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Idaho Healthcare Workforce Summit Presentations

Welcome and Introduction: Linda Powell, MSIPT, President, Idaho Rural Health Association

Keynote Speaker

Robin Dodson, PhD, Idaho State University, Special Asst to Dean of Academic Programming

Robin discussed Governor Otter’s charge to the Select Committee on Healthcare. He spoke about problems with healthcare and healthcare access, and how the committee is to addresses reform. Governor Otter’s mandate to the Committee on Health Care is:



Governor’s Health Care Summit Recommendations (August 21-22, 2007) - pdf

Dr. Dodson recommended this article by the American College of Physicians for reading:

Panel Presentation “State of the State” – A facilitated discussion on health work force issues. Facilitator – Hartzell Cobb, Executive Director, Mountain States Group

Presentation #1 – Health Occupations for Today and Tomorrow (HOTT) Sandra Durick, Director, South Dakota Office of Rural Health Halley Lee, Manager, South Dakota Healthcare Workforce Center, South Dakota Office of Rural Health

Sandra started her presentation by telling us how here program started by asking the Critical Access Hospitals what their most pressing issues were. The main concern mentioned was WORKFORCE. She discussed their initial summit in August of 2006 which was to raise awareness of the issue. The issues that were focused on were: Healthcare Professional Recruitment & Retention; Educational Program Capacity; Clinicals & Internships; Student Perception & Awareness of Health Careers; and the Educational Pipeline.

She discussed the Healthcare Workforce Inter-agency Team that was developed from this summit. Action teams were formed to develop projects and programs that addressed these issues. These were then to be presented during a follow up summit in July of 2007. The result was 22 new projects to be implemented by sponsoring agencies.

Sandra also discussed what sources of data was used to determine areas that have the most need, and how these may be used in the future. One way that they are trying to gain support and interest is to develop healthcare liaisons with the community hospitals and long term care facilities. Also discussed was the Healthcare Workforce Partnership. It is a fund administered through the South Dakota Community Foundation that provides a mechanism for contributors to donate funds that will be used to develop healthcare workforce projects in South Dakota. The three major health systems in South Dakota initiated the fund with generous contributions. The fund is available to anyone or any organization. A steering committee has been developed that will administer this fund. The committee consists of 2 individuals from each of the three health systems, 2 representatives from independent organizations, 2 representatives from long-term care facilities, and 1 individual from an independent clinic in South Dakota. The committee has prepared a request for proposal (RFP) for funding and will be responsible for determining fund recipients.

The monitoring of all these projects is the responsibility of the Healthcare Workforce Center housed in the Department of Health. New projects and programs will also be developed and implemented.

Their future plans include:

Then they moved into a discussion of HOTT. To start they discussed a lesson plan for Kindergarten to introduce health related professions to the students. Following this they talked about the different components of the HOTT program.

The first component is the Health Academy. There were 5 held throughout the state for juniors and seniors with about 20 attending each. This was a weeklong hands-on experience for the students.

Scrubs Camp, started last fall, is a one day hands-on experience. Several different residential type camps are also used on campus at the universities.

Hot Futures is a venture created by the technical institutes where a tote is provided to the teachers and has all they need to provide information to the students about 21 different medical careers, and what is needed to get into that career.

The program also provides a Virtual Health Career Fair for rural area students. It is done through interactive television where students can ask questions of health professionals.

Health in Partnership with Education (HIPE) week promotes partnerships with educational facilities to promote health careers.

The Community Health Nurse Project allows nurses to work in the schools, teach the HOTT lessons, and set up health career fairs, among other things.

The website provides the information for the program. It has links to various partners and the projects that they are involved in. They showed various places within that website that shows healthcare related data and fact sheets from South Dakota. Also discussed were resources and activities available for anyone interested in the different projects. Lesson plans for the differing grade levels are available.

IRHA Update

Linda Powell discussed the new mission statement and the vision of the IRHA. Mission: To provide leadership on issues related to rural health in Idaho through advocacy, communication, and education.

Vision: To be the recognized advocate for rural health issues in Idaho.

She discussed some of the difficulties the organization has had with staffing, promotion, and funding. She explained that this is part of being a fledgling organization, and that they have plans to expand the activities and opportunities that are available through the IRHA. The benefits of becoming a member of the association are:

Linda talked about working with a consultant from the NRHA who helped with the refinement of the Mission and Vision, and helped to develop some activities for the future. Some areas identified in terms of priorities were:
She also talked about the board elections where David Schmitz and Felice Lampert were elected. They plan to expand the board, and will be recruiting additional board members.

