Process Improvement Project


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A project aimed on reducing patient wait time to receive chemotherapy

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  • The University of Michigan healthcare system (UMHS) was selected for the purposes of this project because it is widely accepted as one of the best-in-class healthcare systems in the country. US News and World Report has named UMHS to the "Honor Roll of America's Best Hospitals” for 14 straight years.This meeting re-enforced many of the recommendations we planned to make to the VA Hospital
  • Molly: Make sure you refer to slide 11 for scatterplot graph
  • Molly: Five minutes is NOT part of patient wait time, but time point nurse must spend
  • Molly:Through observations, nurses do not hear when agent was passed throughHelp RN’s prioritize tasks in the most effective manner
  • PSE feels it is vital the VA hospital’s continued success to adopt an electronic tracking system similar to the system used by UMHS. Continual improvement methods such as lean and six sigma are no longer monopolized by the manufacturing industry. If fact Toyotas approach to reducing any waste in the process is widely being used in Healthcare systems across the Country.An Electronic Tracking system would keep all departments in the loop and up to date on any patient, medication or schedule changes. It would also serve as a to gauge the Hospitals improvements and find locate opportunities for improvement.NO WAY TO TRACK OUR IMPROVEMENTS WITHOUT TRACKING
  • Austin: We hope this project will serve the maiden voyage for future relationships between the VA and UM IOE
  • Process Improvement Project

    1. 1. Chemotherapeutic Agent Process Improvement ProjectVeteran’s Affairs Ann Arbor Hospital<br />College of Engineering, University of Michigan<br />Problem Solving Engineering<br />Molly Beggs, Austin Kloske, Brittany Morales,<br />Kyle Valentine, C. Paoro Yin-Blair<br />1<br />
    2. 2. Presentation Agenda<br />2<br />I.<br />II.<br />III.<br />IV.<br />V.<br />VI.<br />
    3. 3. I. Project Definition<br />3<br />
    4. 4. Project Background<br />Team: Problem Solving Engineering (PSE)<br />Client: Veteran’s Affairs (VA) Ann Arbor Healthcare System, Chemotherapy Outpatient Clinic<br />Project Name: Chemotherapeutic Agent Process Improvement Project<br />Three primary areas involved: the Chemotherapy Outpatient Clinic, the Pharmacy, and the Technician Lab<br />4<br />
    5. 5. Project Definition<br />Problem: chemotherapy patients experience long wait times, sometimes up to 8 hours<br />Project goal: minimize patient wait time in chemotherapy outpatient clinic<br />Patient wait time: duration of time from when patient arrives to outpatient clinic to time drug is administered<br />PSE goal: reduce wait time to 30 minutes or less for 80% of patients<br />5<br />
    6. 6. 6<br />Process Overview<br />
    7. 7. II. Summary of Activity and Methods<br />7<br />
    8. 8. Summary of Activity<br />Data Collection:<br />Conducted expert interviews with 5 nurses, 4 pharmacists, and 3 technicians<br />Collected historical data (arrival times and cancellation rates)<br />Gathered relevant chemotherapeutic agent details (i.e. cost, shelf life)<br />Conducted 65 hours of time studies of the process<br />Benchmarked with the University of Michigan Hospital<br />Data Analysis<br />Determined current state<br />Microsoft Excel and Minitab 15 Statistical Software to analyze data<br />Utilized Lean Principles:<br />Process Mapping to identify the current state of the process<br />Cause and Effect Diagrams to identify problem areas for improvement<br />Pareto Analysis to detect areas with the greatest opportunity for improvement<br />Determined feasibility of recommendations and implementation methods<br />8<br />
    9. 9. III. Summary ofData and Analysis<br />9<br />
    10. 10. Current State AnalysisSummary of Total Patient Wait Time<br />10<br />
    11. 11. Current State AnalysisHistorical Data of Patient Arrivals<br />11<br />
    12. 12. Current State AnalysisProcessing Time for Individual Steps<br />12<br />
    13. 13. Benchmarking withUniversity of Michigan Cancer Center<br />Met with Cancer Center Pharmacist at University of Michigan Hospital<br />30 Minute incremental scheduling blocks<br />Chair Scheduling<br />Light signaling system<br />Standardized treatment forms<br />Electronic Tracking System<br />13<br />
    14. 14. IV. Recommendations <br />14<br />
