Benjamin Disraeli inevitable. is Continual Change: Process

Continual Change: Process Improvement in Healthcare

10/9/2019

2019 TPTA Annual Conference 1


• “Change is inevitable. Change is constant.”Benjamin Disraeli

• “When you’re finished changing, you’re finished.”Benjamin Franklin

• “Change the way you look at things and the things you look at change.”Wayne W. Dyer

• “Everyone wants better. No one wants change.”Jonathan Fields

The Learner will…• Explain the purpose of process improvement across various physical therapy settings.

• Describe the LEAN methodology to process improvement.

• List and explain the various types of waste commonly found in the healthcare setting.

• Describe the steps to completing a process improvement project.

• Define the role of leadership and staff throughout the process improvement project.

• Describe at least two examples of process improvement projects and their application in the healthcare setting.

• Choose one process improvement project to pursue upon return to their healthcare setting.

2017 Cost of Healthcare

• $3.5 trillion• $10,739 per person

• Medicare Spending: $705.9 Billion• Part B: $309 Billion (Cubanski & Neuman, 2018)

• Medicaid Spending: $581.9 Billion

Cubanski, J., & Neuman, T. (2018, June 22). The Facts on Medicare and Spending. Retrieved January 01, 2019, from https://www.kff.org/medicare/issue‐brief/the‐facts‐on‐medicare‐spending‐and‐financing/

NHE Fact Sheet. (n.d.). Retrieved January 01, 2019, from https://www.cms.gov/research‐statistics‐data‐and‐systems/statistics‐trends‐and‐reports/nationalhealthexpenddata/nhe‐fact‐sheet.html


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The Solution

•Find a way to provide therapy services with higher quality and lower costs…

Increasing Quality and Decreasing Cost

• Increase patient satisfaction

• Improve patient outcomes

• Decreasing wasteful billing/charges

• Streamlining administrative tasks

LEAN

• Not a new concept. Based on continuous improvement

• Largest basis is from Toyota with a goal of decreasing defects or opportunities of defects

• James Womack introduced “Lean Thinking” in 1995

• Lean and Six Sigma movement in 2002

LEAN Methodology• “…set of concepts, principles, and tools used to create and deliver the most value from the customers’ perspective while consuming the fewest resources and fully utilizing the knowledge and skill of the people performing the work.” (Graban, 2012, p. 17).

• ‘“…provides a way to do more and more with less and less – less human effort, less equipment, less time, and less space – while coming closer and closer to providing customers with exactly what they want.”’ (Womack and Jones, 2003, p. 15 as cited in Graban, 2012, p. 18)

Graban, M. (2012). Lean hospitals: improving quality, patient safety, and employee engagement. Boca Raton: CRC Press.


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What can Lean do?

• Increase productivity by producing more with same resources

• Improve quality• Decrease defects

• Improves on‐time delivery

• Decrease wait

Principles of Lean

1. Specify value in the eyes of the customer

2. Identify the value stream and eliminate waste

3. Make value flow at the pull of the customer

4. Involve and empower employees

5. Continuously improve in pursuit of perfection

Principles of Lean






Value Added vs. Non‐Value Added

Value Added

•Directly affects patient care and satisfaction

• Process step that changes the product to satisfy customer demands and requirements

Non‐Value Added

•Activities that consume time or resources, but do not meet the need of the customer


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Principles of Lean






Process Mapping

8 Types of Waste

Defects Over Production Waiting

Non‐Utilized Talent

Transportation Inventory

Motion Extra Processing

Defects

Over Production

Waiting


Transportation

Inventory

Motion

Extra Processing


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Defects

• Time spent doing something incorrectly

• Inspecting and fixing errors

• Examples: • Incorrect charges for a specific treatment

• Supplies not being restocked appropriately and timely

Over‐Production

• Producing too much of a product

• Producing the product earlier than what is needed

• Examples: • Unnecessary diagnostic procedures

• Medications over produced/available to the floor

Waiting• Time when nothing productive is happening

• Patients and Products, and Employees• Patients and Products

• Waiting for the next procedure or for their appointment

• Bills waiting to be processed

• Lab work waiting to be processed

• Employees• Waiting to be able to perform value added activity

• Therapists waiting to see patients (all settings)