Recently the IRHA went through a bylaw amendment process. The draft bylaws will be available on the website for review, and feedback is welcome. Recently the NRHA provided funding to develop a board orientation process and do some leadership training.

David Schmitz, M.D., who is an IRHA board member, discussed a pilot project that is in the works. The idea for the framework of the project is that using a local forum is the key to the growth of this organization. The goal of the project is to get the local community facilitators to communicate and build relationships throughout the region in these local forums. In this way local issues can be related and discussed with others in the region.

David also talked about the Idaho Meth Project. It is aimed at young people and parents to encourage discussion about this issue. The “Not even once” message is key to this campaign. The project is providing information and discussion forums to the community so that this issue can be brought to light, and adults can learn how to discuss this with the children in their care.

Presentation #2 – The Recruitable Community Program: Changing One Community at a Time Nancy C. Melton, Program Coordinator, Division of Rural Health and Recruitment, Office of Community Health Systems, West Virginia Dept. of Health and Human Services

The program focuses on the roll of the community by increasing its ability to recruit and retain health care providers. Funding is provided through the FLEX program. Working with and paying for the First Impressions Program and the Community Design Team, allow the smaller communities to access these services that the larger communities have. These programs work with healthcare centers instructing them on recruitment and retention, state loan repayment programs, and assist them in maintaining the healthcare providers that they have.

The First Impressions Program goes into a community and looks at what might be seen by the first time visitor to that location. They delve into all aspects of the community and see what it is that the community may want for development. The Community Design Team supports the development of realistic revitalization projects. The services are provided by the West Virginia University Extension services. The team can consists of economic development experts, architects, landscape architects, historians, public administrators, engineers, and city planners. They talk with the city’s planners, and discuss what they can to for them centered on healthcare. The team provides feedback and advice on plans introduced by the community members concentrating on what is most important for the community and its healthcare system. They do not appropriate funds, but can advise on how to get funding (i.e. grants).

The First Impressions 3-person team provides a report outlining what they observed when they went through the community. The Community Design Team provides an extensive report outlining all of the areas of improvement that have been observed during the team’s visit. Many have used this report to obtain grant funding.

The Recruitable Community Team and the Community Design team visit is an extensive 3-day visit to the community. The community is responsible for the application, set up and advertising of the visit by the teams. Several meetings are held to determine who will be selected for the design team. The teams meet with various groups within the community, including the youth, to determine what the community’s wants and needs are. A year later a follow up is done and to determine if anything else can be done to help them.

The benefits of being selected as a recruitable community are:
Communities of 400-500 people are the average size, and 2 rural communities per year have received this program support.

Presentation #3 – Recruitention Tim Skinner, MS Ed, Executive Director, National Rural Recruitment & Retention Network (3RNet)

Tim opened up his discussion by asking the participants to invite their legislators to co-sponsor the Conrad 30 Program. The program was designed to provide each of the fifty U.S. states with 30 waivers for J-1 physicians each fiscal year.

The main discussion started with examples of problems that we still face in getting the rural healthcare facilities to focus on recruitment and retention. He went on to discuss the importance of keeping in mind that recruitment and retention cannot be separated. These two things have to be considered together to interest and retain the healthcare providers that a rural community may need.

He stressed that Recruitention needs to be a part of a process. This involves strategic planning, community needs assessment, developing a plan, sourcing (where to find candidates), setting up the hiring/orientation ahead of time, and succession planning.

The 3RNet basic precepts for success are:
Tim also discussed Rural Health Works. He talked about research that they did which said that for each Physician in a town, $1.3 million in additional support goes to that community. This stresses the importance of the health system growing the community, and the community growing the health system. He went on to talk about how in a small community every person is important to the development of that community, not just the leaders.

He talked about the importance of a needs assessment when considering new recruitment to determine what the community needs. Also mentioned was the fact that over recruitment could be as big a problem as under recruitment. Included in this assessment should be the recruitable community. He talked about how the town could be the thing that could drive away prospective practitioners. He said that we should get someone from outside the town to look at our community, since we may overlook things that a newcomer might see. The goal is to promote the community and the medical practice honestly. Otherwise we will recruit over and over again if we don’t pay attention to the retention side of the equation.

