Presenters:Dale Strong, BS, E.I.T. – Information and Analytics Services, Clinical Analyst

Jeremy Rhoten, RN, BSN – Carolinas Medical Center, Stroke Program Coordinator

Sunday Learning Lab 11

Sunday, December 9, 201813:00

Improve Lives and Lower

Cost, Using Our Lean PI

Tools

DISCLOSURES

• Jeremy Rhoten, RN, BSN and Dale Strong, BS, E.I.T.

• Research -Penumbra Inc,

Jeremy Rhoten and Dale Strong today have no other relevant financial or

nonfinancial relationship(s) within the services described, reviewed, evaluated, or

compared in this presentation.

OBJECTIVES

• Recognize different process improvement methodologies and

gain confidence to implement them in any workplace

• Utilize different tools to identify sources of waste and develop

efficient solutions for improvement

• Discover feedback processes to help involve key stakeholders

in the success of a project

• Develop key strategies on how to ensure sustained success for

a complex workflow

• Discuss different ways to highlight successes so others can also

implement best practices

DISCLOSURES

• Jeremy Rhoten, RN, BSN

• Research

• Penumbra Inc.

• Dale Strong, BS, E.I.T

• Research

• Penumbra Inc.

AGENDA

• Introductions and backgrounds

• Overview of our experience with process improvement

• Introduction to process improvement methodologies

• Deep dive into the DMAIC process

• Case studies and review

• Group discussion and questions

BACKGROUND

• Jeremy Rhoten, RN, BSN, SCRN

• Currently working as the Comprehensive

Stroke Program Coordinator for Atrium

Health's flagship hospital, Carolinas Medical

Center.

• Graduated from Marshall University with an

ASN, University of Texas – Arlington with

and BSN.

• Early career included working as a Critical

Care nurse in Athens GA, Falls Church VA,

Phoenixville PA, and Charlotte NC.

• Worked extensively with process

improvement projects, data analytics, and

data visualization throughout career

BACKGROUND• Dale Strong, BS, E.I.T.

• Currently working as a Clinical Analyst for the Comprehensive Stroke Program at Atrium Health's flagship hospital, Carolinas Medical Center.

• Graduated from Clemson University with a Bachelor’s Degree in Bioengineering

• Early career included working for Stryker Endoscopy providing OR support, and as a Data Management Consultant

• Worked extensively with process improvement projects, data analytics, and data visualization throughout career

• Holds an Engineer In Training certificate, and has taken multiple courses in Lean and Six Sigma

PROCESS IMPROVEMENT

Results:

• Higher product quality

• Better customer satisfaction

• Increased productivity

• Development of employee skills

• Efficiency

• Potential higher and quicker return on investment

Definition: The proactive task of identifying, analyzing

and improving on existing business processes

PROCESS IMPROVEMENT

METHODOLOGIES

Lean

• More value for the

customer utilizing fewer

resources

• Process production that

strives for results in

perfect value with zero

waste

Six Sigma

• Set of tools and

techniques that improve

output quality by

removing defects and

minimizing variability

• Process measured by

Sigma Level

Total Quality Management

• Organizational effort to

establish a culture of

continuous

improvement

• No set definition, but

uses a wide variety of

quality control tools

PROCESS IMPROVEMENT

METHODOLOGIES

• PDSA: Plan, Do, Study, Act

• DMAIC: Define, Measure, Analyze, Implement, Control

OUR EXPERIENCE

• At Carolinas Medical Center, we were tasked with streamlining the

Code Stroke Process to expedite patient treatment in the acute

stroke setting

• 2 month long process following the DMAIC method

Define

• Brainstorming with all stakeholders involved

• Discussed with administration the ultimate goal for the workflow

Measure

• Analyzed available data and process metrics

• Observed the workflow in real-time

• Mapped out the current state process

Analyze

• 5 whys root cause analysis

• Looked for any sources of waste

• Developed new streamlined workflow

Improve

• Trialed different aspects of the new workflow

• Altered workflow based on feedback

• Reevaluated the new workflow to identify other sources of waste/inefficiencies

Control

• Finalized workflow, reevaluated data and process metrics to illustrate observed change

• Established continuous feedback loops with the clinical team to allow for further improvements

STROKE FACTS

• Classifications: Ischemic Stroke, Hemorrhagic Stroke,

Transient Ischemic Attack

• Stroke is the 5th leading cause of death in the U.S.