    15. 15. Criteria for Recommendations<br />Reduction of primary quality metric (Total Patient Wait Time)<br />Benchmarking of similar processes<br />Consider employee interest and input<br />Transferability of recommendations to a new location<br />Potential solutions will not add or subtract major resources (facilities, equipment, labor) and have little to no cost<br />Recommendations were ultimately divided into three areas: Chemotherapy Outpatient Clinic, Pharmacy, and Technician Lab<br />15<br />
    16. 16. A. Chemotherapy Outpatient Clinic<br />Standardized Scheduling Procedure<br />Chair Scheduling<br />Importance of Scheduling Document<br />Removal of Clinic’s side of Pass-Way Door<br />16<br />
    17. 17. Recommendation A1: Standardized Scheduling Procedure<br />Description: A standard procedure for RN’s to schedule patients<br />Benefit: Allow RN’s to have an appropriate number of patients per block of time and thus giving patients adequate attention, reduces overall wait time for patients, and helps pharmacy prepare agents <br />Support: Patients often arrive in batches which cause bottlenecks and increase wait time<br />Implementation: Distribute the Standardized Scheduling Procedure work document to all RN’s, education of new procedure<br />Cost: Time spent on education (~ 1 hour)<br />17<br />
    18. 18. Recommendation A2:Chair Scheduling<br />Description: Scheduling patients per chair in the clinic<br />Support: Scatter plot of patient arrival time <br />Benefit: Reduce wait time for chairs, proper allocation of patients per RN, allow for appropriate attention to patients<br />Implementation: Education of procedure to RNs<br />Cost: time spent on education and scheduling<br />18<br />
    19. 19. Recommendation A3: Importance of Scheduling Document<br />Description: A paper document for patients that explains why they need to arrive on time to appointments<br />Support: Patients do not follow scheduling policies without strict enforcement<br />Benefit: Aids the scheduling procedure, because for scheduling to be effective, patients must arrive on time<br />Implementation: Point nurse will include this document in patients initial briefing session and go over it with each patient<br />Cost: Time spent explaining to patients (~ 5 minutes)<br />19<br />
    20. 20. Recommendation A4: Removal of 1 Side of Pass-Way Door<br />Description: Complete removal of door on clinic’s side of pass-through<br />Support: Large variance in delivery time from dumbwaiter to pass-way door and large variance in time from pass-way door to administration of agent<br />Benefit: Reduce wait time for patients<br />Implementation: Facility maintenance will remove the door<br />Cost: Facility maintenance<br />20<br />
    21. 21. B. Pharmacy<br />Standardized Chemotherapy Order Forms<br />Standardized Work Policy<br />Prepare Chemotherapy in Advance<br />Access to CPRS Templates<br />Signal Lights<br />21<br />
    22. 22. Recommendation B1: Standardized Chemotherapy Order Forms<br />Description: Create and implement a set of standardized order forms<br />Forms will be unique to each treatment<br />Easier to fill out patient and dosage information<br />Support: Per pharmacists’ request and UM Benchmarking<br />Benefit: PSE can reasonably estimate an improvement of 5 minutes per order form<br />Implementation: Pharmacists have begun work on new templates, once complete (2-3 weeks) begin use<br />Cost: No cost<br />22<br />
    23. 23. Recommendation B2: Standardized Work Policy<br />Description: Patient files should be completed the evening before the patient is to be seen<br />Currently happens a majority of the time; should be enforced<br />Especially important for Monday’s files<br />Support: The step for pharmacists to complete paperwork has a larger variation when the forms are not completed beforehand<br />Benefits: Uncompleted files take average of 12 minutes to complete the paperwork<br />At least 10 minutes can be removed from patient wait time<br />Saves more time if doctor consent is missing<br />Implementation: Create a policy that pharmacists must complete files the day before patients are expected (immediate implementation)<br />Cost: No Cost<br />23<br />
    24. 24. Recommendation B3: Prepare Chemotherapy in Advance<br />Description: Prepare certain chemotherapeutic agents in advance <br />Support: The total time in the Technician Lab can be removed from the patient’s wait time<br />Benefits: Can decrease patient wait time by 20-30 minutes<br />Implementation: Determine if any chemotherapeutic agents should be made ahead and treat them as preorders (can be implemented as soon as agents are chosen)<br />Cost: Expected costs of common chemotherapeutic agents<br />Assumed 15% cancellation rate<br />Estimated average cost per dose of each chemotherapeutic agent<br />24<br />
