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Tollgate Int Med Cycle Time 151120

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Adam Reed, PMP

This document outlines a Lean Six Sigma project to reduce cycle time for internal medicine patient encounters at Naval Hospital Jacksonville. The project charter defines problems with the current process including encounters exceeding three days and provider job dissatisfaction. Goals are to increase the three day completion rate from 79% to 95% and reduce cycle time. A core team is established including sponsors, black belts and subject matter experts. Baseline data shows average encounter completion time is 3.27 days. The current state map depicts the patient flow process and identifies opportunities for improvement around support staff and provider cycle times.

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Naval Hospital Jacksonville CAPT Troy Borema, Project Champion LCDR Eugene Smith Jr MSC USN, Lead Belt/Process Owner Ms. Carola Miner, Command Black Belt Mr. Robert Doyle, NME Black Belt Mentor Internal Medicine Encounter Cycle Time CPIMS # DON 020401 1
NME-Naval Hospital Jacksonville-FY15: Internal Medicine Encounter Cycle Time CPIMS # DON 020401 2 Core Team Project Lead Project Sponsor / Champion Command Black Belt Financial SME LCDR Eugene Smith Jr. MSC USN CAPT Troy Borema MC USN Ms. Carola Miner Ms. Wanda Bartley Team Members AWO1 Adam Reed USN (GB Co-Lead) AWO1 Eric Leide USN (GB Co-Lead) Ms. Carla Little RN (Int Med Clinic Nurse) Ms. Ann Mott FNP (Int Med Clinic PCM) LT Steven Koplin MC USN (Int Med Clinic PCM) HN Kyle Bowen USN (Int Med Clinic Corpsman) HN James Messersmith USN (Int Med Clinic Corpsman) HN Yolanda Romero USN (Int Med Clinic Corpsman) HN Jacob Moulton USN (Int Med Clinic Corpsman)
Project Charter 3 Problem Statement: Project Goal: Concern that the current patient demand at Naval Hospital Jacksonville Internal Medicine Clinic may exceed the capacity of Internal Medicine providers was identified during Leadership Rounds in March-April 2015. During FY15, through 31MAR15, the existing processes in the Internal Medicine Clinic have resulted in a three day appointment completion rate of 79%, as well as removal of providers from the appointment schedule to complete encounters and provider job dissatisfaction. • Create a streamlined process that reduces patient cycle time and improves the capacity of the Internal Medicine Clinic to meet patient demand • Increase the percentage of Internal Medicine Clinic encounters meeting the Department of Defense Three Day Completion Standard Expected Benefits: Metric Baseline Improvement Goal Improve capacity of Internal Medicine Clinic to meet patient demand Increase the percentage of internal medicine encounters meeting the DoD Three Day Completion Standard Reduction in provider dissatisfaction 3 Day Encounter Completion 79% Jan-Mar 2015 95% Mean Patient Flow Cycle Times Support Staff-Patient Provider-Patient 33 Minutes 29 Minutes 20 Minutes 20 Minutes Mean Cycle Time Encounter Completion 3.27 Days April 2015 Less than 3 Days Tollgate Planned End Date Actual End Date Primary Metric: Three Day Encounter Completion from monthly DoD DQMC program audit.Pre-Event 29MAY15 19MAY15 Event 26JUN15 09SEP15 Post-Event 17JUL15 12NOV15 Secondary Metrics: Cycle Time: Patient Flow: Patient Check-In to Corpsman Provider Turnover Cycle Time: Patient Flow: Provider Review Patient Info o Proceed to Next Patient Cycle Time: Patient Check-In to Encounter signed in AHLTA Validate 31JUL15 30NOV15
Voice of the Customer CPIMS # DON 020401 4 • Patients: • Patients have to wait past scheduled appointment time when encounter cycle times extend beyond scheduled appointment durations. • Support Staff: • Unique provider preferences for patient appointments can lead to support staff having to scramble to get patient into rooms • Providers: • Providers staying late and needing time out of clinic to complete patient encounters negatively impacting access to care for some patients. • Command Leadership: • During leadership rounds Internal Medicine Clinic providers expressed concern that patient enrollment level may be greater than provider’s capacity to deliver care. • DHA: • Internal Medicine Clinic consistently below DoD standard for timely completion of encounters.
