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Author Archive for: scarey

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How Scrum Can Improve Stand-Up Meetings

In many nursing homes, one of the first items on every day’s agenda is the daily stand-up. Some communities have these quick check-ins down: organized, routine, and efficient, highlighting admissions, needed assessments, and any issues from the 24-hour report. I’ve also seen these meeting sprawl for 20 or 30 minutes, or divert into side discussions that occupy everyone’s time to solve an issue between two departments.

Scrum is a software development methodology based on a flexible, iterative model of team collaboration. When implemented effectively, scrum has helped software developers improve productivity by up to 500% by staying focused on the most important challenges, collaborating as a team, and responding quickly to new challenges. You might think scrum is a funny word for a development strategy, but it has a very important background. In rugby, scrum is the way that play is restarted, similar to a tip-off in basketball. Instead of being an individual effort, like the tip-off, however, scrum involves the whole team working together to gain control of the ball. While individual strength and skill is important, no team can compete effectively unless they work flawlessly together. The same idea has been applied to software teams. (And has something to teach healthcare teams.)

While there is a lot to scrum, one of the key features is the daily stand-up meeting that involves each person on a cross-functional development team meeting briefly. What’s involved in the daily scrum meeting?

  1. All members come to the meeting prepared. In post-acute care, this means accurate information about admissions, discharges, assessments and any resident issues.
  2. The meeting starts at the same time each day. Some communities do this well already, though oftentimes I’ve seen meetings delayed until the administrator or DNS arrives. In a scrum daily meeting, the meeting starts, even if someone isn’t present, and it’s the missing person’s responsibility to learn the information missed.
  3. The meeting is timeboxed. Timeboxing is an important project management tool that limits a meeting to a specific length of time. This keeps issues focused and means that issues are prioritized or dealt with in separate (and usually more efficient) ways. For a 100- 150 resident nursing community, 15 minutes should be plenty of time for a stand-up.
  4. Anyone is welcome to attend (though typically only involved core roles speak), and meetings are oftentimes held in hallways or corridors to emphasize the open component. This is an important commitment to openness that allows other staff to stay abreast of development efforts throughout the organization. With an open stand-up, CNAs, cooks, and housekeepers could see some of the nursing home “machinery” that is critical to the day-to-day work.
  5. The meeting consists of each core person answering three questions: what did I do yesterday? what am I planning to do today? Am I experiencing any stumbling blocks or impediments to getting my work done? The “team lead” (scrum master) documents any challenges, but no discussion occurs during the stand-up. Rather, issues are dealt with in smaller groups, involving only those people required to resolve the situation.

What I love most about the scrum meeting is the focus on what’s happening and whether there are any roadblocks to people completing their work. This approach fits well with Lean philosophy (along with servant leadership, which is eminently vogue in LTC right now), and emphases the role of the team lead as an enabler: their primary role is to ensure the team is able to do its work. This person is responsible to remove identified roadblocks, keep the team on track, and prevent outside distractions (in long-term care, think regulatory issues, corporate initiatives not related to the work, interpersonal challenges between department staff, etc.) from interfering with completing necessary work.

Streamlining and focusing stand-up can have a big impact on staff’s ability to work effectively throughout the day. If your stand-up wanders, or doesn’t focus on the most crucial info to share, look at whether the scrum daily meeting concepts above might be able to improve this crucial meeting.

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Lean Six Sigma and QAPI: Complementary Initiatives to Improve Quality

Lean six sigma is a perfect methodology to comply with the upcoming CMS mandate for QAPI (Quality Assurance and Process Improvement). By combining a rigorous, resident-centered, project-based process improvement philosophy with existing quality assurance program data, providers can not only meet CMS regulations, but also put in place a program that will generate true value for residents by focusing on improving quality and reducing waste in the pursuit of excellence.

Lean Six Sigma and The Five Elements of QAPI

Element 1: Design and Scope

Lean six sigma programs, by design, encompass an entire organization. Indeed, to be successful, lean philosophy must become ingrained in the organization’s core leadership and mission. Providers must commit to relentlessly eliminating waste by practicing continuous, systematic improvement. By promoting a culture of improvement and developing people to understand and create more value in their work, lean six sigma programs also help ensure “everyone is on board.”

