Putting Patients First: Lean, Releasing Time to Care (RTC©) and the Leads framework
During the March 29 & 30, 2012 Ministry of Health ‘Courage to Lead’ Conference in
Saskatoon I had an opportunity to facilitate a dialogue with:
Kyla Avis, RN, Program Director, RTC©, Health Quality Council;
Dan Florizone, Deputy Minister, Department of Health
Pam Molnar, RN, Manager, 5th Medicine, Saskatoon Health Region
Kandy Hennenfent, RN, President, Saskatchewan Registered Nurses’ Association
KA: Four years ago we started a program in Saskatchewan - our first step into looking
at the way we design and deliver care - how we care for patients and understanding our
health care world as a system. Four years later we’re moving away from a project with a
certain group of health care providers to an entire system. The entire health care
system will be involved in that journey; we’re not just asking frontline care nurses and
their managers to look at redesign but everyone throughout the whole organization
doing continuous improvement work. What I’m excited to see is the nurses who’ve
been doing ward-review meetings for the last four years, measuring, 5S1ing, process
mapping. Now that will not just be on their shoulders to do - it will be taken up by
everyone from the CEO to VPs to the quality-improvement-support people. So quality
is becoming everybody’s job now, not just certain people, which is exciting.
I think RNs will have a lot of experience and leadership that they can contribute to that
new way of being, because they’ve been doing it for a long time.
KH: When I reflect on Releasing Time to Care I see it as a systems change. It’s not just a
project that we’re working on - it’s the entire system, and I certainly instill in the
nursing students that once they graduate, this will be how things are done. Right now
students are seeing posters and all of these things that they are not directly involved in,
but this is the way that things will be when they graduate. It’s going to be part of
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Sort, Set in order, Shine, Standardize, Sustain- Elements of LEAN concept.
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providing care every day. Releasing Time to Care is about quality becoming
everybody’s job, that’s certainly the intent, but I see it as systems change. It’s not about
just focusing on RTC© as a project, that we will complete and move on to the next
project. It’s going to be part of our day-to-day job in order to sustain the Releasing Time
to Care.
KA: RTC© was very much an introduction to this [system change]. It was very much
step- by- step on how to do quality improvement. Now what we want to get to is to
have everybody think about quality all the time, not just when you’re working on a
module - not just when you’re 5S-ing a closet. It’s about thinking about it all the time,
having that permeate who you are, the way you think, the way you see - all the time.
Changing the culture is a stepping approach beginning with Releasing Time to Care,
followed by another layer of systems change with LEAN2. Now we are now adding
LEADS3 . I believe we had to start at the beginning with RTC. We couldn’t just start
with LEAN straight away - it would have been too much to start there. I think we
needed to start somewhere and really build on that. It takes a lot of energy – support resilience and momentum to continue to move forward. I believe that when we see that
that is the intention - when we realize this isn’t a project that has a finite start and finish
- we will see that this is how we’re changing the system. I’m accountable and you’re
accountable, and that’s the difference with what and where we’re going. Everybody is
accountable to quality improvement, and that’s what I’m excited about.
DF: So there’ve been signals and kind of a misinterpretation that RTC© is somehow the
old thing and now we’ve got this new thing going on. You can call it LEAN or call it
LEADS or call it Continuous Improvement, but the fact is that RTC©4 is here to stay. It
is a foundational element and we’ve had very strong success in its deployment. The
whole strategy from the beginning - what we really did well – was to prototype then
spread. We figured out a way, in partnership with the UK, to come up with a system
The core idea is to maximize customer value while minimizing waste. Simply, lean means creating more value for
customers with fewer resources.
3 The LEADS Framework represents the key skills, abilities, and knowledge required to lead at all levels of an
organization. It aligns and consolidates the competency frameworks and leadership strategies that are found in
Canada’s health sector and other progressive organizations.