Communication Plan CPIMS # DON 020401 5 COMMUNICATION PLAN: Internal Medicine Encounter Cycle Time Purpose Audience Media Discussion Topics Responsibl e Person Frequency of Communication Location Notes/Status MEETING AGENDA Project Team Email  Project status  Next team meeting (date, time, location, etc.)  Action item status  Other project info Team Leader Q Meeting Outlook CHAMPION MEETING Champion/GB/BB/ Sponsor/Process Owner Face-to Face  Project Charter Brief  Tollgate Briefs  Project status Team Leader w Lead Belt Within 2 weeks of completing Tollgate Varies TEAM MEETING Project Team Face-to Face  Charter, SIPOC, Current State Map, Ishikawa, VOC, VSA & VSM, etc Project Leader As needed. Agenda can include problem solving, evaluation, reporting, decision making, or planning Varries PROBLEM SOLVING MEETING Project Team and Ad Hoc/SMEs as needed Face to Face  Analysis of specific issue using appropriate tools. Team Leader w Lead Belt As needed, may be included in regular team meeting Varies EVALUATION MEETING Project Team Face-to Face  Project Status  Review of barriers to implementation Team Leader Monthly or as needed, may be included in regular team meeting Varies REPORTING MEETINGS Project Team Email  Team progress and updates of outcome or in-process metrics Lead Belt Monthly or as needed. may be included in regular team meeting Varies DECISION MAKING MEETINGS Project Team and Ad Hoc/SMEs as needed Face-to Face  Proposed Charter changes and actions on JDIs Team Leader As Needed, may be included in regular team meeting Varies PLANNING MEETING Project Team and Ad Hoc/SMEs as needed Face-to Face  Plan JDI implementations Project Team As Needed, may be included in regular team meeting Varies
Data Collection Plan CPIMS # DON 020401 6 NH Jacksonville: Internal Med Cycle Time What questions do you want to answer? 1.Is IntMed Clinic meeting DoD requirement for timely completion of patient encounters. 2. How efficient is the patient flow process in Internal Medicine Metric Data Type (Discrete / Continuous) Operational Definition Sampling Notes Source and Location Collection method Who will collect data Three Day Encounter Completion Discrete Per DoD Data Quality Management Control (DQMC) SOP 100% Sample Monthly DQMC Report Obtain from NH Jax Data Quality Manager Ms. Wanda Bartley Cycle Time: Encounter Completion Continuous Time from Patient Check-In to Provider signs AHLTA Record 100% Sample CHCS Ad Hoc “BOCI” Spool and save report as text file. Import into Excel and calculate the difference between Patient Check-In and Provider signature on AHLTA encounter. Health Systems Specialist, Tricare Operations Dept. Cycle Time for Provider and Support Staff Continious Time from Patient Check-In to Corpsman Provider Turnover Time from Provider Review Patient Info o Proceed to Next Patient Minimum of 5 patient encounters for each of 2 providers Internal Medicine Patient Schedule Time study checklist AWO1 Adam Reed How will data be used? How will data be displayed? What is plan for starting data collection? To assess baseline performance and quantify improvements. Cycle time for Provider and Support Staff: Bar Chart Three Day Encounter Completion: Run Chart Cycle Time Encounter Completion: Control Chart Obtain baseline data from DQ Manager Ms.Bartley. Create tracking tool for capturing Provider and Support Staff Cycle Times. Create CHCS ad hoc for encounter completion cycle time.
Baseline Data CPIMS # DON 020401 7 Metric Baseline Goal Delta Previous Support Staff Cycle Time 33 minutes 20 minutes 13 minutes Previous Provider Cycle Time 29 Minutes 20 minutes 6 Minutes Encounter Completion Cycle Time Pt Check-In to AHLTA Signature 3.19 Days <3 Days 0.19 Days Three Business Day Encounter Completion DoD Data Quality Standard 79% Sigma 2.19 95% Sigma 3.14 16% 0.95
SIPOC CPIMS # DON 020401 8 CustomersSuppliers Process •Beneficiaries •IMD •Command Leadership •DON/BUMED •Time to document care •Support Staff •Training •# staff on duty • Appts available •AHLTA -CHCS •# of enrollees •ATC regulations and standards •PCM availability •Check-in process and forms •Patient Encounter Complete •Patient Health •Reported Workload •HEDIS Compliance •Patient Satisfaction •Ancillary Services •Scripts •Lab •X-Rays ect… •CHCS data •Access to care and other PCMH reports •Access to Care •ICE Comments CTQCTP Support Staff Calls Patient Provider Examines Patient Provider Documents Care Inbound: Patient Checks-In for Appt •Patients •PCMs/Providers •Clinic/command leadership •DON, BUMED Inputs Outputs Outbound: Encounter reported complete in CHCS Ambulatory Data Module 2 - 1440 Minutes VOC Limited time to complete encounter documentation requirements
