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Brief Synopsis of some of my Healthcare Projects

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    1. 1. Richard Skiff – Synopses of Healthcare Projects SYNOPSES OF SELECTED PROJECTS IN HEALTHCARE
    2. 2. Richard Skiff – Synopses of Healthcare Projects STEPS TO IMPROVEMENT • Acknowledge that there are problems Easy • Understand the cause(s) of the problem Hard • Solve the problem Harder • Sustain the solution The real challenge!
    3. 3. Richard Skiff – Synopses of Healthcare Projects WHO IS THE CUSTOMER? The customer is anyone whose evaluation of your services has an impact on your ability to continue to deliver those services.
    4. 4. Richard Skiff – Synopses of Healthcare Projects WHAT IS A PROBLEM? A Problem (or opportunity) is Something that is Different than what it Should Be.
    5. 5. Richard Skiff – Synopses of Healthcare Projects EMERGENCY DEPARTMENT IMPROVEMENT ED PROBLEM AVERAGE LENGTH OF STAY © 2013 5
    6. 6. Richard Skiff – Synopses of Healthcare Projects Background Information • Southeastern US Hospital • 81 Bed Emergency Department – – – – – 26 Bed Major Unit (ESI levels 1-2) 32 Bed Minor Unit(s) (ESI levels 3-5) 12 Bed Major/Minor Transition 10 Bed Behavioral Health Unit 1 SANE room. • 100,000 visits per year 6
    7. 7. Richard Skiff – Synopsis of Healthcare Projects Improve Key ED Metrics Average LOS Door to provider Average Length of Stay Minutes 360 300 240 Better 180 120 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Average Length of Stay LWBS Overall Quality of Care % Excellent Overall Quality % Exc % Excellent 100% Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 80% 60% 40% 20% Better 0% Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Overall Quality % Exc
    8. 8. Richard Skiff – Synopsis of Healthcare Projects Phase 1: Minor Treatment Zones 36 37 PA 38 “Yellow Zone” 54 53 52 Green 30 24 Rooms Waiting Room 31 32 33 Open 24 hours Lab Triage and RR Soiled Linen Staffing Varies Throughout Day 39 55 Discharge Eyes “Green” Zone Nurse 3 Rooms RR 56 57 29 34 40 35 Supply 11 Stationam to 11 pm Provider 1 MUS 1 Tech, Area RR 28 41 Nurse’s Pyxis 1 PA, 2 RN, 50 51 Station 43 44 Prep RR and 58 42 Pyxis Radiology 59 Holding “Yellow Intake” 3 Rooms 3 pm to 11 pm 49 48 47 46 45 EMS 1 MD, 2 RN, 1 Tech Suture Suture Suture Office
    9. 9. Richard Skiff – Synopses of Healthcare Projects Expand the demonstrated effectiveness of Phase I FMC ED: Intake Average Length of Stay (ALOS) 300 Baseline: Mean = 240 min 270 Savings of 70 minutes per patient Savings of 70 by going through minutes per Intake Process vs. patient Yellow Zone Trial: Mean = 155 min 240 210 180 150 120 90 Se p09 O ct -0 9 No v09 De c09 Ja n10 Fe b10 M ar -1 0 Ap r- 1 0 M ay -1 0 Ju n10 Ju l-1 0 Ap r- 0 9 M ay -0 9 Ju n09 Ju l-0 9 Au g09 60 O ct -0 8 No v08 De c08 Ja n09 Fe b09 M ar -0 9 Intake ALOS (min) Intake Implemented: Mean = 170 min
    10. 10. Richard Skiff – Synopsis of Healthcare Projects “Supertrack” Phase 2 54 53 52 30 Waiting Room 31 37 PA 3 Rooms; 1 pm to 10 pm Green 36 38 32 33 Triage and Lab Team Intake 1 RR 4 Rooms Soiled Linen 39 11 am to 11 pm 55 Nurse RR 56 57 29 34 41 PACS, Pyxis 50 51 Secretary 43 44 Prep 58 42 RR and 59 40 35 Supply Station Intake 2 Team 4 Rooms Provider 3 pm RR Area to 11 pm 28 Eyes Pyxis Radiology “Yellow Zone” 15 Rooms Open 24 hours Staffing Varies Throughout Day 49 48 47 46 45 Suture Suture Suture EMS Office Close 1 assignment to reallocate staff for expanded Team Intake
    11. 11. Richard Skiff – Synopses of Healthcare Projects Phase 2 Improvements • By focusing a provider (PA or MD), 2 Nurses, and a tech to a “pod” (a set of treatment rooms in close proximity), we found a significant improvement in the ability to focus on patients and patient flow, and therefore reducing the “Average Length of Stay” and “Left Without Being Seen” rates. • We incrementally expanded this concept throughout the minor treatment zone, making adjustments as needed in each phase. • The success was so significant that this process was expanded to include the entire minor treatment zone. 11
    12. 12. Richard Skiff – Synopsis of Healthcare Projects Phase 3 53 52 Green No more Supertrack – incorporated into intake pods 30 Waiting Triage and Lab 32 31 1 pm – 10 pm PA 10 pm – 6 am PA 55 Nurse 56 57 RR Pod A Open 1:00 pm to 6:00 am 28 RR Flex Room 50 34 Supply PACS, Soiled Linen 39 35 Flex Room 41 11 am – 3 pm PA 43 44 Prep 42 Flex RR Room Pod C Open 11:00 am to 11:00 pm and OB? Pod D Open 24/7 48 7 am – 4 pm PA 4 pm – 12 am PA 11 pm – 7 am PA 1 hr overlap 11pm to 12 am 40 3 pm – 11 pm MD 51 Flex Room 49 There is a “Float” PA from 3:00 pm to 8:00 pm RR Pod B Open 9:00 am to 11:00 pm Pyxis Radiology 3 pm – 11 pm PA MUS (2) 58 59 33 9 am – 5 pm PA 29 Pyxis Area D/C; Flex Eyes Station Provider 38 2 hr overlap 3 pm to 5 pm Room Intake Holding: Open 24/7 37 Shared by all pods D/C; Flex D/C; Flex PA Main Lobby / Waiting Room 54 36 47 46 45 EMS Shared by all pods Suture Suture Suture Office
    13. 13. Richard Skiff – Synopses of Healthcare Projects Pre-Implementation Simulation • Patient data from a high volume day was analyzed to “simulate” running all of the Minor Zone as an Intake Process: – Total ED Patients – Minor Zone Patients – BH Patients Arriving 315 209 23 • Note: No patient treatment times were shortened. Efficiencies were gained in through improving patient flow. Patient names are fictitious.
