2. DELIVERING OUTSTANDING IMPROVEMENTS
AT CANADA’S WILLIAM OSLER HEALTH SYSTEM
Morteza Zohrabi, MD, PMP, Medtronic Lean Six Sigma Master Black Belt
Dr. Ronald Heslegrave, PhD, WOHS Chief of Research
Diabetes clinic pilot project expands capacity, boosts efficiency
and delivers sustainable results without adding resources.
EXECUTIVE SUMMARY
In July 2011, William Osler began a partnership with Medtronic’s Integrated Health
Solutions (IHS) on a pilot improvement project to optimize the performance of its
Diabetes Education Centre at Brampton Civic Hospital. The plan was to apply a
Lean Six Sigma approach and also adapt a diabetes clinic optimization model and
process developed by the IHS group and used successfully in a number of clinics in
Europe, particularly for the National Health System in the UK.
The results of the pilot to date have been exceptional — and the numbers are
continuing to improve over time. Not only has the Diabetes Education Clinic vastly
increased its capacity and efficiency in handling patients, but also it has done so
while maintaining patient satisfaction scores and service delivery.
To ensure a sustainable process, the entire project team earned their Lean Six
Sigma Yellow Belts—part of Medtronic’s process with every Lean Six Sigma
project. This has provided the Diabetes Education Centre with the capacity to
be much more effective in improving internal processes on an ongoing basis. The
project has demonstrated that partnerships between industry and health care
professionals can lead to optimized service for patients while at the same time
improving efficiencies and ensuring the sustainability of health services. Medtronic
IHS was pleased to be one of Osler’s key community partners, and looks forward
to partnering with other health care providers to help address the needs of their
communities.
CHALLENGE
Diabetesaffectsmorethan75,000peoplelivinginthecommunitiesservedbyWilliam
Osler, and that number is growing rapidly each year. Peel Region, where William
Osler is located, has one of the highest prevalence rates of diabetes in Canada.
10% versus the national average of just over 5%. All evidence suggests there is a
predispositiontodiabetesintheimmigrantandethno-culturallydiversepopulation
intheregion—andthatthenumberofpeoplewithdiabetesintheregionwillincrease
rapidly in the years ahead, creating a growing challenge for the health care system.
As the health care provider for this high-needs diabetes area, William Osler has a
responsibility to address the growing needs of its residents. William Osler needed
to transform its operations so it could serve more people with diabetes and offer
better care within its existing budget.
The hospital’s primary diabetes clinics were:
• Type II diabetes programs (80% of total annual patient visits)
• Type I diabetes programs (10%)
• Gestational diabetes management programs (10%)
Pilot Project Goals:
• Improve the patient experience, clinic productivity and quality of care
• Demonstrate national leadership through a collaborative partnership and share
learning within the institution
ASTONISHING
IMPACT
As a result of the
Lean Six Sigma
project at Brampton
Civic Hospital, the
Diabetes Education
Clinic experienced:
• A 58% increase in
overall interactions
per clinician
• A 20% increase in
gestational diabetes
management
capacity
• A 45% increase in
glucose tolerance
class capacity
“WOW — THIS IS
THE BEST WAY TO
SEE THE ISSUES
AND RESOLVE
THEM — WE ARE
ANXIOUS TO
IMPLEMENT.”
- NORINE, CLINIC
MANAGER, ETOBICOKE
3. DELIVERING OUTSTANDING IMPROVEMENTS
AT CANADA’S WILLIAM OSLER HEALTH SYSTEM
Morteza Zohrabi, MD, PMP, Medtronic Lean Six Sigma Master Black Belt
Dr. Ronald Heslegrave, PhD, WOHS Chief of Research
APPROACH
• Identify solutions aimed at reducing or eliminating non-value-added
clinical activities and administrative redundancies
Operational issues to be addressed:
• Processing delays; including missing referrals, lack of appointment time
forfollow-upandurgentappointments,andtimedelaysinrecievingreports
from physicians
• Over documentation: excess paperwork or scanning
• Capacity problems: fewer resources available to meet the increasing
demand
• Problems with transfer assessment process: including communication
gaps and lack of standardized reporting to physicians
THE TEAM
A steering commitee was put together to include senior management
and executives from both Medtronic and William Osler as well as a working
group consisting of registered nurses, registered dietitians, a clinic clerk,
a program manager and other administrative staff. Medtronic’s Morteza
Zohrabi, a Lean Six Sigma Master Black led the project.
METHODOLOGY
Assessment
Workbeganwithafive-dayworkshoptoreviewthemainDiabetesEducation
Clinic processes. The working group reviewed the procedures and baseline
metrics of the clinic, including its financial matrix, lead and wait times,
and patient experience measures. Baseline measures were collected by
analyzing a combination of electronic data, written notes and observations.
A system was later developed to routinely record the number of patients
and wait times within the department.
The clinic’s processes were reviewed end to end to identify all bottlenecks
andissues.Thegrouprecognizednonvalue-addedactivitiesandredundant
data entry and administrative process through value-stream mapping,
Lean/Kaizen methodologies and evidence-based learning.
