Managing Patient Throughput by
Process Improvement to Improve
    Quality and Control Cost



             Maria Madrigal
...
Your Takeaways

You will take away from this presentation:
−   In-depth knowledge of the Six Sigma and Lean
    methodolog...
Introduction

Before we get started, we want to hear from YOU!
−   What would make this 45 minutes worthwhile of your time...
A Measurement

Sigma       Parts per Million
Levels         Defective


 2       308,537
 3        66,807
 4         6,210...
Practical Meaning


  99% Good                                    99.99966% Good


Postal System
20,000 Lost Articles of M...
The Hidden Process Yield

                                          OK
                                                   ...
Rolled Throughput in Healthcare

                                                  OK
                                    ...
Variation Causes Defects
                                 Variation in
             No Metrics
                           ...
Breakthroughs in
               Process Performance


BAD
 Performance




                                     3 Sigma (C...
Changing the Decision Making Processes


      Decision Making                          Types of Problems
       Growth Pa...
Overall Approach


Practical Problem
Practical Problem             Statistical Problem
                              Stati...
The Funneling Effect


MEASURE                     30+ Inputs                               All X’s



                   ...
Triage Team
       A.K.A. “Muda Busters!”




1-13                                       Rev. A Printed 5/2/2006
         ...
Accelerated Change Event, “ACE”
Time Period                • 5 Days                              Ground Rules
            ...
What is Lean?
  Lean is the identification and elimination
        of “Waste” with in a process




Waste is define as any...
TYPES OF WASTE

                       PEOPLE

                        Motion

          Processing               Waiting
...
Lean Tools Used

Value Stream Mapping
SIPOC
Spaghetti Mapping
Shift Transition Score Card
Flow Analysis
Time / Value Mappi...
ACE Events Focus on
Non Value-Added Activity To Reduce Lead Time


Typical company      VA              NVA               ...
The Value Stream Map




1-19                                      Rev. A Printed 5/2/2006
                 © 2005 by Sigm...
Reducing Length of Stay

 Team’s Actions                              Potential Time Savings

Central Location for Stretch...
Changes In MTC

Change:
−   Clear criteria at Meeter/Greeter
    and in MTC as to which patients
    can be transferred di...
Changes In MTC

Change:
−   Standardize daytime registration & Fast Track after 11pm
Benefits:
−   Reduction in patient AL...
Changes In MTC

Change:
−   Visible performance tracking metrics
       MTC volume
       ALOS for discharged
       ALOS ...
Changes In MTC
Change:
 −   5s in MTC (everything has a place, everything in its place)
         Move nurse station comput...
Before




1-25                            Rev. A Printed 5/2/2006
       © 2005 by Sigma Breakthrough Technologies, Inc.
After




1-26                            Rev. A Printed 5/2/2006
       © 2005 by Sigma Breakthrough Technologies, Inc.
MTC Tech Travel To Splint




1-27                                     Rev. A Printed 5/2/2006
                © 2005 by S...
MTC ALOS Impact

                 Before           After (conservative)
Process Steps    45                       40
VA Ti...
Quotes

“We have More ‘Blue’ than anything” (blue being waste in the current
process”
“Everything that we’re talking about...
Lean + Six Sigma
   Lean                         Six Sigma
Waste Elimination          σ Variation Reduction
Standard Work ...
Factual Information

113-bed hospital located in Central Texas


35 miles south of Austin; 45 miles north of
San Antonio. ...
VOC, VOB and Problem Statement

Facility had been concerned over customer satisfaction ratings with
wait times in the ED. ...
Metrics Identified

ALOS (Average Length of Stay)
 −   Goal to see a 5% reduction in ALOS
Triage to ER Bed
 −   Goal of re...
Data Collection

                           Cycle Time from
                            Triage to Bed                     ...
Data Collection
                            ALOS
                                                                         ...
Using Lean Tools to Drive Results




