How will Healthcare Reform Impact Reengineering Strategies to Transform Healthcare Delivery?
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Transcript of How will Healthcare Reform Impact Reengineering Strategies to Transform Healthcare Delivery?
How will Healthcare Reform Impact Reengineering Strategies to
Transform Healthcare Delivery?Learning from Experience Presents:
David Belson, PhD, Editor-in-Chief, Journal Society of Healthcare Improvement Professionals
&Imran Chaudhry, FACHE, Regional Executive, Operational
Excellence, Providence Health & Services
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Speaker’s Profile Imran Chaudhry Imran Chaudhry is the Regional Director of the Operational
Excellence and Project Management Offices for Providence Health and Services, southern California. He is responsible for providing the overall leadership for the deployment and execution of the Lean, Six Sigma, Change Management and Project Management methodologies across the Providence southern California hospitals.
Dr. David Belson David Belson, Ph.D. has helped dozens of hospitals and clinics
improve their productivity. He applies his background of over 30 years as a professor in Industrial Engineering. He has developed classes on improving healthcare operations and written articles regarding Lean and other methods for radiology, surgery, emergency departments and other hospital functions. He has initiated research projects funded by the California HealthCare Foundation as well as the federal and California governments.
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“Insanity is continuing to do things the way you’ve always done them and expecting the results to be different.”Albert Einstein
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About Providence Health and Services
• Not-for-Profit faith based healthcare organization
• 2nd largest healthcare provider in the Los Angeles County
• 9th largest employer in Los Angeles County• 700 licensed beds in the region • 12000+ Employees and Medical Staff
Members • 2.7 Million Uninsured people in the county
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History of Six Sigma and Lean
1986Bill Smith originated Six Sigma as a metric
1980’sRolled out in Motorola
1988Malcolm Baldridge National Quality Award
1990’sGE and AlliedSignal (Radical changes in products and services)
2002Providence Health System
2003Providence California
1970’sToyota Production System…”Lean”
Lean Six Sigma
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Commitment and Involvement of the Senior Leadership!!
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2011Certified first batch of 13 Change FacilitatorsIntroduced Design Thinking and Innovation to the organizationExpanded focus to include the Medical Institute.Expanded team to include Project Management
OE OE GrowthGrowth
2006 6 Resources
2011120
Resources
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VOC VOP VOE VOM
• Reduce cycle time• Reduce turn around time• Reduce infection rate• Reduce medication errors
Process Y’s
• Reduce Days to Bill• Increase throughput / Decrease LOS• Patient satisfaction
Year Imperatives – Y’s
• Become Leaders in markets where we serve• High Performance Organization• Achieve Strong Financial Results
Providence Big Y’s
Dir
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f Im
pact
Begin Investigating Here!
x1 x2 x4x3
Linking Business Y’s to Process Y’s
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Level 1Key Business Metric
Level 2 BusinessProcesses
Level 4High LevelProcess Map for Project
Level 5Detailed Subprocess Map –Sub Ys and Xs
Length of StayLength of Stay
Feeder to BedFeeder to Bed ProvideProvideInpatient CareInpatient Care
Discharge Discharge Planning ProcessPlanning Process
Execute Execute Discharge OrderDischarge Order
Nursing Care
Order Turn Around
Time
Physician Referral Process
Practice Patterns
Doc Order
Schedule Exam/Study
Prep Patient
Patient Transport
Lab OrdersPharmacy Orders
Imaging Order TAT
ReadTranscribe
Results Available
Complete Exam/Study
Level 3High-LevelProcesses
Probably Measuring L1
Usually Not Measuring L2s
and L3s
Six Sigma and WO Projects
Levels Of A Process
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Prioritize Opportunities
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Why Define a Standard Metric
What is the Definition of:• ED Door to Doc• OR First Case Start Time• Patient Discharge Time
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In Scope
As Necessary
Out of Scope
Define: Understanding the Scope
What’s in the scope of the project
Make Sure all team members are on the same page
What may be looked at
What will not be assessed or reviewed in this project
PROJECT SCOPING
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Discuss Resources and Time Commitment Upfront!
