seen as an autocrat.
Questioning Nature - trainers should question the content of a job and fully understand why each step is important. They have already
asked all of the questions that students come up. They have sought out the answers on their own and are willing to share this insight.
CopyrightAdapted
2010 Virginia
Directly Mason Medical
from: Liker CenterToyota
and Meier’s All Rights Reserved.
Talent, Any further use of these materials is prohibited.
2007, McCraw-Hill.
Letters to Participants
19
5/7/2010
Leadership Support
Infrastructure
VMPS
Fellowship
VMPS
VMPS Certification
Leadership
Training
Intro to
VMPS
TIES
Orientation
20
Level
Periop
Level 8
Level 7
Surgical
L l 14
M edicine
NAMES
Radiology
RN Name
Anesthesia
MD Name
LPN Name
Hospitalists
Med/S urg Tech

Residents Name
Pr
e-
w
o
P r rk I
e- HI
w
o PS
P r rk I 10
e- HI 1
w PS
or
V k
30 mins on-line
M IH 102
cu IP
r S
V ri
M cul 103
cu um
V rricu PS
M P
c u l um rin
ci
pl
Pr rricu Hu
oc m e
ed l um an s
H
ur C Fa
ct
an a l P om
do au m or
ff se un s
U Ch ica
ltr ec tio
as n
SKILLS MAP FOR Patient Safety Curriculum JOB INSTRUCTION
90 min classroom
ou kl
U n is
ltr d t*
*
as us
o e*
M und *
D m
Re a
H sp ppi
an ons ng*
d et *
H
It yg o C
ta i all
ke ene s
s T **
M w
ed o*
ic
ati *
H
ig on S
h
R ol
ut
i
30 min Demo/Teach back
Se isk
t-u M on L
p ed ab
Sp S te C e
ec ril hec li ng
im e F k **
** Included in Workshop
Sk en L ield
in ab /
sit el Bar
Ce e p in r
nt r ep
g* ier*
* *
ra **
l
Th L in
15 min 1:1
or eS
ac im
Lu ent e ul
m s at
ba is S ion
Pa r pu i mu
ra nc l
ce t u a tio
D nte s re S n
on is im
S ul
Eq Pe rs im ati
D ui p ona ulat on
of m l io
t e P n
E Per nt rote
Dqui p son ct
iv
on m al e
120 min workshop
St en Pr
er t ot
ec
il e
D PP ti v
of
tS E* e
ter *
Application to Healthcare
i le
Application to Healthcare
PP
E*
*
30 min "Cost
21
5/7/2010
5/7/2010
Application to Healthcare Job Instruction Breakdown Sheet
Task: Securing an indwelling urinary catheter Evidence Source:

Supplies: Barrier pad, Cath-Secure multi-purpose tube holder
Equipment: Cerner
Purpose: An unsecured catheter can injure the urethra and the bladder wall.
Important Steps Key Points Reasons
A logical segment of the operation Anything in a step that might- Reasons for key points
when something happens to advance 1. Make or break the job
the work 2. Injure the worker
3 Make the job easier to do
3. do, ii.e.
e “knack”
“knack”,
“trick”, special timing, bit of special
information
1. Select & Prep site 2. Upper thigh men 1. Upper thigh/inner thigh allows
for slack between meatus &
3. Upper-inner thigh women securing device
4. Wipe skin with barrier pad

2. Apply secure catheter 1. Place sticky side with widest 1. Less cath slippage with wide
edge facing knee side facing knee.
2. Remove adhesive backing 1

wing
3. Remove adhesive backing on

other wing & press to skin
4. Attach catheter 1. Catheter should form a U 1. Prevents trauma to the meatus
from meatus to thigh
2. Wrap Velcro tab around big

lumen
5. Inspect the catheter 1. Tubing should be observed 1. Prevents urine from flowing
system for kinks or dependent loops back into the bladder
2. Ensure tubing is loosely 2. The floor will contaminate the

coiled and secured to the bag & the tubing
bottom sheet on the bed using
plastic clip.
3. Bag should be hung on the

bed or chair below the bladder
& off the floor
6. Document device is 4.
secured
References
• Kotter, John P. and Cohen, Dan S. 2002. The

Heart of Change.
Change Harvard Business School
Press. Boston, Massachusetts.
• TWI Training Manual.
22

The Impact of Job Instruction To Standardize Patient C Care: "If You Are Dreaming About It You Can Do It."

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

The Impact of Job Instruction To Standardize Patient C Care: "If You Are Dreaming About It You Can Do It."

Enviado por

Direitos autorais:

Formatos disponíveis

5/7/2010

To Make things in the Right Way

JUST IN TIME Jidoka

• In just the required amount.

Leveled Production ((Heijunka)

Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)

Improvements Education Activities Other

Certify Execs and 833 Staff Involved 125 Patient Safety Alerts

Collaboration with 601 Staff Involved 3315 Patient Safety Alerts

Education Team 820 Staff Involved* 2710 Patient Safety Alerts

Further Curriculum 65 RPIWs* 2879 Patient Safety Alerts*

Visual Control for Safety

5S Anesthesia “Shadow Board” - Before

Visual Control for Safety

5S Anesthesia Shadow Board - After

Building in Speed of Delivery:

FP Margin 2003 - 2007

Job Breakdown: Hand Hygiene

List of 10 Practice Jobs

Job Breakdown: HH#2

Pilot Based on Kotter’s 8 Steps

• Kotter s step one: Increase Urgency-

• JI step one: Prepare the worker- get the person

Right People, Right Vision

Vision- training is the missing link for

Continued Production Updates

“ areas off the organization will be

Results and Learnings

Patients Notice Reliability

Conversation between discharging patient and his nurse on

Safety/Quality Defect Falls

Job Break Downs in Health Care

Getting The Most Out Of Class

• Healthcare edits to training manual

Communicating With Trainers

• Consistent and specific scripting for how to

After the Class…

More coaching and support is needed:

Our Next Move…

Targeting the right participants-

Average for personal characteristics

Observation and analysis ability

Average for fundamental skills

Adaptable and Flexible-

Med/S urg Tech

Application to Healthcare Job Instruction Breakdown Sheet

Task: Securing an indwelling urinary catheter Evidence Source:

4. Wipe skin with barrier pad

2. Remove adhesive backing 1

3. Remove adhesive backing on

2. Wrap Velcro tab around big

2. Ensure tubing is loosely 2. The floor will contaminate the

3. Bag should be hung on the

• Kotter, John P. and Cohen, Dan S. 2002. The

• TWI Training Manual.

Você também pode gostar