Delivering care in efficient environment medicall 2011 [compatibility mode]
Delivering Healthcare in Efficient Environment Joy Chakraborty Director - Administration Hinduja Hospital, Mumbai.
The Challenges & Transitionin Healthcare• Controlling costs• Government regulations• Increasing competition• Implement new procedures and capabilities• Treatment reimbursement rates are capped based on diagnosis• Number of uninsured
Contd…..•New technologies are “Expensive” and adoption inquestion•Staff shortages in some areas continue to drive upcosts•“Report Cards” on providers – quality, cost,number of procedures• Role of the Private Sector in healthcare delivery• Growth in the number of people age 65 and older
What do our Patients want ?• Favorable patient outcomes• Patient safety• Implement new procedures and capabilities• Controlling healthcare costs• Service with a smile
What does the hospital want? What that leads to: • Available and prompt care • Better patient outcomes • Increased patient satisfaction • Improved financial viability• Smooth operations • Improved patient throughput• Ensure patient safety • Improved publicly reported• Provide quality care information • Higher employee• Effective patient treatment involvement and satisfaction• Utilized staff and resources • Reduced LOS
How do we achieve this?• By Improving QUALITY of health care • Patient safety and risk management • Evidence-based practice • Continuous learning and improvement• Stimulate and improve integration and management of health services• Reduce variation in care and health care costs• Strengthen the public’s confidence in the quality of public’ health care
Examples of Waste•Inventory – unneeded stock or supplies•Motion – movement of staff and information•Overproduction - unnecessary tests•Extra processing – filling out extra paper work•Transportation – movement of patients & equipment• Defects– duplicate work, medical errors•Waiting – delays in diagnosis & treatment
What is Lean?Lean means creating more value forcustomers with fewer resources &elimination of “waste” Vs
Six Sigma is: A disciplined, data-driven approach and methodology for eliminating defects in any process A statistical representation of Six Sigma describes quantitatively how a process is performing At many organizations Six Sigma simply means a measure of quality that strives for near perfection
6σ Level Performance• Six Sigma standard of 3.4 problems per million opportunities• 3 Sigma standard of 67000 problems per million opportunities• 4 Sigma standard of 6200 problems per million opportunities
Nature of Healthcare Business - Outcomes are Variable in Nature
Six Sigma in Health Care• In a HOSPITAL, processes must run correctly• The best option for healthcare organizations is to implement Six Sigma because • It focuses on total improvement with reducing costs, • Improving performance and productivity, and • Ensuring the patient is entirely satisfied with the care he receives • It allows professionals to appropriately and successfully figure the inconsistencies within their operations • It allows medical professionals the ability to detail processes within the field and quickly adjust and standardize them
Lean 6 Lean Six Sigma Total Quality ManagementQuality Assurance Quality Control Inspection
Lean + Six SigmaLEAN SIX SIGMA is a business improvementmethodology which combines tools from both Lean andSix Sigma.Lean and Six Sigma are complementary in natureLean focuses on eliminating non-value added stepsand activities in a process, Six Sigma focuses onreducing variation.
DMAIC: Basics Define Measure Analyze Improve ControlWhat is important The process: The process gains:to the customer: Analyze Data Ensure Solution isProject Selection Identify Root Causes Sustained Team Formation Establish Goal How well we are doing: The process performance measures: Collect Data Prioritize root causes Construct Process Flow Innovate pilot solutions Validate Measurement System Validate the improvement
Benefits of Lean Six Sigma• Improved patient experience and satisfaction• Faster response to patient needs• Increased job satisfaction & reduced stress for caregivers• Improved, standardized & repeatable processes that are more predictable• Ability to focus resources on more value-added activities• Improved asset utilization: people, equipment & technology• Reduced unit costs through increased capability
Benefits of Lean Six Sigma• Improved flow through elimination of bottlenecks (delays) and constraints (limiters)• Dramatic improvement in scheduling predictability – better process management• Participative problem-solving• Engaging the people who know and do the work… the team• Recognition of the need to manage change
Tools Fish Bone AnalysisHypothesis testing Regression VOCCause & Effect Matrix
“It’s not about tools to achievesuccess in Lean Six Sigma. It’s about how to get leaders to believe in and EMBRACE quality!”
