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Establishing and Sustaining a Successful Operations Improvement Program at the University of Iowa Hospitals and Clinics
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Establishing and Sustaining a Successful Operations Improvement Program at the University of Iowa Hospitals and Clinics



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  • 1. UNIVERSITY Éy IOWA HEALTH CARE Establishing and Sustaining a Successful Operations Improvement Program at the University of Iowa Hospitals and Clinics Sabi Singh Assistant Vice President for Operations Excellence Associate Hospital Director for Clinical Services The University of Iowa Health Care
  • 2. “4 P” Model of the Toyota Way Problem Continual organizational learning through Kaizen Go see for yourself to thoroughly understand the situation. Where Most “Lean” Solving (Genchi Genbutsu) Make decisions slowly by consensus, thoroughly Companies are (Continuous considering all options; implement rapidly (Nemawashi) Stuck Improvement and Learning) Grow leaders who live the philosophy Respect, develop and challenge your people People and Partners and teams (Respect, Challenge and Grow Them) Respect, challenge, and help your suppliersIOWA Create process “flow” to surface problems Level out the workload (Heijunka) Stop when there is a quality problem (Jidoka) Use pull systems to avoid overproduction Process Standardize tasks for continuousÉy HEALTH CARE (Eliminate Waste) improvementUNIVERSITY Use visual control so no problems are hidden Use only reliable, thoroughly tested technology Base management decisions on Philosophy a long-term philosophy, even at the expense of short-term (Long-term Thinking) financial goals Jeffrey K Liker, “The Toyota Way” 2
  • 3. Does Healthcare Need Lean? The impending health care crisis has arrived. Coupled with an economic crisis, now has never been a better time to use lean. Hospitals are faced with increased uncompensated care, and less reimbursementIOWA as patients lose employer sponsored health insurance.Éy HEALTH CAREUNIVERSITY 3
  • 4. ProfitsIOWAÉy HEALTH CAREUNIVERSITY Decreases in reimbursement have increased the breakeven volume by 25 to 35% 4 Source: P.D. Mango and L.A. Shapiro, Hospitals get serious about operations. McKinsey Quarterly (2001:2).
  • 5. Healthcare Faces Many Constraints Operational Efficiency Must Improve:IOWAÉy HEALTH CAREUNIVERSITY 5
  • 6. FRONTLINE NURSES CAN SPEND AS LITTLE AS 37% OF THEIR TIME ON DIRECT PATIENT CARE ACTIVITIES % of time spent Direct patient care* 100 1 20 First area of opportunity to remove wasteful 13 activities 11 7 5 4 2 2 36 6 30 Available Motion Paper- Hand- Medi-cines Discus- Per- Other Patient Direct Psycho- Physical time work overs manage- sion sonal flow patient social care and ment and with hygiene care care admin. preparatio other 2 n nurses We should focus on improving (away efficiency of direct patient care from activities as a second step patient). * Approximately equivalent to time spend within patients bedside areaSource: McKinsey Study
  • 7. NursingIOWAÉy HEALTH CAREUNIVERSITY It is predicted that there will be a shortage of nurses Source: HRSA and 7
  • 8. PhysiciansIOWAÉy HEALTH CAREUNIVERSITY The predicted demand of Physicians is greater than the projected supply Richard A. Cooper, Thomas E. Getzen, Heather J. McKee, and Prakash Laud, Economic And Demographic Trends Signal An Impending Physician Shortage, Health Affairs, Vol 21, Issue 1, 140-154 8
  • 9. Fact: Can not increase capacity by hiring more personnelIOWAÉy HEALTH CAREUNIVERSITY 9
  • 10. So how do you transition from Current State to Future State? Do a Kaizen!!! To rapidly improve a process involving the people doing the work. Usually an intensive four- or five-day session focused solely on analyzingIOWA current processes and proposing, testing, and implementing changes.Éy HEALTH CAREUNIVERSITY 10 Source: Going Lean in Health Care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2005
  • 11. Transformation is a Multiyear Journey Service operations excellence Most Leverage these distinctive Providers services to elevate price are at the and/or volume and extend beginning service offerings based on stage Create operational operational competencies excellence necessary to deliver distinctive E.g., target time-sensitive service consumers with choices inIOWA service levels Stabilize operations to generate real E.g., ability to deliver <10 productivity, quality, and service minute ER wait improvementsÉy HEALTH CARE E.g., make basic operationalUNIVERSITY improvements to eliminate waste and variability and ensure consistent service Time 11