Current State Value Stream Analysis 9 • GEMBA walk of patient flow included time study to measure corpsman and provider processes • Support staff cycle time started with patient documentation pocked up by support staff • Provider cycle time started with provider reviews patient information. • Providers are frequently unable to close out patient encounters (AHLTA note signed) until after patient leaves due to next waiting patient, or need for additional info/labs/ect... • Visio Version of process maps included as documents in CPIMS START: PATIENT CHECKS-INFOR APPOINTMENT PATIENTARRIVES ATFRONTDESK FRONTDESKSCANS IDANDCHECKS PATIENTIN FRONTDESKQA PAPERWORK FRONTDESK MOVES PAPERWORKTO INBOX SUPPORTSTAFF CHECKROOM AVAILABILITY CURRENT INSURANCE PAPERWORK CURRENT INSURANCE PAPERWORK FRONTDESKGIVE PATIENTDD2569 TOCOMPLETE FRONTDESKPRINTS SF600ANDSTITCH &TIME FRONTDESKPRINTS PLANOFACTION FORMS FRONTDESKPRINTS PAPFORMS SUPPORTSTAFF PREPS& SANITIZEEXAM ROOM PATIENT DOCUMENTATION PICKEDUPBY SUPPORTSTAFF SUPPORT STAFF CALLS PATIENT PATIENTIS MOVED TRIAGE ROOM SUPPORTSTAFF TAKESWEIGHT, VITALS, AND BLOODPRESSURE DATAINPUTINTO COMPUTER SUPPORTSTAFF INITIALHPION SF600 SUPPORTSTAFF TABSINTSWF INFORMATION SUPPORT STAFFTRIAGE ISSUES PAP FEMALE STANDBY REQUESTED FINDFEMALE STANDBY ROOM AVAILABE ROOM OCCUPIED WAITFOR AVAILABLEROOM PREPPATIENT ROOM MOVEPATIENTTO EXAMROOM SUPPORTSTAFF TURNOVERWITH PROVIDER PROVIDERREVIEWS PAITIENT INFORMATION PROVIDER NEEDS ADDITIONAL INFO PROVIDERPULLS ADDITIONALINFO FROMPATIENT CHART/ ELECTRONIC MEDICALRECORD PROCEEDTOEXAM ROOM NO COMPLETEPATIENT IDENTIFIERS PROVIDERQ&A PROVIDER EXAMINESPATIENT DIAGNOSEAND PRESCRIBE RECOMMENDATION PAP SUPPORTSTAFF PLACESLABELS ONSPECIMENS SUPPORTSTAFF DROPOFF SPECIMENFORLAB PICKUP NEXTPATIENT CHECKEDIN INPUTLABS, MEDICATIONS, CONSULTS,NOTES, ETC... WORKON INCOMPLETENOTES ECT…UNTILNEXT PATENTARRIVES INPUTLABS& MEDICATIONS ANDWORKON NOTE PROCEED TONEXT PATIENT END:ENCOUNTERREPORTEDAS COMPLETEINCHCSAMBULATORYDATA MODULE(ADM) CHECKIN SHEET AVAILABLE YES PATIENT COMPLETES SHEET SUPPORT STAFFPRINTS FORMS FINDSCALETO WEIGH PATIENT MEDICATION REVIEW REVIEWLAST NOTE&LAB DISCUSSESPRIOR TREATMENT EFFECTIVENESS PROVIDES RECOMMENDATIONS DISCUSSES CHIEF COMPLAINT CHECKOUT SHEET AVAILABLE RETRIEVE SHEETFROM OFFICE PATIENT COMPLETES FORM YES NO YES NO YES YES NO YES NO NO YES NO NO YES NO YES YES NO Start Support Staff Cycle Time End Support Staff Cycle Time Avg Support StaffCycle Time 33Min Start Provider Cycle Time End Provider Cycle Time AvgCycleTime PtCheck-Into Completed Encounter: 3.19Days DOCUMENTATON COMPLETE YES NO PRE PRINTED LABELS AVAIL? PRINT LABELS NO YES PROVUNIQUE REQUIREMENT NO Avg Provider CycleTime 29Min Handoff CorpsmantoProvider Handoff CorpsmantoProvider
RCA: Affinity Brainstorming with Multi Voting & 5 Whys 10 Affinity Question: What delays patient flow and completion of encounter documentation Consensus Prioritization 2 1 3 Affinity Header Variation in Patient Flow Not Enough Time Appt Scrubbing/Prep Affinity Cards No consistent use of exam rooms. Room not cleaned after patient leaves Lots of paperwork Enrollment panels too high Not sure what patient needs at check-in (HEDIS, TPC, ect…) Different providers use different forms. Patient did not complete forms. Too much paperwork Too many patients Not knowing time expectations for encounters. Patients don’t always go to the same exam room Appt go over time. Complicated Patients Appt times not long enough to complete notes Equipment needed for patient not always ready. Forms not always available Lots of paperwork Having to look for additional information Not enough time in appt to complete note. Scrambling to find a standby Equipment needed for patient not always ready. Patients don’t know what to do with forms they fill out. Waiting for labs or other info. Patients have more than 20 minutes of problems. Not knowing why a patient is coming in. New corpsman don’t always know what to do. Staff Turnover Need additional information to complete Assessment/Dx/Plan Unrelated follow on questions Having to look for additional information Clinic Orientation for new corpsmen varies. Having to look for additional information Not sure what patient needs at check-in (HEDIS, TPC, ect…) Room not ready, previous patient is still in the room. Different providers use different forms.
Implementation Plan CPIMS # DON021765 11 Date Implementation Action RCA Link Start Finish Responsible Party Team Agreement Process Owner Understanding Comments/Outcome Apr 2015 Optimize utilization of Support Staff with Standard Work SOP (Variation in Patient Flow) 1May15 31Aug 15 Int Med LPO Yes Yes Clarified, standardized and simplified process steps to get patient ready for provider. Created written SOP for support staff process. Apr 2015 Reestablish Team Huddles (Appt Scrubbing/Prep) 1May15 31Aug15 Int Med Team Leads Yes Yes Reestablished daily team huddles which enable identification of patients prep requirements and help to reduces last minute scrambling for information, supplies and equipment that prolong cycle times for support staff and provider processes Apr 2015 Provider Admin Time (Medical Documentation Requirements) 1May15 31Aug15 Champion and Int Med Dept Head Yes Yes Increased patient demand and complexity/variation of patient health issues limit amount of time available to complete all required medical documentation within scheduled appointment times. Champion approved 3 hours of uninterrupted, rotating administrative time per week for providers to complete medical documentation.