    14. 14. Richard Skiff – Synopses of Healthcare Projects Simulation Results – Minor Zone Actual Simulation Savings Average Length of Stay (BH Patients included) 373 min 326 min 46 min Average Length of Stay (BH Patients excluded) 241 min 190 min 51 min Average Arrival to Room 91 min 49 min 42 min Average Time in Treatment Room N/A 52 min Maximum # of Patients in Main Lobby Waiting Room About 24 14 Left Without Being Seen 9 patients 5 patients (estimated)
    15. 15. From Triage Kirksey 28 Room 55 Nurse RR Station 56 Pyxis Helms Provider 57 Area Weathers Boyd Andrade Triage and Lab Supply PACS, 38 Harris Gillespie RR Fox Waiting Baker 119 Jefferson Hendrick Actual Current Process 32 33 30 31 At 16:00, 18 patients in Waiting Room with average wait time of 28 29 34 35 58 minutes to that point 44 43 50 51 Buford Green 37 Alabaster CLOSED King 29 PA Gentry 52 Blake 28 36 Spinks Beck 47 Jones 62 Sinks Bell 39 Burns Dillard Lester Bean 69 Soiled Linen 39 Eyes 40 Stewart 41 Secretary RR Prep 58 Peters Jennings 98 Beeson 41 Archibald Bennett 36 53 Bass 104 Hobson 138 Lamar 21 Minton Kyles 26 Daniels Main Waiting Room 54 DISCHARGE Richard Skiff – Synopsis 36 Healthcare Projects of Brady Billings 32 Johnson 84 Bergman 42 RR and Pyxis Green Radiology 59 Bullins Brewer Baxter Wall Nelson 47 46 45 Grier Calloway Stone Boyd Allen Purvis 48 Summers 49 Jessup Watson EMS 16:00
    16. 16. From Triage DISCHARGE Room Intake Holding 55 57 Watson Pyxis Provider Area Lamar 21 Beeson 41 Billings 32 Kyles 26 Bennett 36 Blake 28 Kirksey 28 Jones Jessup Station Supply PACS, RR Prep and Pyxis RR OB? Daniels Radiology 48 47 Gillespie Johnson 49 46 Spinks Stone 16:29 16:22 16:19 16:15 16:13 16:12 16:10 16:08 16:11 16:30 16:28 16:27 16:26 16:25 16:24 16:23 16:21 16:20 16:18 16:17 16:16 16:14 16:09 16:07 16:04 16:03 16:02 16:01 16:00 16:06 16:05 37 Jefferson BH 38 Harris BH Soiled Linen 39 Eyes 40 Bell 41 Beane Secretary 58 59 RR Alabaster Stewart 56 RR Hobson Nurse Allen Triage and Lab Beck Bass Helms Hendrick BH Weathers Waiting PA Baxter Summers Green Baker Brody Fox 52 Minton 53 Green 54 Jennings King 29 36 Simulated New Process 31 32 33 30 At 16:00, 9 patients in Waiting Room with average wait time of 28 29 34 35 31 minutes to that point 44 43 50 51 Bowers Main Waiting Room Bergman 36 Richard Skiff – Synopses of Healthcare Projects 45 Suture Suture Suture EMS 42 Archibald
    18. 18. Richard Skiff – Synopses of Healthcare Projects What is “Hunting and Gathering?” Anytime a member of the Nursing Staff has to go someplace other than his/her immediate area to get something to provide care to the patient. – Physical hunting and gathering of equipment, supplies, and equipment. – Waiting for information/people/resources that are not where they are needed when they are needed. *In this study, only Nurse hunting and gathering was measured. Hunting and Gathering should also include all other care givers, including Providers and CNAs. 18
    19. 19. Richard Skiff – Synopsis of Healthcare Projects Scope of Hunting and Gathering TCAB Overall Scope Current State Context Diagram Patient Enters Hunting and Gathering is present in all aspects of Nursing Care. Care Planning Patient Assessment Itterative Cycle Admit Patient to Unit Complete Health History Patient Departs Evaluate Patient Response Implement Care and Treatment Complete Patient Discharge Med Administration Hunting and Gathering Admission/ Discharge Care Planning Med Administration 19
    20. 20. Richard Skiff – Synopsis of Healthcare Projects Time Spent Hunting and Gathering Minutes per 12 hr. Nursing Shift Spent..... These are only relatively small snapshots of time, and results are for high level/directional use only Shift/Nurse reporting Misc 6% ; 7% ; 44 min 51 Med General nursing duties scanning min in patient's room and from cart administration of meds 9% ; 1 hr Hunting and Gathering is about 25% of a Nurse’s day 35% ; 4 hr 10 min Bothpaper and computer charting 19% ; 2 hr 14 min Hunting and Gathering 25% ; 3 hr 1 min See Separate Chart 20
    21. 21. Richard Skiff – Synopsis of Healthcare Projects What are they spending time hunting? Percent of Total Nurse time spent Hunting and Gathering for……….. Patient Amenity 2.4% Info Med 1.1% not in 1st Pyxis 1.5% Get Meds from Pyxis 8% Wait for Equip/Pyxis 2.6% Supplies 3.8% Equipment 5.4% Hunting and Gathering is 25% of total RN time 21
