Founded in 1924 and headquartered in Louisville, Kentucky, Baptist Health provides care across 39 counties in Kentucky, six counties in Illinois, and six counties in Ohio. With eight owned hospitals and one managed hospital (comprising approximately 2,700 licensed beds in total) and a provider network of >3,000 employed and affiliated physicians, Baptist Health has >300 points of care.
As part of our ongoing effort to achieve significant improvements in patient safety, quality, efficiency, and effectiveness, we recognized the need for organizational and cultural shifts in our approach to process improvement as well as for a set of methods and tools to facilitate and sustain those shifts. To that end, in 2015, we instituted a “Process Excellence” program to provide us with a standard toolkit and a standard language that we can use to solve problems and to improve processes across the system.
This program leverages data-driven problem-solving methodologies such as Lean and Six Sigma and incorporates change management tools (e.g., elevator speech, resistance analysis, barrier identification, stakeholder engagement) and project management tools (e.g., project planning, work breakdown structure). As we started to use these tools across the enterprise, we saw an opportunity to more effectively engage all frontline staff (comprising >15,000 employees) in our continuous improvement and problem-solving work. Therefore, we developed a program known as “Process Excellence Daily Management” as a way to engage our staff and create a data-driven problem-solving culture that drives the entire organization toward achieving its goals.
Three Components of Daily Management
Our Daily Management program includes three components: (1) alignment of goals and effort; (2) visual data management, daily huddles, and problem-solving; and (3) leader standard work.
Alignment of Goals and Efforts
When we launched our Daily Management program, we noticed that frontline staff often were not aware of the goals and targets set by senior leaders. Therefore, we emphasized the cascading nature of system goals and the importance of alignment between system and hospital goals during training.
Our goals fall under the pillars of Safety, Quality, Patient Experience, People/Culture, and Financials. Each department utilizing Daily Management set its own goals and targets in each of these pillars in alignment with system and facility goals. We found this exercise of aligned goal-setting to be incredibly valuable in that it not only improved awareness of goals among frontline staff, but it also helped them to see how their work contributes to the success of the system.
Visual Data Management, Daily Huddles, and Problem-Solving
- Visual data management: Each unit or department utilizes a visual board to display its goals, targets, and performance metrics. The look and feel of the visual board is standard across our system, with each board including the standard pillars mentioned above as well as a designated space for discussion and prioritization of improvement ideas. The visual board in each unit is located in an accessible area (e.g., around the nurses’ station) so that the data and metrics stay in front of everyone.
- Daily huddles: Daily huddles take place at the unit level and last for about 10 to 15 minutes. Huddles are led by the staff and are attended by all members of the unit or department (except for those who are actively delivering care at huddle time), visiting senior leaders, and, in some cases, physicians. Huddles take place directly in front of the visual board so that the metrics that are displayed on the board can be discussed and updated as needed.
- Problem-solving: A unique aspect of our problem-solving process is the systematic feedback loop from senior leaders or other stakeholders back to the department or unit. We recognize that staff cannot implement all solutions or process improvement ideas alone and that process changes often involve other departments and/or stakeholders. For this reason, part of the daily huddle is dedicated to problem-solving. This portion of the huddle includes a review of improvement ideas submitted by staff, a progress update on ideas that have been selected for implementation, and feedback received from senior leaders on ideas that have been submitted to senior levels for implementation and/or resourcing. Accountability is achieved through review of progress on implemented ideas with use of a simple WWW (What, Who, and When) form. This process of problem-solving (idea generation), reviewing progress, and providing feedback is key to sustaining team engagement.
Leader Standard Work
The third component of our program relates to the role of leadership. For the Daily Management program to be successful, it is critical for leaders at all levels of the organization (including the facility President, Chief Nursing Officer, Chief Medical Officer, Chief Operating Officer, Vice Presidents, and Department Directors) to be committed to the program and visibly present at huddles. The role of these leaders at huddles is to encourage teamwork and collaboration, help remove barriers, mentor and coach frontline staff (who often do not have enough exposure to the big picture), and foster systems thinking (that is, an understanding of the interactions between the work and processes from one team to another).
