Ellis Medicine - A Community Hospital's Quality Story

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  • Our new name reflects that we are more than a hospital, more than a place – we are a body of health information that is continuously accessible to meet the health care needs of our community.
  • Medical home promotes patient-centered, physician-guided, better coordinated and cost-effective care (as opposed to episodic, illness-driven care). The Medical Home is convenient primary care for everyone, supplemented by a full compliment of outpatient services – with unique support for the underserved. Health Service navigators: connect patients with the clinical and social services they need. Shuttle – stops at seven locations in downtown Schenectady before ending at Medical Home, McClellan Street. Ellis provides riders with bus tokens so that they are able to get home after their appointments. Our objective is to make sure every patient has a primary care physician to go to – someone who will coordinate their care in the future.
  • 1926 The first standards manual is printed consisting of 18 pages.
  • New York’s Berger law set into motion dramatic reform in Schenectady that resulted in Ellis Hospital having to take over the services of two hospitals in a short seven month period during 2007 and 2008. Looking back on what we accomplished, it is really unbelievable. Consider that Ellis had to execute a comprehensive transition of services in the fall of 2007 - with only a few months notice - in order to ensure the services of Bellevue Woman’s Hospital would continue, uninterrupted, in the community. Literally thousands of details were involved. Everything from the coordination of billing systems, employee wages and benefits, to physician credentialing, laboratory and pharmacy processes, staffing plans, new signs and a myriad of issues in between. And then we had to repeat this same process, on a much larger scale, and do it all again in the Spring of 2008, in order to assume the services of St. Clare’s Hospital. In all, Ellis retained more than 1,100 employees, an additional $118 million in expense, 10,600 additional discharges … 43,000 extra days of care, … 8,400 more surgeries and 39,000 additional ER visits. Financially, the reform brought impressive results. In fact the hospital posted a $4.6 million operating margin at the end of 2008 … compared to a year earlier when the three hospitals collectively lost $7 million – a big improvement to say the least. Today, we are a unified organization. The traditions of a specialty woman’s hospital, a Catholic hospital and a community hospital comprise a new Ellis. The scope and rapid pace of what took place is likely unprecedented in the hospital industry .. NYS Health Commission Richard Daines described what happened in Schenectady as “a period of extraordinary change.” Indeed, it was … and we are extremely proud of what we’ve accomplished.
  • Reprocessing Neuro/spine Mesh Custom Packs Clean-up kits Orthopedic contract capitated savings Patient Throughput OR-PACU Expansion (2) bays Patient lengthened stay in OR and In PACU CSuite level patient focus Standardization across three campus system Physician Order Forms – FormFAST IT – Sieman’s Soarian and Surgical Information Systems
  • Structured AIM statement that evolves with the PDSA cycle Persistent PDSA cycles aligned with scheduled meetings/monthly conference calls Premier Consults – Patient Throughput and Operational Efficiency Evaluate options to measure impact of Patient lengthened stay in both the OR and In PACU. Chief Operating Officer – Paul Milton, VP Patti Hammond and Director Jonathan Blank highly supportive of the BTS 8 Initiatives with a goal of Savings in Supply Chain Expense and improved operational efficiency. Communication Updates – to all Team Members and COO Garnered Physician Champions following Atlanta - LS1 Chief of Surgery – General Surgeon Orthopedic Surgeon Both highly supportive of BTS 8 – reprocessing*** Team Members attended all three BTS 8 LS 1-3 Atlanta GA, Phoenix AR, St Louis MO
  • Reprocessing – Ascent Looking for a big save of $90K Removed the harmonic scalpal – Temp HOLD save WB 40K Physician resistence – need for further investigation Ascent – Excellence in the industry Custom Packs: Arthroscopy, Total knee, Total Hip, Eye Packs Standardized to three campuses: Removed a disposable clean-up kit (2campuses) replaced with linen Foot Compression Devices – Huntleigh Universal Introduced – compression sleeves – save $2000. Shoulder Drape – 3K Portacath savings of 8K Contracts/Capitated Pricing: Premier and Yankee Alliance Cardinal Custom Procedure Packs Orthopedic Implant Capitated Contract Pricing
  • Slow and steady from the start Persitsence Taking a look in all directions – from small to large $$$ savings in the supply chain. Started with the BIG SAVE but found the smaller SAVES we just as rewarding. TOTAL SAVE of a little over $1.1 million $ 5 months into the process
  • Premier provided the framework for success Reprocessing – Surprising not the outcome we anticipated but are happy none the less to have achieved introduction of reprocessing into the OR – A conservative approach with further evaluation with Bariatric Surgeons Operational Efficiency – can’t happen in a vacumn – global focus Contracts & capitated pricing – persistence WINS don’t relent Capture ALL SAVINGs - “opportunities abound” look in every direction With any change theory process – embrace, set your course and stick to it. Effective Leadership guide and mentor to expected outcomes. PDSA cycles provide structure when obstacles arise
  • Framework for success: #1 – communication at every level with consistent follow-up #2 – persistence is the “name of the game” to realize SAVINGS Vendors, Physicians, OR, PACU MGT/STAFF #3 – Set a goal for savings – look in every area, capture large & small #4 - Global Operational View - sets the standard for efficiency #5 –Senior Leadership – supportive - not prescriptive #6 - Physician Champions – could not achieve what we achieved in this Premier Break Through Series 8 without their confidence, medical expertise and trust. This being our first Break Through Series in Periop we Achieved our AIM statement and had a good time navigating with Premier’s Framework for Success!