• Uneven workload or low workload


• Waste and loss to not having people work at the top of their abilities/license

• Example: • PT serving as a physical therapy tech to another therapist

• PTA working in a front desk position

• Employees constantly searching for supplies


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8 Types of Waste

Defects Over Production Waiting


Transportation Inventory

Motion Extra Processing

Transportation

• Unnecessary conveyance of patients, supplies, or information (patient or supply movement)

• Examples: • Movement of a patient for a procedure

• Location of the cafeteria

Inventory

• Excessive inventory is considered wasteful

• Takes up space

• Expires

• Examples: • Par levels

• Expired supplies

• Out‐of‐date medications that need to be disposed

• Expired wound care supplies

Motion

• Wasteful motion of those doing the work (employee movement)

• Examples: • Excessive movement of staff at a nurses station

• Location of the equipment and supplies in a patient gym

• Excessive movement of staff from centralized office location to patient care areas (hospital)


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Extra‐Processing

• Performing work that is non‐value added

• Performing work at a higher level of quality than is required by the customer

• Example: • Over processing of bills or charts

• Time/date on something that does not require it or the time/date is never used

Principles of Lean






Factors

• Takt Time: total amount of time needed for the process to be completed

• Total amount of time needed to check‐in 1 patient

• Flow: • Minimizing interruptions to the flow• Prevent bottlenecking

• Pull:• Do not complete next step until previous step completed

• Improve: • Continuously work to improve processes

Principles of Lean







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Employees

• Involve and empower employees at all levels

• Employees should take ownership of the project

• Require a team of employees (all individuals who touch the process/problem at hand should need to be involved – key stakeholders)

• May require some type of process improvement training (depending on scope of project)

• All ideas are good ideas (encourage involvement – “parking lot”)

Leadership’s Role

• Choose the employee

• Create the team

• Provide time during the day for meetings and project work

• Monitor individual/group’s progress with weekly check‐ins

• Provide contacts/resources to the group

• Support suggestions and improvement plans

• Ensure continual evaluation of improvements

Principles of Lean

1. Specify value in the eyes of the customer.

2. Identify the value stream and eliminate waste.

3. Make value flow at the pull of the customer.

4. Involve and empower employees.

5. Continuously improve in pursuit of perfection.

Continuous Improvement

• Project never ends (sustainability plan becomes daily routine)• Audits/Data pulls are used to ensure project maintenance

• Always room for improvement

• Continuously improving upon the improvements


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The Process of Process Improvement

Define Measure Analyze Improve Control

Plan Do Study Act

Define•Why is the project critical?

Measure•How does the process perform today

Analyze•Link changes in the process to different outcomes

Improve•Determine solutions

Control•How long term control will ensure sustainment

Define

• Why is the project critical?

• What is the need for improvement?

• Who is involved?

• What areas are impacted by the changes?

Title of Project

Project Team:

Sponsor: (VP Level) Champion: (Executive Director Level)

OCE Leader: (Optional – Lean Leader) Finance Rep: (Financial Rep)

Project Leader: (Person conducting the project) Process Owner: (Director Level)

Team: (Any additional team members who assist with the project)

Problem Statement: Describe what is wrong/current state. Should be as specific as possible. What time frame? What is the main contributor? Where is this happening? How often is it happening? What are the negative consequences?

Opportunity Statement: State regarding the potential impact of implementing a change to the current state. Can have financials attached.

Project Goals:List 2-3 smart goals. Financial impact goals should be included

Business Benefit:Describe the benefit of project implementation

Monetary benefitDefect ReductionIncreased QualityIncreased ServiceEmployee SatisfactionIncreased EfficiencyFTE ReductionWaste Reduction

Areas of Impact/integration:

Areas that will be impacted by the project implementation

Internal

External

Suppliers

Project Scope:

Area of Implementation

Timeframe

Available Resources


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Throughput to Rehab

Project Team:

Sponsor: Dr. Charles Reed, RN, CNRN Champion: Dr. Elizabeth Koyle, PT, DPT, MBA, PhD.

