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WELCOME
Title of Presentation Here
Uteam
Presenter
Leadership
Name Here
Education Forum
Be Safe
Leadership Basics
Month Day, 2012
June 10, 2014
In case of an emergency…
 AED located on wall directly across from
restrooms
 Who is certified in BLS?
 Emergency site location if we have to evacuate
Pavilion
For your safety…
 Police will direct traffic as you exit
Our patients are at the
center of all we do
 We want to eliminate anything and everything that
harms or could harm our patients and/or team members
 We want to decrease activities that keep us from being
effective and efficient
 Most of us only need the right tools and support
Be Safe gives us a process and tools that allow us to
tackle problems in a thoughtful and organized way
Be Safe learning is continuous
Applying
Understanding
Be Safe for Senior Leaders
Awareness
Be Safe 101
April 17th Uteam
Leadership Forum
Teaching Units
June 10th Uteam
Leadership Forum
Summarizing,
translating, discussing
Be Safe Team Member
Essentials
Discovery, observation
Teaching and Coaching
Be Safe for Unit-Based
Leadership Teams
Senior Leader A3s
Experimenting, using
problem solving
methods
KAIZEN
Continuous improvement
Eliminate harm and waste
Make it better now
Make it perfect later
Be Safe learning materials
 On the Mend: Revolutionizing Healthcare to Save Lives
and Transform the Industry
 Focus on patients, value and time using continuous
improvement and respect for people as the foundation
 A3 Problem Solving for Healthcare: A Practical Method
for Eliminating Waste
 Practical workbook, case studies and “how to” instructions
for each A3 section
 Website
HR Homepage
Leadership Tools
Be Safe
Forum objectives
 Understand Be Safe initiative - philosophy and terminology
 Increase awareness of problem solving principles and tools
 Experience problems & activity observation and debrief
 Understand purpose and function of a Unit-Based Team (UBT)
and Unit-Based Leadership (UBL)
 Learn how to teach Be Safe Team Member Essentials to
your unit/department
 Explore how Be Safe changes the way we work, lead and coach
 Necessary leadership behaviors
 Culture change process
Our Journey to
Become the Safest Place
to Work and
Receive Care
Be Safe
is the roadmap
Opening remarks
Rick Shannon, MD
EVP, Health Affairs
Our goals for UVA Health System
 To become the safest place to receive care
 To be the healthiest work environment
 To provide the highest level of clinical care
 To generate biomedical discovery that betters the human
condition
 To train the health care workforce of the future in teams
Ideal state for healthcare
 Exactly what the patient needs, defect free
 One by one, customized to each individual patient
 On demand, exactly as requested
 Immediate responses to problems or changes
 No waste
 Safe for patients, team members and clinicians: physically,
emotionally & professionally
How we will get there
 Prevent problems/harm in our environment
through observation and standardization
of work processes
 Address problems/harm in real-time using
help chains and the A3 Scientific Method
Problem-Solving Tool
 Transform problem-solving and work
processes throughout UVAHS
Our Be Safe initiative
is
advancing our status
as a high performing organization
by systematically applying the scientific method
to improve the safety of our patients and workforce
through real time problem solving
Culture trilogy of Be Safe
 Team members are treated with
dignity and respect by everyone
they interact with
 Team members have the tools to
do their job, including training,
supplies, and encouragement
 Team members are recognized
for the contribution they make by
someone they care about
Respect
Tools
Recognition
Engagement
Be Safe Sponsor
R. Shannon
J. Amato
B. Bell
J. Boswell
T. Cluff
D. Fontaine
S. Kirk
M. Rosner
R. Schmale
R. Skinner
K. White
Training &
Education
R. Schmale, Lead
Technical Tools
R. Skinner, T. Hoke,
Co-Leads
Structure
Be Safe Steering
Committee
T. Hoke, L. Facteau,
R. Cofield,
C. Ghaemmaghami
Be Safe Coordinator
S. Lewis
Be Safe
Senior Leaders
Marketing &
Communications
T. Cluff, Lead
UBL Capacity
Development
T. Hoke, L. Facteau,
C. Ghaemmaghami
Leads
Team Member
Safety
J. Amato, Lead
Situation Room
• McKim 1116
• Every weekday morning at
7:00 am
• Contains problem solving tool
displays and Health system
event data
Transparent sharing
of safety events and solutions
• Daily leadership huddles
review patient deaths,
CAUTI, CLABSI, falls,
pressure ulcers, team
member injuries
Expectations of
Real Time Problem Solving
 Every patient and team member safety event investigated
within 24 hours and solved to root cause and the learning
shared within 48 hours
 In order to accomplish this, front line workers need a help
chain
Expectations of a Help Chain Member
 Respond to safety events from your reports and go to the
place where the event occurred and help to solve the
problem to root cause
 If you cannot solve the problem or it exceeds your span of
control, you call your supervisor for help
 Share with all the learnings and disseminate to others
through the Be Safe Sharing Network
 Responding to pull from the front line is now a fundamental
component of your work as a manager
 To make time, we will eliminate meetings and events that
add no value to patients
What is a Help Chain?
