Lean Daily Management – Huddles Overview

A focused approach to improve workflow & performance

Wilson Lamy
Assistant Director, JHM Quality & Safety System Initiatives
Armstrong Institute for Patient Safety and Quality
Johns Hopkins Medicine
wilsonlamy@jhmi.edu
www.hopkinsmedicine.org/armstronginstitute

February 13, 2024

© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System
The Definition of Insanity

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What is a Lean?

A philosophy, tools, and a culture to maximize value to our customers

• Safety, Quality, Experience, Efficiency
• … the relentless effort of eliminating waste (non-value activities) in
pursuit of the perfect process

What do we mean by relentless?

…Continuous improvement!
We can apply Lean tools and
Where are its origins?
…Automotive Manufacturing principles to any process

Where else is it used?

…Service Industries, Government, Healthcare
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What is a Lean Management System?

A formal system of accountability whereby both leadership

and the front line are connected using visual management
tools to remove barriers and solve problems impacting
patients at the point of care

Key Components
1.Huddles – Staff 2-way communication
2.Huddle boards – Tool to facilitate the huddle
3.Standard work – Uniformity of the huddle process

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What is a Huddle?

Team discussion in the gemba (where the work is done)

• Brief,
• Facilitator led – standardized process
• Communicate the previous and current shift issues
• Mitigate the issues if possible
• Determine the next steps and maintain communication

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Huddle Board – Visual Management

A tool to guide the huddle & reduce variation

Purpose:
• Make alignment visible
• Make performance visible
• Make defects visible
• Make problem solving visible

Promotes standard work

(The best known way of doing something)
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Standard Work System

Documented SW + Training + Process Audits

• Document the Process 1

• Implement the Standard

– Train the people doing the process on the standard
– Observe the people doing the standard 2

– Ensure the performance of the process

• Monitor the Standard
– Regularly observe the process 3

– Is the standard being followed? If not, understand why.

– Improve the Standard 7
What is Standard Work?

Standard work is critical to Lean Daily Management (LDM)

• Leader standard work
• Facilitating the huddles
• Leadership oversight
• Huddle & board layout

All of this helps change behavior

• Behavior shapes culture

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Standard Work for Leading Huddles

• The outgoing Charge Nurse facilitates each huddle, the on-

coming charge should attend
• Pre-populate the board prior to huddle (~ 2 min.)
• Enforce all should attend
• Review each SMESS category, pause and prompt for input
– update board real time
• Ask questions, encourage participation

2x per shift/7days per week

Your team will get out of it, what you put into it!
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Readiness Huddle for High Reliability

Two-way comm. to surface & remediate anticipated issues

SMESS Format
• Safety – Events, near misses, patients to watch, concerns for pts./staff
• Methods/Practice Issues – Issues involving the workflow – defects,
variation in practice, training needs
• Equipment – missing, not working or malfunctioning
• Supplies – right quantity, right location, shortages
• Staff – Callouts, reassignments, sitters, agency, OT

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 Phase 1 - Readiness & Mid-shift (SMESS)

Readiness Announcements /
Mid Shift
Readiness Metrics Reminders • Update
• Start of changes/actions
Shift completed or in
• 2 –way
S Issues / Barriers Next process since shift
comm. M Steps
readiness huddle

E / • Discuss any
S Actions unanticipated
“surprises” or events
S
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Phase 1 - Readiness & Mid-shift (SMESS)
Phase 2 – Performance Improvement
Phase 1 Phase 2
Metric #1 Metric #2 Metric #3 Wacth Metrics

Outcome Outcome Outcome

Process Process Process

Why Why Why

Try Try Try

Reflect Reflect Reflect

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Phase 2- Mid-Shift Metric Improvement
Purpose – To improve performance of metrics (3 maximum). Identify root causes
and solutions. Pilot solutions and reflect on their impact

Implemented later!

Consists of a lagging metric (KPI)

and a process/driver (leading) metric
 Example: KPI - Outcome (lagging) Metric
Gap Top level Typically
Measured
Monthly

Gap

Example: Process (Driver) Metric

Daily Falls Audit Compliance
2nd level 100%
90%
80%
70%
Measured
60%
50%
Daily
40%
30%
20%
10%
0%
 Capture Recurring Issues from SMESS
Why

To identify problems we 25
Recurring Issues
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encounter again & again in 23

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order to fix them

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Count of incidences 13
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Room thermostat issue

Dinamap not working
Sharps containers full

Call bell not working

Trash not picked up

Workstation down

Missing Meds

Bed issues
Greensciencepolicy.org Issue categories 15
 Why

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Call bell in reach

Pt. understands call bell use

Bedside table in reach

Personal items in reach

Nonskid footwear donned

Clutter free

Bed in lowest position

Falls Audit Failure Categories

Chair/bed alarm

Brakes for bed/chair locked

Floor surface dry

Sheet on recliner knotted

Wheelchair belt secured

Example: - Root causes of the GAP

Pareto chart
audit defects
Chair/bed alarm

Referred to as a
not turned is the
biggest cause of
 Example: Team generates ideas & tries 1-2
Try

Ideas generated:
1. Signage in room
2. Educate family to look out for
3. Check during purposeful rounding
Idea selected:
• #3

Pilot the idea!

 Example: What did we learn from what we tried?
Reflect

• Are we all trying the intervention?

• Any issues/barriers present?
• Is it effective in fixing the problem?
• If not, How can we improve it?

