Tan Tock Seng Hospital Lean Journey Lean Six Sigma and Performance Excellence Asia Summit 17-18 September 2014 National Healthcare Group 2 HOSPITALS • Tan Tock Seng Hospital • Institute of Mental Health 1 SPECIALIST INSTITUTION • The National Healthcare Group Eye Institute 1 National Centre • National Skin Centre 7 Business Divisions • NHG College • NHG Diagnostics • NHG Pharmacy • Health for Life • Singapore Footcare Centre • Primary Care Centre • NHG 1 Health 9 Polyclinics 1 The Johns Hopkins – Singapore International Medical Centre TTSH is a part of the National Healthcare Group (NHG) which is a leader in public healthcare in Singapore. Our VISION & MISSION Vision Adding Years of Healthy Life Mission Building on our tradition, Reaching out to the community, Doing our best to serve, care and heal. Together we aim for excellence in costeffective healthcare, education and research Tan Tock Seng 1844 Pearl’s Hill Spanish $7000 Novena Site (TTSH, CDC, CDC2) Ang Mo Kio Site (Rehab, 1-Health) 1,528 Operational Beds (1,058 Main TTSH) 6957 Staff 27 Clinical Disciplines John Hopkins 9 Allied Health Departments Ren Ci LKC School of Medicine TTSH at a GLANCE • Established since 1844 • One of the largest multidisciplinary hospitals in Singapore • 1,515 Operational Beds, 79 ICU & HD Beds • 7,383 staff • 27 Clinical Disciplines • Collaboration with world renowned cancer centre, Johns Hopkins – Singapore International Medical Centre • Multiple Quality Awards winner TTSH @ Novena TTSH & Offsite Facilities NHG1 Health 7 Our SERVICES 27 Clinical DEPARTMENTS Division of MEDICINE Division of SURGERY • Cardiology • Endocrinology • Gastroenterology and Hepatology • General Medicine • Haematology • Infectious Disease • Medical Oncology (Johns Hopkins) • Neurology (NNI@TTSH) • Psychological Medicine • Renal Medicine • Respiratory and Critical Care Medicine • Anaesthesiology, Intensive Care & Pain Medicine • Rheumatology, Allergy & Immunology • General Surgery • Neurosurgery (NNI@TTSH) • Ophthalmology • Orthopaedic Surgery Division of AMBULATORY & DIAGNOSTIC MEDICINE • Diagnostic Radiology • Emergency Department • Laboratory Medicine • Pathology Department • Otorhinolaryngology • Urology Division of INTEGRATIVE & COMMUNITY CARE • Geriatric Medicine • Palliative Medicine • Continuing & Community Care • Rehabilitation Medicine Our SERVICES Specialist Centres Allied Health Services • • • • • • • • • • • • • • Care & Counselling • Nutrition and Dietetics • Occupational Therapy • Physiotherapy • Podiatry • Prosthetics & Orthotics • Psychological Services • Respiratory Therapy • Speech Therapy Communicable Disease Centre (CDC) Complementary Integrative Medicine Dental Clinic Endoscopy Centre Health Enrichment Centre Johns Hopkins Singapore International Medical Centre Pain Management Clinic (PMC@TTSH) Pre-admission Counselling and Evaluation (PACE) Radiotherapy Centre Sports Medicine and Surgery Clinic The Breast Clinic @ TTSH Travellers’ Health and Vaccination Clinic (THVC) Tuberculosis Control Unit (TBCU) STRENGTHS GERIATRIC & INTEGRATIVE COMMUNITY MEDICINE • 1st Geriatric Unit in Singapore INFECTIOUS DISEASE • National role in formulating & implementing disease control • Designated centre for SARS, Avian Flu & H1N1 REHABILITATION MEDICINE • Largest & comprehensive inpatient rehab services EMERGENCY, TRAUMA & INTENSIVE CARE MEDICINE • 2nd largest and one of the busiest • Biggest trauma centre in the region RESPIRATORY MEDICINE • National Tuberculosis Programme – STEP (Singapore TB Elimination Programme) RHEUMATOLOGY, ALLERGY AND IMMUNOLOGY • Largest in Singapore OPHTHALMOLOGY • 2nd largest in Singapore The Silent War Battle plan 1. Frequent, accurate communication 2. Consistent, pragmatic, effective ID measures (Triage, Temperature monitoring) 3. Teamwork 4. Clear, flat, effective command 5. Leadership by example 6. Community support SARS 2003 TTSH is awarded the most Courage Stars and Medals in the Courage Awards Conferred The Public Service Star Award 2004 TTSH wins the Manchester Business School Award for Best Contingency Plan H1N1 • Start of Pandemic exercises • Nation wide drills across the nation • MC Surveillance • Triage • One stop entry screening • Mask fitting, PPE • Re-engineer infrastructure support • Temperature monitoring TTSH AWARDS International Joint Commission International (JCI) ISO 14001 OHSAS 18001 Local People Developer Standard (PDS) Work-Life Excellence Award Singapore Health Award Certified On-The-Job Training Centre A Day at TTSH 155 Inpatient Admissions 286 Operations 28% Inpatient 72% Day Surgeries 2,434 Outpatient Attendances 466 Emergency Attendances 94 Ambulance Cases 1,184 Radiological Investigations 13,140 Lab Tests 1,892 Therapy Attendances Based on CY2013 A Year in Community Care 3,628 Home visits 416 Admissions avoided Data as of Dec 2013 1,290 Participants screened 5,758 Home Therapy under CHEP sessions 177 VH patients enrolled 34.8% ED attendances avoided within 6 months of enrolment 41.7% admissions avoided within 6 months of enrolment 51,479 acute bed days saved through use of sub-acute beds 17,484 bed days saved through Buffer Step-down Unit TTSH’s Lean Journey: An Overview Why Lean? Rising patient expectations Operational bottlenecks Ageing population Starting the Journey Initial review of Toyota Production System & its application in healthcare Early experiments Early mass briefings (Mar-Apr ’08) Senior management buy-in Identification & training of core team Develop roadmap ~ Education / training programme ~ Culture transformation ~ Top-down approach First VSA Event (Apr/May ’08) ~ Bottom-up improvements Engage sensei Just-Do-It First RIE Week (May ’08) MyCare Framework Timeliness Human Development Zero Needless Waiting Zero staff dissatisfaction 100% staff engagement Zero patient complaints 100% patient satisfaction Cost Quality Zero non-value added activities Zero Inpatient Falls Developing Leadership in Our People Enhancing Skills, Capabilities, Building Systems & Teams Providing Support: HR Processes, IT, Facilities Equipping & Empowering Staff MyCare Training Programmes MyCare Advanced Managerial-Level Programme - Form a pool of internal My Care facilitators MyCare Intermediate MyCare Basic MyCare Overview Supervisory Level Programme - Provide essential skills for supervisors in Job Instructions, Job Methods & Job Relations Programme for All Levels - 6S / Waste Management / Daily Improvement - Move the ground with multiple small projects Introduction to MyCare Equipping & Empowering Staff MyCare Training Programmes MyCare Advanced Managerial-Level Programme - Form a pool of internal My Care facilitators MyCare Intermediate MyCare Basic MyCare Overview Supervisory Level Programme - Provide essential skills for supervisors in Job Instructions, Job Methods & Job Relations Programme for All Levels - 6S / Waste Management / Daily Improvement - Move the ground with multiple small projects Introduction to MyCare Ground-Up Projects Ground(Teams) More than 80% reduction of incidences of missing casenotes Start of intervention End of intervention Post Implementation of Missing White Folder – Clinic 2B 3 2 Start of project End of project 1 0 Mar12 Apr12 May12 Jun- Jul-12 Aug12 12 Sep12 Oct12 Nov12 Dec12 Jan13 Feb13 Mar13 Apr13 May13 Jun- Jul-13 Aug13 13 Ground-Up Projects Ground(Teams) Sustain Project end Project start Audrey (left) has trained Natasha (right) on how to provide 2 appointment slots to patients/NOKs Ground-Up Projects (6S Ground& Daily Improvements) Examination tools and PPE all in one location, beside the couch Information and forms required to support the doctor is placed near the PSA workstation. The PSA box (bottom right) was a daily improvement suggested by the team of PSA who was doing 6S in the consultation rooms. Implementing the 6S Equipping & Empowering Staff MyCare Training Programmes MyCare Advanced Managerial-Level Programme - Form a pool of internal My Care facilitators Supervisory Level Programme MyCare Intermediate MyCare Basic MyCare Overview Provide essential skills for supervisors in Job Instructions, Job Methods & Job Relations Programme for All Levels - 6S / Waste Management / Daily Improvement - Move the ground with multiple small projects Introduction to MyCare Standard Work Establishes standardised practices to deliver job safety & quality standards from each staff Equipping & Empowering Staff MyCare Training Programmes Managerial-Level