Context setting
Rebecca Schmale, PhD
Learning Officer
New Logo
Team member safety –
the safest place to work
We are taking care of ourselves as well as our patients
What is Be Safe?
The systematic application of the scientific method
to improve the safety of our patients and team
members through real time problem solving
Solving a problem at the place where the problem
occurs by the people who encounter the problem so
the problem never happens again
Building a community of problem solvers for the
good of our patients and team members
The way we become a high performing organization
by actively seeking out ways to improve work
processes every day in every area
Be Safe reinforces our
RISE values
Respect
• The physical, emotional, and professional safety of
all individuals is ensured at all times
Integrity
• Every individual has the responsibility to call out
safety concerns and activate the help chain
Stewardship
• Eliminate waste and solve problems in real time
through scientific method thinking and tools
Excellence
• Continuously improve processes and collaborate
to yes for patient and team member safety
Be Safe is NOT:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
An “A3”
5S
Dr. Shannon’s project
Clinical only
Dr. Hoke’s job
Value Capture
Quality & Performance Improvement department initiative
Magical way to fix everything
A new way to cut costs
Flavor of the month
Medical Center only
More work added to already busy days
A program
Optional
Terminology
•
•
•
•
•
Help chain
A3
Waste
Standard work
Unit-Based Team (UBT)
and Unit-Based
Leadership Team (UBL)
• Root cause analysis
• Current condition
• Problem
TABLE
ACTIVITY
Do you remember?
Methodologies
•
•
•
•
TQM
Six Sigma
LEAN
PDCA
Tools
•
•
•
•
•
•
Kanban
A3
Scientific Method
5S
Root Cause Analysis
Statistical Process Control
Are you on this bus?
How Be Safe works
Root cause problem-solving
VS
Work-around solutions
Direct observation
VS
Retrospective data
Asking people
VS
Assumptions
Help chains
VS
Chains of command
Quick resolution
VS
Delayed response
Leaders: enablers of an
empowered workforce
VS
Bosses
Countermeasures: progressive
steps toward ideal state
VS
Permanent solutions
Transforming problem-solving and work processes
throughout UVAHS
Preventing
problems/harm in
our environment
through
observation and
standardization
of work processes
Addressing
problems/harm in
real-time using
help chains and
the A3 ProblemSolving Tool
S
A
F
E
T
Y
Observation
Everyone can be taught to “see” problems by learning the
technique of direct observation
Any process has at least 3 versions:
What you think it is
What it actually is
What it should be
Problems & activity
observation
Jody Reyes, RN, OCN
Administrator, Cancer Services
Direct observation
Observation is the starting point of problem solving
• Everyone can be taught to “see” by learning the
technique of direct observation
• Observation helps us understand how work is performed
and to identify where variances and problems occur
• Pilot teaching units are training and deploying
observation teams to watch co-workers in action and
gain insight to the problems they encounter in doing
their jobs
Additional information on observation:
A3 Problem Solving for Healthcare: A Practical
Method for Eliminating Waste
Pages 30-33
Problems and activity
observation
• We will simulate the
experience using a video
• Put on Be Safe Observer
button
• Read Guidelines
• Get Observation Sheet ready to
record what you see
Observation sheet
Key things to observe:
•
What is the need that the team member is trying to meet for
the patient/customer?
•
•
Time
10:35
Record how the need is being met:
•
Time
•
Location
•
Steps they are doing
•
People with whom they are interacting
When team members encounter a problem or are not able to
do the work, what happens?
Location
Pyxis
TS
Doing/Saying What
(To Whom)
RN moves from Pyxis to tube station looking for a med
Problems?
Resolved?
Can’t find med-looked
in multiple places
Found
med in PT
basket
Video
See “Simulated Problems &
Activity Observation” video on
the Be Safe website
Observation debrief
1.
2.
What are your general impressions of the experience you
observed?
Use the Problems & Activity Observation Debrief sheet to
record the following:
Barrier/Obstacle/Problem What team member did
Solved?
What problems did you
observe?
Did the team
member’s
actions solve
the problem?
Resist giving solutions!
Table
Activity
What did the team member do in
response to the barrier/obstacle/
problem encountered?
Debrief
3. Will the team member’s action to solve the problem
prevent it from happening to the team member again
tomorrow?
4. Will that action prevent the incident from happening to
someone else?