Process Artifacts 12 SOP for Internal Medicine Support Staff SOP for CHCS Ad Hoc BOCI
Future State Value Stream Analysis 13 • Support staff process streamlined from 27 to 16 steps. New process includes Standard Work SOP for Support Staff and decreased average cycle time by 19 minutes, from 33 to 16 minutes (↓57.6%). • Provider process streamlined from 22 to 16 steps. New process decreased average cycle time by 6 minutes, from 29 to 23 minutes (↓20.7%). • Visio version of process maps uploaded into CPIMS documents START:PATIENT CHECKS-INFOR APPOINTMENT PATIENTARRIVES ATFRONTDESK FRONTDESKSCANS IDANDCHECKS PATIENTIN CURRENT INSURANCE PAPERWORK FRONTDESKGIVES PATIENT PAPERWORKTO COMPLETE FRONTDESKPRINTS NECESSARYFORMS (SF600,STITCHIN TIME,PLANOF ACTION,&PAP) FRONTDESK MOVESPATIENT PAPERWORKTO INBOX PATIENT DOCUMENTATION ISPICKEDUPBY SUPPORTSTAFF SUPPORTSTAFF CALLSPATIENT PATIENTISMOVED TOTRIAGEROOM SUPPORTSTAFF TAKESPATIENTS WEIGHT,VITALS, ANDBLOOD PRESSURE DATAISINPUTINTO ELECTRONIC MEDICALRECORD SUPPORTSTAFF INITIALSHPION SF600 SUPPORTSTAFF TABSINTSWF INFORMATION SUPPORTSTAFF COMPLETESSF508 MEDICATION REVIEW SUPPORTSTAFF TRIAGESISSUES PAP FEMALE STANDBY REQUESTED FINDFEMALE STANDBY SUPPORT STAFFDOES TURNOVER WITH PROVIDER PROVIDER REVIEW PATIENT INFORMATION PROVIDER REQUEST SUPPORTSTAFF TOORDER REFILLS SUPPORTSTAFF ORDERS MEDICATION REFILLS PROVIDERREADY TOPROCEED REVIEWPATIENT CHART/ ELECTRONIC MEDICALRECORD PROCEEDTO EXAMROOM COMPLETE PATIENT IDENTIFIERS PROVIDERQ&A EXAMINEPATIENT DIAGNOSEAND PRESCRIBE RECOMMENDATIONS PAP SUPPORTSTAFF PLACESLABELSON SPECIMENS SUPPORTSTAFF DROPSOFF SPECIMENSFORLAB PICKUP NEXTPATIENT CHECKED-IN INPUTLABS, MEDICATIONS, CONSULTS,NOTES ETC... WORKON INCOMPLETENOTES ECT...UNTILNEXT PATIENTARRIVES INPUTLABSAND MEDICATIONSAND WORKONNOTE PROCEEDTO NEXT PATIENT END:ENCOUNTERREPORTED COMPLETEINCHCS AMBULATORYDATAMODULE YES NO NO YES YES NO YES YES NO NO YES YES NO NO ESTABLISH& PRIORITIZE PATIENTAND PROVIDERISSUES SETACHIEVABLE GOALSFORTHE VISIT AvgCycle Timefor completed encounter: 2.52Days DOCUMENTATON COMPLETE Intervention: SchedAdminTime Start Support Staff Cycle Time End Support Staff Cycle Time Avg Support StaffCycle Time 14Min Start Provider Cycle Time End Provider Cycle Time Avg Provider CycleTime 23Min Handoff CorpsmantoProvider Handoff CorpsmantoProvider Intervention: StandardWorkforCorpsStaff Intervention:RevitalizeHuddles Allowsforimprovedcare coordinationandimpacts multiplesteps Intervention:RevitalizeHuddles Allowsforimprovedcare coordinationandimpacts multiplesteps
Results Data Three Day Encounter Completion CPIMS # DON 020401 14 • Standardization of support staff process for getting patient ready for provider and scheduled admin time to complete records increased available time to complete patient encounters. • Increased 3 Business Day Compliance by 8%: • from 79% to 87%. • Improved Process Sigma by 0.33: • From 2.3 to 2.63. • Process significantly improved with opportunities for continued improvement.
Results Data Encounter Completion Cycle Time 15 • Time from check-in to provider signature in AHLTA for individual encounters decreased from average of 3.19 days in April 2015 to 2.52 days in Oct 2015. • Upper control limit decreased from 13.7 days to 12.75 days. • T Test for difference in cycle times significant with P-Value of 0.002 and CI of 95%. • Data includes all completed encounters for checked in patients between 1-30 Apr and 1- 15 Oct 2015.
Results Data Patient Flow Cycle Times 16 • After standardization and simplification of patient flow process, mean cycle times decreased for both the support staff and provider portions of the process • Support staff cycle time: • ↓ 19 minutes (57.6%). • Provider cycle time: • ↓ 6 minutes (20.7%)
Control Plan CPIMS # DON 020401 17 CONTROL PLAN Process Name: NH Jacksonville Internal Medicine Cycle Time 1 2 3 4 5 6 7 8 9 10 11 12 Name of Measure Measure Definition Measure Calculation Data Source Goal Measure Frequency Sample Size When to Act/Trigger Who Decides to Act Who Acts Reaction to Out of Control Display Method 3 Day coding compliance Patient Cycle Time Audit Encounter Complete Cycle Time % of Kept Encounters closed within 3 Business Days (Definition in DoD DQMC SOP) Per Data Collection Plan Per Data Collection Plan Monthly average of: # Encounters closed within 3 business days/# of kept encounters. Per Data Collection Plan Per Data Collection Plan Data Quality Report Time Study Checklist Per Data Collection Plan 95% <20Min Avg < 3 days Monthly Monthly Monthly 100% Min of 20 patient and 2 providers 100% When >95% for three consecutive months, or 4 months in a 5 month period. When mean support staff cycle time is >20 min When mean cycle time is > 3 minutes Data Quality Manager IntMed Clinic LPO IntMed Dept Head IntMed Dept Head IntMed Clinic LPO IntMed Dept Head Identify cause of failure and design intervention to correct failure. Identify cause of failure and design intervention to correct failure. Identify cause of failure and design intervention to correct failure. Run chart Run Chart Run Chart
