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Applying the Lean Methodology for Improved Patient Flow
 

Applying the Lean Methodology for Improved Patient Flow

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Prof David Ben-Tovim, Director Redesigning Care, Flinders Medical Centre and Southern Adelaide Local Health Care Network delivered this presentation at the 6th annual Hospital Bed Management & Patient ...

Prof David Ben-Tovim, Director Redesigning Care, Flinders Medical Centre and Southern Adelaide Local Health Care Network delivered this presentation at the 6th annual Hospital Bed Management & Patient Flow conference 2013 in Melbourne. For more information on the annual event, please visit the conference website: http://bit.ly/1f3Pp03

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    Applying the Lean Methodology for Improved Patient Flow Applying the Lean Methodology for Improved Patient Flow Presentation Transcript

    • Applying Lean Methodology for Improved Patient Flow Prof. David I Ben-Tovim Redesigning Care Flinders Medical Centre Southern Adelaide Local Health Network
    • New wing St Thomas’s Hospital 1842
    • American Civil War Hospital
    • Withington Hosptial 1981
    • nvsier Nursing Med Managerial The basic insight Patients make horizontal journeys through vertical organisations Div surgery Div Med Why Lean? But Hospitals are organised vertically
    • Running Board Commutators Front axle Radiator Gas Tank Rear axle Assembly Line R A W M A T E RI A L S Flow production - raw materials come in one end, get transformed step by step along a continuously moving production line until a motor car comes out the other end Flow production (Model T style)
    • Mass Production > Flow production does not work when you need variety. So Ford moved to mass production. > In mass production, production is organised by function in production villages. > A production village is a group of people in a physical location, a cluster of buildings, machines, etc with only one specialised function > And now you start to have the problem of co- ordination
    • Mass Production Annealing Stamping Painting Washing Welding Brazing Assembly Line Mass production
    • Spaghetti World Assembly Components Piece Parts Process
    • Lean Thinking • Is basically a whole set of strategies to improve the scheduling and co-ordination of complicated design and production processes • And since it is the people who do the work that are ‘up close and personal’ with the effects of poor scheduling and co-ordination, it makes sense to involve them at every step. • Using a well-structured implementation methodology
    • P D A S 1 2 3 4 5 Diagnostic Phase ScopeEmbed Sustain Improve Assess Impact Intervention Phase P D A S P D A S P D A S P D A S Lean principles Problem Real Problem
    • • Specify value from the standpoint of your customer • Identify the value stream for each product family • Make the product flow and eliminate waste • So the customer can pull • As you manage toward perfection
    • The Problem.  Evidence of impact on primary purpose  Problem or Concern? Define Scope  First and last step in the process of interest. Diagnose  Map o Track  Look for value stream  Define Metrics-Patient, Staff, Institutional views The real problem  Analyse Redesign Possibility of counter measures to stabilise situation-but balance short and long term outcomes  First experiment ─PDSA o Second Experiment─PDSA  etc  Identify work standards +/- standard work Evaluate  Quantitative and qualitative measures Embed and Sustain  Confirm work standards +/- standard work  New way is the way we do it round here Gant chart- who, what, when, reports, timing, etc Signed and dated………..
