Lean Overview 042109 - Institute of Industrial and Systems ... Overview 042109.… · 5 Overview...

1

Lean Healthcare –

Overview and Applications

© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.

Jody Crane, MD, MBA

ED Physician, Mary Washington Hospital

Adjunct Professor, UT College of Business

[email protected]

1

Overview

� Mary Washington Hospital Background

� Overview of Lean Concepts and Tools

� Applied Lean at Mary Washington Hospital

� Lean Operations Applied to ED Design – The

Stafford Hospital Center ED

© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 2

2


Background:

Mary Washington Hospital (MWH)

� Located in Fredericksburg, VA about 40 miles due south of Washington, DC

� 2001 Reached our limits in 25-bed ED which poorly accommodated 75,000 visits per year, averaging 6% walkouts per year

� Summer 2002 Opened a state-of-the-art 50-bed ED

� Staffing budget based on patient volume and as such, no increase allocated, “It will never fill up.”

� Filled up on first day

� No plan, no organization

� Actual drop in visits to 72,500 despite rapid population expansion

3


Background: MWH ED

� 2003 volume rebounded to 83,000 � Summer brought long waits, onset of hospital crowding

and complaints

� 13 negative letters to the editor in local newspaper in 3 months

� Winter came and brought worse overcrowding� Inpatient beds saturated

� Walkouts climbed to 12%

� Volume dropped to 78,000 in 2004 the following year

4

3


Volume 2001-2007

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Jan-01

Apr-0

1

Jul-0

1

Oct-0

1

Jan-02

Apr-0

2

Jul-0

2

Oct-0

2

Jan-03

Apr-0

3

Jul-0

3

Oct-0

3

Jan-04

Apr-0

4

Jul-0

4

Oct-0

4

Jan-05

Apr-0

5

Jul-0

5

Oct-0

5

Jan-06

Apr-0

6

Jul-0

6

Oct-0

6

Jan-07

Apr-0

7

Jul-0

7

Month

Volume

Monthly

Patient

Volume

2002

73,819

2003

83,608

2001

74,265

2004

78,606

2005

85,720

2006

92,019

2007

? 100K

5


Walkout Rate 2001-2007

0%

2%

4%

6%

8%

10%

12%

14%

Jan-01

Apr-0

1

Jul-0

1

Oct-0

1

Jan-02

Apr-0

2

Jul-0

2

Oct-0

2

Jan-03

Apr-0

3

Jul-0

3

Oct-0

3

Jan-04

Apr-0

4

Jul-0

4

Oct-0

4

Jan-05

Apr-0

5

Jul-0

5

Oct-0

5

Jan-06

Apr-0

6

Jul-0

6

Oct-0

6

Jan-07

Apr-0

7

Jul-0

7

Month

Monthly

Walkout

Rate

Target

2002

2003

2001

2004

2005 20062007

6

4


December Admission Holds

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Date (December)

ER Holds Total Admits ER Admits OR Admits Average Walkouts

Number of

Patients

7


Background: MWH ED

� Changes in 2004

� 100-bed wing opened in February

� New ED nursing manager

� Began focusing on process improvement

� Hospital-wide Patient Flow Team Implemented

� First focus- the admitting process

� Attention then turned to the ED to begin working on treat and released

patient throughput

� In 2006 began to take Lean Operational Approach

8

5

Overview







Lean Healthcare

� An operations and process management strategy

� Derived from the Toyota Production System

� Focuses on creating patient value, eliminating waste, promoting flow and continuous improvement


6

Key Principles

� Key Principles

� Focus on Processes that deliver Customer Value

� Eliminate waste

� Promote flow

� Continuously improve the processes


Key Principles

� Key Principles


� Eliminate waste

� Overproduction

� Movement

� Inventory

� Over-processing

� Waiting

� Correction

� Transportation


7

Key Principles

� Key Principles


� Eliminate waste

� Promote flow



Key Principles

� Key Principles


� Eliminate waste

� Promote flow

� Establish clear signals and handoffs

� Reduce batching and variation

� Establish proper capacity

� Synchronize and “tighten” processes


8

Key Principles

� Key Principles


� Eliminate waste

� Promote flow



Lean Tools

� Value Stream Mapping, Process Mapping

� Standard Work, Demand/Capacity Management

� 5S (Sort, Set in order, Shine, Standardize, Sustain)