5. How many problems did you see in this very short video?
Great organizations put in place a system for stabilizing
the work and solving problems so they do not recur
Types of Work
Value-added
work
• Activities that
transform material,
information, or
people into
something the
patient (customer)
cares about
•Diagnosis, treatment,
care plan
INCREASE
Required non-value-added
Waste non-value-added
• No value in the
customer’s eyes but
can’t be avoided
• Consumes resources
but doesn’t add
value
•Billing, regulatory
tasks
•Looking for supplies,
wait times, rework,
redundant
paperwork, meetings
MINIMIZE
ELIMINATE
Waste
Turn to page 138 in your A3 Problem Solving for
Healthcare: A Practical Method for Eliminating
Waste workbook
•
•
•
•
•
•
•
Confusion
Motion
Waiting
Processing
Inventory
Defects
Over-production
Additional information:
On the Mend
Pages 48-60
Table Activity
• Go around table and assign each team
member a type of waste
• Take 2-3 minutes to read the definition,
examples, causes, and countermeasures for
the type you were assigned
• Each person then shares with the table
Give examples of the 3 types
of work from the video:
Value-added
work
Required non-value-added
Estimate how much time was spent doing each type
Waste non-value-added
Shocking yet true
In healthcare, typically 30% of the time is spent doing valueadded work while the remaining 70% is non-value added or
wasteful
This is not because people are doing a bad job;
it is because of how the system was designed
Great organizations focus their energy helping their team
members (experts in their own work) to see, call out, and
eliminate waste so that all of their time and energy can be
directed toward meeting the customer’s need
Great organizations create a system where problems
never repeat themselves
Activity observation
drawing
• A simple sketch of how the work is done now (current
condition)
• Drawing allows the movement of patients, team members,
products, and information to become transparent
• Go to page 9 in your A3 Problem Solving for Healthcare:
A Practical Method for Eliminating Waste workbook
for an example
• Highlights when there are differences in processes and
waste
Standard work
Variation in process occurs when work activities are not well
defined and can result in variation in outcome
Standard work is the one best way known today to
complete an activity and should evolve over time as we
learn better ways to do the work
Every activity should be specific to:
• Content
• Sequence
• Timing
• Location
• Expected outcome
UVA Current Condition of Variation- Pericare (5C & MICU)
PeriCare - General
Wipes
Gel
Gloves
Assess pt
Change
Linens
Wipes
Gloves
Gow n
Privacy
Turn/Positio
Open Wipes n patient
Explain
Step 7?
dump urine
Put top on
in urinal
reclip clamp urinal
place on
cath
measure
Gel
Gloves
Drain tube
Get urinal
Explain
Move pt
Get absorb
pad
Gloves
Turn/Positio
n patient
Open legs
Dipose of
Wipe r Arm w ipes
dump in
toilet
flush
Wipe Male
pt
Wipe L arm Gow n
Privacy
Gel
Get linens
Gloves
Gow n
Explain
Go to
Warmer
Get help
Privacy
Turn/Positio
n patient
Wipe Arm
Turn/Positio
n patient
w ipe back
Explain
Explain
Go to
Warmer
Wipes
Gel
Gloves
Privacy
Wipe Chest Wipe Arm
Wipe R leg
Wipe r Arm Wipe l leg
Change Pt
Gow n
Turn/Positio
n patient
Lotion
Wipe Male
pt
Wipe Face
Wipe Foley
and
drainage
tube
Open legs
Wipe Male
pt
Wipe Foley
and
drainage
tube
Wipe Male
pt
Wipes
Gloves
Wipe Stat
Lock
Dipose of
w ipes
Wipes
Gloves
replace
tubing
Dipose of
w ipes
Covered up Gel
CHG on
w ashcloth
Wipe Foley
and
drainage
tube
Wipes
Gloves
Explain
Gel
Privacy
Gloves
Wipes
Turn/Positio Wipe Male
n patient
pt
Unclamp
clamp
Wipe female
(around
folds)
Open legs
Unhook L
Hook R SCD SCD
w ashcloth
under
syringe to