OCE Leader: Aaryn Hernandez-Smith Finance Rep: David Paul

Project Leader: Patricia Rivera, PT, DPT, MBA-HM Process Owner: Barbara Saldana, RN

Team: Rehab Clinical Liaisons, Unit Clerks, PCCs, Unit Nursing Staff, Resident Physicians

Problem Statement: Due to the current transfer process, many patients are often delayed arriving to the inpatient rehab unit. This causes a back log of work for our nursing staff and resident physicians. In addition, this causes a slowing of the movement of patient’s discharge until after shift change and may lead to decrease patient satisfaction.

Opportunity Statement: Currently, only 35% of patients arrive on the floor within 2 hours of the discharge order being placed. Decreasing the amount of time it takes to transfer a patient to the inpatient rehab unit can help alleviate bottlenecking and batching of patient admissions. This in turn will lead to safer transfers that are not occurring during shift change and improved patient satisfaction.

Project Goals:1. Increase the number of patients that arrive to the unit within 2 hours of their

discharge order being placed to 50% in order to facilitate safe and timely transfers to inpatient rehab.

2. Decrease the number of admissions after 5pm to 5% to facilitate safe and timely transfers to inpatient rehab.

Business Benefit:1. Facilitate safer transfers that occur prior to shift change.2. Open beds on acute care floor in a timely manner to allow patients to be admitted from the

ED.3. Increasing in patient satisfaction due to streamlined process for transferring.

Areas of Impact/integration:1. Inpatient Rehab 2. Acute Care Hospital Units3. Transport Department4. Nursing 5. Physicians6. Unit Clerks

Project Scope:

University Health System

April 2017 - December 2017

Measure

• What do you want to measure?

• What does it tell you?

• Can you obtain the data?• Resources available to obtain data

• Beware of collecting data just to collect data• Data must have a purpose

Metric Reason for CollectionOperational Definition Data

Source Sampling Method Sample Size

Who will Collect

Form Used?

Item to be measured

Purpose of collection How do you measure the item?

Where is the data coming from?

Random, specific cases, etc.?

n size(typically

30)

Who is collecting the data?

Data Collection Form

Metric Reason for CollectionOperational Definition Data

Source Sampling Method Sample Size

Who will Collect Form Used?

Admission Times

Tracking the admission time will give information regarding when the patient arrived to help give a

baseline measurement.

1. Arrival time to the unit as documented in EMR

EMREvery patient admitted

for 30 days>=30 Unit Clerks

AdmissionTime

Spreadsheet

Reason for Patient Delay

Patients are delayed for a reason and this collection will allow for an aggregate of information to help guide information

1. Patient is considered delayed if does not arrive on the unit within 2 hours of

discharge order being placed.2. Reason for delay is the described reason

written by the Unit Clerks

AdmissionDischarge Transfer Email

Every patient admitted for 30 days

>=30Unit

Clerks/TrishaDelay

Spreadsheet


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Time StudyName Initial Contact Final Contact Documentation

TimeTotal Time

Michelle 8:24 8:32 1:30 9:30

14:48 15:52 1:30 5:30

Analysis

• What is the data telling us?

• Perception is not always reality

• Multiple tools can be used to analyze the date• Do not just need statistical analysis

Analysis Tools

• Value Stream Mapping• Process Mapping

• Spaghetti Diagram

• Root Cause Analysis• 5 Whys

• Cause and Effect Diagram

• Fishbone Diagram


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Root Cause Analysis

• 5 Whys

• Fishbone Diagram

5 Whys

• Asking “Why” several times to get to the root cause of the problem

• Can be used in a formal or an informal setting

• Great to solve daily problems

5 Whys

• Problem: Patients waiting 10 minutes to get checked in for appointment once they arrive

• Line in front office/reception area

• Front desk staff is busy with paperwork

• All paperwork is completed for new patients when they arrive

• Paperwork is not available for new patients ahead of time

• No electronic copies to post online


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Fishbone Diagram 5S and Visual Controls

• Inventory Management

• Organization

• Foundation for continuous improvement

• Safe‐Work Area

Before 5S

1. Sort – Keep only what is needed

2. Store – Arrange and identify for ease of use, organize

3. Shine – Organize and clean regularly

4. Standardize – Make standards obvious and visual

5. Sustain – Set discipline, plan, schedule, train


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After Define•Why is the project critical?