  • 12. Director of Operations Excellence OR/ CSS/ ICU’s & Intermediate Ambulatory Supply Chain Labs/Rx/ ASC/PACU Children’s Care Clinics Management Hospital Epic/Rad. (1 FTE) (1 FTE) (1 FTE’s) (0.5 FTE) (1 FTE) (0.5 FTE) 1 HCIS FTE to support projects in these areas 1 Project Assistant and 1 Secretary Expectations: • Lead Kaizen events and improvement projects. Deliver measurable results and sustainIOWA improvements •Work in the specific areas for 6 -12 months and then rotate •Train and develop champions and staff to initiate, lead, and sustain improvement projectsÉy HEALTH CARE •Develop and implement overall strategy to improve UI Healthcare operationsUNIVERSITY •Develop and implement a strategy to disseminate Lean Sigma culture at UIHC •Institutional resource on process improvement methods and training •Coordinate institutional benchmarking studies •Systemically identify process improvement opportunities •Quantify and report on value added by process improvement •Incorporate process improvement and maintenance tolls into new information systems
  • 13. Operations Improvement Time Allocation Institutional – 1/3 Projects to execute specific tactics in the strategic plan or projects that are defined by Maintenance Director’s Staff Institutional Departmental - 1/3 Projects requested by departments; prioritized by theIOWA Lean Steering Team; and approved by Director’s Staff Maintenance and Training – 1/3Éy HEALTH CARE Activities needed to holdUNIVERSITY previous gains; on-the-spot Departmenta l advising; training & benchmarking
  • 14. The “new” System A multi-disciplinary team focuses one a set of measures Core Measure Teams Area of Greatest Focus Surgical Care Improvement Pneumonia and Blood Heart & Vascular Center Project (SCIP) Stream Infections Blood Ventilator CommunityHeart and Acute Heart Stream Associated AcquiredVascular Myocardial Failure Infections Pneumonia Pneumonia Surgery Infarction (BSI) (VAP) (CAP) 1 Quality Case Manager 1 Quality Case Manager 2 Quality Case Managers 1 CQSPI 1 CQSPI 1 CQSPI 1 Operations Improvement 1 Operations Improvement 1 Operations Improvement
  • 15. Community Acquired Pneumonia Before UIHC Community Acquired Pneumonia Metrics After 120% 100% 80% 60%IOWA 40% 20%Éy HEALTH CARE 0%UNIVERSITY Metric Blood Cultures Pneumoccal Intial Antibiotic Intial Antibiotic Influenza Pneumococcoal Performed in the Vaccination Adult Received Withen 6 Selection for CAP Vaccination Vaccination Emergency Smoking Cessation hours of Hospital in Immunocompete Department Prior to Advice/Counceling Arrival Patient (CMS Initial Antibiotic Measures Only) Received in Hospital
  • 16. Heart Failure Before UIHC Heart Failure Metrics After 120% 100% 80%IOWA 60% 40%Éy HEALTH CAREUNIVERSITY 20% 0% Discharge Instructions Evaluation of LVS Function ACEI or ARB for LVSD (ARB Adult Smoking Cessation added 1/2005) Advice/ Counseling
  • 17. SCIP Before UIHC SCIP Metrics After 120% 100% 80% 60% 40%IOWA 20% 0%Éy Prophylactic Prophylactic Prophylactic Surgery Surgery Surgery Cardiac Surgery HEALTH CARE Antibiotic Antibiotic Antibiotic Patients w ith Patients w ith Patients w ho Patients w ithUNIVERSITY Received Within Selection for Discontinued Appropriate Hair Recommended Received Control 6 A.M. 1 Hour Prior to Surgical Patient Within 24 Hours Removal VTE Ordered Appropriate Postop Serum Surgical Incision for Cardiac VTE Prophylaxis Glucose Surgery and Within 24 Hours CABG) After Prior to Surgery Surgery End to 24 Hours Time After Surgery
  • 18. Swimlane Diagram Before After After 68 Steps, 23 Delay Points, 6 Decision Points10 Forms, 45 Work-Up Widgets in the Patient Process 18
  • 19. Patient Profiles Scenario #1 15% Scenario #2 40%IOWA Scenario #3&4 45%Éy HEALTH CAREUNIVERSITY Scenario #4
  • 20. IOWAÉy LOS Prior to the Event HEALTH CAREUNIVERSITY 235 minutes per patient
  • 21. UNIVERSITY Éy IOWA HEALTH CARE Pharmacy Pharmacist Reception Nurse Patient Nurse Assistant Infusion Suite Process - Part I
  • 22. Infusion Suite Process - Part II Infusion Suite Pre-Kaizen (page 2) Nurse Assistant Schedule next appointment Patient Patient Goes Home Can batchIOWA Nurse Assemble tubing be used? NO Administer Pick up Verify Administer Discharge Complete required End IV Pre-Med order Order Medication Patient Documentation tubing Pharmacy Pharmacist ReceptionÉy HEALTH CAREUNIVERSITY Educate Patient PharmD checks Hx, Prep Labeled lab, clarifies Label Med checked Deliver and problems, Prints Prep by Treatment Bagged verifies entry PharmD on computer
  • 23. Scheduling Changes Began to front load systems to make patient flow (chair capacity) more constant Built scheduling system to more accurately reflect actual capacityIOWAÉy HEALTH CAREUNIVERSITY
