Thursday, June 27, 2013

CQI Daily Management: Boards track positive changes

Leaders on a gemba walk at Cox Monett examine the CQI daily management board mounted in the Radiology department. In pilots at Monett and at Cox South, staff members and leaders have gotten into the habit of reviewing key measures daily and tracking the trends as departments work toward their goals. More boards roll out this month as Scott Rogers, administrative director, Organizational Development; John Chastain, financial analyst; and Stephen Njenga, performance improvement accreditation manager, Cox Monett, lead the effort throughout the system. 

If you’re going to solve a problem, a good way to start is by having it spelled out in front of you, every day. In select departments at Cox Monett and Cox South, staff and leaders have been taking that approach to issues in their areas with a new process known as CQI daily management.

Each day, leaders and staff gather around a tracking board while a staff member explains the top two or three metrics the team is tracking to monitor daily performance and improvements. Maybe they’re looking at staff response times or patient wait times; or the availability of medications or wheelchairs. The entire group hears about whether the department met their goals on the previous day. They see how often the department is hitting its targets and, if they’re falling short, there’s an opportunity to ask why.

The daily check-in is known as a gemba walk – a Japanese term from the Lean process improvement approach developed at Toyota. “Gemba” roughly translates to “where the work is” and the gemba walk takes hospital leaders into departments, where they can see first-hand the issues caregivers are dealing with. The CQI daily management boards offer a granular, front-line look at the incremental changes that form the grassroots of overall process improvement. The tracking boards and the gemba walks are key parts of Continuous Quality Improvement (CQI) – the eight-step model CoxHealth uses to solve problems and drive positive change.

CQI daily management creates that change by giving staff members the chance to identify what they want to improve and then providing a tool to measure small changes. The daily reports allow staff and leaders to identify opportunities, spot trends and work across departments and silos to find solutions. Leaders say the approach is a win-win: improvements drive better care and they make the workday easier for staff members.

“The boards can track anything from small satisfaction things to key strategic things. We want to fix the issues that cause people to vent about work every day,” says Scott Rogers, administrative director, Organizational Development, who is heading up the rollout of CQI daily management. “No one in health care ever says they’re tired of caring for patients. They’re tired of the little things that get in the way of doing their work. If we can improve those things, we’ll know we’ve made an impact and made their days better.”

The first tracking boards at CoxHealth were installed in a few key departments – the ED, Lab, Radiology and Med-Surg – at Cox Monett in April. After a pilot there, the first boards were added in six departments at Cox South. Later this month, a second round of boards will be put in place at South.

A typical walk along the four-board route at Cox Monett takes less than 20 minutes. On one day during the pilot, leaders saw how a low stock of medication affected work in the ED and how waiting on test results slowed patient care in Radiology. On each board, the top row shows the previous day’s performance, with the target met, or not. The second row details the trend – how often has the target been missed recently? And beneath that, the third row details the issues – what is preventing the team from hitting the target? Pretty soon, the recurring problems become clear. For the complex issues, staff and leaders form an interdepartmental team to attack the problem.

At Monett, the tracking has made each department more aware of how their work is affecting other areas. For example, one area didn’t know that wheelchair availability was an issue for another department until it popped up on one of the boards. Staff members say the focus on the boards has improved communication and brought departments together.

On the board in the hallway in Radiology, Heidi Elbert and Frankie Smith point out the service metrics the department is tracking. They’ve been working toward exams with no delays for patients. The board shows recent “fallouts” where the goal wasn’t met: a wrong order, a conflict with another exam, a test delayed by waiting on creatinine results. They say the creatinine delay is the one they’re most concerned with. They’ve formed a team with members from Lab, Radiology and leadership to look at the issue and seek out the root cause.

“This breaks down barriers between staff and administration,” Elbert says. “Having the gemba walkers there in front of you is a level playing field.”

“It opens avenues for communication and it gives the staff a chance to feel heard,” Smith says. “It’s healthy for the facility and the organization.”

Those who have the most experience with the CQI process say daily interaction with data both drives improvement and allows staff members to have daily input into how their department is run. The CQI training at CoxHealth has been led by Aaron Ritter and Diane Fritz from the Lean Transformation Team at BJC Healthcare, where a similar tracking process has driven change for years.

“The data tells you what the problem is, rather than going with your gut feeling,” Ritter says. “Instead of placing blame, it moves the action and discussion into the hands of front-line staff members. It creates a village of problem solvers, as opposed to chiefs.”

At Cox South, the pilot of two “routes” of boards is now complete. Leaders and staff members have gotten into the habit of daily gemba walks and Rogers is eager to expand the project to other departments.

“These are living, breathing charts that people are filling out every day,” Rogers says. “That means we have the ability to impact our daily work. Interaction with something detailed and visual like these boards means staff members and leadership are working on fixing problems today, not three weeks from now.”