• Stroke is the leading cause of disability in the U.S.

• Close to 800,000 strokes occur in the U.S. every year

• Ischemic Stroke accounts for almost 87% of all cases

*All statistics from American Stroke Association Website

CODE STROKE

WORKFLOW

Steps

• Patient Arrival

• Recognition of Symptoms

• Radiological Imaging

• Treatment Decision

Time Is Brain!

Door to ED Physician

10 mins

Door to Code Stroke

15 mins

Door to CT Performed

25 mins

Door to CTA Performed

45 mins

Door to IVtPA

60 mins

45 mins (Stretch)

Door to Groin Puncture

90 mins

60 mins (Stretch)

NEEDS FINDING

Finding the right problem to solve is just as important as finding the solution

CODE STROKE PROCESS

IMPROVEMENT• American Stroke Association has established time goals for

acute stroke

1. Door to IVtPA: 60 minutes

2. Door to Groin Puncture: 90 minutes

Improvements Observed

(Change Between Pre and Post Data)

Door to ED

Physician

Door to Code

Stroke Activation

Door to CT

Performed

Door to CTA

Performed

Door to IV

tPA Bolus

Door to

Puncture

Door to Final

Revascularization

Average

1.3 6.2 3.9 8.9 9.7 20.8 23.7

Median

1.0 5.0 5.0 9.5 10.5 29.0 23.5

PROCESS IMPROVEMENT

IMPACT

• Door to IVtPA Bolus improved by 9.7 mins

• Door to Final Revasc. improved by 23.7 mins

• Patient population observed a decrease Length of Stay on

average of 2,603 mins (approx. 1.8 days)

• NIHSS at discharge improved 1.94 points

• mRS at discharge improved by 0.50 points

DMAIC INTRODUCTION

• Data driven strategy to improve

• More commonly associated with

Six Sigma

• 5 interconnected phases

• Cyclical process that can be

repeated for continuous

improvement

DEFINE

First Phase

Goal: Clearly articulate a problem and establish

a goal to improve on the highlighted problem

• Important to capture the customer input

Phase Tool Box:

• Project Charter

• SIPOC

• Value Stream Map

• Swimlane Map

• VOC

• A3

DEFINE TOOLBOX

• Project Charter

• Outline for the project

• Identifies core team,

stakeholders, and their

roles/responsibilities

• Clearly lists objectives for

the project

• Serves as a reference for

authority throughout the

project

https://expertprogrammanagement.com

DEFINE TOOLBOX

• A3

• Structured and strict guidelines for problem solving

• Fits on a single sheet of ISO-A3 size paper

• Helps illustrate the thinking behind the project

• Brings all project aspects together to keep stakeholders informed

DEFINE TOOLBOX

• SIPOC

• Suppliers, Inputs, Process, Outputs, Customers

• Visualize process from beginning (Suppliers) to end (Customers)

• Higher overview level and not much granular detail

Suppliers

• Who supplies the inputs?

Inputs

• What inputs are needed for the process?

Process

• What happens to the inputs to get your output?

Outputs

• What is the result of your process?

Customers

• Who benefits from or uses your outputs?