Tim talked about resources for needs assessments. He said to start local. For example, Laura Rowen at the Idaho Primary Care Office. He mentioned that 3RNet has a recruitment and retention manual and handouts on their website. The National Health Service Corps, National Association for Home Care & Hospice, National Association of Regional Councils (NARC), Health Resources and Services Administration (HRSA), and the Indian Health Service were some other resources that were mentioned.

We have to have a community plan and medical staff plan put together to develop our strategic plan. With this we can develop a Recruitention Plan. This allows us to define a candidate, and the criteria of where we will compromise. Another thing to consider when developing this plan is compensation. The rural community needs to figure out ways to be competitive with the larger healthcare systems. The plan needs to be put together before we start recruitment, so that we are ready when the candidates make contact. Included in this plan we need a sourcing plan. How do we find the people, where are we going to do our ads? The 3RNet provides a place for recruiters and candidates to connect.

Another thing that Tim talked about was finding the recruiter(s) that is going to do all of these things. He discussed the importance of screening, and used Google as an example of a simple screening method. He stressed the idea of making sure that the person selected for recruiting has the time to properly handle potential candidates/interested practitioners and the interview process. He also talked about the idea that since we did the whole community planning process that this person would be aware of this, and know what’s available in the community that might interest the candidates. We should invite the life partner or spouse into the process early on. Phone interviews are becoming more important all of the time because of the cost of air fare. The phone interview can save you much time and money on someone that is not a good fit for the position. Setting up the interview is crucial. We have to be flexible and prepared for any eventuality. This all has to do with finding “the fit.” The best fit is what is appropriate for the community and the candidate.

Other issues that Tim discussed that affect retention are salary compression, insurance, and malpractice agreements. He also talked about educating practitioners and students about the hiring processes. They should know the right questions to ask to ensure “the fit” is right for them.

Next is the orientation phase. One important thing to do is to keep in touch with someone that we have hired for a position in the future. Some candidates may be hired years in advance. We need to plan for their arrival, and keep them informed of current events. Another thing is finding out what the significant other’s needs are, and providing assistance for them to settle into the community. It is important for them to be welcomed, and prepared for their new position.

A retention plan is important. Not perceived, but actually set in writing with follow up at appropriate intervals. The facility should be aware of what their practitioners are planning for their own careers.

He ended with the idea that as a rural community, we have to be more prepared for Recruitention than our suburban counterparts if we want to be successful.

Presentation #4 – Applying the Toyota Production System to Healthcare Dana L. Nelson-Peterson, RN, MN, Administrative Director of Hospital Operations, Virginia Mason Medical Center

Dana introduced her presentation as the development of a strategic plan based on the principals of the Toyota Production System. She stressed that they were very proud of two things in their plan that she felt was different from other strategic plans. One was that the Virginia Mason Production System is the basis for how they do their work throughout the entire organization. The second was that the plan was developed to put the patient at the top the pyramid.

The strategies used are that everybody has value strings that they work off of. Each workstation has long pieces of paper with work processes written out, timed out, and bulleted lists of areas of improvement opportunities. This provides alignment within the organization to the value streams.

They hold what they call Rapid Process Improvement Workshops (RPIW), which includes a patient. This is a weeklong event, for which the planning starts six weeks in advance. The things that are looked at are quality defects, lead time improvement, set up reduction, 5s (environmental) targets, staff walking distance, and parts moved. For every one of these events there is a standardized metrics sheet that is used. At the end of the week of these events there is a “Report Out” to the management team that is also televised to anyone interested (including clinical patients).

They also hold Kaizen events, a one or two day event for smaller improvement projects. Last year they also started Information Flow Events, from which they develop Information Flow Maps that they use for improvement.

One focus is on MUDA, or wastes. The 7 wastes are defined as:
  1. Over production
  2. Time
  3. Transportation
  4. Over processing
  5. Inventory
  6. Movement
  7. Defects

One thing that is done when they are holding an event for a unit is that they take sticky notes, and find areas for improvement in relation to the wastes that they see. These are all brought back to the workshop and put on a waste wheel.

She talked about using the RPIW model to help improve the Nursing productivity and patient care on a unit that was having problems with this. The idea was to increase the RN and PCT time at the bedside, or value added time (touch time with the patient). None value added time is the processes that draw the provider and staff away from the patient. They wanted to eliminate defects in the daily work patterns, improve safety, decrease the burden of work and focus on the 7 flows of medicine. This involves integrating the flow of the patients, providers, medications, supplies, equipment, information and process engineering. The overall idea is to decrease the lead time (length of stay).

