GA 189 | How to Use Kata in Healthcare with Brandon Brown

You're listening to episode 189 with Brandon Brown.

Welcome to the Gemba Academy Podcast, the show that's focused on helping individuals and companies achieve breakthrough results using the same continuous improvement principles leveraged by companies such as Toyota Del Monte and the U.S. department of Defense. And now here's your host, Ron Pereira.

Hey there. This is Ron Pereira with Gemba Academy, and I'd like to welcome you to another edition of the Gemba Academy podcast. As always, thank you so much for taking time. Thank you out of your day and your week to listen to the show and for watching Arlene at Six Sigma training videos over at gembeacademy.com, we definitely appreciate each and every one of you. Now today, I'm bringing back Brandon Brown. Now, if you listened to last week's episode on Toyota Kata, you heard from Brandon. And today what we're going to do is we're going to share the audio portion of a keynote address Brandon gave. Oh, it's been a few months ago over in San Diego at the Katacon conference. There was a TWI Kata conference and, and he actually gave this talk to the TWI crowd kind of covering Brandon's experience with the Toyota Kata methodology and his experience with how it's impacted the work that they're doing in the healthcare industry, in particular at Baptist Memorial Healthcare. And they're doing some fantastic work over there. Skip Stewart, who we've also had on the show here in the past, is driving some incredible improvements over there in that organization. Now, towards the end of this talk that Brandon gave, I'll give a go ahead and warn you if you're kind of one of those sentimental type of folks who kind of maybe has a tear or two during kind of touching movies or whatever it might be. Well, go ahead and get your Kleenex ready because Brandon tells some powerful stories at the end. And I'll admit when I was listening to it live for the first time, definitely got a little bit teared up myself because it's a very, very powerful message on how the stuff that we practice as continuous improvement practitioners can reach far beyond any sort of productivity improvement or efficiency improvement or whatever. It can really impact people's lives. And that's exactly what Brandon shares. So definitely listen to the whole show. Show notes for this particular episode can be found over@gembapodcast.com just look for episode 189. Also, as I mentioned last week, we've put together a special kind of Toyota Kata landing page, for lack of a better word. Which has links to lots of free Toyota Kata resources. There's going to be past episodes, podcast episodes that we've done. It's going to be just some other free resources that folks can check out to learn more about this Toyota Kata movement. And so that's gonna be over@gembaacademy.com Kata K A T A so again, gembaacademy.com kata okay, enough from me. Let's get to the show.

So I want to start out by a little bit of secret formula that I seem to have found out. A quote from Teddy Roosevelt that I use in a lot of my John Maxwell teachings as well. I'm not gonna read the whole thing, but I think it's important. What he's talking about here is endurance and discipline are the keys to success. It's not the critic who counts, not the man who points out how the strong man stumbles. The credit belongs to the man who's actually in the arena, who best knows in the end the triumph of high achievement. And at worst, if he fails, at least he fails while daring greatly. And I think in kata many times that's what we're talking about, failing, learning from those fails and daring greatly as we do that. So a little catch you up timeline here. 2014 In January, Twiji was started at the DeSoto Hospital in South Haven, Mississippi. In June, it was expanded to the NEA Hospital clinic in Jonesboro, Arkansas. 2014 In August, the Baptist Collier Hospital expanded. We moved on into the Baptist Golden Triangle Hospital. Any of the nurses from the Golden Triangle here right now in the audience? Okay, they're probably over at the cottage. They're getting ready to do some stuff with Beth. TWIJR was started in January 2015 at the NEA Hospital at NEA Clinic in Jonesboro. We moved into the second JR family there. Spring of 2015 through 2016, we expanded to many of the Baptist 19 hospitals. In the April May time frame. Some discussions between Patrick Grop, Skip, myself and Patrick, who has really helped Baptist out a lot with deep dives and really getting to breaking down some very difficult jobs. We started talking about how would we deploy this? How do we continue across the 15,000 employee company in 19 hospitals and over 160 clinics. How do we expand that and get it going? So we started the concept of using Kata to deploy this. Since September 2016, we've been experimenting with TWI job instruction. What we call shepherding groups. Many of you may have heard the term advanced groups within cada. We call them shepherding Groups within Baptist because they're to shepherd the process. They're a leadership group that are experienced in both TWI and kata and their intent is