Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
All rights reserved to Focused Management Ltd. ©2013

1

ENHANCING THE PERFORMANCE OF
PUBLIC HEALTHCARE SYSTEMS:
ACHIEVING...
All rights reserved to Focused Management Ltd. ©2013

The Challenge:
coping with the “scissors” reality

$

Needs

Budgets...
All rights reserved to Focused Management Ltd. ©2013

Here is Edward Bear,
coming downstairs now,
bump, bump, bump,
on the...
All rights reserved to Focused Management Ltd. ©2013

4

Example results
• Assuta Tel-Aviv hospital (old site)
• 20% more ...
All rights reserved to Focused Management Ltd. ©2013

The GOAL
• The GOAL of not-for-profit organizations
• Determined by ...
All rights reserved to Focused Management Ltd. ©2013

Value drivers
Any topic that can significantly increase the value of...
All rights reserved to Focused Management Ltd. ©2013

The complex hospital environment
Emergency
Room

Outpatient
clinics
...
All rights reserved to Focused Management Ltd. ©2013

8

Maybe we need a good comprehensive
model to resolve the complexit...
All rights reserved to Focused Management Ltd. ©2013

Maybe we need some decent I.T.
solutions to resolve the complexity?
...
All rights reserved to Focused Management Ltd. ©2013

Maybe we need complete decoupling
(treat each unit independently)?

...
All rights reserved to Focused Management Ltd. ©2013

What we need is focus

Emergency
Room

Operating
Room
Hospital
speci...
All rights reserved to Focused Management Ltd. ©2013

Focus

Emergency
Room

Operating
Room
Hospital
specific
issue/s
(e.g...
All rights reserved to Focused Management Ltd. ©2013

The Emergency Room (ER aka ED)
Improvement TARGETS:
• Cutting respon...
All rights reserved to Focused Management Ltd. ©2013

Using the Theory of Constraints (TOC)
approach
A constraint
• Any fa...
All rights reserved to Focused Management Ltd. ©2013

A resource constraint
Market
demand: 300
patients/month

Incoming pa...
All rights reserved to Focused Management Ltd. ©2013

Examples of resource constraints
Potential bottlenecks in organizati...
All rights reserved to Focused Management Ltd. ©2013

Bottleneck management
ER physicians are the bottleneck
Requirement
•...
All rights reserved to Focused Management Ltd. ©2013

Increasing bottleneck’s efficiency
• Cutting bottleneck’s “garbage t...
All rights reserved to Focused Management Ltd. ©2013

Reducing bottleneck’s “garbage time”:
Before

In-effective
Effective...
All rights reserved to Focused Management Ltd. ©2013

Reducing bottleneck’s “garbage time”:
After

In-effective
time
Effec...
All rights reserved to Focused Management Ltd. ©2013

Reducing ER physicians’ “garbage
time”
Waiting for
consultants

% ga...
All rights reserved to Focused Management Ltd. ©2013

Reducing lead times in the ER
• Complete kit forms for consultants (...
All rights reserved to Focused Management Ltd. ©2013

Subordination – OFFLOADING the
bottleneck
Offload – relieving the bo...
All rights reserved to Focused Management Ltd. ©2013

Offloading the ER bottleneck
• Offloading physicians
• Phlebotomists...
All rights reserved to Focused Management Ltd. ©2013

The “traffic lights” system in the ER
• Setting the Due-date (e.g. 4...
All rights reserved to Focused Management Ltd. ©2013

Monthly Pareto analysis of Red/Black
occurrences
Neurochirurgy
consu...
All rights reserved to Focused Management Ltd. ©2013

Focus

Emergency
Room

Operating
Room
Hospital
specific
issue/s
(e.g...
All rights reserved to Focused Management Ltd. ©2013

Synchronization of ER and internal
medicine wards
The problem:
• ER ...
All rights reserved to Focused Management Ltd. ©2013

Distribution of arrivals to ER of
patients [admitted to internal war...
All rights reserved to Focused Management Ltd. ©2013