balloon
empties
syringe
w ipe back
Dipose of
w ipes
Gow n off
Dipose of
w ipes
Wipe l leg
Dipose of
Hook R SCD w ipes
Lotion
Foley
collection
on bed
Resnap
gow n
Interruption: Dipose of
Comb Hair w ipes
Wipes
Gloves
Wipe r leg
w ipe back
Gloves
Gel
pull back
underw ear
Wipe Foley
and
drainage
tube
Unhook r
SCD
Turn/Positio Foley bag
n patient
moved
Gow n
Pull dow n
blankets
Gloves
Assess/
Gets
supplies
Change Pt
Gow n
Wipes
Change Pt
Gow n
ProblemWipe Male
Help w ith IV pt
Gel
Wipe Foley
and
drainage
tube
Dipose of
w ipes
Get linens
Turn/Positio
n patient
Wipe neck
Wipe Foley
and
drainage
Wipe Chest tube
Wipe l leg
Dipose of
w ipes
patient
Wipe Male
request
Wipe r leg pt
gow n set
Wipe Foley
Wipe female and
Turn/Positio Pt Request- (around
drainage
n patient
go slow er folds)
tube
Position/Brin
Problemg up bed
Open Wipes Untie gow n Wipe r Arm Wipe Chest Wipe L arm trip on shoe Open legs
Privacy
Wipe Foley
and
drainage
tube
Wipe Male
pt
Dipose of
Wipe Groin w ipes
Wipe l leg
Disconnect
s syringe
Explain
Turn/Positio Problem- o2 Elevate
Hook L SCD n patient
86%
patient
puts in red
bin
Gel
Wash
hands
Turn/Positio
n patient
w ipe back
Change
Linens
Problem
Need
Ultrasorb
Foley bag
moved
Wipe foot
Wipe foot
Get help
Turn/Positio
n patient
Put socks
EHA cream on
Ultrasorb
Resnap
gow n
Gow n on
patient
Removes
monitor
device
Problem:
patient
Desiton
allergic aloe
Cream legs that comes
Assess pt
Turn/Positio
n patient
Turn/Positio
n patient
w ipe back
Wipe Foley
Change
and
dressing on Turn/Positio drainage
Back
n patient
tube
Problem:
cord
unhooked
Put socks
on
Turn/Positio
n patient
HOB Up
Return call
Covered up bell
Turn/Positio
n patient
Foley with Daily Bath
Gel
Gow n
Gloves
Explain
Privacy
Explain
Wipe l leg
Wipe R leg
Untie/remov
Gow n on
Wipe L arm Wipe r Arm e gow n
Adjust abd binder
Wipe Chest patient
Assess/
Gets
supplies
Go to
Warmer
Wipes
Get help
Look in
room for
Wipes
Gel
Gloves
Explain
Get help
Gel
Gloves
Privacy
Turn/Positio
n patient
Explain
Get w ipes
Go to
Warmer
Gloves
Gow n
Gel
Get w ipes
Gel
Gloves
Gel
Gloves
Explain
Washcloth
in bin
Get
Wet
w ashcloths w ashcloth
Soap cloth
Wet
w ashcloth
Wipe l leg
Turn/Positio
n patient
Open legs
w ipe back
Turn/Positio
n patient
Adjust abd binder
Open legs
Position/Brin Turn/Positio Untie/remov
Offer new gow
g up
n bed
n patient
e gow n
Wipe arm
Open legs
Wipe Male
pt
Wet
w ashcloth
Wipe Foley
Wipe female and
(around
drainage
folds)
tube
Wipe R leg
Dipose of
w ipes
Untie/remov
e gow n
Wipe arm
Ultrasorb
Rolls up
stuff and
puts under
old sheets
Gloves
Unhook r
SCD
Unhook L
SCD
Actiflo in
place
Gloves
Explain
Wipe Male
pt
Soap cloth
Wipe L arm Wipe Chest Dries
Dipose of
w ipes
Turn/Positio Turn/Positio
n patient
n patient
Untie/remov
e gow n
Wipe r Arm Dries
Wipe Face
Dipose of
w ipes
Interruption: Interruption:
New gow n rn get gow n Gel
Gow n on
Untie/remov Turn/Positio Untie/remov patient
e gow n
n patient
e gow n
(new )
Obtains
Obtains h2o lube
Inserts
instaflow
Blow s up
balloon
Turn/Positio
n patient
Gloves
Wipe Foley
and
Turn/Positio
drainage
n patient
Wipe Chest tube
Gets more
w ipes
Problem:
Turn/Positio ventilator
Reconnect
n patient
tub pops off tube
Turn/Positio
n patient
w ipe back
Lotion
Change
Linens
Turn/Positio
n patient
w ipe back
ProbleminteruptionActiflo w ipe charge
dow n
nurse
Get help
Gow n on
patient
Change
Linens
Get help
Explain
Turn/Positio Turn/Positio
n patient
n patient
Explain
Male
pt/Female Pt
cleanse
Change
Linens
Turn/Positio
n patient
w ipe back
Interruption:
chg RN
rounds
Get help
Gow n on
patient
Change
Linens
Turn/Positio
n patient
Get help
Turn/Positio
Wipe Chest n patient
w ipe back
Foley with Stool
Turn/Positio Wipe w ith
n patient
Ultrasorb
Wipe Male
pt
Removes
mepelox?
