Visual Management Board Implementation to Enhance High Reliability at a Large VA Health Care System
Background: The US Department of Veterans Affairs (VA) is committed to embodying principles of high reliability organizations and Lean management culture. The practice of making problems readily known to team members and leadership is called visual management, an important tool in the journey to becoming a high reliability organization. Visual management boards (VMBs), or huddle boards, can foster transparency, teamwork, and employee empowerment.
Observations: A variety of health care teams at the Lieutenant Colonel Charles S. Kettles VA Medical Center within the VA Ann Arbor Healthcare System (VAAAHS) created and instituted VMBs. This article highlights the implementation in a large, diverse outpatient cardiology clinic. The incorporation of a VMB into the daily huddle of the outpatient cardiology clinic team led to increased problem identification among staff and leadership and fostered teamwork as issues were addressed. Feedback from teams across the VAAAHS noted how the boards were helpful in prioritizing areas for improvement, fostering teamwork, and increasing staff engagement, empowerment, and satisfaction.
Conclusions: A VMB is a simple, inexpensive, yet potentially powerful tool to bring together diverse health care teams to identify problems in the workplace, engage staff in developing solutions, and enhance communication with leadership. Implementation of VMBs at the VAAAHS may serve as a model for other VA health care systems for the incorporation of visual management into daily workplace culture.
Implementation
The goal of implementing visual management tools at VAAAHS was to empower staff members to identify problems and process improvements, enhance teamwork, and improve communication between staff and section leadership. The Systems Redesign and Improvement Program (SR), which supports Veteran Health Administration high reliability initiatives, helped implement VMBs in VAAAHS departments. Each board was designed to meet the specialized needs of each respective team and could be a physical board, virtual board, or combination. However, all boards sought to create standardized work and identify department needs.
The VAAAHS outpatient cardiology section VMB complemented an existing daily huddle framework. The cardiology section is large and diverse, with 6 subspecialty clinics, and team members who work in multiple locations. The clinic team includes 19 faculty physicians, 14 cardiology fellow physicians,9 nurse care managers, 13 nurse practitioners, 2 licensed practical nurses, and 5 medical support assistants at both the Lieutenant Colonel Charles S. Kettles VAMC and Toledo, Ohio, community based outpatient clinic. Prior to VMB implementation, a morning huddle with clinic team members led by a cardiology manager was an unstructured group discussion about clinic operations for the day. While the daily huddle had a positive impact on staff orientation to daily goals, it did not fully meet the aims of staff empowerment, problem identification and tracking, and knowledge distribution. The VMB was codeveloped with cardiology and the SR program with these goals in mind.
Cardiology was the first VAAAHS outpatient subspecialty clinic to institute a VMB. Two boards were created: a large standard VMB (Figure 1) and a smaller kudos board (Figure 2), which were placed in a central hallway in which staff members and patients pass frequently throughout the day. This location was chosen to promote engagement and promote the VAAAHS commitment to continuous improvement. The VMB focused on identifying and tracking problems, information sharing, and metric monitoring. The goal of the smaller kudos board was to highlight staff achievements and provide an opportunity for patient feedback.
The SR program required that the board incorporate problem identification and a uniform VAAAHS ticket tracking system. Each department could customize the VMB to fit its needs. Staff members are asked to define a problem, complete a ticket describing the issue, consider possible root causes, and suggest solutions. This approach empowers staff to take ownership, make a problem visible, and identify a solution. The problem is then discussed in group huddles using an Impact and Effort Matrix, a tool focused on categorizing and prioritizing those interventions that require low effort and lead to high impact.13
Tickets move along the board as they are addressed using a Plan-Do-Study-Act problem-solving model.14 Plan involves identifying and assigning leadership for the problem and understanding its root causes. Do involves implementing an action plan. Study involves evaluating the results. Finally, Act involves determining whether the plan was successful, and if so, standardizing the improvement and using it regularly.14 Complicated projects that require higher effort or additional resources are moved to the roll-up and parking lot, so they may be addressed by leadership at an appropriate time. Roll up is the escalation of process improvement tickets that frontline staff are unable to resolve with their current resources. The parking lot is for tickets that staff want to address later based on priority determined using an impact vs effort matrix. This allows for enhanced bidirectional communication between the department and high-level leadership, showing a commitment to HRO principles at all levels. The cardiology department customized its board to include essential clinic information, such as faculty staffing for the clinic that day and clinic metric information (eg, patient satisfaction scores, and appointment wait times). The kudos board, a space for patient feedback and to celebrate staff accomplishments, was located across the hall closest to the waiting area.
After the VMB was implemented as a new component to the daily team huddle, the group discussion physically moved to just in front of the board; pertinent clinic information is discussed daily, and the ticketing system is discussed 1 to 3 times per week, depending on ticket progress. Open and unresolved tickets are reviewed for updates on the status by the responsible team member, who receives ongoing feedback and assistance.