OUTPUTS INCLUDED
• project charter
• problem statement
• high level process map (block diagram)
• value stream mapping
• root cause analysis
• waste analysis
• pros and cons analysis
“THIS WAS
A GREAT
OPPORTUNITY
TO LOOK AT
OUR ENTIRE
PROCESS AND
STREAMLINE
THE WORKFLOW
OF THE CLINIC.
THE GROUP
FACILITATOR
REALLY
ENCOURAGED
US TO THINK
OUTSIDE OF THE
BOX TO COME UP
WITH IDEAS”
- SHAISTA, REGISTERED
NURSE, BRAMPTON
4. DELIVERING OUTSTANDING IMPROVEMENTS
AT CANADA’S WILLIAM OSLER HEALTH SYSTEM
Morteza Zohrabi, MD, PMP, Medtronic Lean Six Sigma Master Black Belt
Dr. Ronald Heslegrave, PhD, WOHS Chief of Research
All ideas for improvement were captured in an “ideas parking
lot” ensuring they could be discussed further to enhance the
potentialsolutiondesign.Attheendofeachworkshopday,the
steering committee attended a report-out session to review
the progress of the project and share ideas and concerns.
ACTION PLAN
The group identified 81 potential solutions to reduce over-documentation,
improve workflow efficiency, create more capacity and improve patient
outcomes.Theteamreviewedsolutionsandusedtwolevelsofprioritization,
span of control assessment and impact and effort analysis; to create a
shortlist of 14 actionable items. The team then developed an action plan
and assigned tasks to working group members.
As the project unfolded, clinic staff on the working committee held weekly
performance huddles to review status and discuss any roadblocks to the
action plan. Medtronic followed up monthly with the project coordinator
and working group team lead to ensure the plan was moving forward and to
help resolve any potential roadblocks.
The project lasted 12 months, from initial stakeholder conversations
through new process implementation and data collection.
RESULTS
In surveying the clinic’s processes, the team discovered that almost 40%
of staff time was used to fill out required forms and databases. The team
identified 10 forms, data collection tools, and checklists in the process,
including three different databases that each generated different reports.
Another significant discovery was that there was a 25% overlap in the
information that registered nursess and dietitians were coIIecting during
their patient sessions.
Clinicians were able to find a better way of providing consistent information
with patients and while providing the same high quality training, improving
the patient follow up and seeing 25% more patients.
Based on these findings, the clinic was able to:
•eliminate 10 redundant forms
•combine three databases into one electronic documentation system
(a process that alone saved more than 2,300 working hours per year)
•eliminate redundancies and find better ways to improve the flow and
consistency of high-quality iniormation and training delivered to patients
The streamlined system and process saved significant clinician and
administrative time and allowed staff members to focus less on paperwork
and administration.
RESULTS
THE
STREAMLINED
SYSTEM AND
PROCESS SAVED
SIGNIFICANT
CLINICIAN AND
ADMINISTRATIVE
TIME AND
ALLOWED STAFF
MEMBERS TO
FOCUS LESS ON
PAPERWORK
AND MORE ON
INTERACTING
WITH PATIENTS.
5. DELIVERING OUTSTANDING IMPROVEMENTS
AT CANADA’S WILLIAM OSLER HEALTH SYSTEM
Morteza Zohrabi, MD, PMP, Medtronic Lean Six Sigma Master Black Belt
Dr. Ronald Heslegrave, PhD, WOHS Chief of Research
OVERALL PILOT RESULTS
• 25% improvements in use of clinical time
• 33% increase in new patient visits per staff member
• 20% increase in gestational diabetes visits
• 58% increase in overall interactions per clinician
• 45% increase in impaired glucose tolerance class capacity
• 80% reduction in no shows (rate reduced from 45% to less than 5%)
• 2,600 hours of team time saved annually
• 60% reduction in data redundancy
ThepilotalsoevaluatedpatientexperienceusingtheNetPromotersScore
measure before and after implementation. Patient satisfaction levels were
sustainedthroughouttheproject.Oneissueworthnotingisthattherewas
no focus on patient outcome measures such as A1C during the pilot. As a
consequence no conclusions can be made regarding the influence of this
project on patient outcomes — this is a suggested area for future study.
ABOUT THE PARTNERS
William Osler Health System is one of the largest community hospital
systems in Ontario, serving a population of more than 1.3 million people
living in one of the fastest growing and most culturally diverse regions of
Canada.
Medtronicisarecognizedleaderandinnovatorinmedicaldevices,services
and solutions, with expertise in cardiac, vascular, spinal and neurological
science; minimally invasive technology and diabetic disease management.
Medtronic has expanded its Integrated Health Solutions group in
Canada. Leveraging its gloval knowledge and expertise, Medtronic uses
its resources and capabilities help to improve the Canadian healthcare
system by increasing efficiency and optimizing patient outcomes.