Distribution of internal wards
discharges
Distribution of Internal W...
All rights reserved to Focused Management Ltd. ©2013

Medical admissions to internal wards –
only 18% during day shift
Dis...
All rights reserved to Focused Management Ltd. ©2013

Synchronization of ER and internal
medicine wards – initial directiv...
All rights reserved to Focused Management Ltd. ©2013

33

Define the goal of the internal ward
• Maximizing the throughput...
All rights reserved to Focused Management Ltd. ©2013

Define performance measures
• Throughput
• Number of patients treate...
All rights reserved to Focused Management Ltd. ©2013

35

Identify the constraint
The constraint of the internal wards are...
All rights reserved to Focused Management Ltd. ©2013

36

Subordinate the system to the
constraint
• Discharge ASAP
• End ...
All rights reserved to Focused Management Ltd. ©2013

Subordinate the system to the
constraint [2]
• A “control center” fo...
All rights reserved to Focused Management Ltd. ©2013

“offloading” the physicians
• Phlebotomists
• Medical aides

38
All rights reserved to Focused Management Ltd. ©2013

Implementation
• Focused diagnosis
• Make sure you have a leader / c...
All rights reserved to Focused Management Ltd. ©2013

Sustainability
• Periodic follow-up
• Value-focused performance meas...
All rights reserved to Focused Management Ltd. ©2013

Conclusions - focusing
4 generic improvement areas:
• Synchronizatio...
All rights reserved to Focused Management Ltd. ©2013

Notions and tools
• Constraint management
• Pareto analysis
• Comple...
All rights reserved to Focused Management Ltd. ©2013

Potential improvements
• 20% increase in throughput with existing re...
All rights reserved to Focused Management Ltd. ©2013

Implementation of Focused
Management in other healthcare areas
• HMO...
All rights reserved to Focused Management Ltd. ©2013

“Focused Operations Management for Health
Services Organizations” (R...
All rights reserved to Focused Management Ltd. ©2013

Thank you!
Upcoming SlideShare
Loading in …5
×

Enhancing the performance of public healthcare systems: achieving more with existing resources - Shimeon Pass @ PSE 2013 Vilnius

6,379 views

Published on

Shimeon Pass, expert in Value Enhancement and implementation of advanced management concepts (Israel) @ TOCICO International Public Sector Effectiveness Conference 2013 Vilnius

- Dealing with the complexity of the full scale hospital.

- How can we better synchronize the in-coming stream of patients (from the ER to the internal medicine wards) with the release of patients from wards?

- How do we eliminate the wasted time of physicians and nurses?

- The complete kit concept in ORs, imaging clinics, admission processes and requests for expert opinion.

- Time-based control over the progress of the treatment plan.

- How do we eliminate unnecessary (and risky) waiting times of patients?

More information - http://pse.lt

Published in: Business, Technology
  • Be the first to comment

Enhancing the performance of public healthcare systems: achieving more with existing resources - Shimeon Pass @ PSE 2013 Vilnius