LSS Scorecard CPIMS # DON 020401 18 LSS SCORECARD Metric Name: BASELINE RESULTS POST INTERVENTION RESULTS TOTAL CHANGE FROM BASELINE Patient Flow Cycle Time: (a) Support Staff (b) Provider (a) 33 Min (b) 29 Min (a) 14 Min (b) 23 Min (a) ↓ 19 Min (57.6%) (b) ↓ 6 Min (20.7%) Encounter Completion Cycle Time 3.19 Days 2.52 Days ↓0.67 Days (21.0%) 3 Day Encounter Completion: (a) Percent Complete (b) Sigma (a) 79% (b) 2.30 (a) 87% (b) 2.63 (a) ↑0.67 Days (b) ↑0.33 Sigma

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Tollgate Int Med Cycle Time 151120

  • 1. Naval Hospital Jacksonville CAPT Troy Borema, Project Champion LCDR Eugene Smith Jr MSC USN, Lead Belt/Process Owner Ms. Carola Miner, Command Black Belt Mr. Robert Doyle, NME Black Belt Mentor Internal Medicine Encounter Cycle Time CPIMS # DON 020401 1
  • 2. NME-Naval Hospital Jacksonville-FY15: Internal Medicine Encounter Cycle Time CPIMS # DON 020401 2 Core Team Project Lead Project Sponsor / Champion Command Black Belt Financial SME LCDR Eugene Smith Jr. MSC USN CAPT Troy Borema MC USN Ms. Carola Miner Ms. Wanda Bartley Team Members AWO1 Adam Reed USN (GB Co-Lead) AWO1 Eric Leide USN (GB Co-Lead) Ms. Carla Little RN (Int Med Clinic Nurse) Ms. Ann Mott FNP (Int Med Clinic PCM) LT Steven Koplin MC USN (Int Med Clinic PCM) HN Kyle Bowen USN (Int Med Clinic Corpsman) HN James Messersmith USN (Int Med Clinic Corpsman) HN Yolanda Romero USN (Int Med Clinic Corpsman) HN Jacob Moulton USN (Int Med Clinic Corpsman)
  • 3. Project Charter 3 Problem Statement: Project Goal: Concern that the current patient demand at Naval Hospital Jacksonville Internal Medicine Clinic may exceed the capacity of Internal Medicine providers was identified during Leadership Rounds in March-April 2015. During FY15, through 31MAR15, the existing processes in the Internal Medicine Clinic have resulted in a three day appointment completion rate of 79%, as well as removal of providers from the appointment schedule to complete encounters and provider job dissatisfaction. • Create a streamlined process that reduces patient cycle time and improves the capacity of the Internal Medicine Clinic to meet patient demand • Increase the percentage of Internal Medicine Clinic encounters meeting the Department of Defense Three Day Completion Standard Expected Benefits: Metric Baseline Improvement Goal Improve capacity of Internal Medicine Clinic to meet patient demand Increase the percentage of internal medicine encounters meeting the DoD Three Day Completion Standard Reduction in provider dissatisfaction 3 Day Encounter Completion 79% Jan-Mar 2015 95% Mean Patient Flow Cycle Times Support Staff-Patient Provider-Patient 33 Minutes 29 Minutes 20 Minutes 20 Minutes Mean Cycle Time Encounter Completion 3.27 Days April 2015 Less than 3 Days Tollgate Planned End Date Actual End Date Primary Metric: Three Day Encounter Completion from monthly DoD DQMC program audit.Pre-Event 29MAY15 19MAY15 Event 26JUN15 09SEP15 Post-Event 17JUL15 12NOV15 Secondary Metrics: Cycle Time: Patient Flow: Patient Check-In to Corpsman Provider Turnover Cycle Time: Patient Flow: Provider Review Patient Info o Proceed to Next Patient Cycle Time: Patient Check-In to Encounter signed in AHLTA Validate 31JUL15 30NOV15
  • 4. Voice of the Customer CPIMS # DON 020401 4 • Patients: • Patients have to wait past scheduled appointment time when encounter cycle times extend beyond scheduled appointment durations. • Support Staff: • Unique provider preferences for patient appointments can lead to support staff having to scramble to get patient into rooms • Providers: • Providers staying late and needing time out of clinic to complete patient encounters negatively impacting access to care for some patients. • Command Leadership: • During leadership rounds Internal Medicine Clinic providers expressed concern that patient enrollment level may be greater than provider’s capacity to deliver care. • DHA: • Internal Medicine Clinic consistently below DoD standard for timely completion of encounters.