Improve

• Solutions should come from the staff• Encourage staff to think outside of the box

• May have multiple solutions• Can use an impact‐effort grid to prioritize the solutions

• Create a timeline for implementation/education• Include who is responsible for each step

• Include deadlines

Impact Effort Grid

https://www.edrawsoft.com/impact‐effort‐matrix‐templates.php


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Success?

• Use the same metrics as the during the measure phase to determine if the solutions implemented are providing the desired results

• If not successful, evaluate why…

Define•Why is the project critical?





Control and Sustainability

• Develop a plan to track success• Start with shorter intervals

• Progress to larger intervals

• Create a document that states who is responsible and accountable for each step and metric

Take Homes…

• Process improvement is actually continual improvement

• Long‐term commitment

• Engage employees and staff and get their buy‐in on the project

• Do not immediately jump to solutions without completing the previous steps

• Perception is not always reality


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Thank You!

• Dr. Elizabeth Koyle

• Hannah Willis (Manager of Operational Excellence at University Health System/University Hospital)

References

• Cubanski, J. & Neuman, T. (2018, June 22). The Facts on Medicare and Spending. Retrieved January 01, 2019, from https://www.kff.org/medicare/issue‐brief/the‐facts‐on‐medicare‐spending‐and‐financing/

• Graban, M. (2012). Lean hospitals: improving quality, patient safety, and employee engagement. Boca Raton: CRC Press.

• Lean Six Sigma: Lean Leader/Yellow Belt Training Presentation. (n.d.). Texas Health Resources Presbyterian Hospital of Dallas: Operational Excellence.

• NHE Fact Sheet. (n.d.). Retrieved January 01, 2019, from https://www.cms.gov/research‐statistics‐data‐and‐systems/statistics‐trends‐and‐reports/nationalhealthexpenddata/nhe‐fact‐sheet.html

Title of ProjectProject Team:Sponsor: (VP Level) Champion: (Executive Director Level)

OCE Leader: (Optional – Lean Leader) Finance Rep: (Financial Rep)

Project Leader: (Person conducting the project) Process Owner: (Director Level)

Team: (Any additional team members who assist with the project)

Problem Statement: Describe what is wrong/current state. Should be as specific as possible. What time frame? What is the main contributor? Where is this happening? How often is it happening? What are the negative consequences?

Opportunity Statement: State regarding the potential impact of implementing a change to the current state. Can have financials attached.

Project Goals:List 2-3 smart goals. Financial impact goals should be included

Business Benefit:Describe the benefit of project implementation

Monetary benefitDefect ReductionIncreased QualityIncreased ServiceEmployee SatisfactionIncreased EfficiencyFTE ReductionWaste Reduction

Areas of Impact/integration:

Areas that will be impacted by the project implementation

Internal

External

Suppliers

Project Scope:

Area of Implementation

Timeframe

Available Resources

Appendix A

Project Team:Sponsor: Champion:

OCE Leader: Finance Rep:

Project Leader: Process Owner:

Team:

Problem Statement:

Opportunity Statement:

Project Goals:

Business Benefit: Areas of Impact/integration: Project Scope:

Metric Reason for Collection Operational Definition Data Source

Sampling Method

Sample Size

Who will Collect

Form Used?

Appendix B

Appendix C

Process Mapping

Process Step

Decision

Potential Waste

Process Direction

Appendix CProcess Mapping

Possible SolutionsAppendix D

1.

2.

3.

4.

5.

6.

7.

8.

Impact/Effort Grid Appendix D

IMPACT

EFFO

RT

Documents

Benjamin Disraeli inevitable. is Continual Change: Process