    • RGH; All (Elective+emergency) 0 2000 4000 6000 8000 10000 12000 14000 16000 Jul-08 Oct-08 Jan-09 Apr-09 Jul-09 Oct-09 OBD Actual OBD Expected OBD
    • Hospital crowded and over- budget, patients staying too long, Evidence of impact Transfers from other hospitals refused because over-crowded- impact both within rgh and FMC Scope Buildauthorisati on and permission A3
    • Hospital crowded and over- budget, patients staying too long, Evidence of impact Transfers from other hospitals refused because over-crowded- impact both within rgh and FMC Diagnose Build authorisation and permission A3 Scope Division Medicine- arrival through to discharge
    • Which patient groups do we choose to send to RGH? Who is involved? Is there a standard process for preparation at FMC? Who is involved? How much work up is done? Are they always accepted? What/How transport is used? Handover Pt’s from FMC Early am transfers Four Required Gen Med Resp Card Triage nse S/C night ED Med staff Med Reg Spec Reg DFC in am ED CSC in am AAU CSC Nse Checklist Med Checklist DFC Med Reg Spec Reg Most No -Escalation ring night before -MRO capacity -DFC checks with RGH B/manager - Some refuse to go. SAAS - DFC How- nse Wriiten Medical : Mob phone When: 0800-0830 Who gives: Night Med reg GMA, Spec reg  Spec RGH. Pt’s from FMC Day Transfers Two Req ( total Six) -Overnight Gen med adm -Short Long -5-9pm cohort AAU CSC AAU consultant Nse Checklist Med Checklist CSC Primary Nse RMO Most No - 0855: CSC checks with RGH B/manager -Escalation at 0855 -MRO capacity -Some refuse to go. RGH transporter SAAS 2nd choice How- nse Wriiten Medical : Mob phone When: 0900-1300 Who gives: AAU RMO GMA, Rehab Stroke/Neuro Elect Ortho Funct decline Fract NOF Rehab CPC team, Rhab Reg; Consultant Post referral assessed < 24hrs, 3 outcomes -Accepted -For Review -Declined Rehab CPC. Reg; Stroke Cons: CA Most No Also Triage to other services -RITHOM, Day Rehab, REACT , GEM + other SAAS, access cab, RGH transporter. Assessment form by CPC/triage is the Handover. Casenotes come with pt. No Dr to Dr H/O Other pt’s from FMC In hrs Urology Urol Med No N/A Some Yes SAAS - DFC -Ward Clerk FMC Urol Med to RGH Urol med timely No nursing letter. Issues at this stage? Identifying enough suitable patients Time consuming If spec rad req will not be able to send MRO an issue for all beds SAAS excellent
    • Hospital crowded and over- budget, patients staying too long, Evidence of impact Transfers from other hospitals refused because over-crowded- impact both within rgh and FMC Diagnose Two major value streams Outliers, and Care Progression Build authorisation and permission A3 Scope Division Medicine- arrival through to discharge
    • Picturefield Place images in their own white space – image does not have to be this size or always sit here. Plan Repat 2: Redesign for the Patient. What is the problem: Lack of visibility of clinical and non- clinical processes to understand the timing of the patient journey. Longer LOS against benchmark. Patients are not exiting RGH in a timely manner, resulting in the hospital census being 105% occupancy. High % of outliers which is restricting access for other patients. Unless processes are visible, the opportunities are unable to be maximised to improve timeliness of patient Journey, reduce variation and ensure effective deployment of resources. Current State: RGH working at 105% occupancy over winter 2010 Routine transfers numbers …% below target 36 % of Acute beds are Blue Dots pt’s, many with barriers, Social work struggling Avg of 14 unfunded flex beds open during winter. 15% of all OBD’s are Maintenance Care ( comp with 6% for most other hospitals) LOS data- day of admission ALOS Transferred patients Matched cohort LOS 36 hrs to 48 hrs longer than FMC Weekend D/C rate is 15% ( target is 29%) Follow up/ Evaluation/Outcomes Recommendations/Countermeasures Aims: To maximise RGH resources to continue to deliver high quality and timely patient care to the growing number of patient requiring access. October 2010 •Big Picture Mapping occurred on the 13th October: 55 attendees, all disciplines well represented. •Four obvious area of opportunities •Oultiers: Discharge Planning: Take Roster: Authors: Lauri O’Brien, Pamela Everingham. David Ben-Tovim Jan 201 Next Steps •Governance structure: Steering Group Met 8th Dec 2010. •Two Workgroups being established. Outlier Management & Discharge Processes. Weekly meetings to commence mid Feb 2011. •Training Day, 1st March. To include steering group, work groups and ward staff