  1. 1. All rights reserved to Focused Management Ltd. ©2013 1 ENHANCING THE PERFORMANCE OF PUBLIC HEALTHCARE SYSTEMS: ACHIEVING MORE WITH EXISTING RESOURCES Presented By: Shimeon Pass, Focused Management Ltd., Israel Date: October 24, 2013 Work done in collaboration with: Boaz Ronen, Tel-Aviv University and Focused Management Ltd., Israel
  2. 2. All rights reserved to Focused Management Ltd. ©2013 The Challenge: coping with the “scissors” reality $ Needs Budgets Time
  3. 3. All rights reserved to Focused Management Ltd. ©2013 Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it. A. A. Milne
  4. 4. All rights reserved to Focused Management Ltd. ©2013 4 Example results • Assuta Tel-Aviv hospital (old site) • 20% more throughput (surgeries) within 6 months, with existing resources • North Galilee hospital • 43% more Cataract surgeries within 3 months • Waiting time reduces by 41% within 3 months • Quality improved by 20% • Assuta Rishon-Le’Zion hospital • OR throughput almost doubled, with insignificant addition of resources • Jerusalem imaging clinic • 25% more throughput (patients served) with the same resources within 3 months
  5. 5. All rights reserved to Focused Management Ltd. ©2013 The GOAL • The GOAL of not-for-profit organizations • Determined by its owners • Increasing organization’s value means improving its Key Performance Indicators (KPIs) within budget limits The GOAL of for-profit organizations
  6. 6. All rights reserved to Focused Management Ltd. ©2013 Value drivers Any topic that can significantly increase the value of the organization: • Increasing throughput • Reducing response time • Improving quality of care • Improving customers’ satisfaction • Value-focused performance measurement • •
  7. 7. All rights reserved to Focused Management Ltd. ©2013 The complex hospital environment Emergency Room Outpatient clinics Operating Room Logistics Children’s hospital Obstetrics and Gynecology Professional Professional wards Professional wards Professional wards wards Internal wards Labs and Imaging How can we cope with such a complex environment?
  8. 8. All rights reserved to Focused Management Ltd. ©2013 8 Maybe we need a good comprehensive model to resolve the complexity…
  9. 9. All rights reserved to Focused Management Ltd. ©2013 Maybe we need some decent I.T. solutions to resolve the complexity? Cloud Elec. Medical Records ERP … MRP PACS HIM CCPM …
  10. 10. All rights reserved to Focused Management Ltd. ©2013 Maybe we need complete decoupling (treat each unit independently)? Emergency Room Outpatient clinics Operating Room Logistics Children’s hospital Obstetrics and Gynecology Professional Professional wards Professional wards Professional wards wards Internal wards Labs and Imaging
  11. 11. All rights reserved to Focused Management Ltd. ©2013 What we need is focus Emergency Room Operating Room Hospital specific issue/s (e.g. ICU) Internal wards Labs and Imaging
  12. 12. All rights reserved to Focused Management Ltd. ©2013 Focus Emergency Room Operating Room Hospital specific issue/s (e.g. ICU) Internal wards Labs and Imaging
  13. 13. All rights reserved to Focused Management Ltd. ©2013 The Emergency Room (ER aka ED) Improvement TARGETS: • Cutting response times (lead times) by 50% • Increasing throughput by 20% • Reducing unnecessary hospitalizations by 30%
  14. 14. All rights reserved to Focused Management Ltd. ©2013 Using the Theory of Constraints (TOC) approach A constraint • Any factor that prevents the system from achieving its goal A system may have one, or more, of the following constraints: • Resource constraint (bottleneck) • Dummy constraint • Policy constraint • Market constraint
  15. 15. All rights reserved to Focused Management Ltd. ©2013 A resource constraint Market demand: 300 patients/month Incoming patients Treatment rate Dept. 1 patients/month Dept. 2 Dept. 3 5 patients/month patients/month Discharged patients • The system has a resource constraint • Department 2 is the system’s bottleneck
  16. 16. All rights reserved to Focused Management Ltd. ©2013 Examples of resource constraints Potential bottlenecks in organizations: • An expensive MRI machine • Anesthetists in the OR • OR facilities (the theatres) • Judges • System engineers Bottleneck identity confirmation – the “more/less” criterion
  17. 17. All rights reserved to Focused Management Ltd. ©2013 Bottleneck management ER physicians are the bottleneck Requirement • ER experts (or at least senior physicians) – 24/7