  • PACU Expansion – September 2008 9 Bay PACU January 2009 11 Bay PACU Established Phase III recovery Standardized Monitoring Equipment – Phase I & II Enhanced Communication - OR to PACU 40 minute to close call CSuite Task Force IT – Soarian and SIS Reprocessing – Ascent – Harmonic scalpals dilemma a 90K save reduced – physician resistence for bariatric surgery. Re-examining reprocessing of other items Contracts – Orthopedic Capitated pricing Custom Packs Product Standardization
  • BEFORE and AFTER Operational efficiency included improved communication between OR team and PACU. Patients in PACU receive priority for Bed placement Csuite level task force - now meets colloboratively M-W-F looking at ED, House Census, OR Am Admissions, Cardiac Cath Anticipation of Bed Needs a week in review. Admitting Registration, Physicians, Case Management Phase II fully monitored BAYS Phase III recovery established – Holds in PACU to enhance patient satisfaction allowing family to be with patient until bed placement and patient transfer took place.
  • Where a storage room was in 2008 became (2) addiitonal PACU Bays Giving a total of 9 PACU Bays Before and after Storage space was a challenge – effectively modified inventory levels to reduced PAR levels obtaining more space in the PACU. Eliminated products not used BAR coded Materials Management System Real time ordering – Med series 4 delivers items Just-in time
  • Ellis Medicine - A Community Hospital's Quality Story

    1. 1. MARY ELLEN CRITTENDEN, RN, MS, CPHQ VP, QUALITY SERVICES May 11, 2011 Ellis Medicine A Community Hospital’s Quality Story
    2. 2. Ellis Medicine…. Centralized location for outpatient services, primary and wellness care, and rehabilitation and long term care. Centralized location for inpatient and emergency care. Centralized location for inpatient OB/GYN services.
    3. 3. ELLIS HEALTH CENTER: ELLIS MEDICAL HOME – A MODEL OF PRIMARY CARE <ul><li>Highlights: </li></ul><ul><li>Services: family medicine, pediatrics, dental and insurance enrollment, supplemented by full outpatient and emergency services; unique support for underserved </li></ul><ul><li>Community shuttle: 138 monthly average riders </li></ul><ul><li>Health services navigators: 174 monthly average patient encounters; 160 ED patients w/o a doctor were connected with primary care (Sept 2009-Sept 2010) </li></ul><ul><li>Community Partnerships </li></ul><ul><ul><li>Ready. Set. Kindergarten! 114 children seen </li></ul></ul><ul><ul><li>Health Fairs, Farmer’s Market </li></ul></ul>
    4. 4. The Importance of Quality in Medicine Ernest Amory Codman, M.D. Franklin Martin, M.D. 1910 “ The End Result System of Hospital Standardization” 1913 Founder of the American College of Surgeons
    5. 5. Importance of Quality Monitoring in Medicine 1917 ACS Develops The Minimum Standard for Hospitals (Requirements fill one page)
    6. 6. 1917 The Minimum Standard for Hospitals <ul><li>Staff membership restricted to physicians who are (a) graduates of medicine in good standing, legally licensed to practice in their states, (b) competent in their fields, and (c) worthy in character and in professional ethics; and that the practice of the division of fees, under any guise whatever, be prohibited. </li></ul><ul><li>Staff initiate, with approval of the hospital governing board, adopt rules, regulations, and policies governing professional hospital work. Staff meetings at least monthly. Staff review and analyze at regular intervals clinical experience in the departments, such as medicine, surgery, obstetrics, and other specialties; clinical records as the basis of review and analyses. </li></ul><ul><li>Accurate and complete patient records, filed in an accessible manner. A complete record being one which includes identification; complaint; personal and family history; history of present illness; physical examination; special examinations, such as consultations, clinical laboratory, X-ray and other examinations; provisional diagnosis; medical or surgical treatment; gross and microscopic pathological findings; progress notes; final diagnosis; discharge condition; followup and, in case of death, autopsy findings. </li></ul>
    7. 7. 1917 The Minimum Standard for Hospitals <ul><li>Diagnostic and therapeutic facilities under competent supervision available for study, diagnosis, & treatment of patients, to include, (a) clinical laboratory providing chemical, bacteriological, serological, and pathological services; (b) X-ray department providing radiographic and fluoroscopic services. </li></ul><ul><li>Physicians privileged to practice in the hospital be organized as a definite group or staff. Such organization has nothing to do with the question of the hospital as “open” or “closed,” nor need it affect the various existing types of staff organization. The word “staff” is here defined as the group of doctors who practice in the hospital inclusive of all groups such as the “regular staff,” the “visiting staff,” and the “associate staff.” </li></ul>
    8. 8. 1926 Am. Coll. Surgeons Standards Manual 18 pages
    9. 9. 1951 ACS Standards Manual The American College of Surgeons (ACS) The American College of Physicians (ACP) The American Hospital Association (AHA) The American Medical Association (AMA) The Canadian Medical Association (CMA) Joint Commission on Accreditation of Hospitals (JCAH)
    10. 10. 1964 begins charging for surveys 1987 Name Change: Joint Commission on Accreditation of Healthcare Organizations (JCAHO) “ JCAH” Joint Commission on Accreditation of Hospitals 1990 - 2006 Everyone just calls it: “The Joint Commission” January 2007 Officially Changes Name to: “ The Joint Commission”
    11. 11. Quality Today
