Clinical Process Analysis

Ambulatory Operations Project:

Endoscopy Center Summary

April 6, 2013

STAFF

Laurie Kaufman MSN, RN ManagerGina Aranzamendez MS, RN-BCCourtney Barnes MBABeverly HayesValerie Haywood MBA, BSN, RNDuke Rohe, IEMarvetta Walker, MHA, RN Manager Endoscopy

Time Driven Activity Based Costing (TDABC)

• Harvard University Business School– Michael Porter, PhD– Robert Kaplan, PhD

• Institute for Cancer Care Excellence (ICCE)– Thomas Feeley, MD– Heidi Albright, Director– Head & Neck Center Pilot

• Office of Performance Improvement– Process Flow Charting

TDABC & Clinical Process Analysis

2. HOW WE IMPROVE WHAT WE DO

3. HOW WE PERFORM OUR SERVICES

INPUTS

OutcomesCosts = Value

Vision:Making Cancer

History

Design and Redesign Plans to Improve Our:

• Performance as a System• Knowledge of Variation• Use of the Theory of Knowledge• Application of Psychology

OUTPUTS

4. WHAT WE DELIVER

• Patients• Families• Staff• Suppliers• Equipment• Supplies• Partners• Etc.

Processes that produce:

Work Force Development

Financial Viability

Patient CareResearch

1. WHY WE DO WHAT WE DO

1. To Cure Cancer2. To Provide Patient Care 3. To Develop Our Workforce4. To Maintain Financial Viability

MDACC’s Framework for Improving As A SystemBased on W. Edwards Deming’s “Profound Knowledge”

Adapted From: A Framework for the Continual Improvement of Health Care. Batalden PB. Journal of Quality Improvement

Vol 19 No. 10 1993

Clinical Process Analysis

Program Aim: Create a comprehensive visual display of current work processes for analysis to drive improvement in clinical quality & financial performance.

INPUTS

Current Work Activities Clinical Leadership

Content Experts Clinical Process Analysis Team

OUTPUTS Process Flow Charts In-sync Data Reporting Direct Labor Costs Opportunities for Improvement Embed QI Knowledge Workforce Engagement PI Projects

• Create a shared sense of the future • Align with strategic goals • Develop clearly defined aim and scope • Engage all levels of leadership support • Avoid competing priorities w/optimal scheduling in roll-out • Create two-way communication • Instill psychological safety for staff to share current processes

• Mobilize clinicians to make changes needed for healthcare (Berwick, 2011) • Capture the voice of the patient (Institute of Healthcare Improvement) • Illustrate frontline reality (James, 2012) • Align data reporting to frontline processes (James, 2012)

Precursory Work

Weekly Interviews

Summary &

Evaluation

PHASE I PHASE II PHASE III

Why do this? How to do this?

The Process

Performance Improvement Phase

The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

Process Flow Chart, Direct Labor Cost & Opportunities for Improvement

CPA Methodology

Participants:• Clinical Lead: Designated clinical point person for the project • CPA Team: Clinical Process Analysis Team, Performance Improvement • Clinical Leadership: Clinical Administrative Director; Center Business Manager; • SOT: Senior Operations Team

Nurse Manager; Medical Director; Quality Officer • Center Process Flow Charter: Maintains process flow charts for the Center after • Content Experts: Frontline staff CPA Project is completed

Performance Improvement Phase Weeks 4 - 14

The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

Background: Endoscopy Center Project

• Center Variation

• Scope Development

The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

Process Flow Charts

Aligning Data to Frontline Processes &

Elements of a Process Flow Chart

Direct Labor Cost

Process Flow Chart converted to Excel for Direct Labor Costing

Costing

• Salaries based on FY 2012 from ResourceOne

• Data based on information captured in process flow charts from 10.17.2012 – 12.12.12

• Based on estimated times given by frontline staff in the Endoscopy Center

• Salaries in this report are average adjusted hourly rates including fringe

• Salaries for each Job Code Group are blended by utilizing FTEs to weight the averages:

• MD- Professor, Associate Professor, Assistant Professor• PSC- Lead Services Coord, Patient Services Coord• MLP- APN and APN supervisor

• Data is reported per patient

Costing Summary:Direct Labor Costs

Costing Summary:Estimated Times in Minutes

OFIs (Opportunities for Improvement)

Waste, Delays, Inconsistencies, Rework…

Meet with CAD: validate OFI Categories,

Control level, & Prioritize

Staff (2) assigned to OFIs complete

PDSA 101

Phase II Week 4 Precursory Work

Phase II Week 5 to 8Precursory Work

Quick Fix 1 (scope: 1 wk turnaround)

4hr/staff member

Quick Fix 2 (scope: 1 wk turnaround)

4hr/staff member

PI Week 1 PI Week 2

PDSA Mtg 1Aim Statement/

Baseline Measure4hr/staff member

PDSA Mtg 2Cause Analysis/

Intervention4hr/staff member

PDSA Mtg 3Implementation/Post Measure

4hr/staff member

PDSA Mtg 4Document/

Presentation prep4hr/staff member

PI Week3 PI Week 4 PI Week 5 PI Week 6

Staff present OFI improvements at

Summary Mtg

Summary Meeting

SharePoint Site for Project Storage

• Provides storage for project work-ups• Available for bench-marking• Easy placement in Quality Project database

OFI Summary

• Total OFIs: 53

• OFIs in department's control: 6

• OFIs out of department's control: 14

• OFIs within department's influence: 33

OFI Projects

6 Quick Fixes 8 PDSA 1 CS&E

1. Ready Call pagers2. Consult processing/patient check-in3. Optimization of Endoscopy Online Consult Health questionnaire 4. Bedside consenting5. Nurse sedation practices6. Guidelines for scheduling an Endoscopy procedure7. Physician notification process for patient cancellation or reschedule

OFI Projects

8. iConsent9. PYXIS medication availability10. Anesthesia sedation & recovery charge reconciliation 11. Endoscopy safety procedure checklist12. Room standardization