4 Releasing Time to Care (TM) is a program developed by the NHS Institute for Innovation and Improvement that
we are testing in Saskatchewan. It is a patient-centred approach to improving the quality of care on acute care
nursing units, by freeing up caregivers' time for more direct patient care.
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that had modules that were packaged that resonated, that were tested. We went
through our own version of testing on the ground and we were able to quickly deploy
in a standardized way. The beauty of it isn’t in its rigidity; it’s that ability to really start
to inspire the need for those at the front line, not only to be engaged, but to come up
with creative ideas for improvement. What we’re doing now, is building on that solid
foundation. It’s not a project with a beginning and an end; it’s actually become, the
definition of a culture, the way we do things around here. We’re fundamentally
changing the way we do things around here. I agree with Kandy - that’s
transformation. Some people think transformation is a reorg, or transformation is some
big, visible change that’s led by some single, all-knowing leader. And what it really
comes down to is the real transformation in Saskatchewan is built on the principles
of patient first, patient and family centred care, and the engagement of point of care
staff in coming up with creative ideas. In true diagnosis what we’re doing is looking
at solutions as opposed to simply “bandaiding” a system that’s not working. So I think
that starting bottom-up in terms of that traditional hierarchy was exactly the right place
to start. I think we did that right. But of course what we didn’t do right is we haven’t
connected all the threads. The thread doesn’t pass all the way through, from leadership,
all the way through to the floor. We haven’t also achieved full horizontal with the
deployment: We still have large segments that are untouched and they deserve their
own version of releasing time to care.
KA: At least now we are starting to speak the same language and we know how to 5S a
room or what a process map is and all those things. It’s amazing the adaptability now
what we know what we’ve done and how we can apply that to something else. Even
with other areas and units that haven’t done Releasing Time to Care work it just makes
sense to people and that’s the great thing about it.
DF: The boardwalk that RTC© sites are involved with is hugely impressive. It’s one of
the highlights, witnessing the asking why and learning together. In May, we’re going to
do our first boardwalk at the CEO level.
KA: The boardwalk is talking about the measures that the ward tracks on a public
bulletin board in their ward. This is where they monitor their progress on the things
they are trying to accomplish around patient experience, staff well being, safety and
efficiency. Staff meet around that board to see where they are doing well, whether they
are hitting their target.
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KH: The best part about the boardwalk, for me as a nurse educator, is students have
been able to participate on weekly basis on the boardwalk. This has been very helpful
because students can see the changes on paper. They see the medication errors that are
being tracked on a day-to-day basis and they say “Oh my goodness”.
KA: It [the Boardwalk] is about transparency.
DF: What’s interesting is we’re just on the verge of creating that in a cascading way at
every single level - all the way through to CEOs gathering with me - Chairs gathering
with the Minister. And while it won’t fit all on one board (we’re referring to it as a
wall-walk) it’s a permanent fixture in the TC Douglas Building to have the health
systems metrics that cascade all the way through the system. We’re attempting to
emulate, in a way, exactly what is being done on the ground right now and to create
that connection.
KA: One of the strategies in the 2012-13 Health Plan, is by 2017, there will be 0%
workplace injuries. So, what the Deputy Minister would be doing is meeting with all
the CEOs on a quarterly basis, and looking at the workplace injuries as a system every
quarter to say: where are we at? How many workplace injuries do we have for 100 Fulltime employees (FTE)s, on a consistent basis? Is it going up? Is it going down? There
would be meetings at the hospital, or the region, that would be having a boardwalk, or
a wall-walk, just asking the same question, for our region, what are our workplace
injuries? And then you would have possibly departments, all the way down to the
ward having those same conversations and having those same metrics. So when you
see a rise in injuries, you can start exploring and start asking why is that? Where is that
happening? What’s going on here? What can we do to stop it or address it? And then
that’s where issues get solved.