Real Life ApplicationOrganization Project Outcome AchievementCharleston Area Supply chain for Lower inventory, Improved Saved: supplier relations $163,410 immediately $841,540Medical Center surgical supplies futureCommonwealth Radiology Decreased time between $800,000 savings, 25% better dictation and signature, throughput and eliminated 14Health Corporation Improved wait times and positions staff schedulingFroedtert Memorial ICU lab times Reduced turnaround Cut turnaround times fromLutheran Hospital times 52 to 23 minutesMount Carmel Medicare+ Choice Redefined coding Profit $857,000Hospital Plan working-aged Medicare reimbursement recipientsWellmark Inc. Physician addition Reduced time for Savings: $3 million per to managed care adding physicians to year network medical planScottsdale Over crowded Improved transfer Profits: $600,000Healthcare ED time from ED to inpatient hospital bed
An Overview 381 beds, including 53 ICU beds; 19 Short Stay Service; 11 Operation Theatres and 6 EICU beds Not for Profit Hospital 140 Consultants; 510 nurses and other support staff Exclusive area for Preventive Health Checks Promoting Medical Education along with attached Nursing College State of the Art Technology Application Group is entering into For Profit Segment in Healthcare Well stocked library with over 417 latest online and offline journals. 26
Pioneering Best Practices movement @ HNH• College of American Pathologists (CAP) (1st hospital laboratory to be accredited among the SAARC region countries);• ISO certification in 1996• Recipient of Ramakrishna Bajaj award for healthcare quality.• Participation in Best prax Club competition• ISO 27001 for IT Department for Information Security• Hospital accreditation
FIRST HOSPITAL to adopt six sigma in Healthcare in IndiaRecently, concept of Lean Six Sigma has been applied too.Some Studies :• Turnaround time for patient discharges• Outpatient Satisfaction• Turnaround time for Imaging reports• Satisfaction for Peri - operative care• Average Length of Stay• Operation Theatre support services• OPD waiting time• Discharge waiting time• X Ray turnaround time• Pharmacy items turnaround time
Case Study # 1 Short Stay Services.1. 300 identified surgeries across 8 surgical specialties in scope.2. 19 bedded dedicated self dependent unit with two units3. Preoperative investigations and post-operative follow-up done at home.4. 24 hrs in house dedicated call centre managed by nursing personnel.
Care @ Home Services1. Expansion of reach.2. Range of services provided
Measurable Outcome Year Installed No. of Avg Length Bed Surgeries of Stay Capacity done09 -10 383 11089 4.9 Days10 - 11 372 12149 4.7 Days
Case Sudy # 2Lean Six Sigma Process Improvement Projectat Hinduja HospitalProject Name : Reducing the Turn Around Time for Outpatient (OPD) ServicesProject Goal : To reduce the Idle Waiting time in the Outpatient process by 30-50%
Define PhaseProblem Statement: Over the past few months it has been observed thatthe Turn Around Time for patients to avail OPD services has been anissue of concern for the patients and Hinduja Hospital.Voice of CustomerSelection of the project on Reducing the waiting time in Out PatientServices is based on the concern raised by patients on waiting time inthe regular OPD feed back forms & verbal communication to our customercare.Voice of the customer was used to determine the acceptable Idle WaitingTime.
Measure PhaseData collection : The entire process flow for consultation / investigationwas tracked throughout the OPD working hours using tracking sheets.The activity was divided into sub processes & the overall findingswere : • Queue Time : 5-7 min • Vouchering Time : 3-4 min • Travel Time : 5-7 min • Idle Waiting Time : 40-50 minAll TAT other than the Idle waiting time are within their respectiveacceptable limits and hence not taken up for further studyAcceptable limit for the Idle Waiting Time is considered to be 30 minutes.
