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

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  • Notes for Audience: “What would make this hour worthwhile of your time? What do you want to learn? Do you want to be entertained, educated, or a bit of both? HIT THE AUDIENCE”S NEEDS!!
  • Focused on FLOW TAKT Quality Continuous Improvement
  • Maria
  • Maria
  • Maria
  • Maria
  • John Putnam
  • John
  • Maria—UPDATE GRAPH!
  • John Putnam
  • Maria
  • Maria
  • Transcript

    • 1. Managing Patient Throughput by Process Improvement to Improve Quality and Control Cost Maria Madrigal Black Belt Sigma Breakthrough Technologies
    • 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
    • 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?
    • 4. A Measurement 2 308,537 3 66,807 4 6,210 5 233 6 3.4 Sigma Levels Parts per Million Defective
    • 5. Practical Meaning 99% Good 99.99966% Good Postal System 20,000 Lost Articles of Mail / Hr Airline System Two Short/Long Landings / Day Medical Profession 200,000 Wrong Drug Prescriptions / Yr 7 Lost Articles / Hr 1 Short / Long every 5 Years 68 Wrong Drug Prescriptions
    • 6. The Hidden Process Yield Shrinkage (waste) Redo Hidden Process NOT OK Yield At Measurement Operation Inputs Measure Final ‘Yield’ = OK Final Yield ignores the hidden process. Final yield performance is a function of post measurement. Process Variation Causes A " Hidden Process " Increased Cost – Lost Capacity >95% Customer Quality 65% is not 95% ... why not? Process 1 2 3 90% Yield 90% Yield 85% Yield = FPY/RTY 81 % 69 % 95% Yield 4 65 % >95% ‘Yield’ Final Measurement
    • 7. Rolled Throughput in Healthcare Shrinkage (waste) Redo Hidden Process NOT OK Yield At Measurement X-Ray Patient presents for x-ray Results Final ‘Yield’ = OK Final Yield ignores the hidden process. Final yield performance is a function of post measurement. Process Variation Causes A " Hidden Process " Increased Cost – Lost Capacity >95% Customer Quality 65% is not 95% ... why not? Process 1 2 3 90% X-Ray 90% Correct Test 85% Results = FPY/RTY 81 % 69 % 95% Returned 4 65 % >95% ‘Yield’ Final Measurement
    • 8. Variation Causes Defects Poor Support of Robust Product Functionality Process Capability No standard process for staff members InadequateStaffing Needs Variation in Medical Supplies No Metrics Way off Target Out of Spec. LSL USL
    • 9. Time Performance Breakthroughs in Process Performance GOOD BAD 3 Sigma (CpK = 1) 6 Sigma (Cpk = 2)
    • 10. Changing the Decision Making Processes Decision Making Growth Path Types of Problems You Will Normally Solve 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 Simple Complex How Many Times Have Your Heard This ? “I Think The Problem Is…”
    • 11. Overall Approach Practical Problem Statistical Problem Statistical Solution Practical Solution
    • 12. The Funneling Effect Optimized Process 30+ Inputs 8 - 10 4 - 8 3 - 6 Found Critical X’s Controlling Critical X’s 10 - 15 All X’s 1st “Hit List” Screened List MEASURE ANALYZE IMPROVE CONTROL
    • 13. Triage Team A.K.A. “Muda Busters!”
    • 14. Accelerated Change Event, “ACE”
      • Time Period
      • Team Given
      • Clear Objectives
      • Team Composition
      • Support
      • Timeline
      • Lead time reduction
      • Cost reduction
      • Yield enhancement
      • Meet customer demand
      • 1/3 are process specialists from area
      • 1/3 are people related to the area
      • 1/3 are those from outside of area
      • 5 Days
      • Ground Rules
      • Cannot damage the customer
      • Cannot permanently “harm” internal operations
      • Use creativity before capital
      AM PM MON TUE THU FRI WED TRAINING CURRENT STATE MAP CONCEPT & DETAIL DESIGN “ TAKE ACTION” IMPLEMENT IMPROVEMENTS REFINE Stabilize / Measure IMPROVEMENTS REFINE CHANGES PREPARE PRESENTATION PRESENTATION & CELEBRATION “ TAKE ACTION” DESIRED STATE GAP ANALYSIS
    • 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.
