Ann M. Dohn, M.A.

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Changing the Culture GME-Streamlining and
Standardizing for Cost Savings and Efficiencies

• Ann M. Dohn, M.A.
• Stanford DIO
• Nancy A. Piro, Ph.D.
• Program Manager/ Education Specialist

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Disclaimer

• No Conflicts of Interest to Report

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Session Core Competency Focus

• This presentation addresses the GME Leader Core
  Competencies of
• Developing and Supporting Residency Program
  Directors Coordinators
• Managing the Institutions GME Operations.

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Three Key Session Objectives

• Provide a foundation for the understanding and
  application of lean philosophies and practices to
  GME.
• Describe specific process improvement measures
  that can result in increased efficiency and cost
  savings in a graduate medical education (GME)
  setting.
• Provide a Toolkit
• Forms
• Templates
• Examples to streamline and standardize GME
  processes at their respective institutions.

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Thinking Out of the Box?
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Thinking Outside the Box Looking to Industry
and Corporations

• What does industry have that we can use?
• Conveyor belt to move patients in and out of
  ORs?

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No.

• But they do use a Lean Philosophy
• Respect for People
• Total Elimination of Waste
• And they use Lean Tools such as
• Kaizen
• 5Ss
• 3 Ms

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Lean Toyota Production System (TPS)

• TPS system managed to get by with half of
  everything!
• Physical space
• Personnel
• Capital Investment
• Inventory
• Resulted in far fewer than half the defects and
  safety incidents

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NUMMI
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Lean Culture Shift

• Make problems visible not hide them or not
  talk about mistakes/problems
• Fix problems permanently get to the root
  cause and eliminate it.
• Focus on the value and respect for people.

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Lean Tools --- A Sample

• Kaizen
• Elimination of WASTE - 3Ms
• Problem Solving
• 5 Whys
• Fishbone Diagrams (Ishikawa Charts) 4 Ms
• 4 Ps

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Lean Tools Kaizen

• What is Kaizen?
• Gradual, unending continuous improvement of
  processes
• Processes must be improved to get improved
  results
• By improving and standardizing activities and
  processes, Kaizen aims to eliminate waste

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Kaizen Basics

• Focus is on small, incremental change (not
  necessarily huge leaps, innovation)
• Quality Control quality of people
• A company that is able to build quality into its
  people is halfway to building quality outcomes
• Respect for People
• Only people produce improvements

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Lean Tools 3Ms

• All about Waste- Identifying it and Removing it
• MUDA Waste of using resources without creating
  added value
• MURI Waste of overburdening people or
  equipment/resources
• MURA Waste of unevenness, variability in
  processes

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Five Whys Problem Solving Method

• Keep asking Why until you discover the root
  cause of the problem
• No magic in 5
• might be 3, or 7, or 10
• Why do we? (conduct orientation in person, fill
  out multiple forms, take on line training for non
  MDs)

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Lean Tools Fishbone Charts using the 4Ms 4
Ps

• Manpower/Personnel
• Materials
• Method(s)
• Machines / Equipment
• People
• Process
• Policy
• Principles

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Ishikawa Diagram of ER Prolonged Wait Times
Materials
Methods/Process
WHY?
WHY?
xxx hr wait time in ER
WHY?
WHY?
Manpower/People
Machine\Equipment
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5Ss - Mnemonics Retained

• Sorting
• Simplifying
• Sweeping
• Standardizing
• Self Discipline

• Seiri
• Seiton
• Seiso
• Seiketsu
• Shitsuke

QUICK EXERCISE
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5Ss in Action
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AFTER
BEFORE
ER Rooms
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Now ---How Can this be Applied to GME?

• Have read the books
• Know the materials
• Understand the tools
• Have stolen former Toyota Manager
• So what do we do

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Putting Philosophy into Practice

• Flowchart the processes
• Ask- Why are we doing this?
• Fishbone the problem
• Huddle to discuss with the team
• Look for the 3Ms
• Apply the 5Ss

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Start with the Current State

• CURRENT CULTURE
• Paper driven registration (forms, forms, and more
  forms)

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CURRENT CULTURE

• 87 programs (87 fiefdoms all doing their own
  thing.but having common requirements)

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Current Culture

• Lack of standardization/inconsistencies (MURA)
• Overburden (MURI)
• Waste (MUDA) of both materials and time
• Lots of files
• Time to file personnel folders or
• ACGME letters
• Time-consuming institutional oversight of
  programs (MUDA, MURI)

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Streamlining a GME Process Example

• What GME Processes would be the best targets to
  streamline and improve eliminating waste and
  redundancies?

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Where to start?

• Low hanging fruit vs. most impact on
  residents/faculty/GME staff
• Actually you can do both!!!

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Drivers Where to start?

• Areas of largest number of ACGME citations?
• Questionnaire data?
• Program Directors Needs Analysis
• Incoming House Staff survey data
• Annual GME resident survey data
• Program Coordinator requests

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Where to start?

• Huddle-need team involvement
• Respect for people
• Respect can lead to elimination of unnecessary
  work

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Real Time Examples of What We Standardizing We
Have Done

• Project One Program evaluation standardization
• Project Two Orientation standardization/streamlin
  ing
• Project Three Policy standardization
• Project Four Summative evaluation
  standardization
• Project Five Paperless Office/Registration

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Project One Standardize Program Evaluations

• Factors driving decision to standardize
• Largest number of program citations from ACGME
• Lack of consistent data on program evaluation for
  APRs (MURA)
• Huge amount of paper generated to produce
  suboptimal evaluations (MUDA)
• Burden of work on the coordinators (MURI)

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Standardized Program Evaluations

• What did we do?
• Developed standardized comprehensive core
  competency-based Program Evaluations by Faculty
  and Trainees
• Presented the draft templates to the Program
  Directors who edited and approved them.