    12. 12. THE AFFORDABLE CARE ACT (ACA) OF 3/23/2010 <ul><li>The Act provided for Mandatory Medicare Delivery System Reform: </li></ul><ul><ul><li>Reduce Inpatient Readmissions </li></ul></ul><ul><ul><li>Institute Value Based Purchasing (VBP) </li></ul></ul><ul><ul><li>Reduce Healthcare Acquired Conditions (HACS) </li></ul></ul><ul><ul><li>Institute Meaningful Use (Electronic Healthcare Record-EHR) </li></ul></ul><ul><li>An “incentive” program for hospitals accepting Medicare reimbursement. </li></ul><ul><li>Beginning in October 1, 2012, 1% of Medicare reimbursement due to us for services already rendered will be withheld. </li></ul><ul><li>The amount withheld will increase by ¼ of a percent per year until 2% is reached. </li></ul><ul><li>We have an opportunity to earn back some or all of this money by demonstrating that we give quality care and have satisfied consumers. </li></ul>
    13. 13. BEGINNING THE LEAN JOURNEY AT ELLIS
    14. 14. R EASON FOR LEAN NOW….. <ul><li>Achieve a top performing organization </li></ul><ul><li>A mindset of clinical quality </li></ul><ul><li>Accountability of managers </li></ul><ul><li>Keeping patients first when considering change </li></ul><ul><li>Increasing financial pressures – declining reimbursement </li></ul><ul><li>Consistent monitoring of results and data </li></ul><ul><li>The status quo is no longer acceptable </li></ul><ul><li>Collaboration between departments is expectation </li></ul>
    15. 15. <ul><li>LEAN is a methodology that is used to accelerate the speed and reduce the cost for any process by removing waste (non-value-added activities) </li></ul><ul><li>“ Re-examine the way you think about waste, as it is often difficult to recognize. Start by making waste obvious to everyone.” </li></ul><ul><li>Taiichi Ohno, Founder Toyota Production System </li></ul>
    16. 16. WASTE REDUCTION – 120 DAY CYLE <ul><li>Kick Off - COMPLETED </li></ul><ul><li>30 Day Check-In - COMPLETED </li></ul><ul><li>60 Day Check-In - COMPLETED </li></ul><ul><li>90 Day Check-In- APRIL 26 th 9-11 Auditorium </li></ul><ul><li>Summation – MAY 24 th 9-11 Auditorium </li></ul><ul><li>_________________________ </li></ul><ul><li>120 Days X 3 Cycles =360 Days </li></ul><ul><li>THE NEXT 120 DAY CYCLE BEGINS ON THE SUMMATION DAY. </li></ul>
    17. 17. ROLE OF WORKOUT COORDINATORS <ul><li>Assist the exec champion in managing the logistics of the 120 day Workout </li></ul><ul><li>Support for timely development of the 120 day action plans </li></ul><ul><li>Identifying potential successes and failures </li></ul><ul><li>Providing support to stimulate ideas and discussions </li></ul><ul><li>Act as a coach for the lean process </li></ul><ul><li>Additional Training for LEAN workout coordinators is scheduled. </li></ul>
    18. 18. LEAN -WORK OUT COORDINATORS
    19. 19. EXCELERATOR <ul><li>All managers with a LEM - have </li></ul><ul><li>access to Excelerator. </li></ul>
    20. 20. EXCELERATER RESULTS TO DATE: <ul><li>640 PLANS ENTERED SO FAR </li></ul><ul><li>$400,000 Savings identified for 2011 </li></ul><ul><li>$1.2 Million Savings identified for 2012 </li></ul><ul><li>The Finance Data Sheet is posted on the portal to assist you with valuing your cost savings. </li></ul>
    21. 21. SUMMARY OF 7 TYPES OF WASTE: <ul><li>“ In Quality Staffing” (Over Capacity) </li></ul><ul><li>2. Over‐Correction </li></ul><ul><li>3. Over‐Processing </li></ul><ul><li>4. Excess Inventory </li></ul><ul><li>5. Waiting & Delays </li></ul><ul><li>6. Motion/Transport </li></ul><ul><li>7. Movement of Materials & Information </li></ul>
    22. 22. RAPID CYCLE TEST TEMPLATE
    23. 23. RAPID CYCLE TEST TEMPLATE Source: Manual 7-7-09 Automatic Calculation PRE       POST               Data into grey columns only.                             Count Data Avg   Count Data Avg.   Rapid Cycle Testing Instructions               1 132 112   1 69 82   1. Determine the measure to test & the source of data (manual or IT system).       2 99 112   2 101 82   2. Create the plan to test the change (date to begin test, training, data collection, etc.)     3 102 112   3 63 82   3. Obtain/ collect baseline data (25-30 data points or more if not manual.)       4 99 112   4 73 82   4. Train/orient staff (if needed) & train data collectors (if needed) & conduct 1 &quot;dry run&quot;.     5 78 112   5 89 82   5. Run the test for 25-30 data points over 1-shift, 1-day, 3-days, collecting data along the way.   6 106 112   6 79 82   6. Analyze results. If improvement, &quot;hardwire&quot; the change. If not, cease the change.     7 119 112   7 78 82   7. Repeat the Rapid Cycle Test process.             8 89 112   8 83 82                       9 100 112   9 77 82         Pre Post           10 102 112   10 78 82       Average 112 82           11 150 112   11 89 82       St. Dev. 27 10           12 146 112   12 95 82                       13 123 112   13 94 82                       14 132 112   14 90 82                       15 176 112   15 78 82                       16 102 112   16 84 82                       17 89 112   17 90 82                       18 95 112   18 69 82                       19 96 112   19 69 82                       20 97 112   20 101 82                       21 98 112   21 63 82                       22 102 112   22 73 82                       23 142 112   23 89 82                       24 165 112   24 79 82                       25 132 112   25 78 82                       26 123 112   26 83 82                       27 172 112   27 77 82                       28 69 112   28 78 82                       29 85 112   29 89 82                       30 84 112   30 95 82                       31 76 112   31 94 82                       32 98 112   32 90 82                       33 99 112   33 78 82                       34 100 112   34 84 82                       35 120 112   35 90 82                       36 130 112   36 69 82                                                          
    24. 24. TWO CHANGES PER MONTH <ul><li>ASK STAFF – What processes are interfering with our ability to provide excellent care? </li></ul><ul><li>ASK STAFF – Is there a better way? </li></ul><ul><li>POOR QUALITY AND PATIENT SAFETY RISKS ARE OFTEN CREATED BY VARIATION IN OUR PROCESSES </li></ul>
    25. 25.