    22. 22. Methods and Procedures Equipment Information Richard Skiff – Synopsis of Healthcare Projects Floor Stock Electronic Equipment (Dynamaps, Pulse Ox, etc.) GG Provide own d/c transport GG Pyxis Discrepancy Discharge orders W Med info from pt. for pharmacy GG Insulin Witness GG Transport ancillary (Radiology, Dialysis, Wasted med witness GG Transfers) GG Charts GG Floor Stock NonElectronic Equipment (Wheelchairs, Recliners, walkers, etc..) GG Documentation GG Co-workers GG Providers GG Home meds GG Equipment Failures diagram for “Fishbone” – look for working equip GG, W reasons why nurses spent time Take home and gathering hunting equipment Duplicate Forms GG GG = Go Get Policies GG Radiology Results GG HUNTING AND GATHERING W = Waiting Food Trays W Respiratory Therapy Supplies GG IV Fluids GG Linens GG Checking for missing meds to be delivered from pharmacy GG Nourishment GG Insulin GG Coffee, Snacks, Personal Care items GG Dressings GG Load Med Cart GG Search Multiple Pyxis GG Lab W X-Ray W E.V.S. – Housekeeping W Home Meds GG Non stocked Narcotics GG, W Blood GG Stock Outs GG Supplies & Amenities Medications Ancillary Services Focus Area 22
    23. 23. Richard Skiff – Synopsis of Healthcare Projects 5 Why Analysis Hunting and Gathering: Why do we hunt for…… …..Floor Stock Electronic Equipment? (Dynamaps, PulsOx, Scanners, Med Carts, Phones, Bladder Scanners) Left in room Frequent use by this patient In Use by another No time to return to location No designated place for equipment Multiple storage places Why? Why? Why? Why? Not Returned to Proper Location Hoarded Plan to use for next Patient Not enough storage places Not Charged (Dead Battery Why? Why? A Not enough for each unit Improper use Overuse Took focus areas noted in the fishbone diagram, and generated a “5 Why” analysis to address issues. Too far to walk to return Needed for use Off unit (Borrowed or appropriated ) Broken Equipment shared by multiple units Called to another task Specific Task Item Not plugged in No place to plug in No Accountability See A Past normal life No Preventative Maintenance No replacement plan No PM Program Lack of training Bad cords No Time to charge No charging schedule Unknown charge time 23
    24. 24. Richard Skiff – Synopsis of Healthcare Projects Hunting and Gathering: Why do we hunt for…… Why? …...Floor Stock Electronic Equipment? (Dynamaps, PulsOx, Scanners, Med Carts, Phones, Bladder Scanners) Not enough equipment Why? Unfixable and not communic ated Why? Staff doesn’t enter the request No clear method for engineering to communicate back to the unit the status Don’t know how Process too cumbersome Why? Never sent for repair Why? Why? Sent to Engineering and not returned Borrowed and not returned Waiting for Repair Gave back to wrong unit No way to track Specific Task Item No defined return path Equipment poorly labled so not returned Waiting on parts No defined labeling system that is permanent No replacement process – not communicate to person that can order Another unit doesn’t have the equip they need Ineffective sign out system Not enough ordered or purchased Hoarding No or poor tracking system No easy access to equipment Ability to order equip is too complicated Financial Constraints Takes a long time to come after ordered Don’t know how many we have No inventory guideline Don’t have ownership and a process No Process or Bad Process 24 When comes in not delivered to unit
    25. 25. Richard Skiff – Synopsis of Healthcare Projects Hunting and Gathering: Why do we hunt for…… …...Non-Electronic Floor Stock? (Carts, Wheelchairs, Walkers, IV Poles, Bedside Commodes, Recliners, etc.) Why? No Accountability In a hurry Not enough equipment Went someplace else and when came back equipment was gone In use with another patient Specific Task Item Removed from room EVS does Discharge clean and removes equipment Variable process and equipment needs for each unit When Unit closed and equipment removed and taken elsewhere Inventory issue Borrowed for another patient No Security or ability to lock unit. Broken Missing parts Thrown away Why? Why? Why? No ownership Why? Why? People left equipment in other area (i.e. discharge) 25
    26. 26. Richard Skiff – Synopsis of Healthcare Projects NURSE EFFECTIVNESS HOSPITAL PROBLEM New Hospital Opening – Are We Ready? © 2013 26
    27. 27. Richard Skiff – Synopses of Healthcare Projects NEW HOSPITAL OPENING • A new system 60 bed hospital was slated to open in approximately 70 days. • Worked with start-up team to determine process needs/gaps prior to hospital opening.