� Inventory Management (Pull systems), visual controls

� Setup/changeover reduction (Rapid Changeover)

� Mistake proofing, root cause analysis

� Targeted flow improvements, Continuous flow cells


9

Lean Tools










Process Mapping – “Low Tech”

18

10



Value, Waste, and Tools –System Improvements

20

11


Lean Tools









12

Lean Tools


� Defining the current work sequence and making sure it

functions in accordance with patient demand

� Demand Analysis

� Quantitative analysis of arrival rates/patterns

� Calculating takt time

� Capacity Analysis

� Work sequencing

� Appropriate staffing

� Designed to meet takt time

� Demand Capacity Matching – Applying these principles in

complex service industries where demand varies over time



� Spaghetti Diagram of staff movement processing CT patients

� Total nursing and CT tech walking 4 hours per day

� Total annual cost $35,000

24

13

Stafford Hospital Volume (03/09)


Stafford ED MD Demand/Capacity no

PA (2.5 pts/hr)


14

Stafford ED MD Demand/Capacity

w/PA (2.5 pts/hr)


Lean Tools









15

Lean Tools

� 5S – A tool for redefining the organization and

performance of your workplace to better promote

effective patient care

� 5 phases of implementation

� Seri (sar-ree) Sort

� Seiton (say-tond) Simplify

� Seiso (say-so) Sweep

� Seiketsu (say-ket-soo) Standardize

� Shitsuki (she-soo-kay) Sustain

� “A place for everything, everything in it’s place”


Mainside Team at the Work Place


16

Main ED VSM –

Supply Location Modifications


MD encounter #1

Avg Time

Location

MD

1. H&P/charting:

Othoscope – tips (wrong

ones), bulbs (missing or

not plugged in), functions

improperly

2. Cart supplies:

Tongue depressors (not

there), culture swabs

(usually out of red), guiac

developer/cards/lube,

4x4 gauze (need non-

sterile), tissues

3. Techs (for assistance)

4. Dopplers

1. IV tubing/bags (pyxis)

2. Pumps (trauma room,

supply closet, if any).

Qty? Peds? Trigger for

requested more?

3. Oral contrast: juice

(fridge)

4. IM injections: needles,

syringes and meds (med

room)

5. Band-aids (cart)

6. NG tubes (pyxis)

7. Foleys (pyxis)

8. Poop detail: diapers,

spray (T4 pyxis), wipes

(by doc box)

9. Pelvic exams: carts

(set locations 1 per

team), speculum (pyxis)

10. Bladder scan (T2

secretary)

11. Port-a-cath (pyxis/

med room), Central line

(pyxis)

12. Restraints

13. GI Cocktail: need kits

14. Pharmacy

15. Clot box

RN intervention

Avg Time

Location

RN

1. Lac procedures:

Sutures (T3 pyxis),

suture tray (T3 pyxis &

trauma room), Lidocaine

(med room)-Would like

these in supply bundles

2. Lumbar puncture:

Trays (pyxis), mask,

needles (med room),

consent (forms drawer),

betadine, Mayo stand,

LP needles (other than in

kits)- Would like in supply

bundles

3. Intubations:

disorganized

4. Central Line: Kit

(pyxis), betadine,

consent (forms drawer),

saline flushes (med

room), mask/gloves.

