Dr Dick Mitchell Piedmont Fayette Hospital

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Dr Dick Mitchell Piedmont Fayette Hospital

  1. 1. Taking on the E.D.• What was the burning platform: – Long Time In Department (TID) – Single digit patient satisfaction – High LWBS – Doctors “cherry picking” patients• Plan A: – Reorganize Physical layout – Add RN for triage in reception area – Split into two teams, Acute and Moderate – Add Results Area Pending room (RAP room) to decompress exam rooms• Why didn’t all this work?• Plan B: – Re-evaluation of the process – Implement plan A• Lessons learned the hard way
  2. 2. 6.00 150.00 140.005.00 130.004.00 120.003.00 110.002.00 100.001.00 90.000.00 80.00 May- Jul-06 Sep- Nov- Jan- Mar- May- Jul-07 Sep- Nov- Jan- Mar- May- Jul-08 Sep- Nov- Jan- Mar- May- Jul-09 Sep- Nov- Jan- 06 06 06 07 07 07 07 07 08 08 08 08 08 09 09 09 09 09 10 TID discharged ave. daily census
  3. 3. Before Picture of Process Es co rts Pt. to ro om
  4. 4. Future State
  5. 5. Team in Action!!
  6. 6. PLEASE HELP TO KEEP THIS AREA IN ORDER Return items to the proper place. If you don’t know where they go, leave them in the RESTOCK BIN.BEFORE AFTER
  7. 7. ACUTE MD AT MD M PA/3RD MD Total patients 110 Ideal Prvdr 2.2 2.5 2 for day Prod. Starting Ideal TID all Census at 30 pts in 3.5 Midnight rooms calculated Calculated Calculated Max Exam ActualTime Arrivals in Patients calculated census end ACUTE Theoretical RNs Exam rms rooms Actual RN Exam Calculatedof day each Hour in rooms departures hr. MD MAT MD PA/3RD MD TID needed needed avail. staffing rooms Pts in W R 1 3.2 26.0 4.7 30.0 1 1 4.4 10 28 28 9 26 4 2 2.5 26.0 2.2 28.5 1 4.6 10 28 28 9 26 2 3 1.7 26.0 2.2 28.7 1 4.7 10 28 28 9 26 3 4 1.6 26.0 2.2 28.2 1 4.5 10 28 28 9 26 2 5 1.5 26.0 2.2 27.6 4.2 10 28 28 9 26 2 6 1.8 26.0 2.2 26.9 1 3.9 10 28 28 9 26 1 7 1.6 26.0 2.2 26.5 1 3.7 10 28 28 9 26 0 8 2.2 25.9 2.2 25.9 1 3.5 9 26 28 9 26 0 9 4.1 25.9 2.2 25.9 1 3.5 9 26 28 9 26 0 10 5.3 26.0 4.7 27.8 1 1 3.9 10 28 28 9 26 2 11 5.7 26.0 4.7 28.4 1 1 4.0 10 28 28 9 26 2 12 7.0 28.0 6.7 29.4 1 1 1 3.7 10 28 28 10 28 1 13 6.4 28.0 6.7 29.7 1 1 1 3.8 10 28 28 11 28 2 14 5.7 28.0 6.7 29.4 1 1 1 3.7 10 28 28 11 28 1 15 5.3 28.0 6.7 28.4 1 1 1 3.6 10 28 28 11 28 0 16 5.6 27.0 6.7 27.0 1 1 3.5 10 28 28 11 28 0 17 6.0 25.9 6.7 25.9 1 1 1 3.5 9 26 28 12 28 0 18 6.4 25.2 6.7 25.2 1 1 3.5 9 26 28 12 28 0 19 6.8 24.9 6.7 24.9 1 1 1 3.5 9 26 28 10 28 0 20 6.9 25.0 6.7 25.0 1 1 1 3.5 9 26 28 10 28 0 21 6.6 25.2 6.7 25.2 1 1 1 3.5 9 26 28 10 28 0 22 6.3 25.1 6.7 25.1 1 1 1 3.5 9 26 28 10 28 0 23 5.6 24.7 6.7 24.7 1 1 1 3.5 9 26 28 10 28 0 24 4.2 23.7 4.7 23.7 1 1 3.5 9 26 28 10 28 0 230 237 110 TOTAL PATIENTS TID FOR DAY 3.8