  • 5. Communication Plan CPIMS # DON 020401 5 COMMUNICATION PLAN: Internal Medicine Encounter Cycle Time Purpose Audience Media Discussion Topics Responsibl e Person Frequency of Communication Location Notes/Status MEETING AGENDA Project Team Email  Project status  Next team meeting (date, time, location, etc.)  Action item status  Other project info Team Leader Q Meeting Outlook CHAMPION MEETING Champion/GB/BB/ Sponsor/Process Owner Face-to Face  Project Charter Brief  Tollgate Briefs  Project status Team Leader w Lead Belt Within 2 weeks of completing Tollgate Varies TEAM MEETING Project Team Face-to Face  Charter, SIPOC, Current State Map, Ishikawa, VOC, VSA & VSM, etc Project Leader As needed. Agenda can include problem solving, evaluation, reporting, decision making, or planning Varries PROBLEM SOLVING MEETING Project Team and Ad Hoc/SMEs as needed Face to Face  Analysis of specific issue using appropriate tools. Team Leader w Lead Belt As needed, may be included in regular team meeting Varies EVALUATION MEETING Project Team Face-to Face  Project Status  Review of barriers to implementation Team Leader Monthly or as needed, may be included in regular team meeting Varies REPORTING MEETINGS Project Team Email  Team progress and updates of outcome or in-process metrics Lead Belt Monthly or as needed. may be included in regular team meeting Varies DECISION MAKING MEETINGS Project Team and Ad Hoc/SMEs as needed Face-to Face  Proposed Charter changes and actions on JDIs Team Leader As Needed, may be included in regular team meeting Varies PLANNING MEETING Project Team and Ad Hoc/SMEs as needed Face-to Face  Plan JDI implementations Project Team As Needed, may be included in regular team meeting Varies
  • 6. Data Collection Plan CPIMS # DON 020401 6 NH Jacksonville: Internal Med Cycle Time What questions do you want to answer? 1.Is IntMed Clinic meeting DoD requirement for timely completion of patient encounters. 2. How efficient is the patient flow process in Internal Medicine Metric Data Type (Discrete / Continuous) Operational Definition Sampling Notes Source and Location Collection method Who will collect data Three Day Encounter Completion Discrete Per DoD Data Quality Management Control (DQMC) SOP 100% Sample Monthly DQMC Report Obtain from NH Jax Data Quality Manager Ms. Wanda Bartley Cycle Time: Encounter Completion Continuous Time from Patient Check-In to Provider signs AHLTA Record 100% Sample CHCS Ad Hoc “BOCI” Spool and save report as text file. Import into Excel and calculate the difference between Patient Check-In and Provider signature on AHLTA encounter. Health Systems Specialist, Tricare Operations Dept. Cycle Time for Provider and Support Staff Continious Time from Patient Check-In to Corpsman Provider Turnover Time from Provider Review Patient Info o Proceed to Next Patient Minimum of 5 patient encounters for each of 2 providers Internal Medicine Patient Schedule Time study checklist AWO1 Adam Reed How will data be used? How will data be displayed? What is plan for starting data collection? To assess baseline performance and quantify improvements. Cycle time for Provider and Support Staff: Bar Chart Three Day Encounter Completion: Run Chart Cycle Time Encounter Completion: Control Chart Obtain baseline data from DQ Manager Ms.Bartley. Create tracking tool for capturing Provider and Support Staff Cycle Times. Create CHCS ad hoc for encounter completion cycle time.
  • 7. Baseline Data CPIMS # DON 020401 7 Metric Baseline Goal Delta Previous Support Staff Cycle Time 33 minutes 20 minutes 13 minutes Previous Provider Cycle Time 29 Minutes 20 minutes 6 Minutes Encounter Completion Cycle Time Pt Check-In to AHLTA Signature 3.19 Days <3 Days 0.19 Days Three Business Day Encounter Completion DoD Data Quality Standard 79% Sigma 2.19 95% Sigma 3.14 16% 0.95
  • 8. SIPOC CPIMS # DON 020401 8 CustomersSuppliers Process •Beneficiaries •IMD •Command Leadership •DON/BUMED •Time to document care •Support Staff •Training •# staff on duty • Appts available •AHLTA -CHCS •# of enrollees •ATC regulations and standards •PCM availability •Check-in process and forms •Patient Encounter Complete •Patient Health •Reported Workload •HEDIS Compliance •Patient Satisfaction •Ancillary Services •Scripts •Lab •X-Rays ect… •CHCS data •Access to care and other PCMH reports •Access to Care •ICE Comments CTQCTP Support Staff Calls Patient Provider Examines Patient Provider Documents Care Inbound: Patient Checks-In for Appt •Patients •PCMs/Providers •Clinic/command leadership •DON, BUMED Inputs Outputs Outbound: Encounter reported complete in CHCS Ambulatory Data Module 2 - 1440 Minutes VOC Limited time to complete encounter documentation requirements
  • 9. Current State Value Stream Analysis 9 • GEMBA walk of patient flow included time study to measure corpsman and provider processes • Support staff cycle time started with patient documentation pocked up by support staff • Provider cycle time started with provider reviews patient information. • Providers are frequently unable to close out patient encounters (AHLTA note signed) until after patient leaves due to next waiting patient, or need for additional info/labs/ect... • Visio Version of process maps included as documents in CPIMS START: PATIENT CHECKS-INFOR APPOINTMENT PATIENTARRIVES ATFRONTDESK FRONTDESKSCANS IDANDCHECKS PATIENTIN FRONTDESKQA PAPERWORK FRONTDESK MOVES PAPERWORKTO INBOX SUPPORTSTAFF CHECKROOM