A project SHOULD NOT TAKE more than 4 – 5 months to complete (few exceptions)
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All tools/processes are used synergisticallyAll tools/processes are used synergistically
MWork-OutTM
“Expert-driven”
Lean
“Data-driven”
H
MediumComplexity
HighComplexity
Six Sigma/Lean Six Sigma
“Waste Elimination”
Methodologies
Design for Six Sigma
Varia
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and
Def
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ate
Red
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Cyc
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ime
Red
uctio
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“Change in Paradigm/Futuristic”
CAP (“the glue”)
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Don’t Silo the Methodologies, its all about Continuous Improvement!!
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Change Acceleration Process
Q x A = R7 x 4 = 288 x 4 = 327 x 7 = 49
Quality x Adoption = Result
Focus on Q
Instead focus on A Big Impact
It’s All About the Acceptance
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Leading Change
Changing Systems & Structures
CurrentState
TransitionState
ImprovedState
Creating A Shared Need
Shaping A Vision
Mobilizing Commitment
Making Change Last
Monitoring Progress
Change Acceleration Process
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Lean vs. Six Sigma
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Health Care Operations Improvement Work
David Belson, Ph.D.
USC Department of Industrial and Systems Engineering HCE Conference David Belson 2012
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How do we improve healthcare performance?
Example projects1. Emergency Department, Lean2. Mammography clinic, simulation3. Surgery patient flow, mapping4. Primary care, doctor’s office, redesign5. Technology solutions, RFID, EMR
Fixing the Emergency Department
with Lean
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The most popular tool is LeanToyota method, Lean-Six Sigma, …
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• Hospitals, clinics, suppliers, hospital systems
• California Hospitals• Providers nationally
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Maximizes participation, reality (Kaizen)
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LEAN Tools
• Kaizen, participation• Waste reduction• Mapping• 5 S• Value Stream
mapping• 5 Whys• Cause & effect• Pull
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• Standardize & simplify
• Visual Controls • Standard work• Kanban• Level & continuous
flow• A-3• PDSA / DMAIC
• & more …24HCE Conference David Belson 2012
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Lean event;•ED department •“Lean” triage•Eliminated waste•Results; lower cost and
less waiting
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Ideas from hands-on staff:
Results
ED’s Triage now: • Fewer forms used• Quicker handling of patient visit• Less waiting time• Fewer patients who left without being
seen (the original objective)
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Fixing the Patient Flowwith computer Simulation
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Simulation
Computer Simulation
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No Show
GI Procedure
Recovery,Capacity 3
beds
Prep rooms and Procedure
room empty?Yes
(Exit)
93.9%
(Exit) no recovery
6.1%
No
Prep in Room
Proc bedsMon Tues
Scope to Sterilize
Patient
Check in
82.3%
(Exit) 17.7
Earliness Delay
Colo Scope
Endo Scope
Sterilize
(Exit)
Capture Scopes
Dummy Colo
Dummy Endo
Procedure not done
(Exit)
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daysComp
ScopeTech
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inRoom
Recovering in Room
Sterilize without batching
(Exit)
Get Procedure Room
Recovery Beds
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scopesPerDay
0000
scopesUsed
Decontaminate
Proc beds Tues-Fri
Set up(Prep)
PrepNursePrepNurseMorn
Inventory
Input Data
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• Observation & timing • Following patients and staff, interview• Hospital data
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Steps Average room cycle (minutes)
1 Check-in 2 Registration 3 Waiting at reception area 4 Marsha- prep time 5 Room preparation 3
6 Tech out to bring patients and patient arrival 1
7 Patient changing 2
8 Questionnaire, cleaning etc. 3
9 Exam itself 5
10 Film processing, walk back and forth 7
11 Patient changing 2
12 Patient exit and tech back to room 1
13 Post processing, paperwork 4
Total at room 28 Minutes Average patients per day 19 Hours available 20 Hours Average time per patient 1 Hour
Analysis showed how mammography department could serve 50% more cases with no increase in staff or equipment.