PM: I think the exciting part of that, if we’re all focusing on the same measures, then I,
as a nurse manager, know that there is an issue with injuries or something with
equipment, or, we don’t have funding for something. At least I’m speaking the same
language or having the same conversation with someone that is monitoring the same
thing, so we have that system-wide support to always try and improve and to get that
support all the way through the organization to make it better. That’s what’s exciting
for me.
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KA: A student told me that they applied the LEAN concepts in the aluminum smelter
that they worked at while they went to university for nursing school, and had no idea
that the same huddles and 5s-ing was happening in a hospital.
DF: Exactly, just to give you an example of that, last year in June, we took the CEOs to
Seattle and we watched 737s being built out of the Boeing plant. It’s a bit of a leap
when you’re sitting there as a healthcare CEO and you see three million parts turn into
a plane in eleven days and without defect. In other words, the kind of plane that any of
us would want to jump on. What you saw in action was actually their version of
releasing time to care, of LEAN. They had set out from visual management to 5S, all of
the same principles that we are talking about here; they were in action and being
applied on the ground. And we could actually recognize ourselves in the building of
that plane, what worked for us and what didn’t.
KA: One of the myths that I think is out there with releasing time to care and LEAN,
that it’s all about efficiency, flow, doing things faster. One of the key things we’ve
learned with Releasing Time to Care is that safety, staff well being, patient experience,
and efficiency all have to be balanced. I think staff who have gone through RTC©
understand the balance of all four of those things and that is how it does have to be.
You might be efficient but not safe. You might have good staff satisfaction but the
patients don’t like the care they are receiving. It adds a layer of complexity in terms of
having to watch all of those things but we have a whole segment of our system who
understands the whole interrelatedness.
DF: It’s interesting because they actually connect beautifully - with the quadrupling of
the system - better health, better care, better value, better teams, link-up directly. The
problem we’ve had in the past is that we’ve always focused primarily on one at the
expense of the others. You’re bound to cut a budget and probably destroy something
with respect to team or morale or care or not progress with respect to health. Right
now, our challenge, and the leadership challenge before us, is we’re going to improve
all four all at once.
PM: And you have to be able to watch all four at the same time.
DF: Exactly, because the last thing you want is unintended consequences. Cost cutting
is not the name of the game here. This is really truly about measuring value from the
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patient’s perspective and engaging those in the know and in idea-generation by creating
a learning environment and learning culture.
DF: So the LEADS framework is a beautiful mirror to what it is that we’re talking about.
You can call it LEAN or Continuous Improvement or Releasing Time to Care, but
basically we are talking about the principles by which we do things around here.
Everything from the balanced measures, to measuring, to target setting, to engagement,
to learning, and having conversations to get to the deeper understanding to where the
root of the problem is. In the past, what we’ve been so busy doing is our jobs, and
there’s been very little time to pause, reflect, engage, try, learn, apply, test and cycle
through, you know that PBSA5 type of thinking.
KA: I was involved in something the other day where the person in the webinar said the
questions need to shift from: What should we be doing? To Why can’t we do what we
should be doing?, and How many patients did we treat today? What problems did we
encounter today that we could solve? We know high-performing health care systems
are the ones that can outlearn others. That’s what we need to do, figure out how we can
rapidly learn and apply that learning so we can get the improvements that we need.
DF: The other beauty of this is that it is learn by doing, rather than learn, study, study,
study, study. It’s a process called ‘study do’ that cycles back to evaluate whether what
you did actually had the intended consequence which was an improvement.
PM: I think we’re going to get that culture change by planting, nurturing and
developing little seeds of leadership. Individual leadership spreads and I think that
synergy will be the eventual culture shift. If we’re always planting those seeds in all the
little things that we do - how we talk - in our actions everyday - we are going to
demonstrate that this is the way. This is how we will change how we do things. We
will see it in all of these different areas places we interface with. That is where I see the
big changes happening. The beauty of the LEADS framework
DF: I noticed that in some of the approaches we’ve been taking and the same can be
said about Releasing Time to Care one hundred-fold. Let me use an example, recent 3Pi
work in the Saskatoon Children’s Hospital, and we’ve repeated with a Primary Health
Care site in Regina: You go through these learning approaches and at the end of the
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Performance-based service acquisition – meaning one size fits all.