    25. 25. Recommendation B4: Access to CPRS Templates <br />Description: Pharmacists/Computer Technicians need access to the CPRS templates<br />Some prescription templates are unclear<br />Only doctors have access to change templates<br />Support: Many instances of confusion between doctors and pharmacists cost up to 30 minutes<br />Benefits: Can save about a half hour of clarification time<br />Implementation: Grant access to CPRS templates (immediate implementation)<br />Cost: None<br />25<br />
    26. 26. Recommendation B5: Signal Lights<br />Description: Place a signal light in the Outpatient Pharmacy with two light switches<br />Support: If phones are busy the Outpatient Pharmacy is not called<br />Benefits: Can reduce an average of 5 minutes for the chemotherapeutic agent to reach the Outpatient Clinic<br />Implementation: Install a light in the outpatient pharmacy and indicator light switches next to the dumbwaiter on both floors<br />Cost: $19.70 for two switches<br />26<br />
    27. 27. C. Technician Lab<br />Tubing and Draining IV Bags in Advance<br />Signal Lights<br />Posted Policies<br />Standard Work Instructions<br />Folder Racks<br />White Board<br />27<br />
    28. 28. Recommendation C1: Tubing & Draining IV Bags in Advance<br />Description: Attach tubing and remove extra solution so IV bag is ready for CA at time of patient arrival<br />Support: Median processing time of 6 minutes<br />Benefit: Shorter lead time, free IV technician<br />Implementation: Write standard work instruction, pharmacists share folders with technicians prior to patient arrival (Next 2-4 weeks)<br />Cost: (0.15)*($4.90)*($0.62) = $0.50 / CA = (Cancelation Rate)*(Tubing Cost)*(Bag Cost)<br />28<br />Drain appropriate amount of fluid.<br />Mark bag and hang in queue.<br />Attach tubing to IV bag<br />Select correct tubing and close drip chamber<br />
    29. 29. Recommendation C2:Signal Lights<br />Description: Replace pharmacy intercom system with ‘Drug Ready’ signal lights<br />Support: CA’s commonly wait up to 15 minutes to be checked<br />Benefit: Reduce chances for Pharmacists to forget announcement or not hear announcement<br />Implementation: Install two new light fixtures above pharmacy desk, install two new light switches in Technician Lab<br />Cost: $28.11 + electrician time<br />29<br />
    30. 30. Recommendation C3: Posted Policies<br />Description: Summarize and post all work policies relating to technician lab<br />Support: Certain policies are currently passed between techs as hearsay (i.e. CA’s that must be produced in chemo hood)<br />Benefit: Less time loss over discussion, Eliminate time loss due to CA’s taking space in chemo queue<br />Implementation: Organize, Outline, Write, Post (Next 2-6 weeks)<br />Cost: Lead Technician Time<br />30<br />
    31. 31. Recommendation C4:Standard Work Instructions<br />Description: Clear descriptions of common tasks (not to replace 797 logs)<br />Support: Current lack of standardized training<br />Benefit: Increase confidence between technicians<br />Implementation: Photograph, write, print, post, review, update, repeat (Next 1-6 weeks)<br />Cost: Lead Technician Time<br />31<br />
    32. 32. Recommendation C5:Wall-Mounted Folder Rack<br />Description: Rack to hold chemo folders in queue<br />Support: Congestion related to larger queues<br />Benefit: More counter space, reduce mixing queue order <br />Implementation: Order, Hang (Next 2 weeks)<br />Cost: $28.68<br />32<br />Pre-makes<br />Preps<br />
    33. 33. Recommendation C6:White Board<br />Description: Wall mounted whiteboard in main IV room (36”x24”)<br />Support: Techs often do not transition between shifts<br />Benefit: Less information would be lost across shifts<br />Implementation: Order and hang white board (Next 2 weeks)<br />Cost: $43.59<br />33<br />
    34. 34. V. New Process and Future State<br />34<br />
    35. 35. Future State of Process<br />35<br />Prior to Patient Arrival<br />Post Patient Arrival<br />
    36. 36. Future StateExpected Patient Wait Time Reduction<br />36<br />Expected distribution<br />Recommendations will reduce expected maximum wait time from 89 minutes to 30 minutes for 80% of patients.<br />Current distribution<br />
    37. 37. 37<br />Project Improvements<br />
    38. 38. Tracking Systems in Lean Healthcare Systems<br />38<br /><ul><li>Continual improvement methods are now a part of Healthcare Systems
    39. 39. Implement an electronic tracking system similar to the system used by UMHS in the near future
    40. 40. All departments would be kept up to date on patient and medication information relative to their appointment times
    41. 41. Gauge improvements and identify wastes</li></li></ul><li>39<br />Thank You!<br />Questions?<br />