Healthcare Finance Management Association: Continuous ... · 24.3 0 20 40 60 80 Door to Doc Door to Doc Before After 201.6 82.4 0 50 100 150 200 250 ED LOS ED LOS Before After 6 0

Healthcare Finance Management Association:

Continuous Improvement Foundations

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Continuous Improvement Solutions, LLC 8801 Bethnal Rd., Bella Vista, AR 72714 479.685.8380 [email protected]

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Chad Smith: Trainer, Facilitator, Practitioner of

Continuous Improvement, ASQ Master Black Belt #8





Chad Smith: Pilot, Builder, Aviation Nut





Chad Smith: Musician





Chad Smith: Husband and Dad





Leaning Objectives

• Explore the Need

• See the Improvement Cycle in Action

• Discuss cultural challenges that stand in the way of changing

healthcare processes

• Discuss courage and fear impacting success

• Walk away with good ideas to help you inspire others





The Background

• Large Regional Hospital System: 827 bed facility

• Provides tertiary care to large city

• System is third largest employer in

State

• Hospital System is a non-profit

organization

• Their objective is to serve more

people in the local metropolis





The Need

• Wanted to drive more consistent service and reduce

patients Leaving Without Being Seen (LWBS)

• Wanted more capability to accommodate additional

patients

• Wanted to improve service to their customers by reducing

“door to Doc” time





Team Members

VP Clinical Services

Unit Supervisor ED & Medflight

Director PI

Senior Systems Analyst

Night Shift ED Charge Nurse

Business Manager for ED

ED Medflight

Nurse Educator/Charge Nurse


Paramedic

Central Processing Supervisor






Problem Statement

• Prolonged wait times to be triaged

• LWBS (2015): 4.6 / day

– Avg 10 / day for April 2016

• Not a clear understanding of

Arrival-to-Doc time

• LOS (2015): 203.16 min.





Project Goal

Objectives:

• Reduce LWBS to less than 2%

• Reduce LOS to 60 min for acuity level of 4-5





Are we adding value for our Customers?

We discussed the idea of Value-Add and Non-Value Add activities

and assessing if they are adding value for our customers…

Value Added

Any activity that increases the market form or function of the product or

service. (These are things the customer is willing to pay for.)

Non-Value Added

Any activity that does not add market form or function or is not necessary.

(These activities should be eliminated, simplified, reduced, or integrated.)





Established the Project Customers

• Internal Customers (the

Floors, Physicians, Radiology,

the Laboratory, Surgical

Services, Bed Board)

• External Customers

(Patients, EMS, outside

facilities)





Completed Process Map and 8 Wastes Training

Review 8 Wastes

➢Transportation

➢ Over Production

➢ Motion

➢ Defect

➢ Delay

➢ Inventory

➢ Processing

➢ People/Information

A Process Map is a graphic display of steps, events, and operations that constitute a process.

Includes Value Added ANDNon-Value Added Activities

……………Go FAST !

Activity Delay

Start

the car

Check your

fuel gaugeWait for

defroster

to clear

Put in

gear

ActivityActivity





Completed Current State – Process Map

• Started with initial training

on Process Mapping

• Determine the Start and

Stop

• Start: Patient Arrives

• Stop: Doctor sees Patient

• Silent Brainstorm to get all

the process activities quickly





Cause & Effect

LR Patient Arrival to Hospital and ED treatment.igx

Door to

Doc time

too high

Measurement

Patient acuity

Mother Nature

Holidays - increase volume

Machine

Slow test turnaround

times (lab)

Method

No beds available in hospital

Manpower

Material

No one at mini reg

MD shift change

Registration

Ambulance volume

Patient volume

Doctor time in a room

for high acuity

No beds available in ED

Sometime people come

to get doctor excuse for

another day off after a

holiday

Mondays - higher volume

Transfers out of hospital ED

Transfers into hospital

Shift change for doctors

(staffing)

Distractions in waiting room delaying

triage nurse

Calls - insurance, incoming, transfer calls

(charge nurse)

Slow triage nurse

Staffing - not enough techs for triage

Staffing versus patient load

Several EKG/CT needed at once

Slow documentation time

per Dr Pauls - EPIC

Manpower• No one at Mini-Reg• MD shift change• Call Ins• Distractions in waiting

room delaying triage nurse

• Dr interruptions

• Registration• Slow triage nurse• Zero techs for triage• Staffing vs Patient load• Triage nurse has to take

very sick patient straight back

• Several EKG/CT at once

Method• No beds available (hospital or

ED)• Rising Transfers• Zero beds in hospital

Measurement• Patient acuity• Patient volume• Ambulance volume• High acuity patients

Mother Nature• Mondays• Holidays• Days off

Rising

Door-

to-

Doc

Time





Go to Gemba!