    26. 26. LEAN TEAM KAIZEN EVENT <ul><li>Application of Lean concepts and tools to rapidly improve the process through the removal of waste in the system </li></ul><ul><li>Project charter: Opportunity exists to improve the process of timely medication delivery to new post-op patients. </li></ul><ul><li>Scope: From when physician signs order to when medication is administered to patient in A3 </li></ul>
    27. 27. WHAT IS LEAN?? <ul><li>Philosophy </li></ul><ul><ul><li>Focus on value-added elements in process, drive out waste in system </li></ul></ul><ul><li>Tools </li></ul><ul><ul><li>Throughput time, five Ss, simple visual control systems, spaghetti diagrams, standardized work, smooth flow…. </li></ul></ul>
    28. 28.
    29. 29. Documenting and studying the actual process
    30. 30. PACU PROCESS AND ISSUES Med rec Sign/dated Scanned to pharm by clerk Scanned to pharm by RN RN review order Post op order Sign/dated I ncomplete Orders 15 minutes
    31. 31. PHARM PROCESS AND ISSUES Messages Scan Arrived Scan put into MAK by RX Robot retrieval and bagging Meds put in tube Meds sent via tubes Batch wait time No trace = rework 10 minutes 30 120 20 minutes
    32. 32. A3 PROCESS AND ISSUES Nurse Verifies MAK entry Nurses time spent on non-patient care Meds put in Med room Nurse retrieves med from room Meds to patient Hunt and gather Did meds arrive? Unattended Meds! Pyxis underused
    33. 33. CURRENT PROCESS <ul><ul><li>Example: 6/23 total knee surgery </li></ul></ul><ul><ul><li>Antiemetic (Zofran) ordered at 1745 </li></ul></ul><ul><ul><li>Patient received at 2226 </li></ul></ul><ul><ul><li>Total time 4 hrs 41 minutes from order to delivery </li></ul></ul><ul><ul><li>BUT – Zofran is a PYXIS item. Available immediately on over-ride on A3 unit! </li></ul></ul><ul><ul><li>Patient could have had it in minutes! </li></ul></ul>
    34. 34. OPPORTUNITIES TO REMOVE WASTE <ul><li>PYXIS use up </li></ul><ul><li>Time/date MORE orders </li></ul><ul><li>Tube system alert </li></ul><ul><li>Tube system tracking board </li></ul><ul><li>Tubes cleared by non clinical staff </li></ul><ul><li>Supply room reorganize – hunt and gather </li></ul><ul><li>Room-side cabinet </li></ul><ul><li>Runner? </li></ul>
    35. 35. Spaghetti diagram – RN checking on missing med
    36. 36. Part of the improved tube management system
    37. 37. Increase PYXIS use!
    38. 38. Minimize hunting and gathering - - Utilize and organize Nurse cabinets
    39. 39. Tubes in que For system
    40. 40. Report Parameters: 6/22/2009 12:00AM to 6/23/2009 12:00AM Graph displays orders received by hour and priority for a specified date range to show the demand within a 24 hour time period.
    41. 41. SUMMARY <ul><li>This Lean activity, with its focus on waste reduction, eliminates unnecessary processes, provides better service to patients, and increases both patient and employee satisfaction </li></ul>
    42. 42. EXTRAORDINARY CHANGE <ul><ul><li>Catalyst for change: NYS health care reform (Berger law) </li></ul></ul><ul><ul><li>Ellis assumed responsibility for the services of two hospitals in a short seven month period. </li></ul></ul><ul><ul><li>Thousands of details involved … </li></ul></ul><ul><ul><li>Consider what was added to Ellis: Employees 1,133 </li></ul></ul><ul><ul><ul><ul><ul><li>Expense Budget $118 M </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Discharges 10,600 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Days of Care 43,000 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Surgeries 8,400 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>ER Visits 39,000 </li></ul></ul></ul></ul></ul><ul><ul><li>Financial Turnaround </li></ul></ul><ul><ul><ul><ul><ul><li> 2007 – 3 hospitals lost $7 M collectively </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> 2008 – newly unified Ellis posted $4.6 M operating margin </li></ul></ul></ul></ul></ul>
    43. 43. INTRODUCTION <ul><li>Schenectady, NY </li></ul><ul><li>Three campus hospital system </li></ul><ul><li>455 licensed beds </li></ul><ul><li>3,300 employees (850 RNs) </li></ul><ul><li>600 affiliated physicians </li></ul><ul><li>2009 projected volume: 550,000 patients </li></ul><ul><li>2009 projected births: 2,700 babies </li></ul><ul><li>2009 operating budget $343 million </li></ul><ul><li>2008 operating margin: $4.6 million </li></ul>
    44. 44. BTS 8 FRAMEWORK FOR SUCCESS <ul><li>Aim statement </li></ul><ul><li>Plan – Do – Study – Act PDSA Cycles </li></ul><ul><li>Identify BTS 8 Team </li></ul><ul><li>Garner Physician Champion(s) </li></ul><ul><li>Engage Senior Leadership/Management </li></ul><ul><li>Perform tests on changes and processes leading to implementation </li></ul><ul><li>Monthly Conference Calls </li></ul><ul><li>Update Data for Premier ~ My Community </li></ul><ul><li>Attendance at all three BTS8 Learning Sessions </li></ul>
    45. 45. TEAM MEMBERS <ul><li>Director Surgical Services (Jonathan Blank)  </li></ul><ul><li>OR Manager (Pam Margas) </li></ul><ul><li>PACU Manager (Judy Symolon) </li></ul><ul><li>Physician Champions (Dr. Iftikhar Syed & Eric Aronowitz) </li></ul><ul><li>Purchasing Manager (Coleen Norberg) </li></ul><ul><li>Surgical Supply Manager (Donna Cafaldo) </li></ul><ul><li>Vice President of Operations (Patti Hammond) </li></ul>