  • 24. Value Plot of BK, April 06, and July 06 Pt Arrival by 9:00 am 20 HEALTH CARE Number of Patients 15 DataIOWA 10Éy 5UNIVERSITY 0 BK Pt Arrival by 9:00 am April 06 Pt Arrival by 9:00 am July 06 Pt Arrival by 9:00 am
  • 25. Pharmacy Changes Fax machine installed at reception area of infusion suite Infusion faxes orders upon patient arrival at the reception area Reduced time for entry of order from an average of 29 minutes to an estimated average of <5 minutesIOWAÉy HEALTH CAREUNIVERSITY
  • 26. Infusion Suite Changes Increased nurse to patient contact Created 3 pods so the nurse stays in the same area Brought daily supplies to the nurses fingertips Developed supply carts for each room with replenishment plans Brought medications to the nurses fingertips Added one med cart per pod for easy access Eliminated all RN trips to the pharmacyIOWA Faxing orders to the pharmacy when the patient checks in. NA paged when meds are ready for pickup (expedited orders to the pharmacy) Reduced noise level in the suiteÉy HEALTH CAREUNIVERSITY
  • 27. Infusion Accomplishment: Identified & Reduced Traffic PatternsBefore AfterIOWAÉy HEALTH CAREUNIVERSITY
  • 28. RESULTS ATTAINED Goal Before After % Improvement Reduce patient wait time by 30% 32 minutes 4 minutes 89% reduction Reduce overall ALOS by 10% w/ same resources 235 minutes 186 minutes 21% reduction Increase throughput by 10% 42 pts./day 68 pts./day 38% increase (at peak) (at peak) Reduce staff walking distance by 50% RN: 900 ft./pt. RN: 90 ft./pt. RN: 90% reduction Clinic NA: 230 ft./day Clinic NA: 0 ft./day Clinic NA: 100% reduction PROJECT EFFECTS Productivity •Reducing excessive motion allows more efficient use of nursing and staff time •Improving communication between Infusion Therapy and the Pharmacy eliminates redundant work •Creating more capacity enables more effective use of resourcesIOWA Quality of Care •Developing the pod system organizes caregivers and keeps them in closer proximity to their patients •Reducing wait times shortens overall length of stay •Reducing noise and commotion improves patient experienceÉy HEALTH CAREUNIVERSITY Cost to the Institution •Increasing capacity without increasing staffing costs allows for greater possibilities for generating revenue •Adjusting skill mix more appropriately leads to more effective operations •Increasing patient throughput decreases salary and benefit expenses per patient At Capacity: Staff Salary and Benefit Expenses per Patient Visit Before the Kaizen Event $84.20 After the Kaizen Event $51.04
  • 29. Actions at UIHC: CT Scan Throughput Improvements: Increase capacity from 64 to 84 patients per day – 31% improvement Patient Experience average time reduced from 1:54 to 1:16 – 33% improvementIOWAÉy HEALTH CAREUNIVERSITY 29
  • 30. UIHC Emergency Treatment Center Workload and Patient Satisfaction Scores 20000 80 First Kaizen New ETC Opens EPIC implementation 18000 70 16000 60 % Very Good responses 14000 50 Patients seen 12000 Vol 10000 40 AdultIOWA Peds 8000 30 6000 20Éy HEALTH CARE 4000UNIVERSITY 10 2000 0 0 -1 -2 -3 -4 -1 -2 -3 -4 -1 -2 -3 -4 -1 -2 -3 -4 -1 -2 -3 -4 05 05 05 05 06 06 06 06 07 07 07 07 08 08 08 08 09 09 09 09 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 Quarter
  • 31. Kidney Transplant Program metrics 2007-08 2009-2010 (pre-kaizen) (post-kaizen) Referrals 185 347 (8 mos) Living donor pre- NA 162 evaluations Patients waiting to be 163 20IOWA scheduled for eval (WIP) Wait time, referral to eval 340 days 68 daysÉy HEALTH CARE Transplants 51 96 (8 mos)UNIVERSITY
  • 32. Actions at UIHC: 3RC Improved discharges by 11:00 am, LOS Increased % discharges by 11:00 am from 23% to 41%: a 78% improvement Improved key Patient Experience questions by average of 4% Cumulative Discharge % 100.0% 90.0% % of Discharges Complete 80.0%IOWA 70.0% 60.0% 50.0% 40.0%Éy HEALTH CARE 30.0%UNIVERSITY 20.0% 10.0% 0.0% 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 0:00 Pre-Event Post-Event Time 32
  • 33. Actions at UIHC: Pharmacy GH Pharmacy - Improve throughput Patient Experience reduced wait times form 2+ hours to 45 minutes – 62% improvement Staff Satisfaction – Staff quote “It’s going well, but our volume is down” - Same volume Pomerantz Pharmacy – Improve work flow Introduced “One Piece Flow”IOWA Decrease “Mail-out” lead time from 10 days to 1 day – 90% improvment Walk-up lead time reduced from 1 hour to 35 minutes – 42% improvement Increased capacityÉy HEALTH CAREUNIVERSITY 33
  • 34. Keys to Success Senior Leadership Involvement Change Management Need visible, vocal champions of lean thinking Culture must be supportive and receptive to change Engage and empowerIOWA employees Process Driven Rapid improvementsÉy HEALTH CARE Standardize workUNIVERSITY Consistent Follow - up 34