to go out and those groups that are struggling maybe help shepherd and bring them back into the fold. So we've been expanding that. Beth's been working down at Golden Triangle in Columbus, Mississippi as well. And we had our first annual Baptist TWI summit held at Golden Triangle. We had many hospitals came there, a lot of sharing, some deep dives went on. Patrick did a great job down there and we shared not only our successes but also our struggles. So back to that timeline in about April of last year. Wanted to kind of give you a little bit of background on the hospitals. I mentioned the 19 hospitals, Memphis is the largest, about 700 beds, 450 to 550 daily census. NEA is about a mid sized hospital, probably in the upper tier, but a little bit smaller.228 beds and about 200 daily census. We have 45 certified Twiji trainers that can teach the 10 hour course, 6 certified JR trainers that can teach the 10 hour Course. Ji and JR has been taught over a hundred times, probably within Baptist and to several hundred people. And we've worked at Baptist with the TWI Institute and actually Skip tells me that there's actual materials that fit health care that you can get from the TWI Institute as they partnered with them to be able to take it from manufacturing into healthcare to make it applicable. And Patrick's also helped us out with the first JM class at the Indiana Hospital in Jonesboro. So we talked about many ways to get there from here. What does success look like versus what does it really look like? We do strategic A3s at Baptist. So we looked at that possibility and said, well, you know, it has its advantages, but that's not really at the tactical level that we're talking about here. We talked about Ocean, Conrex Matrix, that's another good method. Does a lot of good things. Being able to strategy deployment, not really fitting what we really were looking for. Traditional project management using Gantt charts. Well, we have timelines, we have training timetables and tools to be able to use that. And most of the time with project management you have scope creep and you have resource constraints and we knew we were going to face all those. But what we decided to do within the Baptist management system was an experiment really. And that's what we call it right now, this experiment. And that's Kata, your twi. And we do that particularly with the concept. I'm Going to try to explain, which is shepherding groups. So for those of you that may not be as familiar with kata, it's basically deliberate practice routines that help you at the beginning, as Mike mentioned, as starter katas. Much like my son here who's playing in a violin concert, he has a kata that he didn't even know that his teacher for the first four lessons was teaching him. He learned to play all the open notes and closed notes on the violin as he went up the octave and down the octave. And I have to remind him of that kata every time he sits down for his mother and I to kind of play and practice because we just love listening to him. To him play, we have to say sit up straight, get the right posture, go through your scales three times, up and down. Those are what kata are. They help you with those meta habits until they leave you with things like learning to drive. Now we don't even think about driving right. We change lanes, turn on the blinker, check our blind spot, eat a sandwich, text somebody, get the kids in the back, then get out in front of lane or in Shelby county in Memphis, we do the Memphis Shuffle or the Shelby Shuffle. That's where you come up on the right side of six lanes and then they won't let you pass so you then you shuffle around this way and they speed up and then you cut them off in order for good. That's the Shelby Shuffle. So what we said was we wanted a process that's aligned strategically and doesn't just. We don't just train to train. We want a process that was sustainable, it had low chance of scope creep. We wanted a daily deliberate attention to be a coach, practice and ensure that what we were doing was forming habits. And we wanted a process whereby we had individuals that were sharing and not shouldering just the burden of being able to deploy this amongst one or two people. And we wanted to form a network whereby individual hospitals and entities could share successes and struggles. So that's where we came up with the TWI shepherding groups. Here's a picture of the Memphis JI shepherding group. They guide the long term deployment of the TWI process. It's five to six of their senior leaders. The lady there in the red that's got her back is the cno Michelle Smith, couple of directors, Allison Kurland over there in the scrubs on the right, Matt Dain looks like he's praying over the next class he's about to teach for his 10 hour course. He's the director of the OR and pre op they develop target conditions actually, and they have concrete outcome metrics. So they actually have a kata board that they are using. And a lot of their metrics, a lot of their characteristics are around where they're at and what they're trying to achieve. They have an overarching challenge. They're to monitor the actual performance and progress. And their responsibilities are one, auditing draft jibs. They had a Foley jib that came to them. They edited it, they modified it a little bit. They're not approving it, they're just making sure it's JI ready, it's ready to go. Then they also go out and they validate. They go out and they found out that the first foley insertion and pericare jibs that they've developed, they asked how long was it taking to do the TWI four step method? 