    46. 46. AIM STATEMENT <ul><li>Improve OR supply chain expense by $125,000 through standardization, utilization, contracting and increased efficiencies across a 3 campus perioperative system by 12/31/09. </li></ul>
    47. 47. STRATEGIES <ul><li>Identify Perioperative Opportunities for Supply Chain Savings. </li></ul><ul><li>Identify Operational Efficiency Opportunities. </li></ul><ul><li>Identify Standardization Initiatives. </li></ul><ul><li>Utilize the BTS 8 “Formula for Success” </li></ul><ul><ul><li>Aim statement </li></ul></ul><ul><ul><li>Persistent PDSA Cycles </li></ul></ul><ul><ul><li>Measuring, Performing Tests on Changes and Evoking Process Evolution </li></ul></ul><ul><ul><li>Garnering Physician Champion Support (General and Orthopedic) </li></ul></ul><ul><ul><li>Engaging Senior Management </li></ul></ul><ul><ul><li>Communication </li></ul></ul>
    48. 48. METHODOLOGY <ul><li>Structured Focus on Aim Statement </li></ul><ul><li>PDSA Cycles </li></ul><ul><li>Monthly Premier Perioperative Conference Calls </li></ul><ul><li>Premier Consultation </li></ul><ul><li>Senior Management Engaged </li></ul><ul><li>Communication Updates </li></ul><ul><li>Physician Champion Support </li></ul><ul><li>Attendance at BTS 8 LS1-3 Conferences </li></ul>
    49. 49. CONTRACT OPPORTUNITY <ul><li>Reprocessing </li></ul><ul><ul><li>Shavers, Trocars, Tourniquet Cuffs, OPCAB Devices – SAVE $40K </li></ul></ul><ul><li>Utilization Custom Pack Changes </li></ul><ul><ul><li>Knee Arthroscopy – SAVE $14K </li></ul></ul><ul><ul><li>Total Knee - SAVE $ 7K </li></ul></ul><ul><ul><li>Total Hip –SAVE $16K </li></ul></ul><ul><ul><li>Physician Eye Packs – SAVE $19K </li></ul></ul><ul><li>Standardization </li></ul><ul><ul><li>Disposable Clean Up Kits SAVE -$45K </li></ul></ul><ul><ul><li>Foot Compression Garments SAVE-$2K </li></ul></ul><ul><ul><li>Shoulder Drape SAVE - $3K </li></ul></ul><ul><ul><li>PortaCath SAVE – $8K </li></ul></ul><ul><li>Premier - Yankee Alliance Contracts & Capitated Pricing </li></ul><ul><ul><li>Cardinal Custom Procedure Packs SAVE -$69K </li></ul></ul><ul><ul><li>Orthopedic Implant Capitated Contract –SAVE $651K </li></ul></ul>
    50. 50. BTS 8 SAVINGS $1,157,170.00
    51. 51. CONCLUSION <ul><li>Premier (BTS 8) - Framework for Success </li></ul><ul><li>Reprocessing – Conservative Approach </li></ul><ul><li>Operational Efficiency – Global Initiative </li></ul><ul><li>Contracts and Capitated Pricing – Persistence WINS </li></ul><ul><li>Capture all SAVINGS – Opportunities Abound </li></ul><ul><li>Change theory – Embrace with Leadership/Mentoring </li></ul>
    52. 52. LESSONS LEARNED <ul><li>Framework for Success: </li></ul><ul><li>Communication </li></ul><ul><li>Persistence </li></ul><ul><li>Savings </li></ul><ul><li>Global Operational View </li></ul><ul><li>Senior Leadership and Physician Champions </li></ul>
    53. 53. PROJECT INITIATIVES <ul><li>Operational Efficiency Component </li></ul><ul><ul><li>PACU Expansion </li></ul></ul><ul><ul><li>Enhanced Communication </li></ul></ul><ul><ul><li>CSuite Task Force </li></ul></ul><ul><ul><li>Information Technology </li></ul></ul><ul><li>Material Management Component </li></ul><ul><ul><li>Reprocessing </li></ul></ul><ul><ul><li>Contracts </li></ul></ul><ul><ul><li>Custom Packs </li></ul></ul><ul><ul><li>Standardization of Product </li></ul></ul>
    54. 54. AIM <ul><li>Improve OR supply chain expense by $125,000 through standardization, utilization, contracting and increased efficiencies across a 3 campus perioperative system by 12/31/09. </li></ul>
    55. 55. BTS 8 TEAM PERIOP RESULTS <ul><li>TOTAL SAVE </li></ul><ul><li>of </li></ul><ul><li>$1,157, 170.00 </li></ul>
    56. 57. OPERATIONAL EFFICIENCY SAVINGS OR/PACU PATIENT THROUGHPUT STANDARDIZATION –EMR/FORMS <ul><li>Labor and Anesthesia Expense Reduction : SAVINGS $19,599 </li></ul><ul><li>Collaboration - BIOMED Equipment Transfer : SAVINGS $199,940 </li></ul><ul><li>Forms Standardization: SAVINGS $3,000 </li></ul><ul><li>Information Technology Specialist: SAVINGS $55,000 </li></ul><ul><li>$277,940 </li></ul>
    57. 58. PATIENT FLOW AND OPERATIONAL EFFICIENCY OPPORTUNITIES
    58. 59. PATIENT FLOW AND OPERATIONAL EFFICIENCY OPPORTUNITIES
    59. 60. OR AND PACU LABOR COST TREND Total Save = $13,677
    60. 61. ANESTHESIA LENGTHENED TIME COST Total Save = $5,922
    61. 62. PREMIER & YANKEE CONTRACT WORK <ul><li>Premier – Custom Procedure Pack Contract </li></ul><ul><li>Yankee – Benchmark for Ortho Capitation Contract </li></ul>
    62. 63. UTILIZATION CUSTOM PACK CHANGES
    63. 64. SUPPLY CHAIN BARRIERS <ul><li>Reprocessing – Surgeon’s previous experience created concern regarding inclusion of harmonic scalpel. </li></ul><ul><li>Waste Form – Not implemented across three campuses. </li></ul><ul><li>Orthopedic Implant – working through vendor resistance and influence. </li></ul><ul><li>Supply Chain Focus versus Clinical – disconnect between clinical side and supply chain initiatives. </li></ul>
    64. 65.