             Lean Tools, such as 5S, allowed
                 us to organize the med...
Result 1: Triage to ER Bed
    Old Process                                                                                ...
Result 2: Average Length of Stay

                                       Old Process                                      ...
Result 3: Left Without Being Seen (LWBS)

                                             I Chart of Rate by Label 2
        ...
End Notes

Before Project:                              After Project:
 −   ER was ranked anywhere                   −   2...
End Notes

Before Project:                              After Project:
 −   ER was ranked anywhere                   −   2...
Questions & Comments




1-42                                      Rev. A Printed 5/2/2006
                 © 2005 by Sigm...
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Microsoft PowerPoint - Presentation - Madrigal SBTI

  1. 1. Managing Patient Throughput by Process Improvement to Improve Quality and Control Cost Maria Madrigal Black Belt Sigma Breakthrough Technologies 1-1 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  2. 2. Your Takeaways You will take away from this presentation: − In-depth knowledge of the Six Sigma and Lean methodologies of process improvement − An example of how Six Sigma and Lean concepts can work together in helping hospitals solve problems and increase revenues − Understanding of how two hospitals found outstanding results by using these concepts − Useful ideas on beginning these types of initiatives in your healthcare facility 1-2 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  3. 3. Introduction Before we get started, we want to hear from YOU! − What would make this 45 minutes worthwhile of your time? − What initiatives in your facility prompted you to attend this conference? − What tools are you hoping to return with? − Do you want to be entertained? Educated? Both? 1-3 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  4. 4. A Measurement Sigma Parts per Million Levels Defective 2 308,537 3 66,807 4 6,210 5 233 6 3.4 1-4 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  5. 5. Practical Meaning 99% Good 99.99966% Good Postal System 20,000 Lost Articles of Mail / Hr 7 Lost Articles / Hr Airline System Two Short/Long Landings / Day 1 Short / Long every 5 Years Medical Profession 200,000 Wrong Drug Prescriptions / Yr 68 Wrong Drug Prescriptions 1-5 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  6. 6. The Hidden Process Yield OK Final >95% Inputs Operation Measure ‘Yield’ = Customer Quality Yield At Measurement Redo NOT Hidden Process OK Shrinkage Process Variation Causes A "Hidden Process" (waste) Increased Cost – Lost Capacity Process Final Measurement 1 2 3 4 90% 90% 85% 95% >95% 65% is not 95% Yield Yield Yield Yield = ‘Yield’ ... why not? FPY/RTY 81 % 69 % 65 % Final Yield ignores the hidden process. Final yield performance is a function of post measurement. 1-6 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  7. 7. Rolled Throughput in Healthcare OK Final >95% Patient presents X-Ray Results ‘Yield’ = Customer Quality for x-ray x- Yield At Measurement Redo NOT Hidden Process OK Shrinkage Process Variation Causes A "Hidden Process" (waste) Increased Cost – Lost Capacity Process Final Measurement 1 2 3 4 90% 90% 85% 95% >95% 65% is not 95% X-Ray Correct Test Results Returned = ‘Yield’ ... why not? FPY/RTY 81 % 69 % 65 % Final Yield ignores the hidden process. Final yield performance is a function of post measurement. 1-7 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  8. 8. Variation Causes Defects Variation in No Metrics Medical Supplies No standard Inadequate process for Staffing staff members Needs LSL USL Poor Support of Robust Product Functionality Way off Out of Target Spec. Process Capability 1-8 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  9. 9. Breakthroughs in Process Performance BAD Performance 3 Sigma (CpK = 1) 6 Sigma (Cpk = 2) GOOD Time 1-9 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  10. 