Use of Continuous Performance Improvement in Academics: A Culture Change
Article Outline
CPI, Continuous performance improvement, RPIW, Rapid process improvement workshop
The close alignment of academic pediatric departments with the clinical mission of children’s hospitals and university health systems has created a “burning platform” for the highest quality patient outcomes. With our hospital partner, Seattle Children’s Hospital, we began a long-term cultural transformation to achieve excellence through ongoing, incremental change by using a process of continuous performance improvement (CPI). CPI focuses on patients and families as the beneficiaries of all interventions and improvements to provide the highest standards of quality, safety, delivery, and cost efficiency with an engaged staff and administration. The foundation of CPI methodology is the Toyota Production System, known in Japan as the “Kaizen” system.1 In the past 8 years, the Department of Pediatrics not only embraced the principles of CPI in our clinical programs, but also sought applications in our teaching and research missions.2, 3
Principles of CPI
Our organization determined that regardless of the type of process being improved (clinical care, hospital operations, teaching, or research), the value must be defined by benefit to patients and families. In CPI, a value stream maps the flow of a process from beginning to end and then measures the cycles of work required to complete the process. For patient care, a value stream maps the referral of a patient to discharge or, perhaps, to completion of therapy. For teaching, it might map the resident’s work day and cycles of care interfacing with teaching, as in the ordering of total parenteral nutrition. For research, it might map the time from a creative idea to commercialization. To maximize flow, waste must be eliminated. Various types of waste include processing, correction (re-work), searching, transportation, poorly used people, poorly used space, inventory, complexity, and waiting. Despite the amount of effort expended, 90% to 95% of most process steps are non-value-added to the patient and are therefore “waste.” Some non-value-added steps are necessary (eg, regulatory requirements), although not directly of value to the patient.
To implement improvements, value streams are created, and all steps and cycles are quantified. Seattle Children’s Hospital uses rapid process improvement workshops (RPIWs) as one improvement tool. Each RPIW has an executive sponsor, one or two process owners, and an improvement team with key stakeholders, including a patient representative, residents, and a management oversight team. A 5-day RPIW offers some CPI training during day 1 and implements an improvement on day 4. Implementation is an integral component of this activity and differentiates our improvement process from traditional approaches that may take weeks or months to implement. Every RPIW has a goal of at least 50% improvement in the process. Audit metrics are evaluated at 30 and 90 days to ensure that improvements are sustained and are reported at a monthly hospital-wide meeting.
CPI and Education
Education is a core mission of our Department of Pediatrics and of Seattle Children’s Hospital. To ensure that the educational mission is not inadvertently challenged during CPI improvements, we have included a resident or residency representative in all CPI projects that affect clinical care. Often, the educational mission and clinical process are inextricable. Teaching rounds are but one example and were one of the initial targets for standardization and process mapping. The goal of the first workshop was to completely reorganize the day on the inpatient medical services. Unfortunately, our first RPIW was far too ambitious, and although educational for the participants, it brought significant frustration because of the inability to control many of the ancillary processes outside of the scope of the workshop. However, from this workshop, family-centered rounding was established, a patient care coordinator was added to all teams, and a system for entering orders as the team met with families was developed. A hallmark of the CPI process is persistence, permission to fail, and taking the long view. A second effort that addressed the role of the senior resident during morning rounds held much greater success and began a succession of incremental improvements that have been sustained. The “senior resident RPIW” addressed challenges the team had in seeing all patients in the allotted time for rounds, team teaching, and conference attendance.
As processes were mapped, we learned that 17% of rounding time was lost while waiting for attending physicians to arrive for rounds. Waiting for interpreters was another delay. Residents were subjected to >100 interruptions (pages and phone calls) during work rounds each week. We learned that the average time needed for family-centered rounds was approximately 10 minutes per patient. Improvements from this workshop included: phone calls during rounds were required to be text messages, except for emergencies; attending physicians on both the general medicine service and specialty services agreed to strict schedules; interpreters were scheduled before rounds; teams split, so patients could be seen when the number of patients exceeded time available for rounds; the roles of the senior resident and attending physician for teaching during rounds were standardized; and noon conferences were moved to 12:15 p.m. to allow time to finish work before the conference. The resident daily schedule for medicine CPI event targeted improved communication to families, improved resident education, and optimizing continuous advancement of care. The metrics for these included documentation of discharge criteria and the daily plan of care on patient whiteboards (goal 80%); applicable patients receive family-centered rounds (goal 100%); an increase in noon conference attendance by residents (goal 50%); improve resident rating of experience on rotation; and standardize rounds to match the time needed for rounds (cycle time) with the time available (takt time). Family-centered rounds improved to approximately 100%. Discharge criteria and plan of care documentation metrics improved at 30 days, but fell back to baseline at 60 days. Resident attendance at noon conferences increased from baseline of 40% to 58% at 60 days. Resident satisfaction increased from baseline of 3.25 to 3.6 (scale, 0-5). There were virtually no duty hour rule issues for our residents, which is an indirect proxy for completing rounds on time.