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day, using the Children’s Hospital, some people would look at it and say we’re building
a hospital, which is true, but we’re actually building a team. And we’re building
leadership capacity that can outdo anything we’ve ever envisioned in the past. It
would literally bring you to tears to see the emergence of such tremendous ideas. If
there is something that we need to continue to keep our eye on, it’s that need to work
across disciplines and across professions. We need to actually make Releasing Time to
Care not one particular profession’s initiative, or LEAN one particular profession’s
initiative, because I’ve got to tell you - the ideas are generated by maintenance,
housekeeping, and nursing, and doctors-and when you’re in those teams and they’re
highly functioning -I can’t tell who’s who. But the real learning is when the patient is
there. The patient or family member is coming up with ideas, and we’re getting AHA
moments by the observations that we think we know what would be best for the
patient. But when they’re there in the present, they force a whole different
conversation.
KH: When I hear you talking about that, I think about quality workplace initiatives. We
did involve housekeeping. We did involve maintenance, and we did involve families
and patients. And it really did have a huge impact on different levels.
DF: I’m so happy you mentioned that, Kandy. Some people see these as the flavour of
the month. The reason why RTC© resonated is because of the work on the quality
workplace initiatives: those initiatives and that learning have been building one upon
the other. This isn’t a change of direction: This is an evolution of where we need to go.
So how long do you think Releasing Time to Care is here for? I think I’ve been false in
what I’ve said - I said 50 years, but I think it’s here forever.
KA: Oh for sure, even our language is shifting. Releasing Time to Care is a brand name.
It was a package - a tool- and we, even at HQC, are starting to refer to it as Continuous
Improvement. It could be RTC©. It could be LEAN. All of these things have a name, but
the underlying theory behind them is all the same. You have to use the language that
resonates: But the underlying concepts are all the same.
DF: You know what’s really interesting, is that’s not by accident, and it’s more by
design. Because our thinking has evolved in that way as well, and I’m sure the UK’s
thinking when they designed Releasing Time to Care was really influenced by the
environment.
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PM: They’re complementary. They’re not competing. That’s the difference when we’re
talking about the flavours-of-the month, or this new initiative or this is going to start
and this is going to stop. I have faith in the momentum of the change. They [the
models] are complementary and not competing. You can tie them in together so
beautifully that I see all of those lines blurring together with the work that we’re doing
all the time. You can call it whatever you want, but when you’re really always looking,
how can we do better and serve the patients better, it can go into whatever framework
you want to call it. LEADS is just an easy way to articulate it and to remember and it’s
very easily adaptable. What I see every day is that we have an opportunity to change
things, and those little changes will change our culture and how we do everything.
KH: When you look at the health care system, everyone is here for the same reason, or
I’m hoping that they’re here for the same reasons. The outcome should be that we are
all striving for the same goal: to provide the best patient care that we can possibly
provide. It doesn’t matter what we call it - the ultimate goal should be the same. We
use these tools to accomplish these goals. We still talk to many staff who are not
understanding Releasing Time to Care, and they’re thinking it is a project, and wonder
when we finish that project if there’s going to be another one, and who’s going to work
on it, and we already have enough work to do, etc. We need to keep it in the terms that
all we want to do is provide the best patient care that we can provide, and these are the
tools that we are going to use, and it’s not a project that is going to end. This is forever.
KA: I see why they are asking those questions, because they haven’t seen the system
reshape itself to continue in that way. So that’s what people are going to start seeing
now: A system that is realigning and reshaping itself, restructuring itself to be able to
keep going. If it stays the way it is now, it will be a project where at the end of the
modules it will be done. It won’t be if you create the system around it to keep it going.