10 minutes, 15 minutes? Well, let us come out and see what you're doing there because it's not really supposed to take you that amount of time. So they were out there supporting, helping, not criticizing, not necessarily critiquing, but helping them, enabling them, helping them be successful a little bit more about tita, about kata. You see there, the center circle there in the cata trajectory, See leaderships, they establish the vision and they help set the challenge. And that's what these shepherding groups do. They have a challenge themselves and then it's up to the unit managers, the nurse managers within these floors to actually use the kata both at the areas of their individual challenges, but also pull in TWI when they need to. As it pertains to the TWI shepherding group, this is their challenge. And I like to always use fun words that they can use. They say it will be catastic if by 9, 30, 2017, Baptist Memphis has achieved clinical trainer ratio of 1 to 7 and non clinical ratios of 1 to 10 and is consistently using JI tools to train on a minimum of three jibs per department. And those three jibs were the three critical jibs that the CNO had attached to Cautis, clapsies and falls, which were the key metrics for quality within that department. And you see all the outcome metrics they're trying to achieve. This is an actual shot from their storyboard. You see they have a current condition and a target condition they're trying to reach. The shepherding group started meeting every day in the first few months. And then the learner and coach began to meet every day. And the extended team would come back with obstacles. They had their own obstacle parking lot. Each one would take an obstacle Take a pdca, go out, go and conduct that pdca, come back the next week at the weekly meeting and have an update. So no one's shouldering it all together. Another example, some of their PDCA records of the step, what happened, what they expect and what they learned from that process. So they actually are using kata. On the deployment of twi. I mentioned three, but there was a fourth one. In order to kind of dust the dust off of the TWI cards and get the trainers back in the mode of doing the training they went with Hand hygiene. Hospital wide hand washing is the first thing. They started with Catheter associated urinary tract infections or Cauti's CLABSI Central bloodline infections, Falls prevention. Those were the four that were at the strategic level where they were going to start with their deployment. Here's their trainer staff ratios. You can see month one, it's a little bit fuzzy there, but on the nursing side they had 77. They're up to 142 in the third month. People that are certified to be able to go out and train within the 10 hour course. The clinical trainers started out at 55, they're up to 78. They taught several classes in that November and December 2016 timeframe in order to try and get these ratios. And there's nothing magical about that ratio. We talked with Patrick, we talked with some. We tossed the 1 to 10 ratio as far as the trainer to amount of staff that's on that unit. For clinical areas, we felt like in the lab and areas like that, we didn't really need more than 1 to 10, maybe even 1 to 12 in some cases for like food and nutrition and stuff. For nursing, we felt like it needed to be a little bit closer because of the turnover rate. So we went to 1 to 7 on that. And it's an experiment as well. Here's what we've done with CAUTIS 2015. 90 CAUTI infections were experienced at this location, 41 in 2016. Since incorporating Kata and TWI, they've had 5 in the last 5 months of FY17. You can download this quote, it's from Judy Mann, who's one of the TWI shepherds. Basically she's saying that they basically have had a controlled deployment of this particular Foley JIB and Pericare jib. They've been able to release that under control with the right amount of people and the right people that are trained to be able to do it. And she's very excited about the results. Clabsi Central bloodline infections in 2014, they had 133 in Memphis, 104 in 2015. We started Kata specifically on one of the oncology units. And we started using CADA to progress toward their challenge to have no more than I think at that time was four. We ended 2016 hospital wide with 43 so far in five months of 2017. Six clabs that they've had. Yes. Okay, so a CAUTI is an abbreviation for a. A catheter associated urinary tract infection. So if you come out of an ICU without a surgery or whatnot and you can't urinate on your own, you have a Foley that they put in actually a catheter. And if there's something that doesn't happen just according to