SIPOC - GoLeanSixSigma.com

DEFINE TOOLBOX

• VOC

• Voice of customer

• Translate what the customer is saying or describing into something tangible that you can measure and impact within your process

• Helps to maintain the progress focus around what’s most important… the customer

• Results in CTQs (Critical to Quality Requirements)

VOC

Large Customer Database

Surveys

Social Media Feedback

Purchase History

Direct Phone calls &

Interviews

Market Research

CODE STROKE

WORKFLOW TREND

Project Implementation

EMS CODE STROKE

PI PROJECT - DEFINE• Project Selection:

• Patients arrive via EMS, Private Vehicle, or Inter-Facility Transfer

• “Ranked” each arrival mode to determine which patient population/workflow to focus on for the PI Project

Project Volume Feasibility Potential Impact CMC Ownership Total (Multiply all)

EMS Arrival 3 3 2 3 54

Private Vehicle

Arrival2 2 3 3 36

Transfer Arrival 2 2 3 1 12

MEASURE

Second Phase

Goal: Understand how the process

performs in its current state

• Important to plan how to collect data,

ensure data reliability, and collect

baseline data

Phase Tool Box:

• Data collection plan

• Operational definitions

• Process maps

• Project charter

MEASURE TOOLBOX

• Process Map

• Diagram of the overall workflow

• Identifies necessary steps and parallel processes

• Multiple maps or flowcharts with slight differences depending on what you want to review

MEASURE TOOLBOX –

PROCESS FLOWCHART

MEASURE TOOLBOX –

PROCESS FLOWCHART

MEASURE TOOLBOX –

SWIMLANE DIAGRAM

MEASURE TOOLBOX

• Data Collection Plan

• Determine how you are going to gather data throughout the project

• What you collect?

• Who will collect?

• When will they collect?

• Sample of collection?

• Can be high level overview or go into detail as much as you want to

Data Collection Plan

Performance Measure

• CTQ

• VOC

Definition within the

project

Data Source

How will it be

collectedWho When

Sample Size

https://www.managementstudyguide.com/data-collection-plan.htm

ASSESSMENT OF CODE

STROKE WORKFLOW

Accuracy: Ability to hit your target and/or goal

Precision: Ability to consistently hit the same spot

(Pre-Project Implementation)

EMS CODE STROKE PI

PROJECT - MEASURE

Door to ED

Physician

Door to Code

Stroke

Activation

Door to CT

Performed

Door to CTA

Performed

Door to

IV tPA

Bolus

Door to

Puncture

Door to Final

Revascularization

Average8.1 20.3 29.6 46.3 59.1 111.3 137.0

Median4.0 12.0 22.0 36.0 52.0 108.0 134.5

Pre-Implementation Data

*All values in minutes

Door to ED Physician

10 mins

Door to Code Stroke

15 mins

Door to CT Performed

25 mins

Door to CTA Performed

45 mins

Door to IVtPA

60 mins

45 mins (Stretch)

Door to Groin Puncture

90 mins

60 mins (Stretch)

ANALYZEThird Phase

Goal: Identify the cause of the observed

problem

• Important to examine the process from all

angles, graphically display what you find,

identify causes of the problem and then

verify the causes

Phase Tool Box:

• Value Stream Map

• Value added flow analysis

• Pareto charts

• 5 Whys

ANALYZE TOOLBOX

• Root Cause Analysis

• Start with a visible issue and

then dive deeper to figure

cause of the problem

• Proactively eliminate issues

instead of waiting for them to

arise

1. What happened?

2. How did it happen?

3. Why did it happen?

4. What can I do to prevent it from

happening again?

5 Whys Technique

Fishbone Diagram

https://4improvement.one/knowledge/tools-techniques

https://leanmanufacturing.online/the-fishbone-diagram/

EMS CODE STROKE PI

PROJECT - ANALYZE• In 2017, CMC had 467 Code Stroke (CS) Patients present through the ED

• 333 via EMS = 71.3% of total ED CS Volume

• 134 via Private Vehicle = 28.7% of total ED CS Volume

• For Large Vessel Occlusion Strokes 1.9 million neurons die every minute a patient goes without treatment

• Average Door to Bolus Time for IVtPA 2017 (Jan-Jun) = 59.1 min [Goal = 60 min]

• Average Door to Groin Puncture for IA 2017 (Jan-Jun) = 111.3 min [Goal = 90 min]

