Christopher DeFlitch, MD, FACEP


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  • Clinical Value Streaming helps organizations visualize the impact of waste – in this case ‘Waiting’ - on value stream performance. This particular example is a ‘Time Value Stream Map’ which focuses on VA/NVA analysis. Remember ‘wait time’ is just one of the ‘7 Wastes’ that can be present in a value stream. Now let’s take a quick look at the performance of this ‘Arrival Until Care’ value stream for a representative patient: The total time from patient arrival to bed is 82.33 minutes of that, just 12.00 minutes represents value added time the remaining 72.33 minutes is all non-value added or wait time. Now multiple this performance times 60 to 120 to 180 patients over a 24 hour period and what do you get? At a minimum a lot of really mad patients! In worst case examples you have patients leaving without treatment and the possibility of severe medical complications while waiting in a queue. It’s all about learning to see the waste in the value stream. Once you can see the waste, you can begin the process of eliminating the waste. As a side note, this example took hours to generate in PowerPoint and all of the math – albeit simple – was done by hand. As you will see in the next slide, Microsoft and their partner the Orlando Software Group have developed a value stream mapping & analysis solution that greatly improves on the current manual and visual tools used by most organizations.
  • Chris – I would delete this 2 nd example of a ‘Time Value Stream’.
  • Christopher DeFlitch, MD, FACEP

    1. 1. Chris DeFlitch, MD, FACEP Penn State Hershey Medical Center Connected (CIS) Physician Champion Founder, Penn State Partners for Healthcare Engineering Director & Vice-Chair, Dept of Emergency Medicine Healthcare Engineering with Physician Directed Queuing (PDQ) TM Success Stories-Triage and Process with EDIS
    2. 2. HEALTHCARE TODAY <ul><li>BOARDERS </li></ul><ul><li>No Beds for ED Patients </li></ul><ul><li>HALLWAY Patients </li></ul><ul><li>Ambulance DIVERSION </li></ul><ul><li>Dissatisfied Providers </li></ul><ul><li>Dissatisfied Patients </li></ul><ul><li>Regulatory Issues </li></ul><ul><li>Define Capacity as Bed </li></ul>
    3. 3. Emergency Department (50,000) <ul><li>Traditional Targets </li></ul><ul><li>37 patient stations </li></ul><ul><ul><li>(1350 visits/station) </li></ul></ul><ul><li>44K sq ft </li></ul><ul><li>0 stations short </li></ul><ul><li><1% LWOTS </li></ul><ul><li>0 Hallway beds </li></ul><ul><li>0 Boarders </li></ul><ul><li>Satisfied Providers </li></ul><ul><li>Satisfied Patients </li></ul><ul><li>Patients Safe </li></ul><ul><li>Right Care, Right Location </li></ul><ul><li>Reality Capacity for 28,500 </li></ul><ul><li>20 open stations </li></ul><ul><ul><li>(2589 visits/station) </li></ul></ul><ul><li>24K sq ft </li></ul><ul><li>17 stations short </li></ul><ul><li>>7% LWOT </li></ul><ul><li>Hallway care </li></ul><ul><li>10+ Boarders </li></ul><ul><li>Dissatisfied Providers </li></ul><ul><li>Dissatisfied Patients </li></ul><ul><li>Safety, Regulatory? </li></ul><ul><li>Some Care, Any Location </li></ul>
    4. 4. Use EDIS for Success <ul><li>Understand workflow, map processes </li></ul><ul><ul><li>Critical Resources </li></ul></ul><ul><ul><li>Demand-Capacity </li></ul></ul><ul><ul><li>Interdependencies </li></ul></ul><ul><li>Apply Queuing and IE science to flow </li></ul><ul><li>Define Value with EDIS DATA </li></ul><ul><li>Redefine & Expand Capacity to Care </li></ul><ul><ul><li>Limited Resources </li></ul></ul><ul><ul><li>Limited Capital </li></ul></ul><ul><li>Actually DO IT…..TRANSFORM </li></ul>
    5. 5. Add Operational DATA to Workflow <ul><li>Arrival distributions </li></ul><ul><li>Critical Interval Processing Times </li></ul><ul><li>Resources data, number and type </li></ul><ul><li>Perspective Flows </li></ul><ul><ul><li>Patient </li></ul></ul><ul><ul><li>Provider </li></ul></ul><ul><ul><li>Resources </li></ul></ul>
    6. 6. Provider Perspective Flows
    7. 7. “Typical” Arrival Patterns
    8. 8. Define the ISSUE with Operational Data No Capacity High Demand
    9. 9. Understand Queuing Systems <ul><li>Science of WAITING </li></ul><ul><li>All queuing systems possess the same basic elements: </li></ul><ul><ul><li>Customer (Demand) </li></ul></ul><ul><ul><li>Resources (Capacity) </li></ul></ul><ul><ul><li>Queues </li></ul></ul><ul><li>When analyzed, it is clear that queuing systems are ubiquitous in healthcare. </li></ul>“ One mans WAIT is another mans WORK”
    10. 10. Value-Added Activity <ul><li>Must be performed to meet customer needs </li></ul><ul><li>Adds form or feature to service </li></ul><ul><li>Enhances service quality </li></ul><ul><li>Customers willing to pay for this work </li></ul>George ML. Lean Six Sigma Pocket Toolbook. 2005 If you STOP the activity, would your customer complain? If yes, then it’s likely Value-Added.