Request
Instaflow
Visible stool
removed
w ipe back
Change
Linens
Privacy
Explain
Explain
Open legs
Remove
bedpan
Turn/Positio Turn/Positio from pt w ho Empty
n patient
n patient
remains in bedpan
Turn/Positio Visible stool
n patient
removed
Wipe Foley
Wipe female and
(around
drainage
folds)
tube
Get w ipes
Turn/Positio
n patient
Open legs
Get help
Visible stool
removed
w ipe back
Privacy
Gloves
Gow n
Assess pt
Look in
room for
Wipes
Wipes
Gloves
Assess pt
Gow n
Explain
Privacy
Assess/
Gets
supplies
Wipe Male
pt
Gel
Wipe Foley
and
drainage
tube
Get w ipes
Go to
Warmer
Gloves
Gow n
Gel
Get help
Explain
Open legs
Privacy
Introduce
self
Wipe w ith
pull cover Turn/Posit CHG front
lift gow n ion patient to back
Ultrasorb
Wash
hands
Gloves
Open CHG
w ipes
Explain
Gloves
Gloves
Ultrasorb
Gow n
Turn/Positio Visible stool
n patient
removed
Wipe Foley
Wipe female and
(around
drainage
folds)
tube
New pad
under
patient
Wipes
Change
Linens
Change
Linens
Turn/Positio
n patient
Dipose of
w ipes
Get linens
Turn/Positio Dipose of
n patient
w ipes
Wipe Foley
and
drainage
tube
Explain
Dipose of
w ipes
Gloves
Dipose of
w ipes
Get linens
Wipe w ith
CHG front Turn/Posit roll out
to back
ion patient clean pad
Turn/Positio Contain
n patient
visible stool Explain
Opens
instaflow
Probleminteruptionspeech to
do sw allow
Wipe Foley
and
drainage
tube
Change
Linens
Turn/Positio
n patient
Dipose of
w ipes
Turn/Positio
n patient
Open legs
Wipe Foley
and
Turn/Positio drainage
Reassure pt n patient
tube
Explain
Dipose of
w ipes
Change
Linens
Wipe Male
Reassure pt pt
Unhook r
SCD
Rem ove
pad and
place in
trash
Unhook L
SCD
BM
Interruption:
Device:Actif speech
Turn/Positio
low
pathology
n patient
w ipe back
Lotion
ask about
diaherra
Wipes
throw
aw ay
Wipe Tube trash
Wipe pt
w ipe back
Wipe pt
Wash
hands
Covered
up
Wipe BM
Device
sim ulated Foley w ith stool
Turn/Positio
n patient
Change
Linens
Turn/Positio
n patient
Standard work
•
Is different from a best practice because it is designed to be
tested and changed because there will always be
opportunities for improvement no matter how “good” the
“best practice” may be
•
Reduces variability, waste, and costs
•
Is easier to learn and practice
•
Everyone must practice the standard consistently
Teach standard work
Audit standard work
Draft of standard work developed
by front line staff in MICU and 5C
Supplies
Prepare at bedside
You and your team members will
participate in the
Problems & Activity Observation
training session
when your UBL & UBT go live
Now that we have
“observed a problem”
we are ready to do problem solving
A3 thinking
Tracey Hoke, MD
Chief, Quality & Performance
Improvement
A3 thinking
•
•
Structured problem solving
approach that uses a tool
called A3
The scientific method is the
foundation for A3 thinking
Plan
Act
Shewhart
Cycle
Check
Do
A way to look with
“new eyes” at a
specific problem
identified by direct
observation or
experience
The A3 scientific method
problem solving tool
• Effective learning is what A3 thinking and problem solving
is all about
• Rigorous use of tool prevents problem solvers from jumping
directly to solutions without identifying root cause(s)
• Encourages collaboration, interaction and continual
experimentation
Assess all processes and activities against the Rules in Use
Four Rules in Use
Rule 1: Clearly specify all steps
Activities
Rule 2: All steps in the request for a product or
service are as simple and direct as possible
Connections
Rule 3: The pathway (or flow of steps) required
to produce the request is simple and direct
Pathways
Rule 4: All problems are addressed, as close in
time and in person as possible, under the
guidance of a coach
Improvement
Turn to page 15 in
A3 workbook
You will always find at least
one of these in a problem
Rule 1: Work is not clearly defined
Rule 2: The way two areas connect isn’t clear or direct
Rule 3: The process isn’t clearly defined and so many paths
could be traveled that they create opportunities for error
Rule 4: The method for solving problems doesn’t use the
scientific method, doesn’t include the people who do the
work or doesn’t involve the people who have the
perspective and authority to change processes that
cross more than one area
A3 Format
1. Need/ Rationale
3. Target Condition
- Background
- Problems/needs
- Measures
4. Reasoning
- Hypothesis
2. Current Condition
- Drawing
- Key issues
- Root causes
5. Action Plan
- Action steps
- Timeline
- Expected outcomes
- Accountability
6. Key Learning
Additional information:
A3 Problem Solving for Healthcare: A
Practical Method for Eliminating Waste
Pages 35-48
The way things happen now
Left Side
1. Need/ Rationale
A better way to work
Right Side
3. Target Condition
- Background
- Problems/needs
- Measures
4. Reasoning
- Hypothesis
2. Current Condition
- Drawing
- Key issues
- Root causes
5. Action Plan
- Action steps
- Timeline
- Expected outcomes
- Accountability
6. Key Learning
Case study: EKG Leads
• Read the case study and
answer the questions at the
end
• A debrief and an overview of
the completed A3 will take
place following this exercise
Case study debrief
• Question 1 – Sources of Waste:
Confusion, Waiting, Overprocessing, and defects
• Question 2 – Relationship to the 4 Rules in Use:
• Rule 1: Work not clearly specified. (There was no process for
replacing defective labeling on the EKG machine.)