    • Hospital crowded and over- budget, patients staying too long, Evidence of impact Transfers from other hospitals refused because over-crowded- impact both within rgh and FMC Diagnose Two major value streams Outliers, and Care Progression A3 Scope Division Medicine- arrival through to discharge Ward Round redesign Journey Board introduced and used Allied health Unit based and major Wards restructured Real Problem Major redesign required for allied health practices
    • Key: Needs / Referred  Seen  Unsuit for D/C  F/U for D/C  GTG  c se Bed Patient Team Pre admit profile Health Referrals LOS EDD Discharge Destination Waiting For PSY PT OT SW DN SP Other 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
    • Repat 2: Redesign for Patients. ALLIED HEALTH WORK GROUP PROGRESS REPORT What is the problem: 4 Broad Issues facing Allied Health have been identified: 1/ How do we allocate ourselves to services (wards or units?) 2/ How do we manage our workload within existing staffing resources and provide cover for planned/unplanned leave? 3/How do we redesign our processes to meet changing demand 4/ How do we meet future demand? (how does allied health work in the medical ward reconfiguration) Next Steps - Repeat Self tracking - Establish Hub Boards - Establish staff identification process - AHRO modification - Identify next 3 improvement projects Authors: Karen Brown, Steve Basso, Mel Lewis, Lauri O’Brien 1st Feb 2013 Issue Action Need to identify AH structure and function issues •Work group formed to manage ongoing improvement strategies- meet monthly and report to AH leadership group. Need to gather accurate data on current work practices- tracking •Initial tracking late 2011. Re-tracking planned 14th February Need to identify consumer satisfaction levels • Survey results presented to Consumer council Need to review current leave patterns, polices and practices •Standard leave management guidelines accepted and adopted across all AH depts Need to establish clear referral guidelines • revised referral guidelines distributed •Oacis use guidelines completed & distributed Need to establish clear assessment priority guidelines • amended guidelines distributed Time and efficiency of clinical handover processes Need to identify AH best fit with ward/ medical team reconfiguration process 26% reduction in clinical handovers achieved Workgroup established to manage 3 initial improvements from list of 40+ identified by AH staff survey Interventions Progress Allied Health staff working in acute wards all unit based. Communication and function issues post reconfiguration reviewed. Staff identification and client contact processes Fully implemented Survey about options for clearer staff identification (from staff and patient surveys) Hub Board designed and to be installed in wards in late February. Leave cover processes Completed Clinical handovers Reduced internal handovers but to modify handover formats and processes in line with hospital clinical handover committee Referrals & referral guidelines Completed Allied Health Referral Officer role review Tracking completed, staff survey completed, decision to modify role into AH team leader with more relevant functions
    • Hospital crowded and over- budget, patients staying too long, Evidence of impact Transfers from other hospitals refused because over-crowded- impact both within rgh and FMC Diagnose Two major value streams Outliers, and Care Progression A3 Scope Division Medicine- arrival through to discharge Ward Round redesign Journey Board introduced and used Allied health Unit based and major Wards restructured Real Problem Major redesign required for allied health practices Program extended to Urology