Try
Did it work? If not, what’s next?
Reflect
Monitoring: K-Card (Kamishibai) – A visual tool to help
ensure we are doing the standard work
Step 1 – Create a K-Card listing Step 4 – Place cards on rack
items to be checked showing green side for
K-CARD K-CARD pass/red side for deficiency
I-PAD COMPLIANCE I-PAD COMPLIANCE
Purpose: To ensure compliance to tablet issuance and usage Purpose: To ensure compliance to tablet issuance and usage
K-CARD

Example:
Process: The Charge Nurse for each (AM/PM) shift will Process: The Charge Nurse for each (AM/PM) shift will
identify the nurse who is caring for a patient and together
I-PAD COMPLIANCE
identify the nurse who is caring for a patient and together
perform the K-Card checks. perform the K-Card checks. K-CARD
Purpose: To ensure compliance to tablet issuance and usage

I-PAD COMPLIANCE

three pass
Process: The Charge Nurse for each (AM/PM) shift will
identify the nurse who is caring for a patient and together
 I-pad present?  I-pad present? perform Totheensure
K-Cardcompliance
checks.
Purpose: to tablet issuance and usage K-CARD
Process: I-PAD
The Charge
I-pad present? COMPLIANCE
Nurse for each (AM/PM) shift will
 I-pad provisioned?  I-pad provisioned? identify the nurse who is caring for a patient and together

one “not”
perform the K-Card checks.
 Purpose:
I-pad provisioned?
To ensure compliance to tablet issuance and usage
K-CARD
 Did the patient know what it was?  Did the patient know what it was? Process:
I-pad present?
The Charge Nurse for each (AM/PM) shift will
I-PAD
 Did the patient knowCOMPLIANCE
what it was?
identify the nurse who is caring for a patient and together
perform the K-Card checks.
I-pad provisioned?
 Purpose:
Were the To“5 Things”
ensure card reviewed
compliance to tabletatissuance
hand? and usage
 Were the “5 Things” card reviewed at hand?  Were the “5 Things” card reviewed at hand? 
I-pad present?
Did the patient know what it was?
 Is bedside tablet charted as “activated” in daily cares
 flowsheet?
I-pad
Wereprovisioned?
the “5 Things” card reviewed at hand?
 Is bedside tablet charted as “activated” in daily cares  Is bedside tablet charted as “activated” in daily cares
flowsheet? flowsheet? 
Did the patient
Is bedside know
tablet what
charted asit“activated”
was? in daily cares
flowsheet?
 Were the “5 Things” card reviewed at hand?

Green front Red back

 Is bedside tablet charted as “activated” in daily cares
flowsheet?

Step 2 – Make copies for # of Step 5 – Update Check sheet

process checks/shift and review at mid-shift
huddle
Step 3 – Perform the check w/
Q-Card Metric:
Month/Year: ______________ Target % = Pareto Chart for Non-Compliant Findings – Enter date
Date Checker(s) # Target Target
Pass/Total Met (%) Missed (%)
1st
2nd

the staff taking care of the pt.

3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
14th
15th
16th
17th
18th
19th
20th
21st
22nd
23rd
24th
25th
26th
27th
28th
Enter root cause

Enter root cause

Enter root cause

Enter root cause

Enter root cause

Enter root cause

Enter root cause

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29th
30th
31st
Total
Prior 3 Months
% Good
Huddle Reflection
• Did the huddle leader lead an effective huddle?
• Is the team realizing value from the huddles?
• What could be improved?
Basic Activity Basic Advanced Activity Adv.
Points Points
Current date shown
Status section & SMESS updated pre-huddle
Appropriate use of dots (all items have them, appropriate color)
Facilitator stands during huddle
Facilitator uses std. work huddle tool during huddle Another staff member uses audit checklist tool
Attendance – majority of staff present at board - Number __ ~ 80% of staff attending or calls/seeks missing staff
Each element of status section reviewed Ask if any questions when section is complete
All SMESS elements reviewed w/ actions/follow-up After each element - ask for input, pause, update board
Review announcements Ask if anyone has anything else to add & update
Thank everyone & announce the huddle is complete
Huddle facilitator demonstrates overall competence Leads with enthusiasm/Role model

Scoring Instructions
A) Enter Total points – add up each score (total in both Basic and
Advanced columns)
B) Enter 17 if beg. Of shift huddle OR 15 if mid-shift

Calculate score using above = A/B & enter % score

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The “Awareness Iceberg”- Issues at Point of Care
~4% Problems known to
executive leadership
~9% Problems known to
directors

~74% Problems known

to managers/supervisors

We need a system to
~100% Problems known
elevate issues to leadership
to those working at the
that cannot be resolved on
point of care
a unit level 21
Adapted from UMMHC CITC UMASS Memorial Health Care
Leader Standard Work
Round on huddle boards per a schedule

Gemba Questions:
• Go see, ask why, show respect • What is your priority today?
• What issues do you have?
• What data are you tracking?
• Support and mentor problem solvers • What have you tried?
• What did you learn?
• What’s your next step?
• Understand what specific leadership • What support do you need
(barrier removal, help
support is needed prioritizing)

Starting point for Gemba walks:

“Look at the scoreboard. Go watch the game.” 22
Cascading Huddles/Boards –
Visual Management at all Levels Communication
and
status/resolution
of issues

Communication
and Elevation of
issues
A system to enable system wide LDM
Questions

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Getting Started to Perform Shift Readiness

Pre-work (LMS)
1. Meet with Departmental leadership – support and commitment
2. Review this package with Nurse Managers & Charge Nurses
3. Install huddle boards – ID location, procure, mock-up board
4. Communicate/review process with staff
1. Expectation is all staff will attend – every day, all shifts
2. Staff will learn by doing
5. Determine huddle times and go-live date for each unit

Begin huddles
1. Update board for 1st huddle (don’t forget the date)
2. Coach to observe first few huddles and support/observe as needed
3. Phase 2 (Problem solving) will be introduced later
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