Element 2: Governance and Leadership

QAPI requires that the governing body and administration commit both in writing and in practice to a culture of quality improvement and excellence. A lean six sigma program starts with acceptance and promotion by the governance structure and is most successful with active administrative support. Lean six sigma takes leadership a step further and commits to a method of problem solving that respects people and creates lasting value in pursuit of the organization’s mission.

Element 3: Feedback, Data System, and Monitoring

Built on the principle of continuous improvement, lean six sigma programs provide a rich framework to monitor quality, measure improvements, and maintain gains. By focusing on data, lean six sigma is primed for compliance with QAPI. Further, by creating systems of quality and cultures of active participation and respect, lean six sigma can help organizations move quickly beyond traditional nursing metrics and look at value creation opportunities in dining, marketing, and ancillary services.

Element 4: Performance Improvement Projects

By integrating Six Sigma project discipline, improvement activities will already by organized into measured, documented projects in compliance with CMS standards. While lean six sigma promotes continuous improvement, most focused activities are completed in projects, either through a DMAIC process or with A3 thinking, meaning organizations will be well prepared to demonstrate effective improvement project outcomes.

Element 5: Systemic Analysis and Systemic Action

Lean six sigma culture, through documented quality improvement, ensures an organization strives forward. As hospitals and health systems look more and more to partner with organizations that can prove their value, a lean six sigma base provides hard data on organizational excellence. Further, the program allows organizations to quickly attack any problem area with a focused, universal improvement discipline, increasing teamwork across functional silos and generating a stronger sense of togetherness across the organization.

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No Layoffs

I recently attended the American College of Health Care Administrators Convocation and was very intrigued by the session on Lean in long term care. While the presentation provided a solid overview, I was dismayed when the presenter mentioned that after an initial lean deployment, a nursing home operator eliminated almost 15% of its staff due to efficiencies gained.

In LTPAC, where margins are constantly being squeezed, there is always temptation to make cuts as soon as capacity allows. Acuity-based staffing, albeit temporary, is a symptom of this practice. Unfortunately, cutting staff first puts short-term financial gains ahead of long-term value creation, and stifles an organization’s ability to innovate practices and lean value into operations. It also creates an adversarial atmosphere where management constantly tries to limit costs and employees try to protect jobs no matter the cost to the organization– both without regard to what’s best for residents!

“We’ve also made a commitment to our staff that there will be no layoffs related to this work. This frees them to concentrate on process improvements without worrying about continued employment. Once staff have the opportunity to experience the power and potential VMPS holds for our organization, they are excited to use the tools to improve work in their own areas.” – J. Michael Rona, President, Virginia Mason Medical Group

At the beginning of a lean journey, it’s crucial that organizations commit to a “No Layoff” policy, as Virginia Mason did when first bringing lean into healthcare. Without such a commitment, it is nearly impossible to engage front-line staff in identifying opportunities to eliminate waste, since staff will more likely be interested in protecting their jobs rather than leaning themselves out of one. Fortunately, there are numerous areas where labor can be redeployed to improve quality, increase offerings and otherwise contribute to enhancing revenue and decreasing costs (long-term value creation). What’s more, because lean places such an emphasis on the resident at the center of the value process, employees better understand that they work for the residents and the organization as a whole, rather than individual departments and silos that is all too often the reality in current environments; this makes the process of labor redeployment much easier.

Through the process of attrition, sometimes workgroups themselves will step forward and indicate that a position might not need to be refilled. In these cases, redeploying the wage resources into existing employees can be an effective way to enhance recruitment and retention, particularly in low-wage positions, and organizations oftentimes see savings almost immediately in lower turnover costs and higher productivity yields.

One of my first lean projects involved such an approach. By combining two separate food-service programs on a campus into a single entity, and redesigning workflows to maximize efficiency of different job classifications, we were able to begin a 24-hour dining program and raise staff wages while still creating $50,000 of hard cost savings in the first year.

A “No Layoff” policy is a crucial underpinning of the beginning of a lean journey, and embodies a true respect for people that is so critical to the success of any lean endeavor.