Measure Phase Waiting time for the OPD Services (in mins) Idle Total Queue Vouchering Travel Waiting Waiting Service Time Time Time Time TimePulmonology 5 4 5 19 33Cardiology 3 3 4 10 20Neurology 4 4 10 45 63Laboratory 6 3 2 10 21X Ray 8 1 3 17 29Physiotherapy Retrospective billing 8 8Urodynamics Retrospective billing 29 29Scopy (UGI, LGI) Retrospective billing 47 47Bronchoscopy Retrospective billing 28 28Consultation 4 4 3 33 44
Analyze PhaseA further investigation was done of the serviceswhich have Idle Waiting Time beyond 30minutes • Neurology • UGI / LGI Scopy • Consultation
Analyze Phase Neurology services Idle Waiting TimeEMG 101EEG/ BERA/ VEP/ SSEP 21EMGIdle Waiting Time– EMG is done in 2 steps :1.NCV2.Complete EMGFirst step is conducted by the Neurology Technician & the second step is done by the Consultant. The increased Idle waiting time was observed in specific cases of pediatric neurology wherein the patients were uncooperative & had to wait for patient to settle down.
Analyze Phase : Conversion of EX Dr. Delayed for Consultation patient to HH patient miscellaneous reasons Wrong Time Wrong HH no. File not requested entered at time of Dr. gone for vouchering File archived Emergency Dr. in OT Wrong Dr.s Name Requested fileWrong Date Appts after 8pm not reflecting not reflected in in MRD Delta appt list since list report Wrong Wrong details captured at Dr. on HH no. time of giving Appointment printed before 8pm Rounds / Procedure WRONG APPOINTMENT BILLING MRD FILE NOT RECEIVED DR NOT AVAILABLE DOUBLE APPOINTMENT PATIENT LOST NURSE NOT AVAILABLE PATIENT DELAYED Previous patient Slot not Nurse busy with taken in late Dr. or Patient available Patient cannot find Tea Break Training of new location Patient staff came late Dr.s Shortage of Nursing Staff Instructions Dr.s Wrong allowing Non Instructions Appointment Wrong Appointment Instructions given Patients – Emergency Walk-ins Patient
Improve Phase : Solution Matrix – Consultation Idle Waiting Time Process Step Constraint Cause Solution Non appointment patients to be seen after the appointment patients as per Dr. instructions Non appointment Slot not available patients taken in Appointment Checking Slot Patient called as advance only if the next Scheduling Availability non appointment patient has not arrived patients Reserve specific slots in between appointment slots for non appointment patients Slot is available but cannot System change to take appointments on same reflect the file request day due to system limitations for same day for file retrieval appointments
Improve Phase : Solution Matrix – Consultation Idle Waiting Time Process Step Constraint Cause Solution File request not System change to Appointments could reflected in the MRD reflect the file request Printing of not be taken on report for the same for same day Delta report same day day appointmentsFile retrievalin MRD Any additional appointments after the list is printed are Appts after 8pm not added by the Nurse in Printing of Updated reflected in appt list the appointment list Appointment appointment list not since list printed and informed to the list available before 8pm Doctor
Analyze Phase :UGI/LGI Scopy Aerated Lime drink Endoscopy Suite not available not available Dr. Delayed for miscellaneous Wrong Time reasons Training of Wrong Dr.s Call Centre Wrong Patient Delayed Name Staff Date Emergency Dr. in patient taken Dr. gone for Procedure Patient did not Emergency follow given Wrong instructions given Wrong HH instructions Patient arrived no. Dr. Delayed late for Patient preparation Dr. on misunderstood Rounds instructions PATIENT NOT PROCEDURE DELAYED WRONG APPOINTMENT PREPARED DR NOT AVAILABLE DR.S PRESCRIPTION NOT SCOPY SUITE PATIENT DOUBLE APPOINTMENT AVAILABLE NOT AVAILABLE DELAYED Previous Outpatient Wilkins patient Inpatients Patient forgot Dr;s Previous taken in late sent prescription patients randomlyConsecutive procedure Non Appointmentslots for ongoing Patients- Wilkins No ApptsMultiple Dr. not available Cleaning Inpatient sent given toprocedures to give fresh Previous patients randomly inpatientsnot available prescription procedure ongoing Overlapping U. P. patient taken Patient Emergency Appointments previously came late Patient