    65. 66. THE IMPORTANCE OF LEAN SIX SIGMA PROCESS TRACKING TO ACHIEVE IMPROVEMENT AND MAINTAIN IT. <ul><li>Lean at Ellis </li></ul><ul><ul><li>Change the way of thinking / culture </li></ul></ul><ul><ul><li>Consulting firm to assist in laying the foundation </li></ul></ul><ul><ul><li>Focus on quality </li></ul></ul><ul><ul><ul><li>Improve patient flow </li></ul></ul></ul><ul><ul><ul><li>Increase patient volume </li></ul></ul></ul><ul><ul><ul><li>Eliminate non-value added activities </li></ul></ul></ul><ul><ul><ul><li>Improve staffing </li></ul></ul></ul>
    66. 67. WHAT IS LEAN? <ul><li>A philosophy & improvement methodology focused on eliminating waste & improving workflow </li></ul><ul><li>Focus on value stream analysis </li></ul><ul><li>In Lean, costs exist only to be reduced </li></ul><ul><li>Flow optimization </li></ul><ul><li>Pull versus push (“Chocolate Factory”) </li></ul><ul><li>Perfection (zero waste) </li></ul>
    67. 68. <ul><li>Mobilize the entire </li></ul><ul><li>organization </li></ul><ul><ul><li>Board </li></ul></ul><ul><ul><li>Senior Leadership </li></ul></ul><ul><ul><li>Middle Management </li></ul></ul><ul><ul><li>Physicians </li></ul></ul><ul><ul><li>Front line staff </li></ul></ul><ul><ul><li>Set targets and deadlines up front </li></ul></ul><ul><ul><li>Set financial targets </li></ul></ul><ul><ul><li>All levels held accountable </li></ul></ul><ul><ul><li>Include front-line staff </li></ul></ul>
    68. 69. <ul><li>Basic set of standardized terms </li></ul><ul><ul><li>Posted on intranet </li></ul></ul><ul><li>Discuss at Open Forums </li></ul><ul><ul><li>Open discussion with all employees </li></ul></ul><ul><ul><li>Ask staff for brainstorming </li></ul></ul><ul><li>Communication cascades </li></ul>
    69. 70. GETTING STARTED / INFRASTRUCTURE <ul><li>Sr Management Oversight Committee for project selection & overall stewardship of activities </li></ul><ul><li>Consultant for initial education, teaching materials & coaching </li></ul><ul><li>Administrative support for scheduling & clerical functions: Critical Need! </li></ul><ul><li>System for tracking projects & results </li></ul><ul><li>Strong ties to and support from Finance </li></ul>
    70. 71. <ul><li>120-day cycle with 30-day check-ins </li></ul><ul><li>Disciplined, focused engagement </li></ul><ul><li>Built database tracker to promote accountability & adherence to timelines </li></ul>
    71. 72. <ul><li>Activate engagement </li></ul><ul><ul><li>Set targets and deadlines up front </li></ul></ul><ul><ul><li>Set financial targets </li></ul></ul><ul><ul><li>All levels held accountable </li></ul></ul><ul><ul><li>Include front-line staff </li></ul></ul>
    72. 73. Sort, Straighten, Shine, Standardize, Sustain
    73. 74. <ul><li>7:00 AM anesthesia arrives </li></ul><ul><li>7:45 AM OR starts </li></ul><ul><li>Large Bariatric growth over last 5 years </li></ul><ul><li>Have PACU holds increased since the closure of B2 </li></ul><ul><li>Anesthesia does not see the patients prior to the day of surgery (except for some cardiac cases) </li></ul><ul><li>How can we improve </li></ul><ul><ul><li>Patient tracking system in the PACU/OR </li></ul></ul>
    74. 75. “ BEFORE SURGERY” TEAM MEETING   <ul><li>What is working: </li></ul><ul><li>Diligent staff that keeps on top of things (in relation to scheduling and paper work) </li></ul><ul><li>Having extra staff for turnovers helps move the cases along </li></ul><ul><li>Teamwork </li></ul><ul><li>Pick sheets have been improved </li></ul><ul><li>Moving towards an enterprise wide pick sheet. </li></ul><ul><ul><li>Currently working with purchasing and the OR buyer to standardize supplies </li></ul></ul><ul><ul><li>Will have an electronic system for inventory contro </li></ul></ul><ul><li>What is not working: </li></ul><ul><li>Paper </li></ul><ul><ul><li>Large amount of un-needed paper in the scheduling / PAT phase </li></ul></ul><ul><ul><li>Duplication of work </li></ul></ul><ul><ul><li>Missing documentation </li></ul></ul><ul><ul><li>Would like to move to a central scanning system </li></ul></ul><ul><li>Process to notify patient in regards to OR time changes </li></ul><ul><ul><li>Going to start reminder calls to patients with the arrival time, not the OR time </li></ul></ul><ul><ul><ul><li>Once up and running, MD office will no longer need to call patients with time </li></ul></ul></ul><ul><ul><li>Gives more flexibility in moving cases around </li></ul></ul><ul><li>Patients that come in early for blood work wind up sitting in Day Surgery without having the blood drawn </li></ul><ul><ul><li>A facilitator