    • Plans: • Theatre schedules & Emergency theatre review & analysis - possible Urology surgery 5 days/week- possible ‘emergency’ theatre list- Re-scheduled some Urology lists to give better cover across week. • Review registrar roles to ‘even up’ work load- Developed new guidelines, to be micro managed and formally reported on fortnightly • Review surgical booking format/ processes- Developed initial electronic format for trial from February • Review current orientation and information formats and processes for patients and staff- new information/ orientation packages developed and implemented from February Repat 2: Redesign for the Patient. Surgical Services Urology Workgroup Progress Report What is the problem: Surgical Booking policies and practices leading to delays, inefficiencies, problems with bed management and patient complaints Follow up/ Evaluation: • Assess outcomes from PAC interventions • Monthly updates to BPM session attendees about findings, actions and outcomes • Future Directions session March 2013. Authors: Steve Basso, Lauri O’Brien, Viv Ma Feb 1st 2013 Issue Intervention & Outcomes Progress 1.1 delays and perceived inefficiencies in some surgical service provisions- Urology Leadership group- fortnightly meeting 1.2 uncertain about extent of or specific nature of current perceived problems- Urology Big Picture Mapping process 27th July- 40 attendees and 3 facilitators.- number of issues agreed about. 1.3 need to gather appropriate data to help identify current state and inform issues identification Significant data gathering, tracking RMO/registrars, target based capacity and demand Theatre utilisation data collated. 1.4 develop work groups for issues identified at Big Picture Mapping and from Leadership group Work group established- fortnightly work group meetings 1.5 apparent capacity and demand mismatch Epidemiology unit at FMC analysed comprehensive target-based demand and activity data 1.6 workload for medical staff Tracking ‘junior’ medical officers Aug 7trh and Registrars Oct 15th. Business cases for increased staffing. 1.7 medical consent and patient information inconsistencies Aligned with standard state systems and processes 1.8 Pre anaesthetic clinic function Review of current structure and functions- see next section Current State Diagnostic phase with ongoing reviews and assessments. Some Interventions already developed and introduced Pre Anaesthetic Clinic (PAC) and related processes: Work group Diagnostics & Interventions • Urine/blood test recording/reviewing- developed short term process in Ward 8 RMO room. Developed electronic options to trial in Feb • Number of PAC visits- reducing from 2 to 1 visit. Working more efficiently • Surgery delays on day of surgery- increased number of patients admitted at start of session. Improved theatre session cancellations. Develop antibiotic scheduling guidelines for RMO. Trial guidelines being completed • Day of surgery patient information- draft information developed. Trial draft in PAC • PAC function and staff role information- developed draft of guidelines for all PAC staff. Trail draft • Aboriginal & Torres Strait islanders – establish formal, automated referrals/ communication with Karpa Ngarratendi- draft automated notifications processes being developed- for application in all surgical units • Alternatives to in hospital admissions pre surgery- identify strategies for avoiding prolonged in patient stays for pre-surgery work-ups. Incorporate into booking & PAC processes
    • Outcomes Process Outcomes • Improved structure and format of ward rounds • Formal discharge planning meeting structure • Better use Journey Boards • Easy identification of Team Leaders at unit level • Three-times weekly outlier discussions between unit CSC • etc
    • Outcomes Patient/Unit level outcomes 14% improvement in Relative [Length] of Stay Index –from 1.07 (ie well above national values) to 0.92 (well below) 46% decrease outliers 32% decrease in bed-use by Long-stay outliers ( 12 bed capacity increase) 15% increase medical separations, and 92% decrease in ‘escalation”= refusal to accept transfers/admissions because full.
    • 3 4 5 6 7 Jan-2010 Mar-2010 May-2010 Jul-2010 Sep-2010 Nov-2010 Jan-2011 Mar-2011 May-2011 Jul-2011 Sep-2011 Nov-2011 Jan-2012 Mar-2012 May-2012 Jul-2012 Sep-2012 Nov-2012 Jan-2013 RGH; ALOS of UNPLANNED separations; wards 1,2,5,6,8,CC,IC,SH combined
    • 0 20 40 60 80 100 120 140 160 180 Jan-2010 Mar-2010 May-2010 Jul-2010 Sep-2010 Nov-2010 Jan-2011 Mar-2011 May-2011 Jul-2011 Sep-2011 Nov-2011 Jan-2012 Mar-2012 May-2012 Jul-2012 Sep-2012 Nov-2012 Jan-2013 RGH; number of UNPLANNED separations; transferred in; wards 1,2,5,6,8,CC,IC,SH combined