    28. 28. Richard Skiff – Synopsis of Healthcare Projects Three Main Hospital Value Streams INPUTS VALUE STREAMS Walk-ins Emergency Regional Physician Offices Direct Admit Procedures (In /Out Patient) OUTPUTS Discharge into Community
    29. 29. Richard Skiff – Synopsis of Healthcare Projects High Level Value Streams
    30. 30. Richard Skiff – Synopsis of Healthcare Projects Surgical Services Value Stream Patient Arrival Developed Key Quality Characteristics for each value stream. From MD Offices From Emergency From Inpatient Pre Arrival Information Registration Pre Cert, etc Patient Info Name DOB Demographics Insurance Clinical Information Procedure/Infusion Length of Procedure Allergies Special Needs Order for Consent Regular Orders Pre-Anesthesia Visit Medical History and Physical Pre-op Teaching/instructions If face to face; RN will notify pt. Provider Information Surgeon/MD; Does Patient need a PAV? Each stream had three main steps: •Patient Arrival •Patient Treatment Schedule Patient Enter into PICIS •Patient Departure Patient Arrival Arrival at Front Desk Escort to Surgical Services Greeter entry into Smartrak Escort to ACU Update Smartrak
    31. 31. Richard Skiff – Synopsis of Healthcare Projects Patient Treatment Perform Surgery Pre-Op Complete Assessment Pre-Procedure verification Outside Ancillary Tests Completed and Charted The key steps in each process were determined, and then processes needed to accomplish that task were identified. Signed Consents Site Marked Prep Patient Activate RDY button when Pt. is completely ready Operating Room RN go to ACU/Preop to meet/greeet patient Transport Patient to OR Then they were evaluated for “readiness to open” Green = Ready to Go Yellow = Needs some refining Red = Needs a lot of work Update Smartrak - Circ RN MD-Surgeon - Sign and mark Anesthesia - Interview blocks Perform Sugery Upon Completion, Call ACU/PACU when close to transporting patient (RNA or RN) How do Ancillary Services communicate / hand-off to Surgery? - Radiology - Pathology - Labs - Respiratory - Pharmacy - ICU - Wound
    32. 32. Richard Skiff – Synopsis of Healthcare Projects Patient Departure PACU Receive Patient and Report from OR / ORNA Patient Recovery Update in Smartrak Hand off to Next Level of Care These “maps” were jointly developed and rated by the functional department, clinical personnel, administration, related ancillary services, etc. Bed Control ACU ICU Med Surg How do Ancillary Services communicate / hand-off to Surgery? - Radiology - Labs - Respiratory - Pharmacy - Wound Care ACU Patient Report from OR / CRNA / PACU From there, the functional areas were able to focus on “Gaps” prior to the opening of the hospital. Patient Recovery Food and Nutrition Update in Smartrack Discharge to Community Communicate Discharge Reports and Instructions Provider/Nurse Ask Me Three Written and Verbal Vital Signs Referrals Insure Feedback and Follow-up Movement of Patient Exit Transportation Meds/Prescriptions
    33. 33. Richard Skiff – Synopses of Healthcare Projects ULTRASOUND TIME EFFECTIVENESS PROBLEM: Uncertainty on the time effectiveness of Ultrasound Technicians © 2013 33
    34. 34. Richard Skiff – Synopses of Healthcare Projects TIME STUDY PROTOCOL • Methodology: Followed one sonographer for an entire shift, logging the time spent doing his/her normal tasks. Times shown are only for one sonographer, and do not reflect activities of others in the department at the time. SHIFT # of Patients # of Exams Day 8 10 Day 8 8 Evening 8 8 Evening 9 9 34
    35. 35. Richard Skiff – Synopsis of Healthcare Projects Hospital Ultrasound Scheduling Process Radiology – Ultrasound “Scheduling” Process Page 1 Order comes in via Printer Is order for today? Yes No Put order in Future Basket Is it an ED request? Yes Put request in ED Slot Yes Print off Labwork sheet Is labwork complete? Yes Add order to Day Sheet To A Yes Place request in “Ready Patient” slot To B No Will procedure need a labwork check? No Call RN and order labwork Yes Put request in ED Slot Continue to check with RN until labwork is complete No Is patient to come to radiology unit? Unit Secretary No Go to computer and print out Outpatient schedule Near end of shift, fill out Day Log. Add to day Log if already started. Is the portable request Stat? No To Outpatient Process Page 2 Put request in Portable Slot Place patient requests and Day log into future basket At beginning of day shift, pull requests from future basket Is patient a Portable, ED, or Outpatient? Yes Is patient in ED ? No “A” Attach blank “yellow sheet” (Hand off communication tool) to every inpatient request. Call proper unit and ask for Patient’s RN; Fill out questions on Yellow Sheet To Outpatient Process Page 2 Put in 2nd slot in rack Put request in Outpatient slot When a Sonographer, room, and machine are available, send for patient To ED Process Page 2 No No Is Request for a Portable unit? Yes Put request in Portable Slot “B” Transporter picks up request To “Portable” Process Page 2 Put front sheet in proper slot – to keep track of what patients have been sent for