10. Changing the Decision Making Processes Decision Making Types of Problems Growth Path You Will Normally Solve Simple 1. Intuition, gut feel, I think ….. 2. We have Raw Data and look at it 3. We make graphs / charts of the data 4. We use advanced statistical tools to evaluate the data Complex How Many Times Have Your Heard This ? “I Think The Problem Is…” 1-10 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  11. 11. Overall Approach Practical Problem Practical Problem Statistical Problem Statistical Problem y = f ( x1 , x2 ,..., x k ) Practical Solution Practical Solution Statistical Solution Statistical Solution 1-11 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  12. 12. The Funneling Effect MEASURE 30+ Inputs All X’s 10 - 15 1st “Hit List” ANALYZE 8 - 10 Screened List IMPROVE 4-8 Found Critical X’s CONTROL 3-6 Controlling Critical X’s Optimized Process 1-12 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  13. 13. Triage Team A.K.A. “Muda Busters!” 1-13 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  14. 14. Accelerated Change Event, “ACE” Time Period • 5 Days Ground Rules Cannot damage the customer • Lead time reduction g Team Given Cannot permanently “harm” • Cost reduction g internal operations Clear Objectives • Yield enhancement g Use creativity before capital • Meet customer demand Team Composition • 1/3 are process specialists from area Support • 1/3 are people related to the area • 1/3 are those from outside of area Timeline MON TUE WED THU FRI DESIRED STATE IMPLEMENT Stabilize / Measure PRESENTATION TRAINING AM GAP ANALYSIS IMPROVEMENTS IMPROVEMENTS & CELEBRATION CURRENT STATE CONCEPT & DETAIL REFINE CHANGES MAP REFINE PM DESIGN PREPARE PRESENTATION “TAKE ACTION” “TAKE ACTION” 14 1-14 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  15. 15. What is Lean? Lean is the identification and elimination of “Waste” with in a process Waste is define as anything that adds cost but Does not add value to the process. 1-15 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  16. 16. TYPES OF WASTE PEOPLE Motion Processing Waiting TYPES OF Fixing QU Defects WASTE Inventory AL ITY Making Too Moving Much Things TITY QUAN 1-16 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  17. 17. Lean Tools Used Value Stream Mapping SIPOC Spaghetti Mapping Shift Transition Score Card Flow Analysis Time / Value Mapping 5S C & E Matrix Kanban Visual Workplace Consensus Building 1-17 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  18. 18. ACE Events Focus on Non Value-Added Activity To Reduce Lead Time Typical company VA NVA Original lead time Traditional cost reductions VA NVA Minor improvement ACE waste Major VA NVA reduction improvement Reducing value-added (VA) activities usually results in only minor gains Reducing Non Value-added (NVA, aka Waste) usually results in major lead time reductions without adding resources or capital Don’ t make capital investments on improving VAs until the NVAs achieve equilibrium with the VAs 1-18 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  19. 19. The Value Stream Map 1-19 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  20. 20. Reducing Length of Stay Team’s Actions Potential Time Savings Central Location for Stretchers and Wheelchairs 5 min RN/tech start blue form 2 min RN/tech to take vital signs 2 min Pt waiting to be triaged 5 min Triage paper to Reg/MD 2 min Wait to be seen by MD 30 min Wait to be tasked 30 min Taking specimen to lab 2 min Total Potential Savings of 1’18” 1-20 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  21. 21. Changes In MTC Change: − Clear criteria at Meeter/Greeter and in MTC as to which patients can be transferred directly to MTC Benefits: − Reduction in ALOS for MTC − Reduction in load on ER Triage 1-21 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  22. 22. Changes In MTC Change: − Standardize daytime registration & Fast Track after 11pm Benefits: − Reduction in patient ALOS − Cuts registration from 2-3 hours to 15 minutes 1-22 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  23. 