Post on 07-Jun-2020
BARCELONA HEALTHCARE.
THE CASE OF THE HOSPITAL CLINIC
EMERGENCY DEPARTMENT Miquel Sánchez MD, PhD
Director, Accident & Emergency Department Hospital Clínic de Barcelona
Lean Practitioner Program Certification, UPC
UK LEAN SUMMIT 2016 Kenilworth 15th of November, 2016
AGENDA - Introducing Hospital Clinic ED
- Purpose
- People
- Process
- Creating Stability
- Lessons Learnt
AGENDA - Introducing Hospital Clinic ED
- Purpose
- People
- Process
- Creating Stability
- Lessons Learnt
700-bed university tertiary care hospital
LEVEL-3 AREA
LEVEL-4-5 AREA
LEVEL-2 AREA
OPERATING ROOMS
PSYCHIATRY AREA
ADMINISTRATIVE AREA
RELATIVES WAITING ROOM
TRIAGE + LEVEL-1 AREA
1.1
16.7
52.1
26.5
3.6
LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5
92.000 ATTENDANCES/YEAR
AGENDA - Introducing Hospital Clinic ED
- Purpose
- People
- Process
- Creating Stability
- Lessons Learnt
LEAN = Purpose + People + Process
Are you in the waiting list?
Our Purpose
78%
0%
20%
40%
60%
80%
100%
< 15 min
Level 2
53%
0%
20%
40%
60%
80%
100%
< 60 min
Level 3
70%
0%
20%
40%
60%
80%
100%
< 120 min
Level 4 97%
0%
20%
40%
60%
80%
100%
< 240 min
Level 5
LEVEL 3 AREA
LEVEL 4-5 AREA
LEVEL 2 AREA
OPERATING ROOMS
PSYCHIATRY AREA
ADMINISTRATIVE AREA
RELATIVES WAITING ROOM
TRIAGE + LEVEL 1 AREA
LEVEL 3: waiting time and hour of arrival (min)
Patients left without being seen (%)
Staff Job Satisfaction (Font Roja Questionnaire)
DOCTORS NURSES ADMINISTRATIVE STAFF
Patient (“client”) Satisfaction Survey (2013)
DOOR TO DOCTOR TIME
AGENDA - Introducing Hospital Clinic ED
- Purpose
- People
- Process
- Creating Stability
- Lessons Learnt
LEAN = Purpose + People + Process
May, 2014. Meeting for “the change”
(The New) Principles of the Team
-Patients’ problems are our problems. Patients’ perspective.
-Ok, generally speaking we work quite well but... Can we do it better? Seeking perfection.
-Despite all our efforts, we do have problems. What can we do to solve them? Problem-solving culture.
12 November 2014 18 December 2014 4 March 2015 27 April 2015 3 Juny 2015
207 people trained...
AGENDA - Introducing Hospital Clinic ED
- Purpose
- People
- Process
- Creating Stability
- Lessons Learnt
LEAN = Purpose + People + Process
WASTE IDENTIFICATION
Level 3 VSM
Problem-Solving Methodology
First Assessment Area
Observe and Measure
LEVEL-3 PROCESSES CYCLE TIME
ENTRY PREPARATION VITAL SIGNS
NURSE
DEPARTURE PREPARATION
COUNSEL
NURSE
TO DRAW BLOOD TO GIVE
MEDICATIONS
NURSE
DECISION: DISCHARGE
vs OBSERVATION
DOCTOR
ASSESSMENT TEST REQUEST
MEDICATION PRESCRIPTION
DOCTOR
X-RAY LABORATORY
PORTER
Cycle Time of our Processes
THE 7 WASTES or MUDAS
Rooms 1-8
Rooms 9-13
Waiting to be seen
X-ray
31 meters
First Assessment Area
First medical assessment
Lab results pending
START
END?
Transportation
Searching for patients
Searching for medication
Searching for documentation
Motion
Looking for each other
Nurse Resident
“ALL FOR ONE AND ONE FOR ALL”
SEEMS NOT TO WORK
Batching blood tests
Batching X-Rays
Overproduction
Inventary
Clarificar ordres
The same test performed in a
very different way
Overprocessing
The same information colleted many times
Chaos facilitates to make a mistake
Fixing and adding medications
Defects-Correction
A lot of reworks
X-RAY RACK
Waiting for a bed
Waiting for ancillary services
Esperes d’altresespecialistesEsperes d’altresespecialistes
Waiting… for the perfect specialist.