    • 16. TYPES OF WASTE PEOPLE TYPES OF WASTE Processing Motion Waiting Fixing Defects Making Too Much Moving Things Inventory
    • 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
    • 18. ACE Events Focus on Non Value-Added Activity To Reduce Lead Time
      • 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
      Typical company VA NVA Original lead time Traditional cost reductions VA NVA Minor improvement VA NVA Major improvement Don’ t make capital investments on improving VAs until the NVAs achieve equilibrium with the VAs ACE waste reduction
    • 19. The Value Stream Map
    • 20. Reducing Length of Stay Team’s Actions Potential Time Savings Total Potential Savings of 1’18” 2 min Taking specimen to lab 30 min Wait to be tasked 30 min Wait to be seen by MD 2 min Triage paper to Reg/MD 5 min Pt waiting to be triaged 2 min RN/tech to take vital signs 2 min RN/tech start blue form 5 min Central Location for Stretchers and Wheelchairs
    • 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
    • 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
    • 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
    • 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
    • 25. Before
    • 26. After
    • 27. MTC Tech Travel To Splint
    • 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”
    • 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!”
    • 30. Lean + Six Sigma SPEED STABILITY & ACCURACY LEAN + SIX SIGMA = A POWERFUL UNION Lean
      • Waste Elimination
      • Standard Work
      • Flow
      • Customer PULL
      Six Sigma
      • Variation Reduction
      • Scrap / Rework Elimination
      • Process Optimization
      • Process Control
    • 31.
      • 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
      Factual Information
    • 32. VOC, VOB and Problem Statement
      • Only 27% Patients reported being “Very Satisfied”.
      • Where do unsatisfactory delays occur?
        • 81 % stated before being taken to a treatment room.
        • 56 % stated before being treated by a physician.
      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)
    • 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
    • 34. Data Collection Cycle Time from Triage to Bed Using Six Sigma tools, we began collecting data on variables in the process. We found that the average waiting time for a patient to be placed in a bed was over 42 minutes!
    • 35. Data Collection ALOS We also found that the Average Length of Stay for our ED patients was 2.5 hours.
    • 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 .
    • 37. Result 1: Triage to ER Bed Old Process New Process Average of 19 Minutes Average of 43 Minutes Over 50% reduction in overall cycle time!
    • 38. Result 2: Average Length of Stay Old Process New Process Variation of 29 Minutes Variation of 87 Minutes Over 60% reduction in overall variation!
    • 39. Result 3: Left Without Being Seen (LWBS) Reduction from 2% to 0.84%! 60% Reduction in LWBS
    • 40. End Notes
      • Before Project:
        • ER was ranked anywhere from 7 to 10 out of the Multi-State region of 17
        • No goals to become the “2 nd to None” ED
        • No formal data collection process to prove where the problems were coming from
        • We knew we had problems, however lacked a clear roadmap
      • After Project:
        • 2 nd to None ED-pushing into national top quartile customer satisfaction ratings
        • Moving to become the benchmark (leading) ED
        • LWBS = $181,800.00 savings
        • Reducing Average Length of Stay to allow for increase of 95 patients per month
        • Medical supplies returned and par level adjustments = $32,923.70
    • 41. End Notes
      • Before Project:
        • ER was ranked anywhere from 7 to 10 out of the Multi-State region of 17
        • No goals to become the “2 nd to None” ED
        • No formal data collection process to prove where the problems were coming from
        • We knew we had problems, however lacked a clear roadmap
      • After Project:
        • 2 nd to None ED-pushing into national top quartile customer satisfaction ratings
        • Moving to become the benchmark (leading) ED
        • LWBS = $181,800.00 savings
        • Reducing Average Length of Stay to allow for increase of 95 patients per month
        • Medical supplies returned and par level adjustments = $32,923.70
    • 42. Questions & Comments