23. Changes In MTC Change: − Visible performance tracking metrics MTC volume ALOS for discharged ALOS admitted patients 5s scores Benefits: − Sustain the gains − Pride of ownership 1-23 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  24. 24. Changes In MTC Change: − 5s in MTC (everything has a place, everything in its place) Move nurse station computers to central area Relocate crash carts, eye-trays, Pixus, glove dispensers, slit lamp, fridges, linen Remove unnecessary items Mend exam light Painted Omnicells redesigned, removed unused inventory and repositioned Increased accessibility to & visibility of crash carts Benefits: − Reduced travel time − Improved patient / visitor safety − Increased workspace efficiency − Decreased inventory − Increased patient throughput − Reduce patient ALOS 1-24 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  25. 25. Before 1-25 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  26. 26. After 1-26 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  27. 27. MTC Tech Travel To Splint 1-27 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  28. 28. MTC ALOS Impact Before After (conservative) Process Steps 45 40 VA Time (mins) 48-123 46-121 NVA Time 100-926 95-712 Historical MTC ALOS = 7’30” End of the week MTC ALOS = 3’04” 1-28 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  29. 29. Quotes “We have More ‘Blue’ than anything” (blue being waste in the current process” “Everything that we’re talking about we’ve been trying to change for 2 years” “I think there are a lot of us that are working against ourselves” “It usually takes 6 months to move a computer, we’ve moved 3 today” “It usually takes 2 months to move an Omnicell, we did it in hours” “These teams could put a man on the moon” “We’ve achieved more this week than we have in the last year!” 1-29 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  30. 30. Lean + Six Sigma Lean Six Sigma Waste Elimination σ Variation Reduction Standard Work σ Scrap / Rework Elimination Flow σ Process Optimization Customer PULL σ Process Control STABILITY & SPEED ACCURACY LEAN + SIX SIGMA = A POWERFUL UNION 1-30 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  31. 31. Factual Information 113-bed hospital located in Central Texas 35 miles south of Austin; 45 miles north of San Antonio. Out migration has always been a problem 57.7% of inpatient admissions come through the Emergency Department 1-31 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  32. 32. VOC, VOB and Problem Statement Facility had been concerned over customer satisfaction ratings with wait times in the ED. It was thought that people from the community were heading to area hospitals in Austin and San Antonio to receive care (with shorter waiting times) 4 Only 27% Patients reported 3.5 2.97 2.90 2.95 being “Very Satisfied”. 3 2.73 2.5 Where do unsatisfactory delays 2 occur? 1.5 − 81 % stated before being taken 1 to a treatment room. 0.5 − 56 % stated before being 0 treated by a physician. Q3 02 Q4 02 Q1 03 Q2 03 1-32 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  33. 33. Metrics Identified ALOS (Average Length of Stay) − Goal to see a 5% reduction in ALOS Triage to ER Bed − Goal of reducing turnaround time by 20 minutes LWBS (Left Without Being Seen) − Goal to reduce LWBS to under 2% Patient Satisfaction − Measured Gallup poll scores in these areas: ED Overall Satisfaction Wait Time Helpful and Courteous Staff ED Efficiency Speed of Service 1-33 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  34. 34. Data Collection Cycle Time from Triage to Bed Using Six Sigma tools, we 300 began collecting data on variables in the process. We found that the average waiting time for a patient to 200 be placed in a bed was over Frequency 42 minutes! 100 Std. Dev = 29.73 Mean = 42.3 0 N = 1023.00 0. 20 40 60 80 10 12 14 16 18 20 22 0 .0 .0 .0 .0 0. 0. 0. 0. 0. 0. 0. 0 0 0 0 0 0 0 LOS (minutes) Triage to ER bed Median = 34 minutes Mode = 25 minutes 1-34 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  35. 