Teaching rounds have been the focus of many subsequent workshops. The pediatric intensive care unit established scripted rounds with each member of the multidisciplinary team responsible for presenting specific data in a standard order during rounds. This improvement resulted in the work of rounds being completed and not left for later in the day. This standard method of presentation was replicated on hematology/oncology teaching rounds and later on the general medicine service.
CPI in Research
Accepting the usefulness of CPI in research was embraced first by the research technical and administrative staff. Funded principal investigators have gradually engaged in CPI, but often express concerns about balancing time required to maintain research productivity and grant funding with time commitments for improvements. Despite this concern, many of our research administrators and some of our leading scientists have participated in CPI leadership training. CPI initially addressed research support functions: developing new cage-washing procedures in the vivarium; routing institutional review board proposals; patient admission processes in the clinical research center; and processing grant applications. Work in the vivarium resulted in a dramatic reduction in daily animal housing costs to investigators. The institutional review board application process and contracting forms have been simplified and modified to reduce redundant steps. Applications were simplified to be more user friendly.
In CPI, to improve processes, one must be able to see the process by eliminating clutter with a methodology called 5S (sort, simplify, sweep, standardize, sustain). The entire Seattle Children’s Research Institute has made a significant effort to reduce waste, unnecessary inventory, and duplication of equipment and resources. In addition, two of our research center directors now hold twice weekly, 30-minute improvement sessions at a “Kaizen” board. This prominently visible, erasable wall allows any staff member, technician, or investigator within their research center to write concerns or problems that impair their daily work. The session is attended by any interested center members and the president of the research institute. At these sessions, issues are aired and discussed. When the group prioritizes a problem, an individual is assigned to address the issue with a date set for a progress report. A problem is not erased from the board until it is remedied.
Seattle Children’s Research Institute now has a research CPI office with an active schedule of improvement processes. A current value stream is mapping the flow of an idea with potential for technology development to successful commercialization. We also are evaluating how CPI methods may speed our translation of laboratory advancements into clinical studies.
Summary
CPI in an academic environment cannot be accomplished without the strong endorsement of academic physician leaders and requires patience and persistence in changing the culture. By nature, academic physicians are data driven and reluctant to accept new approaches without controlled trials. Many of our faculty initially believed that efforts to standardize processes were an attempt to improve revenues and considered the program to be an intrusion into their patient care. Persuading the faculty that eliminating waste and improving flows allows for more time to interface with patients and teach was initially met with skepticism. As the institutional resolve to use CPI methods to be the “best” children’s hospital was recognized and demonstrable improvements in the work flow for physicians occurred, more and more physicians accepted the CPI culture. Yet, when we agreed throughout the department and institution that the “customers” for all our improvement efforts were patients and their families (whether clinical, teaching, or research), we accomplished a more general acceptance in residents and academic faculty. Many faculty and residents have developed academic products, such as abstracts and publications, from their CPI efforts. Seattle Children’s Hospital has significantly invested in creating the culture and infrastructure for CPI, and the Department of Pediatrics has been critical in the successful application of CPI in the clinical programs at the hospital. CPI is now the method and language of how we conduct our daily clinical and academic work at Seattle Children’s Hospital.
References
- In: Liker JK editors. The Toyota way. New York: McGraw Hill; 2004;
- . Modifying the Toyota production system for continuous performance improvement in an academic children’s hospital. Pediatr Clin North Am. 2009;56:799–813
- In: Wellman J, Hagan P, Jeffries H editor. Leading the lean healthcare journey: driving culture change to increase value. New York: Productivity Press; 2011;
PII: S0022-3476(11)00709-8
doi:10.1016/j.jpeds.2011.07.013
© 2011 Mosby, Inc. All rights reserved.