AVAILABILITY CURRENT INSURANCE PAPERWORK CURRENT INSURANCE PAPERWORK FRONTDESKGIVE PATIENTDD2569 TOCOMPLETE FRONTDESKPRINTS SF600ANDSTITCH &TIME FRONTDESKPRINTS PLANOFACTION FORMS FRONTDESKPRINTS PAPFORMS SUPPORTSTAFF PREPS& SANITIZEEXAM ROOM PATIENT DOCUMENTATION PICKEDUPBY SUPPORTSTAFF SUPPORT STAFF CALLS PATIENT PATIENTIS MOVED TRIAGE ROOM SUPPORTSTAFF TAKESWEIGHT, VITALS, AND BLOODPRESSURE DATAINPUTINTO COMPUTER SUPPORTSTAFF INITIALHPION SF600 SUPPORTSTAFF TABSINTSWF INFORMATION SUPPORT STAFFTRIAGE ISSUES PAP FEMALE STANDBY REQUESTED FINDFEMALE STANDBY ROOM AVAILABE ROOM OCCUPIED WAITFOR AVAILABLEROOM PREPPATIENT ROOM MOVEPATIENTTO EXAMROOM SUPPORTSTAFF TURNOVERWITH PROVIDER PROVIDERREVIEWS PAITIENT INFORMATION PROVIDER NEEDS ADDITIONAL INFO PROVIDERPULLS ADDITIONALINFO FROMPATIENT CHART/ ELECTRONIC MEDICALRECORD PROCEEDTOEXAM ROOM NO COMPLETEPATIENT IDENTIFIERS PROVIDERQ&A PROVIDER EXAMINESPATIENT DIAGNOSEAND PRESCRIBE RECOMMENDATION PAP SUPPORTSTAFF PLACESLABELS ONSPECIMENS SUPPORTSTAFF DROPOFF SPECIMENFORLAB PICKUP NEXTPATIENT CHECKEDIN INPUTLABS, MEDICATIONS, CONSULTS,NOTES, ETC... WORKON INCOMPLETENOTES ECT…UNTILNEXT PATENTARRIVES INPUTLABS& MEDICATIONS ANDWORKON NOTE PROCEED TONEXT PATIENT END:ENCOUNTERREPORTEDAS COMPLETEINCHCSAMBULATORYDATA MODULE(ADM) CHECKIN SHEET AVAILABLE YES PATIENT COMPLETES SHEET SUPPORT STAFFPRINTS FORMS FINDSCALETO WEIGH PATIENT MEDICATION REVIEW REVIEWLAST NOTE&LAB DISCUSSESPRIOR TREATMENT EFFECTIVENESS PROVIDES RECOMMENDATIONS DISCUSSES CHIEF COMPLAINT CHECKOUT SHEET AVAILABLE RETRIEVE SHEETFROM OFFICE PATIENT COMPLETES FORM YES NO YES NO YES YES NO YES NO NO YES NO NO YES NO YES YES NO Start Support Staff Cycle Time End Support Staff Cycle Time Avg Support StaffCycle Time 33Min Start Provider Cycle Time End Provider Cycle Time AvgCycleTime PtCheck-Into Completed Encounter: 3.19Days DOCUMENTATON COMPLETE YES NO PRE PRINTED LABELS AVAIL? PRINT LABELS NO YES PROVUNIQUE REQUIREMENT NO Avg Provider CycleTime 29Min Handoff CorpsmantoProvider Handoff CorpsmantoProvider
  • 10. RCA: Affinity Brainstorming with Multi Voting & 5 Whys 10 Affinity Question: What delays patient flow and completion of encounter documentation Consensus Prioritization 2 1 3 Affinity Header Variation in Patient Flow Not Enough Time Appt Scrubbing/Prep Affinity Cards No consistent use of exam rooms. Room not cleaned after patient leaves Lots of paperwork Enrollment panels too high Not sure what patient needs at check-in (HEDIS, TPC, ect…) Different providers use different forms. Patient did not complete forms. Too much paperwork Too many patients Not knowing time expectations for encounters. Patients don’t always go to the same exam room Appt go over time. Complicated Patients Appt times not long enough to complete notes Equipment needed for patient not always ready. Forms not always available Lots of paperwork Having to look for additional information Not enough time in appt to complete note. Scrambling to find a standby Equipment needed for patient not always ready. Patients don’t know what to do with forms they fill out. Waiting for labs or other info. Patients have more than 20 minutes of problems. Not knowing why a patient is coming in. New corpsman don’t always know what to do. Staff Turnover Need additional information to complete Assessment/Dx/Plan Unrelated follow on questions Having to look for additional information Clinic Orientation for new corpsmen varies. Having to look for additional information Not sure what patient needs at check-in (HEDIS, TPC, ect…) Room not ready, previous patient is still in the room. Different providers use different forms.
  • 11. Implementation Plan CPIMS # DON021765 11 Date Implementation Action RCA Link Start Finish Responsible Party Team Agreement Process Owner Understanding Comments/Outcome Apr 2015 Optimize utilization of Support Staff with Standard Work SOP (Variation in Patient Flow) 1May15 31Aug 15 Int Med LPO Yes Yes Clarified, standardized and simplified process steps to get patient ready for provider. Created written SOP for support staff process. Apr 2015 Reestablish Team Huddles (Appt Scrubbing/Prep) 1May15 31Aug15 Int Med Team Leads Yes Yes Reestablished daily team huddles which enable identification of patients prep requirements and help to reduces last minute scrambling for information, supplies and equipment that prolong cycle times for support staff and provider processes Apr 2015 Provider Admin Time (Medical Documentation Requirements) 1May15 31Aug15 Champion and Int Med Dept Head Yes Yes Increased patient demand and complexity/variation of patient health issues limit amount of time available to complete all required medical documentation within scheduled appointment times. Champion approved 3 hours of uninterrupted, rotating administrative time per week for providers to complete medical documentation.