Challenges and Strategies
As is the case with any systemwide change, launching Daily Management presented its own set of challenges related to staff buy-in, resources, and ongoing support.
In general, individuals and organizations are averse to displaying metrics and data related to performance. Thus, it was critically important to gain the trust of staff by emphasizing that the program had been established in the spirit of problem-solving and would not be used for punitive purposes. To that end, we started the program at each hospital by first establishing a visual board and daily huddle for the senior administration team only. Setting up a board and huddle for the senior team not only demonstrated their support of the program, but it also established the idea that it was OK if the metrics displayed were in the “red” (i.e., not meeting target).
The training program for Daily Management is exhaustive. Over a period of 4 consecutive days, the Department Director, Unit Leader (e.g., manager, coordinator, charge nurse), and at least two frontline employees (1) attend classroom training in the Daily Management methodology, problem-solving techniques, and change-management tools; (2) set up the visual board and collect initial data; (3) populate the board; and (4) prepare communications to engage the entire department (via email announcements, posters, etc.). On the fifth day, the department has its first huddle. In addition to the staff in training, two dedicated trainers (Process Excellence–certified experts) are needed for each of these “launch weeks.”
To account for these resource needs, we select four to five departments at each hospital to participate in each launch as a cohort and schedule all necessary resources (such as staff time, data analysts, meeting rooms, etc.) ahead of time. Given the large number of departments across the system, we also institute a “train-the-trainer” program to enable facilities to continue to expand the program after initial launch. During the process of launching the program in the first 10–15 departments at each hospital, we identify and groom two individuals to carry the training forward to the rest of the departments. This program has reduced the burden on the Process Excellence team itself.
Highlighting improvement opportunities, idea prioritization, and evaluation are not part of frontline employees’ normal work. These behaviors need ongoing encouragement and mentorship beyond the initial training. Strong, capable department leadership and visible senior leadership are crucial for encouraging, recognizing, and promoting these behaviors and accountabilities to sustain Daily Management.
Progress to Date
Between January 2017 and March 2018, we launched the Daily Management program in seven of our eight hospitals. Overall, >60 units (between 5 and 25 units per hospital) are now using the program, and our goal is to have most units and departments using it by the end of 2019. We also have launched the program in several of our medical group practices. In the first year, we learned that cutting training too short or providing training only to director-level leaders did not work; without enough time spent in the “why” and “how” of the Daily Management program, the visual board did not yield positive outcomes.
In total, >800 process/workflow/safety-improvement ideas have been submitted and addressed by various departments in these Daily Management huddles. About 45% of these ideas have been fully implemented. Improvement ideas have ranged from simple things such as new chairs in the nurses’ station to the creation of an Emergency Department split-flow process to expedite evaluation and treatment of lower-acuity patients. In total, across the 60 Daily Management visual boards, about 520 distinct metrics (approximately 12 metrics per board) are tracked. Following the institution of this program, we have seen some notable improvements in Safety, Quality, and Patient Experience metrics:
- Improving turnaround time for radiology orders from the Emergency Department from 40 minutes to <30 minutes.
- Improving time-out documentation compliance for radiology procedures from 76% to 95%.
- Reducing transfers from Emergency Department to other facilities due to lack of available beds.
- Reducing the median length of stay in the Emergency Department from >150 minutes to <135 minutes.
- Increasing the rate of medication scanning compliance from <70% to >90% (our system completed system-wide Epic implementation in February 2017, and Daily Management helped to bring these metrics back on track following implementation).
- Anecdotally, we have heard that Daily Management is helping to improve employee engagement and reduce turnover. We are currently analyzing internal data to validate this correlation.
A Critical Tool for Engaging and Empowering Employees
We have found that Daily Management empowers employees to identify potential safety and process concerns, recommend potential solutions, and learn by implementing process changes. Daily Management, if done right, can be a critical tool in any organization’s toolbox to engage frontline staff in problem-solving and in making care delivery safer and more efficient for patients, staff, and the organization.