 

 

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eSSee Consulting to Present at LeadingAge NC, LTPAC HIT Conferences in May, June

We are pleased to share that we will be presenting on EMR integration and optimization strategies at the upcoming LeadingAgeNC Spring Conference in Myrtle Beach, SC on May 12- May 14, and at the LTPAC HIT Summit in Baltimore, MD on June 22- June 24. Our presentations will focus on using lean six sigma to examine the landscape, build the project, and ensure ongoing measurement to increase adoption.

We look forward to seeing you there!

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Respect For People

At the core of Lean thinking is the concept of Respect for People, and it’s this part– more than continuous improvement and elimination of waste– that makes us believe Lean has so much to offer the long-term and post-acute care environments. Many nursing homes and assisted living communities have already engaged in culture change activities over the past several years, and one of the most crucial elements to success– as well as a benefit in and of itself– is empowering and engaging line staff in the change journey. Lean can complement and strengthen this area, and serves as a link between organizational philosophy and quality improvement activities.

Respect for people is altogether both simple and difficult to understand and implement. For most healthcare organizations, respect means treating employees fairly, providing adequate training and supervision, and providing a safe and stable working environment. In Lean, respect for people is much more involved; it means line staff are understood to be experts of their work areas, supervisors and managers spend time on the floor with line staff, all employees are involved in problem-solving, and errors are generally assumed to be system-induced.

The problem solving process is a key example used in describing respect for people from a Lean perspective, as noted in this e-letter from James Womack, the founder of the Lean Enterprise Institute:

Managers begin by asking employees what the problem is with the way their work is currently being done. Next they challenge the employees’ answer and enter into a dialogue about what the real problem is. (It’s rarely the problem showing on the surface.)

 

Then they ask what is causing this problem and enter into another dialogue about its root causes. (True dialogue requires the employees to gather evidence on the gemba – the place where value is being created — for joint evaluation.)

 

Then they ask what should be done about the problem and ask employees why they have proposed one solution instead of another. (This generally requires considering a range of solutions and collecting more evidence.)

Then they ask how they – manager and employees – will know when the problem has been solved, and engage one more time in dialogue on the best indicator.

 

Finally, after agreement is reached on the most appropriate measure of success, the employees set out to implement the solution.

 

For many of us that doesn’t sound much like respect for people. The manager after all doesn’t just say “I trust you to solve the problem because I respect you. Do it your way and get on with it.” And the manager isn’t a morale booster, always saying, “Great job!” Instead the manager challenges the employees every step of the way, asking for more thought, more facts, and more discussion, when the employees just want to implement their favored solution.

This back and forth process demonstrates how each person in the organization brings a perspective, and true problem solving means involving and engaging each individual. It’s not in making employees feel good, or in dodging tough issues, but rather actual, committed problem solving that enables each member of the organization to thrive. Indeed, as Mike Rother notes, “respect for people means that it’s disrespectful of people to not utilize their human capability to learn and to grow. That is, each person’s working day would ideally include some challenge, and each person is being taught a systematic way of meeting challenges.”

This is a much different view than is typically practiced in nursing homes. When problems occur, staff are oftentimes blamed for not following a policy (without regard to whether the policy is reasonable or even doable), counseled (to provide documentation that the facility acted on the problem) and scapegoated (often in a demoralizing way as other staff know it could happen to any of them).

Mark Graban shared a video in a recent post on respect for people that highlights a great example of how an organization shifted during an incident to exemplify a respectful problem solving process:

Creating an organization built on respect for people cannot happen overnight, and it can’t be done without the commitment of senior leadership. As we’ve noted in the past, organizations need to evaluate their entire process of problem solving, especially around incident investigations. Organizations must also stop penalizing employees for system failures due to lack of adequate resources, ineffective safety measures, and organizational policies that harm open communication and dialogue.

In Mark’s post, he notes the similarity between respect for people and just culture, and there is certainly a lot of overlap. Implementing a just culture is also a proven risk management strategy, as it leads to fewer errors and more complete problem solving. Examine this diagram from Outcome Engenuity:

jcdiagram

Respect for people holds that most errors are not caused recklessly or maliciously, but rather catch people up in a poorly designed or poorly functioning system, and, in order to rectify and prevent these errors from happening again, we must involve everyone in an organization in a thoughtful, purposeful journey of continuous improvement.

Ready to get started? So are we!