  8. 8. CAPABILITY V DEMAND 9 8 7 MUDA (EXCESS) 6PATIENTS/HOUR 5 4 MURI (OVERBURDEN) 3 2 CAPABILITY = PATIENTS THAT COULD BE SEEN IN AN HOUR DEMAND = PATIENTS ARRIVING IN AN HOUR 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 TIME OF DAY
  9. 9. ACUTE MD AT MD M PA/3RD MD Total patients 130 Ideal Prvdr 2.2 2.5 2 for day Prod. Starting Ideal TID all Census at 30 pts in 3.5 Midnight rooms calculated Calculated Calculated Max Exam ActualTime Arrivals in Patients calculated census end ACUTE Theoretical RNs Exam rms rooms Actual RN Exam Calculatedof day each Hour in rooms departures hr. MD MAT MD PA/3RD MD TID needed needed avail. staffing rooms Pts in W R 1 3.7 26.0 4.7 30.0 1 1 4.4 10 28 28 9 26 4 2 2.9 26.0 2.2 29.0 1 4.9 10 28 28 9 26 3 3 2.0 26.0 2.2 29.8 1 5.2 10 28 28 9 26 4 4 1.9 26.0 2.2 29.5 1 5.1 10 28 28 9 26 4 5 1.8 26.0 2.2 29.2 1 5.0 10 28 28 9 26 3 6 2.2 26.0 2.2 28.8 1 4.8 10 28 28 9 26 3 7 1.9 26.0 2.2 28.7 1 4.7 10 28 28 9 26 3 8 2.6 26.0 2.2 28.4 1 4.6 10 28 28 9 26 2 9 4.8 26.0 2.2 28.8 1 4.8 10 28 28 9 26 3 10 6.3 26.0 4.7 31.4 1 1 4.7 10 28 28 9 26 5 11 6.8 26.0 4.7 33.0 1 1 5.0 10 28 28 9 26 7 12 8.2 28.0 6.7 35.1 1 1 1 4.6 10 28 28 10 28 7 13 7.5 28.0 6.7 36.6 1 1 1 4.8 10 28 28 11 28 9 14 6.8 28.0 6.7 37.4 1 1 1 4.9 10 28 28 11 28 9 15 6.3 28.0 6.7 37.5 1 1 1 4.9 10 28 28 11 28 10 16 6.7 28.0 6.7 37.1 1 1 1 4.9 10 28 28 11 28 9 17 7.1 28.0 6.7 37.1 1 1 1 4.9 10 28 28 12 28 9 18 7.5 28.0 6.7 37.4 1 1 1 4.9 10 28 28 12 28 9 19 8.0 28.0 6.7 38.3 1 1 1 5.0 10 28 28 10 28 10 20 8.1 28.0 6.7 39.6 1 1 1 5.2 10 28 28 10 28 12 21 7.8 28.0 6.7 41.0 1 1 1 5.4 10 28 28 10 28 13 22 7.5 28.0 6.7 42.2 1 1 1 5.6 10 28 28 10 28 14 23 6.7 28.0 6.7 42.9 1 1 1 5.7 10 28 28 10 28 15 24 5.0 28.0 4.7 42.9 1 1 6.7 10 28 28 10 28 15 240 237 130 TOTAL PATIENTS TID FOR DAY 5.0
  10. 10. CAPABILITY V DEMAND 9 8 7 MUDA (EXCESS) 6PATIENTS/HOUR 5 4 MURI (OVERBURDEN) 3 2 CAPABILITY = PATIENTS THAT COULD BE SEEN IN AN HOUR DEMAND = PATIENTS ARRIVING IN AN HOUR 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 TIME OF DAY
  11. 11. CAPABILITY V DEMAND 9 8 7 MUDA (EXCESS) 6PATIENTS/HOUR 5 4 MURI (OVERBURDEN) 3 2 CAPABILITY = PATIENTS THAT COULD BE SEEN IN AN HOUR DEMAND = PATIENTS ARRIVING IN AN HOUR 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 TIME OF DAY
  12. 12. ACUTE MD MAT MD FST TRK MD PA Total patients 130 Ideal Prvdr 2 2.2 3.5 1.5 for day Prod. Starting Census at 30 Ideal TID all 3 Midnight pts in roomsTime of Historical calculated Calculated Calculated Max Exam Actualday(hour arrival Arrivals in Patients calculated census end Theoretical RNs Exam rms rooms Actual RN Exam Calculatedends at) pattern each Hour in rooms departures hr. ACUTE MD MAT MD FST TRK MD PA/3RD MD TID needed needed avail. staffing rooms Pts in W R 1 3.8 3.7 28.0 4.2 30.0 1 1 3.5 10 28 28 11 28 2 2 3 2.9 28.0 4.2 29.5 1 1 3.4 10 28 28 11 28 2 3 2 2.0 26.0 4.2 28.3 1 1 3.5 10 28 28 9 26 2 4 1.9 1.9 26.0 2.0 26.0 1 3.0 10 28 