• Gemba simply means the place where Value is Created

• Imperative to see what is really happening in the process!

• Critical Time to engage the Docs- the are integral to driving the

improvements and must be on board





Current State Data

Patient Arrival by Day and Hour

Monday is the highest volume day of the week

9am – 7pm are the highest volume hours of the day





Current State – ED Process Map





Improvement Ideas

• Add NP/APN to assist at triage

– Provider gives rapid medical

evaluation and begins orders

• Fast Track / Flex Bed

• Quick-Reg Process (did not address

at this time)

• MD shift change (did not address

at this time)





Acuity Levels: Refresher





Future StatePatient Arrives

Quick Reg

Triage

Is Patient a 4-5 ?

Medical Screening (APN)

Order any req’d tests

Move Patient to Waiting Room

(Family Rm)

Lab/X-Ray get Patient from Waiting Rm.

Move Patient to Waiting Rm (Family Rm)

Nurse gets Patient

Dispo / Discharge

Main ER

Fast Track

no

yes

Acuity

Level 4

and 5 no

longer

going to

main ED!!!





Future State Pilot

Wednesday Pilot - RTU

• Dr. Purvis up front

• Used rooms near triage

• Streamlined flow to minimize

walking

Thursday Pilot

• Dr. Pahls acted as an APN

• Saw all acuity levels and que

test orders immediately

• Run 10:00 – 12:00

• Saw 8 Patients

• Remainder of Thursday is

same process as

Wednesday’s pilot with Dr.

Chaffin up front





Rapid Treatment Unit Pilot

Rm-3

Blood Draw

Rm-2

Triage Nurse

Rm-1

Registration/

FinancialSecurity

Quick

Reg

Dr

De

sk

Rm-25

Discharge

Rm-26

Assessment

RTU

Waiting

POC

1

2

3

5

4

6

7

8





Future State Pilot Results






DATE: 5-20-2016

LEADER:

BEFORE GOALS AFTER % IMP 2 WEEKS 1 MONTH 3 MONTHS 1 YEAR

Arrival-to-Doc (min) 66.21 40 24.34 63%

LWBS (Pilot run 11am-11pm) 6 3 0 100%

LOS (Acuity=4-5) 201.61 60 82.42 59%

Arrival-to-Dispo 170.04 85 69.96 59%

LOS (Overall) 252 224 11%

REMARKS:

"BEFORE" data is based on 1 wk prior to trial

AREA: ED

RTU, Acuity level of 4-5

KAIZEN REPORT CARD






60.1

19.6

0

20

40

60

80

Door to Room

Door to Room

Before After

66.2

24.3

0

20

40

60

80

Door to Doc

Door to Doc

Before After

201.6

82.4

0

50

100

150

200

250

ED LOS

ED LOS

Before After

6

00

2

4

6

8

LWBS

LWBS

Before After





Tools We Used

• Kaizen Philosophy

• Process Mapping

• GEMBA

• Silent Brainstorming

• Parking Lot

• Affinity Diagrams





Action Items

After determination of go-forward is confirmed, work with

team to finalize plan

Meeting: Date

Action Item Owner Category Due Date Comments

1Install 1 workstation for Physician and 1 workstation for

Scribe4 3 2 1 4 3 2 1

0% Complete

2Work with team to develop go-fwd plan after admin

evaluation4 3 2 1 4 3 2

25% Complete

3 Map physicaian's computer to printer in new location 4 3 2 1 4 3 50% Complete

4 Move existing PACS to new physicaion location 4 3 2 1 475% Complete

5 Change 7 Flex Beds to monitored ED beds 4 3 2 1100% Complete

6 Determine APN long-term strategy 4 3 2 1

7 Map nurses printer 4 3 2 1

Progress Progress Key

Progress Key

Action Item Register

Improvement Group

Team Members4/22/2016

Team leader is the

person that will keep the

champion updated,set up

team meetings, push for

completion, etc.





➢ Deming’s Principle #8: Drive Out Fear

“Drive out fear, so that everyone may work

effectively for the company”

➢ Fortunately for this team, the culture of open and

honest communication was developed during the

event

➢ In fact, they had embraced a saying often repeated

by Donnie Smith, Former CEO of Tyson Foods

“Say it in the room!!!”