  18. 18. All rights reserved to Focused Management Ltd. ©2013 Increasing bottleneck’s efficiency • Cutting bottleneck’s “garbage time” • “Garbage time” – all activities that do not add value • “Garbage time”, nearly everywhere, is about 50% of the working hours: • Missing information or tools (“incomplete kit”) • Re-doing • Unnecessary emails • Unnecessary attendance in meetings or forums • Too much forms/administration/logistics • Delays in starting activities, meetings etc.
  19. 19. All rights reserved to Focused Management Ltd. ©2013 Reducing bottleneck’s “garbage time”: Before In-effective Effective time time 50% 50% • What would happen if we could cut 20% of in-effective time?
  20. 20. All rights reserved to Focused Management Ltd. ©2013 Reducing bottleneck’s “garbage time”: After In-effective time Effective 40% time 60% • We get 20% increase in the effective time!
  21. 21. All rights reserved to Focused Management Ltd. ©2013 Reducing ER physicians’ “garbage time” Waiting for consultants % garbage time Incomplete kit Physicians are the bottleneck of the ER Patients that can be treated in the community A B C D E F G H J I Sources of garbage time
  22. 22. All rights reserved to Focused Management Ltd. ©2013 Reducing lead times in the ER • Complete kit forms for consultants (manual or computerized) • Service Level Agreement (SLA) for consultations • Better triage
  23. 23. All rights reserved to Focused Management Ltd. ©2013 Subordination – OFFLOADING the bottleneck Offload – relieving the bottleneck by transferring part of its workload to non-bottleneck resources • Example: Dr. DeBakey
  24. 24. All rights reserved to Focused Management Ltd. ©2013 Offloading the ER bottleneck • Offloading physicians • Phlebotomists • Nurses • Paramedics – resuscitation • Medical assistants • Group technology – walk-in clinic • Offloading nurses • Medical secretaries • Nurse assistants
  25. 25. All rights reserved to Focused Management Ltd. ©2013 The “traffic lights” system in the ER • Setting the Due-date (e.g. 4hrs) • Green – no action required • Yellow – attention • Red – expedite • Black – immediate corrective actions Green – 1hr • SLA85% Yellow – 1hr Red – 2hrs Black
  26. 26. All rights reserved to Focused Management Ltd. ©2013 Monthly Pareto analysis of Red/Black occurrences Neurochirurgy consultant Number of cases Waiting for …. Cardiac echo imaging Blood tests routine ER expert A B C D E F G H I J Sources of delays
  27. 27. All rights reserved to Focused Management Ltd. ©2013 Focus Emergency Room Operating Room Hospital specific issue/s (e.g. ICU) Internal wards Labs and Imaging
  28. 28. All rights reserved to Focused Management Ltd. ©2013 Synchronization of ER and internal medicine wards The problem: • ER and internal wards are not synchronized Ramifications: • Overcrowded internal wards (part of the day) • Overcrowded ER (part of the day) • Inferior medical quality due to late-start of medical treatment and increased risk of cross-infections • Wasted (extra) of ½-1 days of hospitalization
  29. 29. All rights reserved to Focused Management Ltd. ©2013 Distribution of arrivals to ER of patients [admitted to internal wards] Distribution of arrivals to ER of patients admitted to internal wards 8% Day shift – 43% 7% 6% 5% 4% 3% 2% 1% 0% 00-01 01-02 02-03 03-04 04-05 05-06 06-07 07-08 08-09 09-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23 23-24 Arrival to ER
  30. 30. All rights reserved to Focused Management Ltd. ©2013 Distribution of internal wards discharges Distribution of Internal Wards Patients Ward Discharge 25% Day shift – 39% 20% 15% 10% 5% 0% 00-0101-0202-0303-0404-0505-0606-0707-0808-0909-1010-1111-1212-1313-1414-1515-1616-1717-1818-1919-2020-2121-2222-2323-24 Ward Discharge
  31. 31. All rights reserved to Focused Management Ltd. ©2013 Medical admissions to internal wards – only 18% during day shift Distribution of Internal Wards Patients Ward Medical Admission 7% Day shift – 18% 6% 5% 4% 3% 2% 1% 0% 00-01 01-02 02-03 03-04 04-05 05-06 06-07 07-08 08-09 09-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23 23-24 Ward Medical Admission