    36. 36. Richard Skiff – Synopsis of Healthcare Projects Ultrasound Scheduling Process (cont.) Radiology – Ultrasound “Scheduling” Process Outpatient Process “Portables” Process ED Process Page 2 From ED Page 1 Wait for call from ED to say that patient is ready for exam Take paperwork from ED slot, write “R” on the top of the sheet, and place it in the first open “Ready Patient” slot Next available Sonographer retrieves paper, gets portable machine, and goes to ED Sonographer performs exam Are there more exams in ED? No Return to department Yes From “Portable” Page 1 From “Outpatient” Page 1 US Supervisor pulls all “Portable” exam paperwork out of “Portables” slot and place in “Ready Patient” slot Next available Sonographer retrieves chart, gets portable machine, and goes to Patient location Sonographer performs exam Return to department Scheduled Outpatient comes to US Department US department processes paperwork and puts in next “Ready Patient” slot Sonographer gets paperwork and patient, takes to room Sonographer performs exam or procedure Put completed paperwork in stack of completed exams Unit secretary takes batches of paperwork to Medical Records (once or twice a month)
    37. 37. Richard Skiff – Synopsis of Healthcare Projects Individual Sonographer Process Sonographer Process Return to US Dept Check US “ready” rack Is there an ED Exam ? Go to ED Yes Ultrasound room Get paperwork from printer Check T-system for room, relevant info Get equipment ready Go to Pt Room Perform exam Return to ED US Room Enter results of exam into computer Is there another ED Exam ? No Yes No A Is there “Portable” Exam Yes Are there any Transcranial exams? Yes Check with supervisor for priority Check Medical records for previous exams Get equipment ready Go to Pt Room Perform exam Did images transfer from Portable? Is there another Exam in batch? Yes Do these first Go to charting computer, begin charting process Return to US Dept No Yes No No Sonographer Does work-flow allow Portables now? Yes Enter exam results into computer system File paperwork To A No Push images to computer Is there an “in department” exam or procedure? No Do Mandantory Education, Department housekeeping, restocking, professional development Yes Is patient here? No Send transport to get patient Yes Grab chart Check yellow sheet for issues Check Medical records for previous exams Perform exam or procedure Go to charting computer, begin charting process File paperwork No
    38. 38. Richard Skiff – Synopsis of Healthcare Projects Time Study Results Ultrasound Time Study: In Room Time - Combined Shifts 70% 65.6% Found that the ultrasound department actually had a very high percent of their time actively working with patients. Some improvements could be made at end of shift procedures scheduling. 60% Ultrasound Time Study: Combined Shifts % of Time 50% 40% 50% 44.5% 30% 40% 20% 9.9% 9.3% 10% 5.1% % of Time 30% 3.6% 2.3% 2.0% 1.9% 0.3% 9:33:45 0:44:29 0:31:30 0:20:15 0:17:45 0:16:15 0:03:58 20% 1:21:15 Examination Possible 1:27:00 0% Post Exam Clean-up Pre-Exam Prep Room Prep Paperw ork Chart Check Computer Delay Delay Other Opportunity 10.7% 10.5% 10% 8.1% 3.0% 2.7% 2.5% 2.4% 2.3% 0:44:45 3.8% 0:47:00 6.3% 3.3% 1.0% Delay Scan Paperw ork Behind Misc Chart Admin Review Dow ntime 1:05:45 Misc prep 0:19:30 0:58:15 Lunch 0:49:45 1:14:00 Travel 0:52:30 2:03:15 In room Dow ntime Computer - No Charting Patients 2:39:46 3:25:45 3:30:45 14:34:44 0% Misc Dow ntime Other
    39. 39. Richard Skiff – Synopses of Healthcare Projects Opportunity: Waiting for Patients Why is a Sonographer Waiting for Patients? – – – – – Waiting for Transportation – Why? End of a Shift - Why? Waiting for Labs - Why? No exam/procedure requests Other
    40. 40. Richard Skiff – Synopses of Healthcare Projects NUCLEAR MEDICINE PROCESS STUDY PROBLEM: What are some of the issues affecting Nuclear Medicine? © 2013 40
    41. 41. Richard Skiff – Synopses of Healthcare Projects Nuclear Medicine Process Study • Observed Nuclear Medicine and PET for four shifts, including nights and weekends. • Collected responses from the “magic wand*” sheets, as well as from conversations with staff. * Staff were asked the question: “If you could wave a magic wand and change three things in your area, what would they be?
    42. 42. Richard Skiff – Synopses of Healthcare Projects Process Improvement The Nuclear Medicine and PET Groups were continually making changes to improve their department. As one technologist said, “...every two or three weeks we’re trying something different to try to make things better.” This is exactly what we need to encourage – people who actually do the work having input and making changes to improve the delivery of value to the customer.
    43. 43. Richard Skiff – Synopsis of Healthcare Projects Who is Requesting Procedures? Nuclear Medicine: Breakdown of Procedures June 13 - December 9, 2010 Emergency, 17.4% Inpatient, 50.4% Outpatient, 32.2% PET Procedures - Requesting "Unit" Inpatient, 248, 16% Outpatient, 1286, 84%
    44. 44. Richard Skiff – Synopses of Healthcare Projects Procedures Issues • CCK and Lasix; RN vs. Technologist injections • Outpatients with Ports, getting an RN in a timely manner • Cardiolytes, getting a PA in a timely manner. One cardiology practice has recently cut PA positions – now have to wait for an MD to monitor.