5. Chest tube: Suction

(pyxis), CT tray (pyxis/

chest cart), lidocaine,

needles (med room),

betadine

MD Procedures

Avg Time

Location

MD

1 1

31

Spaghetti Diagramming

� Before event, nurses wore

pedometers for entire shift x

1 week

� 3 miles walking during a

shift

� Team mapped different

paths based on supplied

needed for a typical patient

� Eliminated 80% of supplies

� Reduced Staff Movement

� Improved satisfaction and

productivity


17

Pyxis Supplies to POUMost Patients

Description Cost Charge

IV start kit $1.58 $ 0

IV Catheter $1.68 $24

PRN Adaptor $3.25 $12

Maxidrip set $3.26 $15

1000ml NaCl $1.20 $36

Adult Nas Can$0.53 $2

Total/patient $11.50 $89

Few Patients

Description Cost Charge

Yankauer $0.39 $22

Suction Can unk. $16

Adult Ambu $7.52 $167

Peds Ambu $11.46 $48

Infant Ambu $18.89 $175

Peds pulse ox $11.70 $40

Proshield Cr. $7.60 $30

Pink Spray $2.15 $9

Total/patient $59.71 $507


Future Directions

� Eliminate ED supply room in

favor of point of use supplies

� Implementing innovative

POU supply management

system based on

scales, louvers and active

tracking to eliminate Pyxis

� Reduce Human work to 3

min per day


18


Chest Tube Tray

Before After

35


MWH Implementation- 5S

Simplify/Standardize

36

19

Lean Tools










The Pelvic Cart

38

20


Top DrawerSecond Drawer

Third Drawer

The Pelvic Cart

Fourth Drawer

39

Adaptor

welded by

engineering

dept

The Pelvic Cart


21

Lean Tools









Mistake-Proofing Examples

Bloodloc: Mistake-proof Transfusions Stick-proof IV Catheters

Right-site Surgery

Oxygen Delivery

Smart Bandage


22

Lean Tools









Overview







23



“Super

Track” � Fast Track

located in or near

triage for the purpose of promptly treating patients who require very low resource utilization

Treatment Room 1

Treatment Room 2

Procedure

Chair

Entrance/Exit

1 MD/PA1 Nurse1 Tech

Results Waiting

46

24


� Pre process-improvement seen in the “low acuity area” of the ED� ESI levels 4,5

� ESI Level 3’s sometimes spill over backlogging 4,5 patients

� 16 beds, 3 PAs, 3 RNs, 2 techs

� PA productivity 2.1 patients per hour with 5-6 beds each

� LOS 2.5 hours for low acuity patients

Before

Low Acuity

Area

Entrance/waiting area

Triage

47


Rapid Cycle Testing / Implementation

� “Leaned” the process

� Procedure trays pre set-up to reduce set-up times

� Point of use supplies

� One Piece Flow

� Load Leveling

� Virtual Beds for patients getting ancillary testing

48

25


� Beds – 74%,

� Beds Closed

� PAs – 33%

� RNs – 33%

� Productivity (RN and PA)

75-100%

� LOS – 60-66%

� Patient Satisfaction-

Incredible!

After

Beds free to

see higher

acuity

patients

49


Today….

50

26



Consider a different scenario that

actually happened here at Mary

Washington Hospital

52

27


“Team Triage”*

� Team of providers utilizing an “intake team” mentality for promptly assessing, treating, and discharging level 3 patients