Waiting for consultors
Waiting Time
Staff Waiting for test result
Waiting time (“ques”)
Time in the First Assessment Area: (2014)
0
1
2
3
4
5
6
DISCHARGED HOME ADMITTED AT OBSERVATIONMedian 75P 90P
AGENDA - Introducing Hospital Clinic ED
- Purpose
- People
- Process
- Creating Stability
- Lessons Learnt
Our Purpose
A3 Structure
A3 Structure
A3 Structure
10 min 10 min 20 min 20 min 20 min
60 min
TIME IN THE FIRST ASSESSMENT AREA 90P = 160 min
40 min NURSE 40 min DOCTOR
ENTRY PREPARATION VITAL SIGNS
NURSE
DEPARTURE PREPARATION
COUNSEL
NURSE
TO DRAW BLOOD TO GIVE
MEDICATIONS
NURSE
DECISION: DISCHARGE
vs OBSERVATION
DOCTOR
ASSESSMENT TEST REQUEST
MEDICATION PRESCRIPTION
DOCTOR
X-RAY LABORATORY
PORTER
A3 Structure
Albert Einstein
“Insanity: doing the same thing over and over again and expecting different results.”
A3 Structure
STANDARD ZERO -Nurse-Doctor team -Assigned boxes to each team
STANDARD OPERATING SHEET
STANDARD OPERATING SHEET
STANDARD OPERATING SHEET
STANDARD ZERO -Nurse-Doctor team -Assigned boxes to each team -Staff needed time per patient: 40 min
-One patient to box every 40 min -2 parallel processes of 20 min each -First assessment area time = 160 min -4 patients simustaneously -Visual management of the process
NURSE Frees up box and enters new patient
Procedures and Meds
DOCTOR Assessment
Decision
Visual Management
STANDARD ZERO -Nurse-Doctor team -Assigned boxes to each team -Staff needed time per patient: 40 min
-One patient to box every 40 min -2 parallel processes of 20 min each -First assessment area time = 160 min -4 patients simustaneously -Visual management of the process
-First time quality: no reworks
JOB INSTRUCTIONS
Foto carro infermeria amb peticions a sobre
STANDARD ZERO -Nurse-Doctor team -Assigned boxes to each team -Staff needed time per patient: 40 min
-One patient to box every 40 min -2 parallel processes of 20 min each -First assessment area time = 160 min -4 patients simustaneously -Visual management of the process
-First time quality: no reworks -PCs assigned to each team -Nurse cart assigned to each nurse
STANDARD ZERO -Nurse-Doctor team -Assigned boxes to each team -Staff needed time per patient: 40 min
-One patient to box every 40 min -2 parallel processes of 20 min each -First assessment area time = 160 min -4 patients simustaneously -Visual management of the process
-First time quality: no reworks -PCs assigned to each team -Nurse cart assigned to each nurse -One patient’s relative allowed in the FAA
Patient arrivals per hour (2014)
Client Time (2014)
Client Time (2014)
ATT1
Client Time (2014)
ATT1
ATT1/2=ATT2
Client Time (2014)
ATT1
ATT1/2=ATT2
ATT1/3=ATT3
As much as 10 trials were done before definitively implementing
0
1
2
3
4
5
6
DISCHARGED HOME ADMITTED AT OBSERVATIONMedian 75P 90P TRIAL 90P
March, 25th: general trial: 3 teams
-39% -38%
JULIO AGOSTO SEPTIEMBRE1 2 al 15 15 al 31 1 al 15 15 al 31 1 al 15 15 al 27 28 29 30
VALORACIÓN POR EL GRUPOINFORMACIÓN AL STAFF MÉDICOINFORMACIÓN A MEAUSINFORMACIÓN A ENFERMERÍAINFORMACIÓN A ADMINISTRATIVOSINFORMACIÓN A RESIDENTESIMPLANTACIÓN
Implementation Plan
A3 Structure
Visits per day (october)
p=0.09
+5,9%
Time in the First Assessment Area (october)
p<0.001
Time in the First Assessment Area and Hour of Arrival (min) october
Door to Doctor Time (min) october
-44% p<0.001
Door to Doctor Time and Hour of Arrival (min) october
A3 Structure
1902
1779 1802
2050
1983 2017
1983 1982 2011
2141 2110
1983 2028
1889
2061 2094
2063
2358
2063
2166
1996
2235
2124 2136
1500
1750
2000
2250
2500
Oct Nov Des Gen Feb Mar Abr Mai Juny Jul Ago Set
2014-2015 2015-2016
Number of visits per month
75
88
99
121 125
48
58 56
75 77
62 68
42 45
61 67
78
86
45
53
43 44
36
48
0
20
40
60
80
100
120
140
Oct Nov Des Gen Feb Mar Abr Mai Jun Jul Ago Set
2014-2015 2015-2016
Door to Doctor Time (min) (median)
AGENDA - Introducing Hospital Clinic ED
- Purpose
- People
- Process
- Creating Stability
- Lessons Learnt
Factors for the success.
- The change is actually performed by the staff who do the work, the rest are mere enablers.
- Start transforming processes in which chances to succeed are high
- Focus on how the work is organised and simplify the process,
eliminating waste. - Put your effort in little, fast and efficient changes.
- Visual Management: visual and intuitive tools
... And the most important...
- Using only 6 tools: - VSM - Spaghetti Chart - PDCA - A3 - Standardised Work - Visual Management
- You can do it!!!! DIY
... THANKS SO MUCH!!!!!