    45. 45. Richard Skiff – Synopses of Healthcare Projects Scheduling Ideas / Issues • Mail appointment times and instructions to outpatients. • STAT orders to NucMed on 2nd and 3rd shift – how to know that they are there. • PET Procedure printing after 3:00 pm • Possible use of pagers in Waiting room – to let patients know when to come back
    46. 46. Richard Skiff – Synopsis of Healthcare Projects Transporter Process Improvement Location of Transports to/from Other 1.9% METHODOLOGY: PET 12.3% MRI 35.0% Compiled NucMed Transporter Log 11/30/2010 – 12/10/2010 10 Days Total Nuclear Med 26.5% Rad/Onc 24.3% Over 60% of transports are done for other departments than NucMed and PET
    47. 47. Richard Skiff – Synopses of Healthcare Projects Individual Transporter Data The percent of time that a transporter was actively transporting ranged from 39 to 50 % Transporter Worked Minutes Total Trips A B C D 4599 3720 3600 4230 100 81 61 83 10 days X 8 Hrs, less PTO Calculated Average Calculated % Total Trips per of Time transporting Hour Transporting Minutes 1.3 2280 49.6% 1.3 1847 49.6% 1.0 1391 38.6% 1.2 1892 44.7% Includes trips taken with another transporter Total Trips times 22.8 minutes per trip
    48. 48. Richard Skiff – Synopsis of Healthcare Projects The percent of time that a transporter was actively transporting ranged from 39 to 50 % Transporter Worked Minutes Total Trips A B C D 4599 3720 3600 4230 100 81 61 83 10 days X 8 Hrs, less PTO Includes trips taken with another transporter Calculated Average Calculated % Total Trips per of Time transporting Hour Transporting Minutes 1.3 2280 49.6% 1.3 1847 49.6% 1.0 1391 38.6% 1.2 1892 44.7% Total Trips times 22.8 minutes per trip
    49. 49. Richard Skiff – Synopses of Healthcare Projects SYSTEM WIDE ED STROKE IMPROVEMENT PROBLEM Individual hospital process variation affected system wide ED Stroke Response times © 2013 49
    50. 50. Richard Skiff – Synopses of Healthcare Projects ED Stroke Project Methodology • Observed and process mapped main hospital and four satellite hospital ED stroke processes • Process Mapped each Hospital’s processes, and Gathered ED stroke response data • Brought all hospitals together to review process maps • Determined best practices system wide to improve ED Stroke response, and began implementation of those practices
    51. 51. Richard Skiff – Synopsis of Healthcare Projects Main Hospital ED Code Stroke Data 90 18.4 75 tPA Order to tPA Start 60 Minutes 28.9 16 CT Read to tPA Order CT Complete to CT Read 45 CT Order to CT Complete 25 30 15.4 10.2 15 14.1 11 10 2 0 Mean Median Door to CT Order
    52. 52. Richard Wide Synopsis of Healthcare Projects Mission SystemSkiff –ED Stroke Process: Current State Comparison MEMORIAL Main Hospital ANGEL Satellite #1 BLUE RIDGE Satellite #2 TRANSYLVANIA Satellite #3 McDOWELL Satelilte #4 Denotes Targeted Best Practice Notify ED, start IV ED notifies Radiology and Lab ED Alerts ED of incoming possible stroke, and ETA Draws blood, if possible Notify ED of inbound stroke ED notifies MD, Radiology, and Lab. Begin moving Robot when Code Stroke is called, for all EDs except Memorial EMS Arrival; put in ED room POV: Triage makes first stroke assessment Draw Blood Register pt. at door if possible POV: Registration or Triage recognizes stroke symtoms POV: Registration or Triage makes first stroke assessment; call “Code Stroke” If clear “Rule In,” MD orders CT Scan and If CT is busy, contacts MMH Neurology via phone for may do EKG acceptance of transfer, without using while patient is telestroke waiting for CT Assessment done at Triage or EMS stretcher (Preferred) or in ED room “Clot Box” with Protocol and Stroke supplies available Register pt. at door if possible If using Telestroke, bring robot to room. (sometimes while in CT, sometimes after back in room. Decision to admit or transfer Pt to Memorial Bring Telestroke Robot RN Standing orders allow for CT order CT Scanners alert Radiology if > 20 min w/o interpretation RN Prepares tPA RN administers tPA RN Prepares tPA RN administers tPA RN administers tPA Connect to Neurologist via Telestroke Bring Telestroke Robot Place patient in room. Draw Blood if possible Connect to Neurologist via Telestroke EMS: Place patient in room Start NIH assessment Draw blood for lab Register Pt if not done before. 2 “boxes” of tPA ingredients kept in ED Omnicell; 2 more in Pharmacy Lab samples taken MD Assess Pt. for Stroke in ED Room EMT assesses Pt. Start IV if possible Perform CBG test MAMA (only) can call Code Stroke RN administers tPA RN or Pharmacist Prepares tPA Bedside POV Assessment ?? POV: Notify CT and Lab; call Code Stroke POV: Registration or Triage makes first stroke assessment RN administers tPA RN Prepares tPA Draw lab samples when back in ED room, if not drawn before. In house radiology available 8-5; after hours use Asheville Radiology. Consistently good response times. RN Standing orders allow for CT order EMS Assessment on Stretcher Dispatch contacts ED with preregistration info and ETA RN Prepares tPA tPA Ordered by Neurologist Quick Register Pt. May also alert Telestroke Notify Dispatch with Name, DOB, and pt. address Connect to Neurologist via Telestroke when back in room MD assess for stroke Draw blood in room, if not done yet EKG, X-Ray if ordered by MD 2 CT Scans: Plain CT followed by an Angio CT with contrast POV: PACE RN or Triage determines possible Stroke; either can call Code Stroke EMS Process Patient Arrival Patient Assessment; CT Ordered CT Scan CT Read tPA Ordered STK-4 Criteria: Patients administered tPA within 60 minutes of presentation to ED (Patients admitted to hospital) OP-23 Criteria: CT read within 45 minutes of presentation to ED: (Patients “discharged” from ED – i.e. transferred to another hospital) tPA Prepared tPA Given Transfer Protocol to Memorial
    53. 53. Richard Skiff – Synopses of Healthcare Projects HOSPITAL SUPPLY CHAIN CHALLENGE IMPROVE SUPPLY CHAIN EFFECTIVENESS © 2013 53