Fixing Surgerywith Mapping
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Lean Value Stream Map from Focus Group
Kaizen
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Value Stream Map – Hospital Discharge
Spaghetti Diagram
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Operating Rooms
Admitting, registration
Pre Op Pre Op Holding Recovery(PACU)
Inpatient Bed
Entry from outside Hospital
Inpatient Bed
Exit, return home
Basic Surgery Flow
QQQ
Q QQQ
Q
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Surgery SurgerySurgeryRoomTurnover
1. Surgery end to wheels out2. Room turnover, wheels out to wheels in
3. Wheels in to surgery start
RoomTurnover
Room Turnover Time, includes:• Wheel-out prior patient• Move out equipment from prior case• Clean room• Move in equipment for following case• Interview patient in Pre Op• Transport patient to operating room• Wheel-in following patient• Potential causes of delay:• Patient not ready in Pre Op• Patient paperwork not ready• Transport staff not available• Room not clean• Surgeon, anesthesiologist or nursing not available
Move not ordered
1. Surgery end to wheels out, includes:• Extubation of patient• Move patient to transport bed• Completion of paperwork• Disposal of drugs
Wheels in to surgery start, includes:• Assembly of clinical staff
(surgeon, anestheologist, surgeon)
• Confirmation of plan, “time out” step
• Move patient from transport bed to surgery bed
• Prep of patient• Intubation of patient
Surgery SurgerySurgeryRoomTurnover
1. Surgery end to wheels out2. Room turnover, wheels out to wheels in
3. Wheels in to surgery start
RoomTurnover
Room Turnover Time, includes:• Wheel-out prior patient• Move out equipment from prior case• Clean room• Move in equipment for following case• Interview patient in Pre Op• Transport patient to operating room• Wheel-in following patient• Potential causes of delay:• Patient not ready in Pre Op• Patient paperwork not ready• Transport staff not available• Room not clean• Surgeon, anesthesiologist or nursing not available
Move not ordered
1. Surgery end to wheels out, includes:• Extubation of patient• Move patient to transport bed• Completion of paperwork• Disposal of drugs
Wheels in to surgery start, includes:• Assembly of clinical staff
(surgeon, anestheologist, surgeon)
• Confirmation of plan, “time out” step
• Move patient from transport bed to surgery bed
• Prep of patient• Intubation of patient
Wheels Out Time
Wheels In Time
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Typical Surgery Patient Flow
Problems
Pre Op delays
Physical Layout constraints
Pull system needed
Scheduling inaccurate &
ineffective
Communicat ions lacking
Charge Nurse ineffective
Report Card lacking
Utilization of staff and rooms low
Surgery Operational Problem AreasIssues are similar among hospitals.
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Fixing the Primary Care Doctor’s Office with Redesign
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Old Process
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New Process
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Fixing Patient Waiting with Technology
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Patient wristband with RFID chip
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Staff can see what patient is where and how long they have been there.
Who does Healthcare improvement?Who does Healthcare improvement?
• External consultantsExternal consultants• Designated internal departmentDesignated internal department• Responsibility of managersResponsibility of managers• Certified or uncertifiedCertified or uncertified• Corporate vision (or not)Corporate vision (or not)
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• Time for a given activity reduced by over 50 %• Amount of human effort needed reduced by > 50
percent.• Defects reduced by > 90 %• Injuries and sick days reduced by over 50%• Cost of a given activity reduced by 30 – 50 %• Work force dissatisfaction and turnover reduced
dramatically.
Results are significant
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David Belson, Ph.D.
USC Department of Industrial and Systems Engineering
HCE Conference David Belson 2012
http://healthcareengineering.usc.edu
http://www.jship.org/home/