• Rule 4: The initially suggested solution for improvement
(retraining staff) did not get to the root of the problem and would
not have assured that the problem wouldn’t occur again
• Question 3 – Potential questions
•
•
•
•
•
Why
Why
Why
Why
Etc.
did the EKG need to be repeated?
were there increased costs to the hospital and patient?
were the staff frustrated and confused?
were the materials not labeled correctly?
1
Need/Rationale
• Focus on a specific event or problem, not multiple problems,
and describe it clearly
• State the issue through the eyes of the patient or customer
• Include background information needed to understand the
problem and why it is important
• Provide quantifiable data (safety, quality, financial, etc.)
– Includes baseline data
– Data collected during the A3 experiment is compared to the
baseline to validate the hypothesis and actions
Turn to Pages 134 and
135 in A3 workbook
2
Current Condition
• Describe, preferably in a drawing, how work is actually done
• Reflect actual observation (“Go and see”)
• Involve the people who do the work
• Use the Rules in Use to see the system and identify
problems
• Utilize the ‘5 Whys’ as a means of determining the root
cause of problems
5 Whys
•
The concept of asking a series of causal questions in order
to discover the root cause of a problem
•
Typically the root cause is related to activities, connections
pathways, and improvement (Rules in Use)
•
Compare what occurred at each step with what is
supposed to occur and at discrepancies, ask the 5 Whys
to determine the cause of variance
•
Don’t get hung up on counting the Whys; the
point is to drill down into a problem in order to
understand it deeply
3, 4
Target Condition &
Reasoning
• A pictorial representation of an improved state; how work will
be done (how the process is expected to work) based on the
changes we develop
• Moves work design toward Ideal and is more consistent with
the Rules in Use than the Current Condition
• Target condition is not the same as ideal condition but gets
you closer to the ideal
• Reasoning is the hypothesis for change - IF (we do these
actions), THEN (we will expect these changes
which will produce these results)
Action Plan
5
• State the activities required to implement the solutions
proposed by target condition
• Link actions to specific problems identified in current
condition
• Be specific in terms of ownership, time lines and expected
outcome
EXAMPLE
Root
Cause #
Who
What
By When
Test of
Value
6
Key Learning
• Make explicit what each participant expects to learn from
this experiment
• State what was actually learned through carrying out the
experiment
– Did you achieve your expected result? Why or
why not?
– What did you learn as a result of your efforts?
• Share with others in the organization who may be able to
apply the learning to their work
Coaching A3s
• Daily work of leaders is to coach others in problem solving
and coach development of A3s
• Review chapter 7 on coaching in A3 Problem Solving for
Healthcare: A Practical Method for Eliminating Waste
workbook
• Effective coaches:
Go “see”
Ask “Why?”
Show respect
You’ve learned some tools,
now let’s hear how Be Safe is
actually coming to life in a unit
Unit-Based Leadership
(UBL) and
Unit-Based Teams (UBT)
Kyle Enfield, MD
Medical Director
Unit-Based Leadership (UBL)
•
Formalize the problem solving process in the unit
•
Solve problems encountered in the course of work in real time
•
Create time to learn and improve
•
Includes the nurse manager, unit clinical nurse specialist or
improvement specialist (QPI), and unit medical director
Our unit ensures a UBL
member or designee is
available 24/7
UBL tasks
•
•
•
•
•
•
•
Meet Monday-Friday in am (time defined by group) to review
“bumps in the night”
Address urgent safety issues
Identify safety problems that can be addressed at unit level
Elevate safety problems that can’t be addressed at the unit
level up the Help Chain
Review identified problems at next daily huddle
One person from the team or a designee is available 24/7
to help stabilize problems and collect perishable knowledge
after an event
Nurse manager or medical director are “interruptible” to
coach problem solving
Unit-Based Team (UBT)
•
All front-line staff on the unit who are trained in the
fundamentals of Be Safe
•
UBT members call out safety problems in real-time,
ensure the patient or team member’s needs are
met, then notify their immediate manager (or other
UBL designee) of the incident or observation
•
UBT members participate in problem solving by sharing
perishable information, answering the 5 Whys, and direct
observation of work
Help chain
• Activated when team members call out problems
• First link: Unit-Based Leadership that investigates situation,
seeks additional assistance if needed, helps develop
countermeasures
• If more help is needed, escalation occurs to higher
leadership levels that can break down barriers and allocate
resources beyond the unit level and that can provoke a
deeper understanding of problems and solutions
• Last link: EVP
Real-Time Help Chain for Safety Problems:
Standard Work for Roles
INFORMATION AND TECHNOLOGY
CEO
AVPs
Patient or
Team Member
Safety Event
Chiefs
Management
Directors,
Administrators
and ACMOs
Unit-Based
Leadership
Patient
Teams (UBL)
Staff
Providers & Team
Be Safe Events
Role Responsibilities:
• Meet immediate need
• Initiate RT-RCPS*
• Call out problem
• Inform/seek
• Assist in RT-RCPS*
assistance as needed
• Report event in “Be Safe • Develop and
Events”
implement
experiments
• Update investigation
and learnings
•
•
•
*RT-RCPS: Real Time - Root Cause Problem Solving
• Provoke a deeper
Support UBL
understanding of
investigations and