    54. 54. Richard Skiff – Synopses of Healthcare Projects PROCESS APPROACH • Value Stream Map of Materials Distribution • Process Map of Materials Ordering – Transactional Processes • Process Map of Post Product Approval Process
    55. 55. Richard Skiff – Synopsis of Healthcare Projects Materials Distribution: Current State Map Lawson or Omnicell Orders Lawson or Omnicell Orders Lawson or Omnicell Call Ins (Urgent) Non-Stock and Misc. Non-Stock P.O.s and UPS / Fed Ex Cath Lab / Surgical Procedures OR Requisition Items SDC to SPD to OR Deliveries OR Cases
    56. 56. Richard Skiff – Synopsis of Healthcare Projects Supply Chain Processes: Current State Map Forms Need Follow-Up Process Map Equipment It does not appear that there is an Equipment Review/ Approval Process Go back to department for New form is created someplace No Yes Equipment New Equipment Request Clinical Equipment Approval Process Fill out request in Ascend Software Is it Capital? (> $5K) Bidding and Vendor Approval Process Capital Buyer gets OK to purchase Is item over $25K No Lease or Use Agreement Process Rental Equipment Process Yes Review through MD Buyline Process Pass MD Buyline? Yes Place PO with vendor Receive Equipment in Ridgefield or designated other location Periodic status updates between buyer and vendor No Yes Does it have Lawson Number? Yes Yes Is it Biomed? Go through Biomed approval process Forms Install Equipment Requester goes to Printshop Process No No To A OR Emergency Totes Non- Lawson (Special) Orders Unit sends in a requisition form to purchaser Paper/Faxed Has this item been ordered before? Yes Is Vendor Approved No Develop clear guidelines on what needs to go through product review. Yes Item Qty meet “Add to Lawson” Criteria? No Does item need Product Review? Can it be purchased someplace else? No Yes There is a new Product Review Process (Value Analysis Process) instituted 2/6/13; but it has not been fully vetted. Yes Go through Lawson approval process IT Adds item to Lawson Put into Template or Par To B OR Emergency Totes No Will it be ordered again? Post Product Review Transactional Processes. Mapped 2/21/13 New Entity or Department to be set up in Lawson Go to Finance to create; Maps to “X” Cost Center Finance sends out email that “I’ve created Cost Center and its Called Y” Someone in this cost center orders something Yes Hand Held Orders (Open Stock) Both Stock and Non Stock items Warehouse Perpetual Orders Materials asks “Who are you and what cost center are you?” Yes Is Cost Center set up in Lawson? Materials tries to determine if this cost center will order stuff Unit orders via a Lawson Template Unit completes the order and releases it Mtls coordinator orders item via Handheld (Lawson) Transmits order to Mobile Supply Chain (MSCM) Item has reached a Par or below level in Warehouse Lawson create a PO for Item? Are you a “Requestor” If so, creates a requesting location in Lawson Are Yes you authorized to order for this cost center? Yes No Send computer services authorization form No Is there a template set up? Yes When done, email sent back to Materials IT Get authorization and set up their profile No Dialog with unit for needs. Look to see if there is “someone like you.” Build Template To C Sometimes Qty is to be transferred from another warehouse Pick items and ship No WH does “In Transit” receipt release and Decrements “From” WH When received at “To” WH, does release of “In Transit Receipt” and increments receiving WH Decrements On Hand Quantity Omnicell hits a Re-order point Query to Omnicell: “How are you in stock level?” Omnicell creates an electronic Requisition file: “This is what I need” Is it a Stock Item? Force a “Job” in Lawson Yes Yes Lawson looks at available stock on hand C Lawson creates a pick ticket in Warehouse for each Omnicell Item is Picked (Mtls Distribution VSM) Prints “Killed” items at bottom of ticket Yes Lawson “Kills” Quantity, may revise with lower Qty. Lawson creates a P.O. for nonstock item Cycle Count Correction of Stock Amounts in Omnicell during stocking. Is enough quantity? Lawson sends an email to requestor about Qty change No No Decrements On Hand Quantity account Creates record of Patient and Item Transactional Ordering Process Map Ready to order Warehouse Perpetual Orders Omnicell Orders Is item Patient Chargeable? Stage to put on next truck for delivery No Requisition created in Lawson A Pseudo pick ticket prints at “From” Warehouse Item is scanned out of Omnicell Is there a tote ready? Floor Stock Patient Equipment Distribution Process (exp – IV pumps, Dynamaps, etc.) Lawson Template Items Hand Held Orders (Open Stock) Set up requesting location for cost center. No, Transfer Omnicell Yes Fax to SDC Add Vendor to Lawson Credit Card Purchase No Lawson Template Items Prints out Spreadshe et order form Build the tote Lawson Template SetUp B OR orders replenishm ent emergency tote It does not appear that there is a Recall Process for products or equipment Yes No Feedback to requestor that item needs to go through product review process Product Review Process Lawson Template Set-up To B No To B Is it on a Template? Does Yes Lawson have Form Template? No A Non Lawson Orders (Specials and New Items) Requisition to Materials that someone needs more of that form Forms Approval Process If only one item on P.O., Lawson will not print a pick ticket. Buyer revises order (Quantity, Price, other) Lawson routes P.O. to a Buyer Create a new P.O. Yes At 5:00 am; Omnicell transfers information into Medipac P.O. sits in Buyer queue as “Unreleased” Buyer reviews P.O. Revision needed? Yes No Release item in Lawson Is Yes Vendor set up EDI? Order goes to GHX (Clearing House) GHX sends order to Vendor Vendor confirms order No Medipac creates a patient bill Vendor set up Autofax? Enough to fulfill order? Yes Yes Lawson job looks for released Autofax POs Autofax order to Vendor Buyer calls or faxes vendor Vendor Confirms order No Lawson prints out order Buyer gets Online confirmation Email from Autofax to Vendor; “I sent P.O.”, Confirms by Fax No Vendor feeds back expected ship date Buyer gets back with requestor Is revised ship date OK? No Is there a substitute available No Requestor has to wait. Yes Vendor Ships Order