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Standardized Program Evaluations Process
Implementation

• Annually the GME office
• Delivers --via our Residency Management System
  (RMS)--176 evaluations
• Aggregates each programs data after the evals
  have been completed
• Prints (electronically to pdfs) their aggregate
  Program evaluation reports
• Posts the Program Eval Reports (pdfs) on their
  APR site (in the RMS)

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Program Evaluation Standardization Toolkit
Example
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Standardization of Program Evaluations

• Benefits
• Fewer citations
• Can be input to our Institutional Report Card
• Easy oversight by DIO/GMEC
• Early warning system

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Results of Project One

• Less paper wasted (none used)
• Program evaluations sent out centrally by GME
  using standard evaluation forms
• Compliance with program evaluation can be easily
  monitored by GME
• Reduction in ACGME citations
• Less concern about confidentiality from house
  staff

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Project Two OrientationStandardization/Streamlin
ing

• 360 incoming residents/fellows attending one day
  orientation sessions
• Completion of various mandated training
• Issuance of computer codes, pagers, ID badges,
  parking permits, etc.
• How do we cope with residents unable to attend
  orientation?

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CURRENT CULTURE

• Face to face orientation
• great to know what we look like but big
  differential in quality of some presentations
• inability to really control content of each
  presentation and test knowledge of materials

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Project Two OrientationStandardization/Streamlin
ing

• Wasted both incoming trainee time and staff time
  - MUDA
• 20 speakers
• Long lines waiting for such stations as photo ID
  - MURI
• Lack of standardization of presentations - MURA
• Loss of the one auditorium large enough to hold
  group
• Difficulty in keeping the attention of the
  trainees (material overload vs. shopping at
  Nordstrom's) - MURI

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Project Two Web-based Orientation

• Based on the input from resident orientation
  questionnaires
• All mandatory modules became Web-based
• Offered in advance of orientation
• Many have post tests
• Can verify completion of training
• Can be done from home/Starbucks

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Unintended Outcome

• Have we gone too far?

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Project Three Standardization of Policies

• Design a policy template for common program
  requirement policies to reduce redundancies
  (MURA, MURI, and MUDA)
• Supervision
• Moonlighting
• PLAs
• Recruiting
• Duty Hours
• Work Environment
• Beyond Duty Hours
• etc.

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Policy Development
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Teaching the Use of Policy Templates

• Program director noon conferences
• Policy writing workshop

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Monitoring Implementation of the Policies

• Verify in our residency management database
  (system which cannot be named)

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Easy Online Policy Verification for each program
- Example
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Project Four Summative Evaluations The Drivers

• ACGME Citations
• Incoming and Outgoing!!
• Multiple / variable forms (MURA)
• Redundant wasted paper (MUDA)
• Overburden PCs and PDs (MURI)

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How Do We Do This Efficiently and Effectively?
Fill in the blank? Multiple
Choice?? Can my coordinator help me out here?
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Project Four Summative Evaluations What did we
do?

• Developed Standard Evaluation Template for
  Summative Evaluations
• Comprehensive over program training years
• Core-competency based
• User friendly word document
• Held Program Director and Program Coordinator
  Teaching Sessions / Workshops
• Taught the use of the template and how to pair
  it with aggregated evaluation data from our RMS

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Use of Resident Evaluations from RMS

• Programs could select the evaluations to use
• We recommended
• Evaluations Competencies by Resident
• Resident/Faculty Ranking Report (aggregate)
• Aggregate Comments Report
• Evaluation Competencies Report

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Coordinate with Aggregated Evaluation Data
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Summative Evaluation Template
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Macro-enabled Word Doc
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Additional Considerations

• Special Cases
• At the end of a preliminary year (internship)
• Need to list Rotations

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Final Points

• Review report with trainee
• Place a copy of the summative evaluation in the
  Trainees permanent file and upload to our
  residency management system

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Project Five The Paperless GME Department

• Files
• Program reviews
• Registration
• PIF reviews

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Project Five The Paperless GME Department

• Load all forms into the residency management
  system (RMS)
• Scan
• Upload
• Direct enter

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Project Five The Paperless GME Department

• Program reviews
• Review on line
• Duty hours
• Policies
• Annual program review documentation
• Evaluations
• complete
• Ranking status
• 360s
• Surveys
• Board pass rates
• etc

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Project Five The Paperless GME Department

• PIF Reviews
• shared document review on line

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Project Five The Paperless GME Department

• Incoming House Staff
• Learning modules web-based
• Standardized content
• Post tests
• Tracking that all modules complete
• Annual review of module content
• Registration
• Summative Evaluation Acquisition
• Access to RMS system to enter data
• Upload forms/documents

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Project Five The Paperless GME Department -
Results

• 500 fewer pages of paper per Internal Review x
  times 2 drafts and an average of 20 Internal
  Reviews per year
• Savings of 40 reams of paper
• Two entire trees saved (17 reams of paper one
  tree)
• Time Saved (walking, waiting, mailing eliminated)

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Questions?
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Contact Information

• Ann Dohn, DIO
• adohn_at_stanford.edu
• Nancy Piro, Program Manager
• npiro_at_stanford.edu