35. Data Collection ALOS We also found that the 300 Average Length of Stay for our ED patients was 2.5 hours. 200 Frequency 100 Std. Dev = 88.84 Mean = 149.6 0 N = 1285.00 25 75 12 17 22 27 32 37 42 47 52 57 62 67 .0 .0 5. 5. 5. 5. 5. 5. 5. 5. 5. 5. 5. 5. 0 0 0 0 0 0 0 0 0 0 0 0 Tl Length of Stay (LOS) in minutes Median = 128 minutes Mode = 55, 90, and 95 minutes 1-35 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  36. 36. Using Lean Tools to Drive Results Lean Tools, such as 5S, allowed us to organize the medical supply closets in the ED. Labels were created, excess inventory returned and par levels adjusted to provide a savings of over $32,000.00. 1-36 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  37. 37. Result 1: Triage to ER Bed Old Process New Process Triage to ER Bed October Direct April 150 100 Individual Value 50 UCL=48.7 _ X=19.2 0 LCL=-10.4 -50 1 29 57 85 113 141 169 197 225 253 Observation Average of 43 Minutes Average of 19 Minutes Over 50% reduction in overall cycle time! 1-37 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  38. 38. Result 2: Average Length of Stay Old Process New Process Summary for LOS Summary for June A nderson-Darling Normality Test A nderson-Darling N ormality Test A -S quared 56.75 A -S quared 0.56 P -V alue < 0.005 P -V alue 0.140 M ean 142.68 M ean 127.61 S tDev 29.72 S tDev 87.28 V ariance 883.18 V ariance 7618.62 S kew ness -0.152343 S kew ness 1.32885 Kurtosis -0.856168 Kurtosis 2.54811 N 31 N 2587 M inimum 76.00 M inimum 1.00 1st Q uartile 108.00 1st Q uartile 80.00 M edian 126.00 M edian 123.00 3rd Q uartile 157.00 3rd Q uartile 183.00 80 100 120 140 160 180 M aximum 178.00 0 100 200 300 400 500 600 M aximum 680.00 95% C onfidence Interv al for M ean 95% C onfidence Interv al for M ean 116.71 138.51 139.31 146.04 95% C onfidence Interv al for M edian 95% C onfidence Interv al for M edian 119.40 137.52 120.00 127.00 95% C onfidence Interv al for S tDev 95% C onfidence Interv al for S tDev 9 5 % C onfidence Inter vals 23.75 39.72 9 5 % C onfidence Inter vals 84.97 89.73 Mean Mean Median Median 120 125 130 135 140 120 125 130 135 140 145 Variation of 87 Minutes Variation of 29 Minutes Over 60% reduction in overall variation! 1-38 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  39. 39. Result 3: Left Without Being Seen (LWBS) I Chart of Rate by Label 2 Before After 4 1 3 6 Individual Value 2 UCL=1.950 2 2 2 1 6 _ 2 X=0.84 0 LCL=-0.270 1 7 13 19 25 31 37 43 49 55 Observation Reduction from 2% to 0.84%! 60% Reduction in LWBS 1-39 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  40. 40. End Notes Before Project: After Project: − ER was ranked anywhere − 2nd to None ED-pushing into from 7 to 10 out of the Multi- national top quartile State region of 17 customer satisfaction ratings − No goals to become the “2nd − Moving to become the to None” ED benchmark (leading) ED − No formal data collection − LWBS = $181,800.00 process to prove where the savings problems were coming from − Reducing Average Length of − We knew we had problems, Stay to allow for increase of however lacked a clear 95 patients per month roadmap − Medical supplies returned and par level adjustments = $32,923.70 1-40 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  41. 41. End Notes Before Project: After Project: − ER was ranked anywhere − 2nd to None ED-pushing into from 7 to 10 out of the Multi- national top quartile State region of 17 customer satisfaction ratings − No goals to become the “2nd − Moving to become the to None” ED benchmark (leading) ED − No formal data collection − LWBS = $181,800.00 process to prove where the savings problems were coming from − Reducing Average Length of − We knew we had problems, Stay to allow for increase of however lacked a clear 95 patients per month roadmap − Medical supplies returned and par level adjustments = $32,923.70 1-41 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
  42. 42. Questions & Comments 1-42 Rev. A Printed 5/2/2006 © 2005 by Sigma Breakthrough Technologies, Inc.
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