    57. 57. Richard Skiff – Synopsis of Healthcare Projects Post Value Analysis (Product Approval Process Map) A B C DB I Add: Type Cost Department CDM (Charge Master #) Markup Price Scale (Price to Patient: “Extended Price” DB I Open “Item Class Template” in Cerner Copy and Paste Item Number (Lawson) and Class into Template .CSV After A, B, C, loops, this is the last step in this loop Cerner exists to have clinical documentation and make items patient chargable After Class, repeat for Location and Locator; each location must be done separately E An item has been approved Value Analysis (i.e. Product Approval) and is to be made ready for purchase. Assumes that the New Process (2/6/2013) is in place Is it a Surgical Material? Yes Contract Administrator sends information to Data Base Specialist: Contains: Vendor Product Number Description Unit of Measure Buy Distribute Pricing Par Levels Contract person generates letter of approval Creates Excel Spreadsheet with information and sends to Database Specialst II. 100% Manual Entry Check for Duplicates in Lawson Assign Lawson Number to Item(s) Upload to Lawson “Lawson Build” DB II sends Excel file back to: DB I Contracts Go to Explorer menu in Cerner; click “Execute Query Output Item Master” Save resulting file in .CSV format File in C:Drive “Item Master Active” Open Access, Delete current “Item Master Active File” Import New .CSV file into Access. 1) “Item Master Active” 2) Create Backup File Run Query in Access - produces file. Compares Lawson Item Master to Cerner Item Master – Produces new items. Cerner file exported to “Prod Weekly” Excel File New items need to build in Cerner Copy and paste “Prod Weekly” file into Cerner Items Upload File .CSV Cerner Item Master Template In Cerner, go to “Materials Management Upload Manager” A Import .CSV file Commit Check for Errors. If after “A” loop, then do not do an error check. Go to “B”. After “B” loop, go to “C” Are there any errors? No Item built in Item Master B Wait for Cerner Ops Jobs 10:00 am; 1:00 pm Cerner Ops Job populates Pricing Tool Manually to into each item number and item location, click “Group Complete.” (Pricing tool application) Open Explorer menu in Cerner Run “Pricing Tool Data” file Exit Cerner. Save as Excel file in Pricing Tool Reports Open Access. Import Pricing Tool File and the File from the Build. Email to “Donna” (Cerner Person) Save as .CSV in “Upload Files for Donna.” Manipulate file to add: Supply (copy and paste) Different Header Add bill code Add price schedule cost and mark up. Go into Excel and open the file Export file to “Upload Files for Donna” Query produces combined Excel file: “Query Upload.date” Run Access Query to compare the two files. Yes Adds Ship to Location Stock/Non-Stock/Facility Send a letter of approval to Team Lead, Materials, and Vendor. Create and send Change Upload File (Excel) to DB II Manually make corrections in Lawson Manually correct errors in Cerner No. Comes out of Clinical Materials Product Review Contracts uploads file to Access Load into “Item Entry System (Access) Lawson Number Approver Store Location Vendor Number, etc. Chargeable? No New Item? No, it’s a replacement Is it a Cerner Item? Yes Send email to Surgical Materials manager Surgical materials manager determines: Usage Locations Pull vendor Price File (Access) and match to Lawson Build File Communicate change to various locations Output file with: Lawson Number Vendor Item Number Price Unit of Measure Description Notify DB I to make change in Cerner Export back to Excel Go into Lawson; Create Vendor Agreement Header Is File over 50 Items? No Key in Manually Contract person activates “Release” function in Lawson Item can now be purchased Cerner uploads to Pricing Tool Yes DBI adds additional mfg to Cerner Manually change price in Pricing Tool (if needed) Yes Notify DB II to make change in Lawson Send to DB II Upload to Lawson Lawson creates file (Still Access) Contract Person(s) manually review file to determine items needing action Approver sometimes has to “nudge” contract person by email Approver: Go to Vendor. Email: Mfg Code Usage Set up contract Release Contract Send to DB II to Auto Upload Enters Order Process at Unit: Omnicell Lawson Template Special Orders Etc. Found that this process takes over 30 steps, and involves 17 file format changes! Communicate to Users that “Item is available to order.” The timing of this communication is critical – to balance ordering with when it will be available from vendor. Need to define this process Buyer Message Item comes in with Differences from P.O. Vendor notifies Mission their ETA to ship stock Invoice Receiving FUTURE STATE Item is approved (2/6/13 Process) Clear message from Value Advisor to Execute Information arrives from Vendor in Mission Excel Template DB I adds Mission Specific information Look for duplicate: Descriptions Manufacturing Item Numbers Manual fix Lawson and Cerner dialog and put out a final product Generate exception report for conflicts. Fix manually
    58. 58. Richard Skiff – Synopses of Healthcare Projects ADDITIONAL “Projects” Root Cause Analysis of Patient Safety Events © 2013 58
    59. 59. Richard Skiff – Synopses of Healthcare Projects Patient Safety Events: Root Cause Analyses Facilitated • Neptune Recall • Phenobarbital Detox • WOW Cart Overheating • NICU Freezer Failure • Propofol Syringe in Patient Room • Vancomycin Extra Dosage • Cardiologist Office Wrong Echocardiogram • Propofol Syringe in NTICU • OR Vacuum Reduction • Trocar Injury • Direct Admit Flu Exposure • Physician Office Complaint • Surgical Sight Specific Infection