This floor work was setting up the scope for the upcoming work RPIW. Then in preparation, the team spent time measuring what percentage of time the staff spent doing various activities, whether patient needs were being met, and the number of call lights (a defect because they have not anticipated the patients needs).

One thing developed from this was the U-shape arrangement of the work space as suggested by the production system. So co-location of patients within the U-shaped cell was started. This saves the staff time in movement and allows more visual control. Pairing a nurse with a tech to work together also improved production and value added time. Another improvement was having the shift change report conducted within the cell.

Other things were developed during the week. One was to document in the rooms at the bedside (one piece flow). This reduced overtime. Nursing/environmental services supply boxes were developed to be used in the patient room to reduce the time used in getting supplies. Omni cells were removed and “two bins” were installed. When the first bin is emptied the second bin is pulled to the top, and then the second bin could be resupplied for use when needed.

When the workshop week is over they hold “the rigor.” This is where the process owner, workshop leader, team leader, and the sponsor are held accountable to go back and do re-measures of their gains. These are done at 30, 60, and 90 days and are reported back. After 90 days the gains were huge, and the patients love it.

This has been used throughout the house, and patient and staff satisfaction has improved.

The next objective that they moved towards is flow. The idea is to take the cyclical work and standardize it. This was to move from chaos to flow. They developed a 12 step checklist for the work within a room. The staff said the 12 steps were too many to remember. So they grouped them into teams, and grouped the steps into 6. These are six things that need to be done every time you go into a patient’s room. They developed flow stations with whiteboards within the cells. With this they developed a system to get help if it were needed from an assistant nurse or resource nurse. This allowed them to remove the timers from the doors, and put them at the cell. In the near future they will use Vocera (a hands free wireless communication device).

This was also instituted throughout the house. Fall rates are down, patient satisfaction is up, and the length of stay has reduced significantly.

Various RPIWs have been used since the beginning of the production system.

12 RPIWs were instituted over 4 years in the GI clinic focusing on standardizing the work being done. These RPIWS were for: the turnover of the rooms, travel distance of staff within the department, scheduling of patients and providers, room setup, supplies and equipment, and inventory. There were tremendous gains over these 4 years without adding additional procedural rooms.

The Hyperbaric Unit was another success story. Before the new system was instituted there were many problems. It would only fit 4 patients at once or one stretcher for emergencies. No hospital O2 was being used, it was provided in canisters. The hospital had to pay ambulance expenses to transport patients across the street to the unit. Also, one provider had to take care of 4 dives at a time. Thus they instituted the Production Preparation Process (3P).

The 3P process was used in planning the new building for the Hyperbaric Unit. The 3P is like a RPIW only bigger. It involves 25-30 people for a full week that came from multiple areas of expertise. This included physicians, community providers, patients, administrators, engineers, and architects. The idea was for these people to get together and think like 12-year-olds, or outside the box (use your imagination). Instead of building a new building as was planned, they were able to bring the Hyperbaric Unit into the hospital using existing space that could be moved across the street. They used this space to build a state-of-the-art hyperbaric chamber. There was a huge reduction in the number of hours of work, the elimination of ambulance services, and the ability to use the hospital oxygen supply. Also, emergency patients can be treated simultaneously with regularly scheduled patients. There was a significant improvement to the bottom line.

The production system is really working, and Virginia Mason is breaking ground on a new hospital. This new construction is being built using LEAN principals and concepts.

Various articles about Lean thinking:
More resources Courtesy of Joan Wellman & Associates, Inc.

Books:
Womack, James, and Daniel Jones. Lean Thinking. New York: Simon and Schuster, 1996.

Suzaki, Kiyoshi. The New Manufacturing Challenge. The Free Press, 1987.

Liker, Jeffrey. The Toyota Way. McGraw-Hill, 2004.

Lean Memory Jogger, Goal QPC, 13 Branch Street, Methuen, MA 01884



Articles:
McAuliffe, Jeff, Tom Moench, and Joan Wellman. “The Lean Enterprise Meets Health Care.” Health & Health Networks Online, February 10, 2004.

McAuliffe, Jeff, Tom Moench, and Joan Wellman. “The Lean Enterprise: Three Phases of Development,” Health & Health Networks Online, February 22, 2005.