problems and
development of
solutions
experiments
Provoke a deeper
• Allocate resources
understanding of
and break down
problems and
barriers to facilitate
solutions
RT-RCPS*
Enable experiments
that span departments
• Provoke a deeper
understanding of
problems and
solutions
• Allocate resources and
break down barriers to
facilitate RT-RCPS*
• Address issues that
require Board or
external action
Crossover and Sharing
INFORMATION AND TECHNOLOGY
Higher levels of Help Chain are pulled into the problem solving as needed
via Crossover
Risks &
Solutions
Communicated
Across
Help Chain
Risks &
Solutions
Communicated
Across
Help Chain
Unit-Based
Leadership
Management
Teams (UBL)
• Assist in investigation when it involves
their area
• Assist in developing experiments with
staff who do the work
• If experiment crosses departments
inform/seek assistance from other
managers
• If process breakdown did not occur in
their department, work with manager of
other department to advance RT-RCPS*
• Report any events and solutions in the
sharing system
• Read all events from prior day and
mitigate all risks that exist in your area
Chiefs
Directors,
Administrators
and ACMOs
• Assist in investigation when it
involves areas of responsibility
• Assist in developing experiment with
managers and staff who do the work
• If experiment crosses departments,
inform/seek assistance from peers
• Inform other s as needed to
continue RT-RCPS*
• Report any events and solutions in
the sharing system
• Read all events from prior day and
mitigate all risks that exist in your
areas
* RT-RCPS: Real Time - Root Cause Problem Solving
• Read all events from prior day and
mitigate all risks that exist in your area
• Work with Directors and others to
develop experiments as needed
• Collaborate with peers to support
experiments that span areas of
responsibility
• Break down barriers and allocate
resources as appropriate to facilitate
RT-RCPS*
• Provoke a deeper understanding of
possibilities and solutions
• Inform and seek assistance of AVPs
• Report any events and solutions in the
sharing system
Help Chain is part of a
successful problem solving system
•
Each team member has a designated “first responder” that
helps/coaches
•
If that “first responder” does not have command of the
resources to meet the immediate need and investigate the
root cause, the first responder goes up the chain to the next
level
•
Everyone has clear roles and timeframes for response
•
Information is shared transparently
MICU UBL Standard Work
Meet the Immediate
needs of the
patient, staff
member, or visitor
Shift Manager
gathers
information
about the
event from
those
involved
Shift Manager
and other team members
Shift Manager
determines if
the event
could happen
again
Shift Manager
UBL team
If, Yespage UBL
team for
additional
assistance
OR
Patient
Event
UBLs share
learning
across the
institution as
applicable.
Staff
Event
System
Help Chain
PIC # 1689
Everyone with
information about
the Event
MICU UBL Standard Work
On-call system for coaching (8am-5pm), PIC # 1689
Daily Reviews:
• Identify all patient Mortalities in the last 24hrs
• List of patients in MICU with Foleys and Lines
• Identify all Foley’s in place >2 day - Talk with the RN caring
for the patient
• Talk with the Shift Manager to identify Patient or Team
Member Events
o Go to the area in which the event occurred and talk to the
most proximal person involved - Ask “What” and “Why”
• Identify patients transferred to MICU <3 calendar days from
admission- Root Cause Analysis
Pilot lessons learned
• There are initially too many problems to solve
• UBLs must determine and communicate guidelines to the
number and type of problems they have the capacity to
solve
• Use documented Be Safe Events within unit as starting point
 Falls
 Medication errors
 Team member injuries
• Start small with 1-2 A3s on Be Safe Events
• Culture change is important
UBL & UBT Roll Out
Tracey Hoke, MD
Chief, Quality & Performance
Improvement
Roll out of UBLs and UBTs
•
First wave – inpatient units
•
Second wave – ambulatory setting and non-unit based
functions (pharmacy, therapies, etc.)
•
Medical Director and Nurse Manager roles being redefined
•
Leadership commitment to decrease non-value added
activities (meetings, etc.)
Train the Trainer
Be Safe Team Member Essentials
Rick Carpenter, RN
Nurse Manager, MICU
Be Safe Training
•
Be Safe Team Member Essentials is awareness training
delivered by the manager, assistant manager, RNAC or
supervisor
•
Our goal is for all team members to complete Be Safe
Team Member Essentials by October 1, 2014
•
Once your UBL Team is formed, the UBL Team will go
through additional training on problem solving
What team members need
to know:
1. What Be Safe is and why it is important
2. Professional safety and the responsibility to call out issues,
problems, events as soon as they see or experience them
3. Team members’ role in problem solving
4. UBT and UBL roles
5. Terms they may hear in the course of problem solving
6. Next steps and how they can learn more
Train the Trainer
•
We will go through the Be Safe Team Member Essentials
training and provide several options that you can adapt to
your situation or group
•
You have a bag full of materials and online resources to help
you train your team members:
IN BAG
1 - Team Member Essentials Facilitator’s Guide
1 - Team Member Essentials Tabletop Slides
2 - Problems & Activity Observation Pads
2 - Be Safe Clipboards with clocks
3 - Be Safe Observer buttons
2 - Terminology Activity card
1 - Job aid for LMS documentation
ONLINE







Video: Cofield on Be Safe 101
Slides: Be Safe 101
Be Safe glossary
Video: Bob and the UBL
Today’s forum
Articles
More added weekly!