28 9 26 0 5 1.8 1.8 18.0 2.0 25.9 1 6.9 9 26 28 7 18 8 6 2.2 2.2 18.0 2.0 25.7 1 6.8 9 26 28 7 18 8 7 1.9 1.9 18.0 2.0 25.8 1 6.9 9 26 28 7 18 8 8 2.7 2.6 18.0 2.0 25.7 1 6.8 9 26 28 7 18 8 9 4.9 4.8 26.3 2.0 26.3 1 3.0 10 28 28 10 28 0 10 6.4 6.3 28.0 4.2 29.1 1 1 3.3 10 28 28 10 28 1 11 6.9 6.8 28.0 9.2 31.2 1 1 1 1 3.3 10 28 28 11 28 3 12 8.4 8.2 28.0 9.2 28.8 1 1 1 1 3.1 10 28 28 11 28 1 13 7.7 7.5 27.8 9.2 27.8 1 1 1 1 3.0 10 28 28 13 28 0 14 6.9 6.8 24.0 8.5 26.1 1 1 1 1 3.3 10 24 24 13 24 2 15 6.4 6.3 24.0 8.5 24.5 1 1 1 1 3.1 10 24 24 13 24 0 16 6.8 6.7 22.3 8.5 22.3 1 1 1 1 3.0 9 24 24 13 24 0 17 7.2 7.1 20.5 8.5 20.5 1 1 1 1 3.0 8 22 24 13 24 0 18 7.7 7.5 19.1 8.5 19.1 1 1 1 1 3.0 8 22 24 13 24 0 19 8.2 8.0 18.2 8.5 18.2 1 1 1 1 3.0 8 22 24 13 24 0 20 8.3 8.1 17.8 8.5 17.8 1 1 1 1 3.0 7 18 24 13 24 0 21 8 7.8 17.5 5.0 17.5 1 1 1 3.0 7 18 24 13 24 0 22 7.6 7.5 20.4 4.2 20.4 1 1 3.0 8 22 24 13 24 0 23 6.8 6.7 23.6 6.4 23.6 1 2 3.0 9 24 24 13 24 0 24 5.1 5.0 23.9 6.4 23.9 1 2 3.0 9 24 24 13 24 0 219 266 130 TOTAL PATIENTS TID FOR DAY 3.7
  13. 13. CAPABILITY V DEMAND 10 9 8 MUDA (EXCESS) 7 6PATIENTS/HOUR 5 4 MURI (OVERBURDEN) 3 2 CAPABILITY = PATIENTS THAT COULD BE SEEN IN AN HOUR DEMAND = PATIENTS ARRIVING IN AN HOUR 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 TIME OF DAY
  14. 14. average provider acceptable wait production from ED time for service 0.5 DATA 2.21 fraction in that LW BS LIKELYHOOD wait time 0.75 MEASURE 0.33 Actual number total providers needed calculated wait time withTime of Adjusted providers from ED to meet above actual providers from ED probability ofday arrivals DATA perameters DATA (hours) LW BS # LW BS 1 3.7 2 3 0.69 0.00 0.0 2 2.9 2 3 0.34 0.00 0.0 3 2.0 2 2 0.11 0.00 0.0 4 1.9 1 2 1.54 0.00 0.0 5 1.8 1 2 1.34 0.00 0.0 6 2.2 1 2 2.16 0.00 0.0 7 1.9 1 2 1.54 0.00 0.0 8 2.6 1 2 3.04 0.05 0.1 9 4.8 1 3 4.15 0.18 0.9 10 6.3 2 4 1.77 0.10 0.6 11 6.8 4 4 0.21 0.00 0.0 12 8.2 4 5 0.42 0.00 0.0 13 7.5 4 5 0.31 0.00 0.0 14 6.8 4 4 0.21 0.00 0.0 15 6.3 4 4 0.15 0.00 0.0 16 6.7 4 4 0.20 0.00 0.0 17 7.1 4 4 0.24 0.00 0.0 18 7.5 4 5 0.31 0.00 0.0 19 8.0 4 5 0.39 0.00 0.0 20 8.1 4 5 0.40 0.00 0.0 21 7.8 3 5 0.97 0.05 0.4 22 7.5 2 5 1.94 0.13 1.0 23 6.7 3 4 0.71 0.00 0.0 24 5.0 3 4 0.29 0.00 0.0 130 Total patients per day 3.0 LW BS
  15. 15. 6.50 TID DISCHARGED PATIENTS6.00 TEAM PROCESS 3/25 EXPAND WEEKEND COVERAGE 8/1 EXPRESS TRACK 10/45.505.004.504.003.503.002.502.00 3/1/09 4/1/09 5/1/09 6/1/09 7/1/09 8/1/09 9/1/09 10/1/09 11/1/09 12/1/09 1/1/10 2/1/10 3/1/10 TID RUNNING 30 DAY RUNNING 7 DAY GOAL
  16. 16. 6.005.004.003.00 TID BEFORE2.00 TID AFTER TEAMS1.000.00 1 2 3 4 5 6 7 8 9 10 11 H. D D D D D D D D D SC D D M M M M M M M M M M M DI D TI
  17. 17. 8.007.006.005.004.00 MD 5 TARGET3.002.001.000.00 3/1/09 3/29/0 4/26/0 5/24/0 6/21/0 7/19/0 8/16/0 9/13/0 10/11/ 11/8/0 12/6/0 1/3/10 1/31/1 2/28/1 3/28/1 4/25/1 9 9 9 9 9 9 9 09 9 9 0 0 0 0