Wellman, Joan. “Lean Healthcare: A Journey, Not a Destination, Part 1.” Child Health Corporation of America Executive Institute Special Report, September 2007.

Fred Bazzoli. “Hospital Posts Many Happy Returns on its CPI Investment,” Healthcare Finance News Online, February 1, 2008.

Note: The four articles above can be accessed in the resource section at www.joanwellmanassociates.com website.

Appleby, Chuck. “Industrial Strength: Patient Safety Means Leading Pre-ndustrial Health Care Into a Post-Industrial World.” Trustee, January 2002.

Hinckley, C.M. “Make No Mistake-Errors Can Be Controlled.” Qual Saf Health Care, 2003.

Myers, Megan. “Hospitals Turning Into Lean Machines.” Sioux Falls Argus Leader, November 2005.

Gawande, Atul. “The Checklist.” The New Yorker, December 2007.

Johnson, H. Thomas. “Management by Financial Targets Isn’t Lean.” Manufacturing Engineering, December 2007.

Jajchrak, Ann and Qianwei Want. “Breaking the Functional Mindset in Process Organizations.” Harvard Business Review, Sept-Oct, 1996.

Panchak, Patricia. “Lean Health Care? It Works!” Industry Week, November 1, 2003.

Schonberger, Richard J. “Supply Chains: Tightening the Links – Your Lean Journey Must Include Suppliers.” Manufacturing Engineering, September, 2006. Vol. 137 No. 3.

Spear, Steven J. “Decoding the DNA of the Toyota Production System.” Harvard Business Review, 1999.

Piazza, Judyth. “Deputy SG Talks About Future of Air Force Medicine.” News Blaze, Daily News, 2006.

Sobek, Durward K. II and Cindy Jimmerson. “Applying the Toyota Production System to a Hospital Pharmacy.”

Spear, Steven J. “Fixing Healthcare from the Inside, Today.” Harvard Business Review, September 2005.

Jordan, Erin. “Toyota Plan Aids University of Iowa Hospital Efficiency.” The DesMoines Register, April, 2006.

Matzek, MaryBeth. “ThedaCare Shares Lean Secrets.” Appleton Post Crescent, December, 2005.

“Organizing for Lean.” The Lean Manufacturing Advisor, Productivity, Inc., May 2000.

“Applying Lean In Healthcare.” Healthcare Performance Press, Productivity Press, 2004.

“Unsnarling Traffic Jams in the O.R.” The Wall Street Journal, August 10, 2005.

Koelling, C.P., D. Eitel, S. Mahapatra, K. Messner, and L. Grove. “Value Stream Mapping the Emergency Department.”

Hammer, Michael. “The Process Audit.” Harvard Business Review, April, 2007.

Spear, Steven J., “Learning to Lead at Toyota.” Harvard Business Review, May, 2004.

Thompson, Debra and Steven J. Spear. “Driving Improvement in Patient Care: Lessons from Toyota.” JONA, November 2003

Bevan, Helen and Lendon, Richard and Silvester, Kate and Steyn, Richard and Walley, Paul. “Reducing Waiting Times in the NHS: Is Lack of Capacity the Problem?” Clinician Management, 2004.

Bartholomew, Doug. “Streamlining Healthcare with Lean Thinking.” Microsoft Executive Circle, 2006.

Gabor, Andrea. “Running a Hospital Like a Factory, in a Good Way.” The New York Times, February 22, 2004.

Tonkin, Lea. “Metamorphosis: Healthcare’s Ongoing Transformation. Healing and Cultural Change Have Begun.” Target Magazine, 2005.

Swank, Cynthia Karen. “The Lean Service Machine.” Harvard Business Review, October, 2003.

“To Fix Health Care, Hospitals Take Tips From Factory Floor.” The Wall Street Journal, April 9, 2004.

“Going Lean in Health Care.” Institute for Healthcare Improvement, 2005.

“The Value Stream Manager.” Lean Enterprise Institute, September, 1999.

“Toyota Assembly Line Inspires Improvement at Hospital.” Washington Post, June 2, 2005: AO1.

“Toyota Gives Virginia Mason Docs a Lesson in Lean.” Puget Sound Business Journal, September 12, 2003.

Weber, David Ollier. “Toyota-style Management Drives Virginia Mason.” The Physician Executive. January-February, 2006.

Roberts, Jeremy. “Hospital’s Assembly-Line Cure-All.” The Australian, April, 2004.



Following the presentations there was a wrap up, and the Summit was adjourned.