    11. 11. WASTE (non-value added) <ul><li>Handling beyond what is minimally required to move work </li></ul><ul><li>Rework to fix errors </li></ul><ul><li>Duplicative work </li></ul><ul><li>Wait </li></ul><ul><li>Idle time </li></ul><ul><li>Delays </li></ul><ul><li>Unnecessary motion </li></ul><ul><li>Over processing (too many steps to complete the job) </li></ul>George ML. Lean Six Sigma Pocket Toolbook. 2005 If you STOP activity, would any customer know the difference? If not, then it’s probably Non-Value-Added.
    12. 12. Clinical Value Analysis
    13. 13. Clinical Value Streaming - TRIAGE
    14. 14. Clinical Value Streaming- CP Triage
    15. 15. “ Healthcare is the only industry I have ever heard of that actually has a name for a major category of waste . You have waiting rooms . Most organizations outside of healthcare would go bankrupt if they thought like this”. <ul><li>Page 33 Lean-Six Sigma for Healthcare </li></ul><ul><li>Caldwell et al </li></ul>“ Infuse care into the queue (waiting) ….define capacity to CARE not a bed” Penn State Healthcare Engineering Team DeFlitch et al
    16. 16. Critical to Healthcare Engineer <ul><li>Burning Platform </li></ul><ul><li>Defined CRITICAL Resource(s) & interdependencies </li></ul><ul><ul><li>Boarders </li></ul></ul><ul><ul><li>Ancillaries </li></ul></ul><ul><ul><li>Information </li></ul></ul><ul><ul><li>Providers </li></ul></ul><ul><ul><li>Minimal Space </li></ul></ul><ul><li>WITHOUT Adding Resources </li></ul>
    17. 17. <ul><li>Physician (or MLP) </li></ul><ul><ul><li>Determines Queue passively </li></ul></ul><ul><ul><li>Listens to RN traditional “triage” </li></ul></ul><ul><ul><li>Delegates Procedures </li></ul></ul><ul><ul><li>Initiates work-up when no beds </li></ul></ul><ul><li>Triage Nurse(s) </li></ul><ul><ul><li>Arrives patient </li></ul></ul><ul><ul><li>Manage Minor Emergency </li></ul></ul><ul><li>Technician support </li></ul><ul><ul><li>Splint </li></ul></ul><ul><ul><li>Transport </li></ul></ul>Physician Directed Queuing (PDQ) TM
    18. 18. PDQ Year-to-Year Results Comparison <ul><li>Baseline </li></ul><ul><li>5.6% </li></ul><ul><li>8h 6m </li></ul><ul><li>71 min </li></ul><ul><li>93 min </li></ul><ul><li>5h 34m </li></ul><ul><li>5h 51m </li></ul><ul><li>Healthcare Engineered </li></ul><ul><li>2.7% </li></ul><ul><li>6h 16m </li></ul><ul><li>45 min </li></ul><ul><li>60 min </li></ul><ul><li>3h 9m </li></ul><ul><li>1h 23m </li></ul>LWBS Length of Stay Door-Rm Door-Dr ESI 4 ESI 5 <ul><li>52% </li></ul><ul><li>23% </li></ul><ul><li>37% </li></ul><ul><li>35% </li></ul><ul><li>44% </li></ul><ul><li>76% </li></ul>
    19. 19. Current Front-End Space Ambulance Walk-In TRIAGE “ need” 20K sq ft … get 7k
    20. 20. Currently under Construction Visitors to Hospital PDQ Triage1 Triage2 Check in Checkout Private Complex Dx Queues Technician Staffing Private Minor Dx Queues
    21. 21. Minor Emergency, Walk In Visitors to Hospital Triage PDQ Full Reg & Checkout
    22. 22. Minor Emergency, Ambulance Visitors to Hospital Triage PDQ Full Reg & Checkout
    23. 23. Room Required & Available, Walk In Visitors to Hospital Triage
    24. 24. Room Required & Available, Ambulance Visitors to Hospital Triage1 Mini Reg
    25. 25. Room Not Available, Walk In Visitors to Hospital Private Complex Dx Queues FullReg Triage PDQ
    26. 26. Room Not Available, Ambulance Visitors to Hospital Private Complex Dx Queues FullReg Triage PDQ
    27. 27. Next Venues of Healthcare Engineering <ul><li>Service Line Flow (Neurosurg) </li></ul><ul><li>Peri-Op Processing (Operative Suites) </li></ul><ul><li>Hospital Capacity Management </li></ul><ul><li>Other Interdependent ED flows </li></ul><ul><li>Informatics Project Management </li></ul><ul><li>Quality Outcomes (MRSA, Diabetes) </li></ul><ul><li>Process Simulation with OSGi </li></ul>
    28. 28. Future of HEALTHCARE ENGINEERING <ul><li>Process simulation models </li></ul><ul><ul><li>Explicitly represent variability </li></ul></ul><ul><ul><li>Predict interdependency </li></ul></ul><ul><ul><li>Manage complex systems in a computer </li></ul></ul><ul><li>Predict system performance under varying inputs (loads) </li></ul><ul><li>Compare alternative system designs </li></ul><ul><li>Determine the effects of alternative policies on system performance </li></ul>