  32. 32. All rights reserved to Focused Management Ltd. ©2013 Synchronization of ER and internal medicine wards – initial directives ER • Implement all the above mentioned action items • Transfer patients to an internal ward with full OutKit as soon as decision has been made and there is an available bed Internal medicine wards • Start medical admission and treatment ASAP • At least 3 discharges until 11:00 • At least 3 medical admissions until 15:00
  33. 33. All rights reserved to Focused Management Ltd. ©2013 33 Define the goal of the internal ward • Maximizing the throughput of the ward without compromising the quality of care
  34. 34. All rights reserved to Focused Management Ltd. ©2013 Define performance measures • Throughput • Number of patients treated • Lead time • Average length of stay • Time-to-medical admission • Quality • Percent of re-admissions • Percent of cross-infected patients 34
  35. 35. All rights reserved to Focused Management Ltd. ©2013 35 Identify the constraint The constraint of the internal wards are the physicians • Internal medicine experts • Residents (specializing physicians) • Dealing with sources of “garbage time” for the physicians • Taking blood samples • Patients that stay in ward since there is yet no arrangement for an acute/rehabilitation unit • Patients that stay in ward since their family is not available • Re-admissions
  36. 36. All rights reserved to Focused Management Ltd. ©2013 36 Subordinate the system to the constraint • Discharge ASAP • End of day-shift identification of patients that have potential for discharge • Adapting the daily routine with priority for tests and examinations of patients with potential for discharge • Preparing medical discharge documentation in advance • Defining a medical plan during medical admissions – “the patient as a project”
  37. 37. All rights reserved to Focused Management Ltd. ©2013 Subordinate the system to the constraint [2] • A “control center” for medical plan progress follow-up operated by a medical secretary • Follow-up and expediting lab tests and imaging • Follow-up and expediting consultations • Arrangements in acute/rehabilitation units • Prior notification of families about planned discharges • Provide prior notice re patients requiring pre-discharge procedures: catheters, anti-coagulants, etc. • Complete kit and SLA for consultations • Incentives for increased throughput and shortened time- to-medical admission • Labs and imaging 24/7 availability for the most common tests and scans (Pareto)
  38. 38. All rights reserved to Focused Management Ltd. ©2013 “offloading” the physicians • Phlebotomists • Medical aides 38
  39. 39. All rights reserved to Focused Management Ltd. ©2013 Implementation • Focused diagnosis • Make sure you have a leader / champion • Knowledge transfer by a 4-day hands-on seminar to top management • Value drives • Tools • Communication and language • Facilitated implementation teams • Training all parties involved • Internal training (TTT) • Sustainability (see below)
  40. 40. All rights reserved to Focused Management Ltd. ©2013 Sustainability • Periodic follow-up • Value-focused performance measures • Internal training (TTT) • Protocols • Inclusion in IT procedures and workflows
  41. 41. All rights reserved to Focused Management Ltd. ©2013 Conclusions - focusing 4 generic improvement areas: • Synchronization of ER – Internal wards Importance • ER • OR • Labs and imaging Oysters Pearls OR Synch ER Labs Img White elephants Low-hanging fruits Ease
  42. 42. All rights reserved to Focused Management Ltd. ©2013 Notions and tools • Constraint management • Pareto analysis • Complete kit • Group technology • The patient as a project • “Traffic lights” • Subordination to patients’ discharge • Medical plan • “Control center”
  43. 43. All rights reserved to Focused Management Ltd. ©2013 Potential improvements • 20% increase in throughput with existing resources • 30-50% lead-time reduction • Improved medical quality • Improved customer satisfaction
  44. 44. All rights reserved to Focused Management Ltd. ©2013 Implementation of Focused Management in other healthcare areas • HMOs • Clinics • Primary care • Healthcare software solutions development (hospitals and HMOs) • Drugs and medical devices registration • Administrative processes (logistics, sterilization, etc.)
  45. 45. All rights reserved to Focused Management Ltd. ©2013 “Focused Operations Management for Health Services Organizations” (Ronen, Pliskin with Pass) Boaz_R@netvision.net.il Shimeon@Passmgmt.com
  46. 46. All rights reserved to Focused Management Ltd. ©2013 Thank you!

×