Programme - Form a pool of internal My Care facilitators MyCare Advanced MyCare Intermediate MyCare Basic MyCare Overview Supervisory Level Programme - Provide essential skills for supervisors in Job Instructions, Job Methods & Job Relations Programme for All Levels - 6S / Waste Management / Daily Improvement - Move the ground with multiple small projects Introduction to MyCare Value Stream Analysis One--Health Ambulatory Centre 2P One RIE: Set-up using lean principles to: • Optimise space usage • Create simplified patient flow Key Improvements: • Cost savings: $45,000 • Preserved washrooms • Need not install 2 leadlined walls • Reduced space planning norms by 30% • Created: • Extra Consult / Procedure Room • Simplified staff & patient flow Capacity: MEC (Clinics) Master Plan 15 (end ‘08) to 24 (end ‘11) rooms per clinic (avg) 4-Step M-Flow to Enhance Patient Flow Clinical Cluster Concept New Queue & Self-Reg System Capacity: ED Master Plan - Emergency Diagnostic Therapeutic Centre (EDTC)/ Invasive Cardiac Lab (ICL) Angio Suite Angio Suite Hyb -rid Lab ICL Proposed floor plan EDTC – 20 Subsidised Beds – 2 Private Beds 23 Clinical EDTC Protocols ICL (existing) - 2 Angio Suites New ICL @ EDX Level 3 - 2 Angio Suites; 1 Hybrid Lab Door-to-balloon (DTB) Time 2010 – 70 min Target – 30 min (office hr); 45 min (aft office hr) Product Process Planning (3P) incorporating Design Thinking elements Multi-disciplinary team of doctors, nurses, therapists and other allied health, MOHH staff and IICH project architects and consultants Cubicle (Bed Mockup) by considering usage/process by staff and caregivers (care delivery), usage by patients (receive care) A Year in Kaizen 676 trained in MyCare Basic 274 trained in MyCare 58 trained in MyCare Advanced 150 MyCare Basic trainers Intermediate 47 MyCare Basic Projects 480 DIBs 74 Standard Work 16 VSAs / 3Ps Based on Sep 2012 – Aug 2013 data External Recognition – Visits & Attachments Frankfurt School Of Finance & Mgmt MBA Students (Nov ’09) HK NT West Cluster (Jul ’08) Siriraj Hospital (Sep ’12) PS-MOF (Oct ’08) APO-Healthcare Accreditation Thailand Delegation (Apr ’10) St Thomas Elgin General Hospital (Feb ’13) HK Kowloon West Cluster (Oct ’09) K. Thach From Darden School Of Business (Jul-Aug ’10) External Recognition – Awards & Accolades Asian Hospital Mgmt. Award 2009: Human Resource Devt. Category 2 Runners-up Asian Hospital Mgmt. Award 2010: Human Resource Devt. Category Winner Asian Hospital Mgmt. Award 2012: Service Improvement for Internal Customers Category Excellence Award International presentations: ~ Int’l Forum on Quality & Safety in Healthcare (Apr 2010) ~ Int’l Society for Quality in Healthcare (Oct 2010) ~ 1st Annual Asian Lean Six Sigma & Process Excellence Summit, February 2011 ~ International Forum on Quality & Safety in Healthcare, April 2011 Asian Hospital Mgmt. Award 2013: Customer Service Category Excellence Award ~ 9th International Clinical Microsystem Festival, March 2012 ~ International Forum on Quality & Safety in Healthcare, April 2012 ~ International Forum on Quality & Safety in Healthcare, April 2013 Enhancing Staff Awareness Newsletters ~ Mainstay for communication efforts MyCare Lunchtime Talks ~ Started July 2009 ~ Platform for learning & sharing Roadshows ~ Used early in journey: Propagate message ~ Late-2008 onwards: – Fun & interactive elements – Reinforces learning & understanding Our Publications Our Challenges Staff Numbers ~ Large population: Makes cascading of information challenging Middle Management Interface ~ Information lost in transmission/translation Management Engagement ~ Ability of senior managers to engage, inspire and motivate Time & Commitment ~ Competing priorities, e.g. demands of clinical, teaching & administrative workload Moving Forward How Might We Include These Into Our Practice? Evidence Experience Values – Patient & Staff Activity Based Costing Teams Acknowledgements Simpler Consultancy Toyota Memorial Hospital, Nagoya University of Michigan Bolton Hospitals King’s College Hospital Denver Health Alexandra Hospital (Khoo Teck Puat Hospital) Conclusion No Big Bang… It’s Continuous Improvement! Thank You!
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