Improve Phase : Solution Matrix – Scopy Idle waiting Time Process Step Constraint Cause Solution Appointments taken for Inpatients Reserve slots specifically for Inpatients / Inpatients only taken in vacant slots Inpatients beingAppt for In patient No appointments taken randomly in Inpatient taken after all OutProcedure Appt taken for Inpatients between scheduled patient Appts patients Assign point of contact in Scopy who will co-ordinate with Floor Nurses to ensure the Inpatients are taken in a scheduled manner
Improve Phase : Solution Matrix – Scopy Idle Waiting Time Process Step Constraint Cause Solution Changes in slot scheduling : 1 UGI is a shorter Only single slot Slot 30 minutes for shorter procedure than LGI but allotment done in procedures and 2 slots of 30 the same single slot system: minutes each for longer (of 30 min) is given Overlapping procedures e.g. Colonoscopy when scheduling all appointments will be given 2 slots instead of 1 the appointments slotAppt for ApptProcedure Scheduling Separate slot timings given for multiple procedures on same Multiple process should be Slot not available patient when If given consecutive slots and if consecutively for continuous slots not required rescheduling of next multiple procedures available but patient procedure done consecutively
Improve Phase : Solution Matrix – Scopy Idle Waiting Time Process Step Constraint Cause Solution When preparation to be done in Hospital, Appointment Cell to ask Patient came late for patient to follow Dr.s instruction Delay for next patient preparation / Patient at time of giving appointment when patient is readyIf Scopy did not follow Dr. and call a day prior to confirm Patient given for procedurepatient is instruction the same i.e. patient to come to preparation at Hospital at least 2 hrs earlier /asnot Hinduja per requirementprepared Hospital Patient did not bring Requisite preparation along the requisite Cafeteria to deliver the aerated solution not available aerated drink required drink for the patient for preparation
Performance: Consultation and ScopyIdle Waiting Mean SD Sigma Level Time (in min) BEFORE TARGET AFTER BEFORE TARGET AFTER BEFORE TARGET AFTERConsultation 33 15 14 36 5 11 -0.06 3 1.45 Scopy 47 30 25 35 5 21 -0.07 3 1.70
Waiting time for the OPD Services (in mins) - YR 2010 vs YR 2011 PRE LSS POST LSS FOLLOW UP Idle Idle Idle Waiting Time Waiting Time Waiting Time Service 2010 2010 2011Pulmonology 19 19Cardiology 10 10Neurology 45 25Laboratory 10 05X Ray 17 09Physiotherapy 08 01Urodynamics 29 46Scopy (UGI, LGI) 47 25 30Bronchoscopy 28 35Consultation 33 14 18
Case Study # 3Project Name : Reducing the Turn Around Time for Patient DischargeProject Goal : To reduce the Patient Discharge Time by 30-50%Average TAT for Patient Discharge beyond 2 hours is considered as a defect.
Average Times (in minutes) BEFORE AFTERy1= Written order to Finance folder sent 85 18y2 = Finance Folder sent to received in Billing 9 7y3= Finance folder received to taken for billing 8 8y4= Finance folder taken for Billing to DischargeSlip given to relative 50 48y5= Discharge Slip given to relative to receipt bynurse 21 19y6= Discharge Slip received by nurse to patientphysically leaves bed 22 21 Y = Written Intimation to Patient leaves floor 194 121
Performance: Discharge Process Mean Max SD BEFORE TARGET AFTER BEFORE TARGET AFTER BEFORE TARGET AFTER y1 85 40 18 385 50 45 94 5 9(in min) y4 50 30 48 188 50 89 36 5 16(in min) Y 195 120 121 525 150 205 108 5 22(in min)
DID YOU KNOW.....??. .Do you Know ?• “Hospitals report that the biggest challenges inimplementing lean or six sigma include sustainingimprovements, competition from other initiatives,leadership commitment and availability of resources” - American Society for Quality, 2009
The Week – IMRB Exclusivesurvey ranks Hinduja Hospital as no. 1 in the region for the 4th year consecutively 54