  • 12. Process Artifacts 12 SOP for Internal Medicine Support Staff SOP for CHCS Ad Hoc BOCI
  • 13. Future State Value Stream Analysis 13 • Support staff process streamlined from 27 to 16 steps. New process includes Standard Work SOP for Support Staff and decreased average cycle time by 19 minutes, from 33 to 16 minutes (↓57.6%). • Provider process streamlined from 22 to 16 steps. New process decreased average cycle time by 6 minutes, from 29 to 23 minutes (↓20.7%). • Visio version of process maps uploaded into CPIMS documents START:PATIENT CHECKS-INFOR APPOINTMENT PATIENTARRIVES ATFRONTDESK FRONTDESKSCANS IDANDCHECKS PATIENTIN CURRENT INSURANCE PAPERWORK FRONTDESKGIVES PATIENT PAPERWORKTO COMPLETE FRONTDESKPRINTS NECESSARYFORMS (SF600,STITCHIN TIME,PLANOF ACTION,&PAP) FRONTDESK MOVESPATIENT PAPERWORKTO INBOX PATIENT DOCUMENTATION ISPICKEDUPBY SUPPORTSTAFF SUPPORTSTAFF CALLSPATIENT PATIENTISMOVED TOTRIAGEROOM SUPPORTSTAFF TAKESPATIENTS WEIGHT,VITALS, ANDBLOOD PRESSURE DATAISINPUTINTO ELECTRONIC MEDICALRECORD SUPPORTSTAFF INITIALSHPION SF600 SUPPORTSTAFF TABSINTSWF INFORMATION SUPPORTSTAFF COMPLETESSF508 MEDICATION REVIEW SUPPORTSTAFF TRIAGESISSUES PAP FEMALE STANDBY REQUESTED FINDFEMALE STANDBY SUPPORT STAFFDOES TURNOVER WITH PROVIDER PROVIDER REVIEW PATIENT INFORMATION PROVIDER REQUEST SUPPORTSTAFF TOORDER REFILLS SUPPORTSTAFF ORDERS MEDICATION REFILLS PROVIDERREADY TOPROCEED REVIEWPATIENT CHART/ ELECTRONIC MEDICALRECORD PROCEEDTO EXAMROOM COMPLETE PATIENT IDENTIFIERS PROVIDERQ&A EXAMINEPATIENT DIAGNOSEAND PRESCRIBE RECOMMENDATIONS PAP SUPPORTSTAFF PLACESLABELSON SPECIMENS SUPPORTSTAFF DROPSOFF SPECIMENSFORLAB PICKUP NEXTPATIENT CHECKED-IN INPUTLABS, MEDICATIONS, CONSULTS,NOTES ETC... WORKON INCOMPLETENOTES ECT...UNTILNEXT PATIENTARRIVES INPUTLABSAND MEDICATIONSAND WORKONNOTE PROCEEDTO NEXT PATIENT END:ENCOUNTERREPORTED COMPLETEINCHCS AMBULATORYDATAMODULE YES NO NO YES YES NO YES YES NO NO YES YES NO NO ESTABLISH& PRIORITIZE PATIENTAND PROVIDERISSUES SETACHIEVABLE GOALSFORTHE VISIT AvgCycle Timefor completed encounter: 2.52Days DOCUMENTATON COMPLETE Intervention: SchedAdminTime Start Support Staff Cycle Time End Support Staff Cycle Time Avg Support StaffCycle Time 14Min Start Provider Cycle Time End Provider Cycle Time Avg Provider CycleTime 23Min Handoff CorpsmantoProvider Handoff CorpsmantoProvider Intervention: StandardWorkforCorpsStaff Intervention:RevitalizeHuddles Allowsforimprovedcare coordinationandimpacts multiplesteps Intervention:RevitalizeHuddles Allowsforimprovedcare coordinationandimpacts multiplesteps
  • 14. Results Data Three Day Encounter Completion CPIMS # DON 020401 14 • Standardization of support staff process for getting patient ready for provider and scheduled admin time to complete records increased available time to complete patient encounters. • Increased 3 Business Day Compliance by 8%: • from 79% to 87%. • Improved Process Sigma by 0.33: • From 2.3 to 2.63. • Process significantly improved with opportunities for continued improvement.
  • 15. Results Data Encounter Completion Cycle Time 15 • Time from check-in to provider signature in AHLTA for individual encounters decreased from average of 3.19 days in April 2015 to 2.52 days in Oct 2015. • Upper control limit decreased from 13.7 days to 12.75 days. • T Test for difference in cycle times significant with P-Value of 0.002 and CI of 95%. • Data includes all completed encounters for checked in patients between 1-30 Apr and 1- 15 Oct 2015.
  • 16. Results Data Patient Flow Cycle Times 16 • After standardization and simplification of patient flow process, mean cycle times decreased for both the support staff and provider portions of the process • Support staff cycle time: • ↓ 19 minutes (57.6%). • Provider cycle time: • ↓ 6 minutes (20.7%)
  • 17. Control Plan CPIMS # DON 020401 17 CONTROL PLAN Process Name: NH Jacksonville Internal Medicine Cycle Time 1 2 3 4 5 6 7 8 9 10 11 12 Name of Measure Measure Definition Measure Calculation Data Source Goal Measure Frequency Sample Size When to Act/Trigger Who Decides to Act Who Acts Reaction to Out of Control Display Method 3 Day coding compliance Patient Cycle Time Audit Encounter Complete Cycle Time % of Kept Encounters closed within 3 Business Days (Definition in DoD DQMC SOP) Per Data Collection Plan Per Data Collection Plan Monthly average of: # Encounters closed within 3 business days/# of kept encounters. Per Data Collection Plan Per Data Collection Plan Data Quality Report Time Study Checklist Per Data Collection Plan 95% <20Min Avg < 3 days Monthly Monthly Monthly 100% Min of 20 patient and 2 providers 100% When >95% for three consecutive months, or 4 months in a 5 month period. When mean support staff cycle time is >20 min When mean cycle time is > 3 minutes Data Quality Manager IntMed Clinic LPO IntMed Dept Head IntMed Dept Head IntMed Clinic LPO IntMed Dept Head Identify cause of failure and design intervention to correct failure. Identify cause of failure and design intervention to correct failure. Identify cause of failure and design intervention to correct failure. Run chart Run Chart Run Chart
  • 18. LSS Scorecard CPIMS # DON 020401 18 LSS SCORECARD Metric Name: BASELINE RESULTS POST INTERVENTION RESULTS TOTAL CHANGE FROM BASELINE Patient Flow Cycle Time: (a) Support Staff (b) Provider (a) 33 Min (b) 29 Min (a) 14 Min (b) 23 Min (a) ↓ 19 Min (57.6%) (b) ↓ 6 Min (20.7%) Encounter Completion Cycle Time 3.19 Days 2.52 Days ↓0.67 Days (21.0%) 3 Day Encounter Completion: (a) Percent Complete (b) Sigma (a) 79% (b) 2.30 (a) 87% (b) 2.63 (a) ↑0.67 Days (b) ↑0.33 Sigma