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

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


The Challenge:
coping with the “scissors” reality

$

Needs

Budgets

Time


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

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


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


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
•
•


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

Maybe we need a good comprehensive
model to resolve the complexity…


Maybe we need some decent I.T.
solutions to resolve the complexity?
Cloud

Elec.
Medical
Records

ERP
…

MRP

PACS
HIM

CCPM

…


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


What we need is focus

Emergency
Room

Operating
Room
Hospital
specific
issue/s
(e.g. ICU)

Internal
wards

Labs and
Imaging


Focus

Emergency
Room

Operating
Room
Hospital
specific
issue/s
(e.g. ICU)

Internal
wards

Labs and
Imaging


The Emergency Room (ER aka ED)
Improvement TARGETS:
• Cutting response times (lead times) by 50%
• Increasing throughput by 20%
• Reducing unnecessary hospitalizations by 30%


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


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


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


Bottleneck management
ER physicians are the bottleneck
Requirement
• ER experts (or at least senior physicians) – 24/7


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.


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?


Reducing bottleneck’s “garbage time”:
After

In-effective
time
Effective
40%
time
60%

• We get 20% increase in the effective time!


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


Reducing lead times in the ER
• Complete kit forms for consultants (manual or

computerized)
• Service Level Agreement (SLA) for consultations
• Better triage


Subordination – OFFLOADING the
bottleneck
Offload – relieving the bottleneck by transferring part of
its workload to non-bottleneck resources
• Example: Dr. DeBakey


Offloading the ER bottleneck
• Offloading physicians
• Phlebotomists
• Nurses
• Paramedics – resuscitation
• Medical assistants
• Group technology – walk-in clinic
• Offloading nurses
• Medical secretaries
• Nurse assistants


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


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


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


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


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


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


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

Define the goal of the internal ward
• Maximizing the throughput of the ward without

compromising the quality of care


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

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

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”


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)


“offloading” the physicians
• Phlebotomists
• Medical aides

38


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)


Sustainability
• Periodic follow-up
• Value-focused performance measures
• Internal training (TTT)
• Protocols
• Inclusion in IT procedures and workflows


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


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”


Potential improvements
• 20% increase in throughput with existing resources
• 30-50% lead-time reduction
• Improved medical quality
• Improved customer satisfaction


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.)


“Focused Operations Management for Health
Services Organizations” (Ronen, Pliskin with Pass)

Boaz_R@netvision.net.il

Shimeon@Passmgmt.com


Thank you!

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

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (12)

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

Similar to Enhancing the performance of public healthcare systems: achieving more with existing resources - Shimeon Pass @ PSE 2013 Vilnius (20)

More from commonsenseLT

More from commonsenseLT (15)

Recently uploaded

Recently uploaded (20)

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

Editor's Notes