DF: You know it’s interesting, it’s like the system is trying to catch up with Releasing
Time to Care. We started there, and now the system is literally trying to catch up. It’s
going to be a thing of beauty.
KA: And that’s why the frontline staff has such a role to play - because they have been
doing it- they know what that looks like- they know the struggle around measurementthey know how awkward it is to have a ward review meeting with all your staff looking
at you. They know the challenges of measurement. They know the challenges of
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working across areas and across disciplines. So they are ready. This is going to be a
breeze for them.
DF: You know, we could have done it the other way around, but that was not in
keeping with signalling the kind of change that was necessary. It was very intentional
that we went right to where the work and value is being generated and care is being
delivered. Start it there to create immediate sense that there is hope, there is change,
and something is coming. Now the system is about to become what it is that Releasing
Time to Care has delivered. And they’re going to feel hugely supported. And we
actually have a lot to learn from those levels that are ahead of us.
KH: Certainly leadership is all part of Releasing Time to Care and LEAN. In the
LEADS model there is recognition that the leader you are is the person that you are. It is
important to get people to recognize that. Participating in these initiatives, when you’re
talking about frontline staff, you have to recognize that they are having a huge impact
day-to-day on the Releasing Time to Care and providing better quality care to the
patients. I don’t know that staff recognizes their impact on the day-to-day business-the
impact they have on Releasing Time to Care and the LEAN model. They are leaders,
and they have impact on change.
DF: They are literally transforming the healthcare system. But it isn’t a single person, or
single group. They all across the system are transforming the healthcare system.
PM: There’s a quote that says, “If you want to know about water, don’t ask a fish,”
because when you’re in it, you don’t know, you don’t see it, you don’t know it’s
happening. But if you watch from outside, the feedback that we have from all over
Canada and the United States and places all over the world, “Oh my goodness, I can’t
believe you guys are doing this.”
KH: Those are the comments that you get from the nursing students that stand back
and watch the boardwalk, “Oh my goodness, this staff is doing amazing work in
tracking all of these things and then taking action.” Coming from their perspective, they
can see it, but like we said, when you’re the fish in the water, you don’t necessarily see
the work that is being done.
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DF: It’s kind of exciting to see, with this group of students, the generation that’s coming
through - this will be the only way that they know. They don’t have to worry about the
past, five years ago, ten years ago. This is the new way.
KH: They certainly won’t be saying that this is a project. They will say- this is the way
we do our day-to-day work.
PM: The one thing I did want to mention when Dan was saying about going to Seattle,
with the Boeings - the thing I value most about Leadership is the message: have the
courage to take the risks to think out of the box of how we do things. And that’s
where I was thinking, we just need to open our eyes a little bigger - jump out of the
fishbowl if we can, and see it through another lens. See what the opportunities are - to
not be stuck within the constraints of this is how we’ve always done things, but to see
the opportunities. Involve the patients and families. There are some keys things that
will happen when we have the courage to take the risk to do something different. It’s
amazing the outcome you can see.
KH: Registered Nurses need to take that risk and have that courage.
Releasing Time to Care -RTC©: Releasing Time to Care (TM) is a program developed by the
NHS Institute for Innovation and Improvement that we are testing in Saskatchewan. It is a
patient-centred approach to improving the quality of care on acute care nursing units, by freeing
up caregivers' time for more direct patient care. Check out RTC© online.
LEAN: The core idea is to maximize customer value while minimizing waste. Simply, lean
means creating more value for customers with fewer resources. Check out LEAN online.
LEADS: The LEADS Framework represents the key skills, abilities, and knowledge required to
lead at all levels of an organization. It aligns and consolidates the competency frameworks and
leadership strategies that are found in Canada’s health sector and other progressive
organizations. Check out LEADS online.
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Production Preparation Process (3P) focuses on eliminating waste through product and process
design.
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