position has been approved and will be posted soon </li></ul></ul><ul><li>Missing pre-op antibiotics </li></ul><ul><ul><li>These are either not ordered or ordered at the last minute </li></ul></ul><ul><ul><ul><li>Can OR nurses have access to the PACU Pyxis </li></ul></ul></ul><ul><li>Outdated H+Ps </li></ul><ul><ul><li>Same day surgery is checking the charts the day prior </li></ul></ul><ul><ul><li>Looking at having the PA update the H+P </li></ul></ul><ul><li>  </li></ul><ul><li>Process </li></ul><ul><li>MD has set block time </li></ul><ul><ul><li>~ 90% of block time is utilized </li></ul></ul><ul><li>Case is scheduled by Joanne once the paperwork is received from the MD’s office </li></ul><ul><li>Schedule PAT appointment </li></ul><ul><ul><li>7 - 30 days prior to OR date </li></ul></ul><ul><li>Return completed booking sheet to the MD </li></ul><ul><li>Worksheet is generated and sent to PAT to secure the financials, pre-certs </li></ul><ul><li>Patient arrives for surgery </li></ul><ul><ul><li>1 ½ hours prior to OR time </li></ul></ul><ul><ul><li>Patient is escorted to Day Surgery, blitzed by staff, then waits for surgery </li></ul></ul>
    75. 76. <ul><li>What is working: </li></ul><ul><li>Staff works hard </li></ul><ul><li>Teamwork </li></ul><ul><li>What is not work: </li></ul><ul><li>Patient not ready </li></ul><ul><ul><li>Blocks - RNs not available to assist </li></ul></ul><ul><ul><li>Incomplete charts </li></ul></ul><ul><li>PACU holds at 9:30 AM </li></ul><ul><ul><li>Is this due to staffing </li></ul></ul><ul><li>Add-ons </li></ul><ul><ul><li>Stresses the staff / anesthesia </li></ul></ul><ul><ul><li>Extra rooms running at 5 PM </li></ul></ul><ul><li>Payer mix </li></ul><ul><ul><li>~ 50% government funded </li></ul></ul><ul><ul><li>Increasing bariatric patients but most are on Medicaid with minimal reimbursement </li></ul></ul><ul><li>On time starts </li></ul>
    76. 77. DURING SURGERY” TEAM MEETING <ul><li>“ What is working: </li></ul><ul><li>Teamwork </li></ul><ul><li>Dedicated staff </li></ul><ul><li>Positive outcomes </li></ul><ul><li>Patient comes first most of the time </li></ul><ul><li>Much talent in the OR </li></ul><ul><li>They have the needed tools to get the job done </li></ul><ul><li>What is not working: </li></ul><ul><li>Cost savings by the MD </li></ul><ul><ul><li>MD will require a certain product that is more expensive than a similar product </li></ul></ul><ul><ul><li>Opening all products that could possibly be used for the procedure </li></ul></ul><ul><li>Start times of first cases </li></ul><ul><li>Schedule of OR has expanded past the blocked time </li></ul><ul><ul><li>Rooms are running later in the day </li></ul></ul><ul><ul><li>No room for the add-ons </li></ul></ul><ul><li>Underutilization of EHC for ambulatory cases </li></ul><ul><li>No enforcement of the un-utilized block time </li></ul><ul><li>OR holds caused by no PACU beds </li></ul><ul><li>Reciprocation for the hard work of the staff </li></ul><ul><li>Redundancy in steps </li></ul><ul><ul><li>Assessment, chart check, ect. </li></ul></ul><ul><li>Patients brought into the OR that are not ready </li></ul><ul><li>  </li></ul><ul><li>Process </li></ul><ul><li>Introduction and visual assessment of the patient in the holding area </li></ul><ul><ul><li>Seen by anesthesia </li></ul></ul><ul><li>Chart review for missing documentation </li></ul><ul><li>Universal protocol </li></ul><ul><li>Update missing documentation </li></ul><ul><li>Patient is brought into the OR </li></ul><ul><li>Surgeon arrives </li></ul><ul><li>Anesthesia begins </li></ul><ul><li>Time out </li></ul><ul><li>Surgery </li></ul><ul><li>Case closed </li></ul><ul><li>Room turn over </li></ul><ul><li>Next case begins </li></ul>
    77. 78. AFTER SURGERY” TEAM MEETING <ul><li>What is working: </li></ul><ul><li>Send the surgical PA to the floor earlier </li></ul><ul><li>What is not working: </li></ul><ul><li>Long LOS </li></ul><ul><li>Crunch time for beds in PACU is Noon </li></ul><ul><ul><li>Peak time for hospital discharges is 4PM </li></ul></ul><ul><li>Delay to PACU admission </li></ul><ul><li>Nursing units are at capacity </li></ul><ul><li>Room turnover on floors </li></ul><ul><li>No reports to floors during shift change </li></ul><ul><li>Unit nurse is needed for patient transfer to ICU </li></ul><ul><li>Anesthesia purges patients from PACU </li></ul><ul><li>Process </li></ul><ul><li>Call from OR to PACU for space </li></ul><ul><ul><li>Does not always happen </li></ul></ul><ul><li>Patient arrives in PACU </li></ul><ul><li>Moves to Phase II recovery </li></ul><ul><li>Patient is transferred to the floor or discharged home </li></ul>