  18. 18. 8.007.006.005.00 MD 44.00 TARGET3.002.001.000.00 3/1/09 3/29/0 4/26/0 5/24/0 6/21/0 7/19/0 8/16/0 9/13/0 10/11/ 11/8/0 12/6/0 1/3/10 1/31/1 2/28/1 3/28/1 4/25/1 9 9 9 9 9 9 9 09 9 9 0 0 0 0
  19. 19. 6.50 TID DISCHARGED PATIENTS6.00 TEAM PROCESS 3/25 EXPAND WEEKEND COVERAGE 8/1 EXPRESS TRACK 10/45.505.004.504.003.503.002.502.00 3/1/09 4/1/09 5/1/09 6/1/09 7/1/09 8/1/09 9/1/09 10/1/09 11/1/09 12/1/09 1/1/10 2/1/10 3/1/10 TID RUNNING 30 DAY RUNNING 7 DAY GOAL
  20. 20. WHAT HAVE WE LEARNED,WHAT IS THE TAKE HOME?
  21. 21. LEAN IS A LONG TERMENDEAVOR, NOT A QUICK FIX
  22. 22. THE MACHINE DRIVING THE E.D. IS THE DOC, NOT THE EXAM ROOM
  23. 23. INTENSIVE LEADERSHIPINVOLVEMENT AND LONG TERM FOLLOW UP IS THE KEY
  24. 24. DON’T BE AT THE MERCY OF STAFFING
  25. 25. DON’T FORGET THE NIGHT SHIFT
  26. 26. PRESENT DATA IN A SIMPLE, UNDERSTANDABLE AND MEANINGFUL WAY CAPABILITY V DEMAND 9 8 7 MUDA (EXCESS) 6 PATIENTS/HOUR 5 4 MURI (OVERBURDEN) 3 2 CAPABILITY = PATIENTS THAT COULD BE SEEN IN AN HOUR DEMAND = PATIENTS ARRIVING IN AN HOUR 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 TIME OF DAY
  27. 27. USE MEASURE OF SUCCESSTHAT IS IN THE CONTROL OF THE DEPARTMENT 6.50 TID DISCHARGED PATIENTS 6.00 TEAM PROCESS 3/25 EXPAND WEEKEND COVERAGE 8/1 EXPRESS TRACK 10/4 5.50 5.00 4.50 4.00 3.50 3.00 2.50 2.00 3/1/09 4/1/09 5/1/09 6/1/09 7/1/09 8/1/09 9/1/09 10/1/09 11/1/09 12/1/09 1/1/10 2/1/10 3/1/10 TID RUNNING 30 DAY RUNNING 7 DAY GOAL
  28. 28. SOLUTIONS ARE EASY,SUSTAINMENT IS HARD
  29. 29. DON’T BE SUCKED INTO ANAREA IN TURMOIL OR THAT DOESN’T HAVE STABLE LEADERSHIP
  30. 30. Nobody loses their job because of lean implementation Except when you can’t get on the bus with the rest of the folks.• Permanent ED Director had to make appropriate staffing decisions• MD group was unable to provide Docs who could work in the new environment and continued to fill the schedule with “warm Bodies”• Executive staff of the 4 hospital system sends out Request for Proposals to ED MD groups.• Present ED Physician group loses its contract and will be replaced June 1.
  31. 31. 10 lessons learned1. Lean is long term2. The machine driving the ED is the Doc3. You need intensive leadership involvement4. Don’t be at the mercy of staffing5. Don’t forget the night shift
  32. 32. 10 lessons learned6. Present data in a simple and meaningful way7. Use measures of success that are in the control of the department8. Solutions are easy, Sustainment is hard9. Don’t be sucked into an area in turmoil without stable leadership10. Nobody (who can get with the program) looses their job over a lean implementation.
  33. 33. Contact me for any questions: Dick Mitchell M.D. dick.mitchell@co1c.com

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