Be Safe
Team Member Essentials
Be Safe Team Member Essentials
• Pull out Tabletop slides and Facilitator’s Guide
• You may divide the training into smaller chunks to deliver
via huddles or quick meetings
• You may use video, PowerPoint or tabletop slides
Real-Time Help Chain for Safety Problems:
Standard Work for Roles
INFORMATION AND TECHNOLOGY
Escalate up the Help Chain until Resolution
CEO
AVPs
Patient or
Team Member
Safety Event
Chiefs
Management
Unit-Based
Leadership
Staff
Patient
Providers & Team
• Meet immediate need
• Call out problem
• Assist in problem
solving
• Report event in “Be
Safe Events” system
Directors,
Administrators
and ACMOs
Teams (UBL)
• Initiate problem solving
• Inform/seek
assistance as needed
• Develop and implement
experiments
• Update investigation and
learnings
Your Unit-Based
Leadership Team:
Record completion of
Be Safe Team Member Essentials
in Learning Management System
(LMS/ NetLearning)
•
Use your LMS administrator
•
Job aid in your bag
Be Safe Awareness
Training Plan
May
June
July
Aug
Leaders
Unit Based Leadership
Teams
Clinical Staff
Team Members
By Oct 1, 2014, all team members will have completed
Be Safe awareness training
Sept
Oct
Team Member Essentials
Don’t underestimate the change in culture
required to make Be Safe a reality in your area
Culture change
Bo Cofield, DrPH
AVP, Hospital and Clinic Operations
Our Be Safe
journey requires
a culture change
How you react when a team member comes to you with a
problem or issue
Where you find time to coach and facilitate problem solving
How you approach team members who do the work to involve
them in problem solving
How you communicate
What percentage of healthcare errors or sentinel
events are the result of communication failures?
A.
B.
C.
D.
20%
40%
50%
70%
The Joint Commission. Sentinel Events Statistics, 1995-2005.
Accessible at http://www.jointcommission.org/SentinelEvents/Statistics
Be Safe leadership
From
To:
All knowing
Autocratic
Impatient
Blaming
Controlling
Always in meetings
Never asking for help from
above
• Buck stops here mentality
• Lone Ranger
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Coach
Facilitator
Teacher
Student
Helper
Communicator
Respectful
Readily available
Changing leadership habits/
behaviors
•
Dismantle shame and blame with data
 Use tools such as A3 and 5S
Go and “see”
•
Use A3 scientific method thinking
•
Provide visual management that front line staff can
understand and embrace
•
Encourage and follow standard work for leadership
•
Focus effort on value-added work
 Reduce meetings
 Communicate more than ever
•
Leadership challenges
• Reducing waste and non-value added work comes before
adding technology or people
• One leader’s “silo” is another leader’s “value stream”
• Cross-boundary perspective is vital
• Asking for help is not only OK, it is encouraged
• Understanding the organizational and human response to
change and managing resistance
Five stages of change
5. Integration
1. Awareness
Lock in
Standardize
Information
4. Compromise
2. Reality Testing
Dialogue
Experience
3. Resistance
Additional information:
On the Mend
Page 175
Whoa!
Slow down!
Typical emotional responses
Ending
New Beginning
Enthusiasm
Acceptance
Hurt
Anxiety
Shock
Adaptation
Fear
Hope
Anger
Testing
Chaos
Frustration
Understanding
Confusion
Skepticism
Stress
Awareness
Ambivalence
Denial
Resistance and naysayers
•
I don’t feel safe
•
Now management wants me to do their job
•
I don’t get paid enough to solve problems
•
How can I get away from doing my real job to do this
extra stuff?
•
Where are the resources coming from to do this?
•
We tried this before and it didn’t work
•
This too shall pass
How will
you respond?
Leader expectations
• Teach Be Safe Team Member Essentials to your team
members by October 1st
• Attend additional training when scheduled and begin
practicing A3 thinking
• Coach team members to observe and solve problems once
the UBT and UBL are trained
• Maintain a culture of respect and ensure professional safety
• Challenge yourself and others to continuous improvement
• Inspect what you expect
• Collaborate to yes
General questions about Be Safe
Email:
Be_safe@virginia.edu
You have just
completed
Be Safe
Leadership Basics
Our Journey to
Become the Safest Place
to Work and
Receive Care
Be Safe
is our roadmap
Closing remarks
Rick Shannon, MD
EVP, Health Affairs