the specific ways that the job instruction has it laid out, you could cause a urinary tract infection. It's actually a hit against the hospital and they have to stay below certain measurements or they don't. Hospitals won't get the reimbursements that they need for Medicare and other insurance companies. Everything. They're quality rated now with a lot of these. A central line associated bloodstream infection or many of those have a central line. They're a cancer patient or something that they end up getting medication through the central line. If that's not kept clean, it's not kept clean with chlorhexidine baths daily. Same way with pericare. With the Foley, you could get an infection that's on the hospital, that's on the nurses that actually did that. And they found that many of the things that when they went through this, guess what, not everybody's doing the same thing the same way. Different nurses have different experience levels and they have turnover. National average is around 18% in the RN ranks. You got new people coming in all the time that you got to train. So we started Kata there in FY16. It was dropped from 104 to 43 and then down to 6 after we started the shepherding group for the last five months. Again, Judy Mann's quote, basically she feels like they're pioneering the way that they shepherd and deploy cattah. Without the leadership of the Shepherds, they're certain that they wouldn't be able to have this type of a success that they've had deploying this. Here's one that I'm going to come to a conclusion at the end and speak directly to the camera there and speak to the nurses at Memphis that may be watching this later on. This is the one that I'm most proud of because it started out so well. It's a fall prevention master Cotta story board. So right here's Jackie Barton. She's the director of the med Surg floors and she did about a six month caught on fall prevention bed alarms, tether alarms, all those things. So this group here has worked on falls for about four weeks. Their rate going into this where they were experiencing 10 and a half falls after the first two week first the second week, their two week period was 7.4, 7.3. They're down to five falls over a two week target condition period. That's a 48% reduction. And 39 they project 39 fewer patients will fall this year as a result of this nurse pool of five different floors all working together. Busting the myth that group kata doesn't work. Because I think group kata does work in certain situations. They tie that together with their storyboards. At the safety huddle meeting every morning they have a safety huddle meeting. They go over all of these schools. You see falls is on there. And we actually evolved the five question card into an RN5 question card. Whereas if a nurse unit manager has a fall on her floor or his floor, they have to step forward in front of the group and they have to state and answer some of these questions. I won't go through each and every one of these, but basically what was your last step? What's the status of your 4 Peak Rounding training? Where are you at on your jib training? All of those questions have to be answered as well as your next step. What are you going to do? What's your next step and where your area focus on overcoming the next obstacle. And you see Michelle's quote there. So you know she absolutely loves this process and how they interact and share each other. She thinks this is the secret sauce. I'm going to go over a little bit of JR just real quick. They at NEA Baptist in Jonesboro, they also have a storyboard, several slides here. Involuntary terminations. The 2016 is the blue line. You see that it is going up, but it's less than 2017, I mean 2015. And James Keller, director of HR there, he said basically we're seeing a trend in the number and increase of involuntary terminations now that we have job relations trainings in place due to the fact our managers now have the tools to address those issues and address them early on. Their written warnings, which is another metric that we're measuring with their shepherding group is dropping as well. And it's below 2015. NEA's overall job relations deployment, written warnings, 3.6 was the rate per week for written warnings. It's down to 1.72 involuntary terminations down to 1.4 now in 2017. And James has got some great comments there as well. Patrick, I'm going to fast forward a little bit. I wanted to give you credit for the deep dives I've already mentioned. But I've got something specific I want to talk to about falls as we start to go forward into this. But he's done a great job with helping us be able to utilize deep dives and go deep into a complex job and making it standard and more sustainable within the group. So where are we going from here? We've had a job methods deployment starting at the NEA Hospital. We've had our first one and we've had our first annual Baptist TWI summit in October 2016. As I mentioned, down at Golden Triangle, if you talk to Skip Stewart, you see him, go up to him, tell him that Beth Carrington told you you could come to that. All right, so just make sure you mention it's Beth