What it Takes to Drive Daily Improvement





Let’s press pause and

discuss:

Why is it critical that

Fear be eliminated in

your organization?

Power of a ‘Fear Free’ Organization

• Deming’s Principle #8: Drive Out Fear






discuss:

What are reasons for

fear in businesses?

What can we do to

overcome?








discuss:

How does the Process

Improvement Event

reduce the likelihood of

being fearful?







Final Thoughts

• Be willing to establish a big challenge

• Be OK with adapting approaches and tools to meet the

business need

• Practice “Say it in the room”

– Make it your standard work

• Do everything you can to eliminate FEAR

• This can best be done by working as a team!

• Lead by Example!





Leaning Objectives- Recap

• Explore the Need

• See the Improvement Cycle in Action

• Discuss cultural challenges that stand in the way of changing

healthcare processes

• Discuss courage and fear impacting success

• Walk away with good ideas to help you inspire others





What Questions do you have?

I’d Love to Hear from You!!! Link with me on

Linked In, Twitter and Facebook…

Chad Smith, MBB (ASQ #8)

Continuous Improvement Solutions, LLC

8801 Bethnal Rd.

Bella Vista, AR 72714

479.685.8380

[email protected]

www.cisolutionsllp.com

Questions

mailto:[email protected]





Appendix – Provider-in-Triage Industry Study

Background Provider-in-Triage (PIT) Results

Palomar Medical Center EDhttp://www.cepamerica.com/news-resources/perspectives-on-the-acute-care-continuum/july-2014/emergency-department-triage-a-physician-in-triage

Patient volume spiked after

relocating to a new hospital

and ED. Rising Wait times,

triage delays, increased LWBS

• Door-Doc = 15 min (34%

reduction)

• LWBS reduced by 64%

• 35% increase in revenue from ED

patients in first 5 months

• Overall ED patient satisfaction

increased from 80 to 86

percentile (Press Ganey)

Parma Community Hospital.

James J. Augustine, MD, FACEP

Scientific Assembly

Seattle, WA

• 42 min decrease in ALOS (with 10

hr long PIT)

• Improved Physician & Nursing

satisfaction

• Press Ganey results improved

from 30 to 90th percentile

• LWBS decreased by almost half

resulting in increased revenue

GW School of Medicine & Health

Scienceshttps://smhs.gwu.edu/urgentmatters/content/physician-assistant-provider-triage

St Joseph Mercy Hospital

Ann Arbor, MI

Prolonged wait times and LWBS.

Overcrowding ED.

Placed a Physician Assistant

(PA) in triage. To see all patients

EXCEPT those placed on Fast-

Track area of ED

• LWBS decreased by 43% to less

than 1%

• Length of stay decresed 9 min

• Reduction in LWBS more than

covered the cost of the Provider

• Originally started PIT for 7 hr/day,

but extended to 16 hr/day

because financial viability





Appendix – Provider-in-Triage Industry Study

Background PIT Results

A Long-term Analysis of Physician

Triage Screening in the

Emergency Department Jonathan G. Rogg, MD, Benjamin

A. White, MD, Paul D. Biddinger,

PhD, Yuchiao Chang, MD, and

David F. M. Brown, MDhttp://onlinelibrary.wiley.com/doi/10.1111/acem.12113/pdf

Compare ED performance

metrics over 4 year period

(2006-2010) to evaluate PIT

benefits

• LWCA decresed from 4.8% to

2.9%

• Door-to-room decreased from

18.4 to 9.9 min (46% reduction)

• LOS reduced from 362 to 306

min (15% reduction)

Journal of Hospital Administration

2014, Vol. 3, No 1

Improving patient satisfaction by

adding a physician in triage

Study compares patirnt

satisfaction 6 months before

and after PIT implemented.

(Approx 500 patients in each

sample group)

• Study shows a small but

statistically significant

improvement in the absolute

patient satisfaction scores (Press

Ganey) after adding a PIT





Appendix – Current State Data

Patient-RN ratio is above 3.5 from 8am-

10am

Patient-MD Ratio is above 12 from 6am-12pm

1 MD at 6am-7am





Appendix – Current State Data

Staffing vs Patient Volume

• Patient-RN ratio is above 3.5 from 8am-10am

• Patient-MD Ratio is above 12 from 6am-12pm

Documents

Healthcare Finance Management Association: Continuous ... · 24.3 0 20 40 60 80 Door to Doc Door to Doc Before After 201.6 82.4 0 50 100 150 200 250 ED LOS ED LOS Before After 6 0