2 Providers (MD/PA),2 RN,1 Paramedic2 Scribes, 1PSR/HUC

Quick Look Quick Reg

Quick Triage

TreatmentArea

5 Rooms

Results Waiting

53


RATED Implementation

� “Leaned” the process� Visual Management

with color coding

� Point of use supplies

� Rapid Changeover

� Reduced Staff Movement

� Reduced Variation

� Designed to meet takt time

54

28


Super Track

55


Super Track

Intake, D/C

56

29


Super Track

Intake, D/C

Intake, TX, D/C

57


Super Track

Intake, D/C

Intake, TX, D/C

Main ED

58

30

0%

2%

4%

6%

8%

10%

12%

14%

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Month

Volume vs. Walkouts 2001-2009

Volume Walkouts

MonthlyPatient Volume

MonthlyWalkout Rate

2002 20032001 2004 2005 2006 2007

Target

2008


6,000

6,500

7,000

7,500

8,000

8,500

9,000

2:09

2:24

2:38

2:52

3:07

3:21

3:36

3:50

4:04

Mo

nth

ly V

olu

me

Le

ng

th o

f S

tay

2004-2009 Volume vs. T&R LOS

Treat and Released LOS Volume

2005 20062007

2004

2008


31


Creating Patient Value as Indicated by Press Ganey Scores

Jan 2004-Jun 2008

65

70

75

80

85

Jan-

04

Apr

-04

Jul-0

4

Oct-0

4

Jan-

05

Apr

-05

Jul-0

5

Oct-0

5

Jan-

06

Apr

-06

Jul-0

6

Oct-0

6

Jan-

07

Apr

-07

Jul-0

7

Oct-0

7

Jan-

08

Apr

-08

Month

Pre

ss G

an

ey A

bso

lute

Sco

re

61


32


Top RATEDJuly 24, 2008 3:43 am

NOT THAT LONG AGO, most of the letters to the editor that landed here regarding the Mary Washington Hospital emergency room were complaints about the excruciatingly long time a patient had to wait to get treatment. Develop an after-hours high fever and you could count on camping out most of the night. Now, however, we're hearing how delighted readers are with the efficiency, friend-liness, and expertise of the MWH ER staff.

The change stems from a program called RATED ER. The experimental patient-flow process invented by the MWH staff is so effective it's getting national attention. Already called "quite possibly brilliant" by the journal Emergency Medicine News, RATED ER is also slated to get some coverage in TIME.

The innovation's acronym stands for "Rapid Assessment, Triage, and Efficient Disposition of Patients in the Emergency Room." Essentially, it streamlines the process of diagnosis and treatment, focusing particularly on "semi-urgent" patients--those complaining of abdominal pain or nonspecific chest pains who may or may not need admission, depending on test results. More expeditiously treating this large group moves everyone through the ER faster.

It isn't as though MWH was the only hospital where ER visits dragged: The American Medical Association says 90 percent of the nation's emergency rooms are at or above capacity. A 2007 report by Press Ganey found that emergency departments that saw more than 40,000 patients a year (MWH will see more than 110,000 in 2008) had average door-to-door times exceeding 4.4 hours. The MWH average sometimes reached 6 hours.

Now, using RATED ER, that number has fallen to 3 hours, and the number of walk-outs (patients who tire of waiting and leave) is below 2 percent—down from 12 percent.

The emergency room will never be able to provide patients with instant service, but the situation is much better than it used to be. MWH should be proud. Someday, its innovation may help ERs all across the country provide more efficient care--and letters-to-the-editor writers will have to direct their fury elsewhere.

Cable providers, anyone?

63


Key Points� Patient Value Streams can provide valuable

insight and can add value when focusing on

healthcare improvement

� You should focus on eliminating waste from

the patient’s perspective

� Patient waiting

� Set up times for common procedures

� Overproduction (Doing more than the patient

needs or wants)

� Over-processing (redundant information

gathering, steps)

� Patient and staff transportation/movement

64

33

Overview







© 2009, Jody Crane, MD, MBA

Stafford

Medical

Center ED(Opening Feb 2009)

Entrance

Walk-in

Squad

Entrance

34


Stafford

Medical


Rec/

Quick

Security

Waiting

Area

Waiting

Area

Peds

Waiting

Triage

(4)

Intake

RW

Area

Main ED

14 beds 1 Trauma bay

Treat

Bays

(4)

Lab

Rad/

CT

Area

Entrance

Walk-in

Squad

Entrance


EntranceRec/

Quick

Triage

(4)

Intake

RW

Area

Treat

Bays

(4)

ESI 4,5

ESI 2,3

ESI 1,2

Admit

DischargeESI 2-5

Stafford

Medical


35

Summary

� Lean is promising and has tremendous

implications for the future of ED operations and

design

� It is critical to have the operational framework in

place or at least very well conceptualized prior to

a new ED or existing ED redesign

� As patient demographics change, so must ED

flow and design elements to accommodate a

growing lower acuity patient population


Lean Overview 042109 - Institute of Industrial and Systems ... Overview 042109.… · 5 Overview...

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