Carrington, not Brandon Brown, that said you could come to that. Some struggles here. I know you can't read that, but basically that what they learned was that the best process for jib construction was really to have the author meet with the shepherd and teach the jib to an unknown and innocent person that absolutely has no idea how to do it. To flesh that out first and really refresh that trainer on how to properly train. There's some more here that you can look at. As far as some struggles, I didn't want to just have this all about success because there's been some struggles along the way. I want to get to the end here basically because I wanted to talk to you real specifically about a situation. And it starts here with deliberate practice and some of what these nurses are doing. 2014, in July midsummer in Arkansas, my mom, whose health has been deteriorating over the last few years, fell coming back from her neighbors. Apart from she set out for 45 minutes. I got a call from my sister. The ambulance was coming to get her. She ended up at the emergency department with first and second degree burns on her hands after sitting out there on the asphalt in 104 degree heat. Fast forward another year. We began talking to her about being able to care for herself. Was she able to be able to do that on a regular basis? She wasn't eating three meals a day. I'm not in a situation where I can be there. My sister has three Kids under six, she has difficulty being able to care for. May of 2015, she fell as my sister was taking her out to the car to go get some groceries. Broke her elbow. Plate in the elbow. Four rivets. 60 days of physical therapy, not at a Baptist hospital. She came back home, wasn't doing her exercises. We kept talking to her about she had to stay in shape, had to stay lower body, had to stay. I got a text from my sister the other day that they are evaluating her for Parkinson's disease. I think she's coming into some early stages of that. Fast forward another six months. I got a call from my sister, she's fallen again. Coming from her neighbor's apartment. This time she fell on the same arm. Broke the bone on her upper shoulder here, just below the ball. Clean break. The doctor says by the time we get there the next day, though, they're ready to discharge her. So I go to sit down and we're having the conversation about, you know, where are we going to. My sister and I are talking to her about, you're not caring for yourself, you're just not able to, mom. And if we move you to my house, that's great. I'm on the road 165 nights a week. My wife works during the day. You saw the violinist. I also have a three sport athlete. We just transfer the fall point from her living room to my living room. The sister can't take care of her. So I sat down by the nurse by the bedside, and I'm talking to her and I just happen to look and I see the word bed alarm. This is not a Baptist hospital. There are no lights on. I said, mom, show me your left arm. There's no fall band. I go outside the door, there's no fall sign on the door. So I punch the nurse's call button. And I said, has my mom been evaluated for fall risk and fall prevention and been put on fall watch? No, sir, she hasn't. We didn't know she needed to be. I said, she came through your emergency department with a broken shoulder due to a fall. I'd like for you to please set the bed alarm. Please put the band on. Please put the sign outside. They were there in about two minutes. Fast forward two more months. She's now in a nursing facility. She had the shoulder reverse shoulder replacement. I say all that to tell those nurses at Baptist and all those, thank you for educating me. Thank you for being my teacher, to helping me be able to help my mom to prevent her from having a fall. But she's fallen twice. Once in the nursing facility, once at the radiology department. They gave her to the radiologist because she had fallen in the bathroom. They were going to X ray the shoulder to make sure that it was still intact and everything was there. The radiologist hands her the gown, says, I need you to take the sling off and put that gown on so that we can do the X ray. And turns out and walks out the door. Five minutes later, he comes in and she's on the floor, chipped a bone in her femur. She now has a chip bone in her hip. So now, along with the recovery of her shoulder, she's now having to do a lower body physical therapy as well. All because someone didn't follow a standard procedure and wasn't trained properly to not leave that. Leave my mom alone. You see what these nurses are doing at Memphis, what they've been practicing? Their kata started six months back here, 39 fewer patients will fall. Those patients won't say what I'm about to say to those nurses at Memphis. You're moving the culture. Those patients. Families won't say to you, thank you for taking care of our mother, thank you for taking care of our grandmother, our grandfather, our aunts or uncles or cousins. Thank you for following the job instructions that we put in place. Thank you for taking care of our family.

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