    78. 79. <ul><li>Goal </li></ul><ul><ul><li>Achieve an annual tangible cost recovery </li></ul></ul><ul><ul><ul><li>Goal - $3 Million </li></ul></ul></ul><ul><ul><ul><ul><li>Conservative estimate with savings expected to greatly exceed goal </li></ul></ul></ul></ul>
    79. 80. Institution Orientation <ul><ul><ul><li>Redefine Quality in relation to waste </li></ul></ul></ul><ul><ul><ul><li>Define expectations </li></ul></ul></ul><ul><ul><ul><ul><li>Managers responsibility </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Eight changes during 100 day cycle / 2 per month </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>One change must include collaboration with another department </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Every employee is involved </li></ul></ul></ul></ul>
    80. 81. Surgical Services Breakout <ul><ul><ul><li>Identified as an area for substantial waste reduction and savings </li></ul></ul></ul><ul><ul><ul><li>Three teams </li></ul></ul></ul><ul><ul><ul><ul><li>Prior to surgery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>During surgery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>After surgery </li></ul></ul></ul></ul><ul><ul><ul><li>Cross section of specialties on each team to maximize results </li></ul></ul></ul>
    81. 82. Focus on the 7 categories of waste <ul><ul><ul><li>“ In Quality/ Out of Quality” Staffing; Overcapacity </li></ul></ul></ul><ul><ul><ul><li>Correction / inspection </li></ul></ul></ul><ul><ul><ul><li>Over-processing / redundancy </li></ul></ul></ul><ul><ul><ul><li>Over-inventory </li></ul></ul></ul><ul><ul><ul><li>Waiting </li></ul></ul></ul><ul><ul><ul><li>Motion of patients / staff </li></ul></ul></ul><ul><ul><ul><li>Material / information movement </li></ul></ul></ul><ul><ul><li>Encourage process changes, not just simple waste reduction </li></ul></ul>
    82. 83. <ul><ul><li>Rapid cycle testing </li></ul></ul><ul><ul><ul><li>PDSA </li></ul></ul></ul><ul><ul><ul><li>25-30 data points prior to and after change </li></ul></ul></ul><ul><ul><ul><li>Facilitate change for new and innovative ideas supported by data prior to implementation </li></ul></ul></ul><ul><ul><ul><li>Eliminate long evaluation periods </li></ul></ul></ul>
    83. 84. KEY ROLES <ul><ul><li>Senior leaders </li></ul></ul><ul><ul><ul><li>Buy in and support </li></ul></ul></ul><ul><ul><ul><ul><li>Attend monthly check-ins when plans are presented by stake holders </li></ul></ul></ul></ul><ul><ul><li>Workout coordinators </li></ul></ul><ul><ul><ul><li>Managers broken up into approx 12 member teams </li></ul></ul></ul><ul><ul><ul><li>Role of the workout coordinator is to offer guidance/advice, not ideas. </li></ul></ul></ul><ul><ul><ul><ul><li>Ownership of plans is placed on managers </li></ul></ul></ul></ul><ul><ul><li>Finance Liaison </li></ul></ul><ul><ul><ul><li>Support in assigning actual savings when not readily identifiable </li></ul></ul></ul><ul><ul><ul><li>Verify tangible savings when in question </li></ul></ul></ul><ul><ul><li>Communication Coordinator </li></ul></ul><ul><ul><ul><li>Announcement emails </li></ul></ul></ul><ul><ul><ul><li>News letters </li></ul></ul></ul><ul><ul><ul><li>Intranet </li></ul></ul></ul>
    84. 85. <ul><li>Challenges </li></ul><ul><ul><li>Changing old school ways of thinking </li></ul></ul><ul><ul><li>Reducing staffing / supplies without compromising patient care </li></ul></ul><ul><ul><li>Staying the coarse </li></ul></ul><ul><ul><ul><li>This will not go away in a couple of weeks </li></ul></ul></ul><ul><ul><ul><li>Owning the process and maintaining momentum after consultants leave </li></ul></ul></ul><ul><li>  </li></ul>
    85. 86. <ul><li>Change Examples </li></ul><ul><li>B/W vs color printing </li></ul><ul><li>Stop unneeded reports </li></ul><ul><li>Consolidate deliveries </li></ul><ul><li>Fax vs mail reports </li></ul><ul><li>Eliminate face to face meetings: use technology </li></ul><ul><li>Reduce over time </li></ul><ul><li>Contracts/supplies: better pricing options </li></ul><ul><li>Control purchase options </li></ul>
    86. 87. <ul><li>Tracking progress </li></ul><ul><ul><li>Consultant offered software package </li></ul></ul><ul><li>  </li></ul><ul><li>Overview of projects </li></ul><ul><li>Results </li></ul><ul><ul><li>Goal - $3 Million </li></ul></ul><ul><ul><ul><li>To Date - Planned $2.5 Million </li></ul></ul></ul><ul><ul><ul><li>To Date - Actual $1.5 Million </li></ul></ul></ul>
    87. 88.

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