5 Whys?

Technique

Why? Why? ROOT CAUSE

EMS CODE STROKE PI

PROJECT - ANALYZE

DOWNTIME = 8 Sources of Waste

D

Defects

O

Overproduction

W

Waiting

N

Not-Utilized Talent

T

Transportation

I

Inventory

M

Motion

E

Extra Processing

EMS CODE STROKE PI

PROJECT - ANALYZE

• DOWNTIME: 8 Sources of Waste

• Extra Processing: 3 different personnel view patient before CS

Activation Page

• Transportation: moving patient between ED and Radiology

multiple times

• Waiting: depending on treatment strategy the patient was spending

excess time waiting for decisions/supplies

• Motion: clinical decision makers are also tasked with moving

patient multiple times while making the best decision for the

patient caused excess motion in the process

IMPROVE

Fourth Phase

Goal: Implement and check your

solution

• Important to brainstorm, choose realistic

solutions, illustrate the solution, create a

plan that includes multiple solutions when

possible

Phase Tool Box:

• Brainstorming

• PICK diagram

• PDSA/PDCA

• Implementation plan

Brainstorming

Stepladder Technique

Word Association

Writing Down

Individual Ideas

Figure Storming

Rapid-Fire

Round Robin Style

IMPROVE TOOLBOX

• Brainstorming

• Any tool that involves

getting the project group

generating thoughts and

discussions around the

process

• Important start to critical

thinking

• There are many ways to

brainstorm, and the right tool

depends on the project.

IMPROVE TOOLBOX

• PICK Diagram

• A tool to determine which option has the greatest value or impact

• Ranks ideas according to elements that are important to your project team

• Helps eliminate bias in idea selection

Project Volume Feasibility Potential Impact CMC Ownership Total (Multiply all)

EMS Arrival 3 3 2 3 54

Private Vehicle

Arrival2 2 3 3 36

Transfer Arrival 2 2 3 1 12

IMPROVE TOOLBOX• Project Implementation Plan

• Takes strategies discussed and turns them into actionable items

• Puts all team members on the same page and assigns responsibilities

• There are many ways to do this so developing a way that works for your

team is what’s most important

CSC Mock Survey Planning OrganizerSelect a period to highlight at right. A legend describing the charting follows. Plan Duration Actual Start % Complete Actual (beyond plan)

ACTIVITY PLAN START PLAN DURATION ACTUAL STARTACTUAL

DURATIONPERCENT COMPLETE Weeks

1 2 3 4 5 6 7 8 9 10

Book Rooms 1 1 1 1 100%

Finalize Opening Presentation 1 5 1 5 100%

Print Opening Presentation 6 5 6 5 100%

Schedule ED Session 1 5 1 5 100%

Finalize System Tracer 1 5 1 5 99%

Book System Tracer 1 5 1 5 100%

Print System Tracer 6 5 6 5 99%

Schedule Credentialing 1 5 1 5 100%

Print Patient List 1 5 1 5 100%

Order Set 1 5 1 5 100%

Approval On-Call Schedule for Last 3 Months 1 5 1 5 100%

Print On-Call Schedule for Last 3 Months 6 5 6 5 100%

Patient Education 1 5 1 5 100%

Print InHouse Code Stroke Process 6 5 6 5 100%

Print ED Code Stroke Process 6 5 6 5 100%

Public Reporting of Outcomes 1 10

Core Team 6 5 6 5 100%

Obtain Transfer/DC Policies 1 5

Print Transfer/DC 6 5

Follow Up Call: Confirm Documentation 6 5 6 5 100%

Finalize Program Plan 1 5 1 5 100%

Print Program Plan 6 5 6 5 100%

Obtain Thermoregulation Protocol 1 5 1 5 100%

Print Thermoregulation Protocol 6 5 6 5 100%

Obtain Diagnostic Catheter Angio Report 1 5 1 5 100%

Add Diagnostic Catheter Angio Report to System Tracer 6 5 6 5 100%

Update PDSAs 1 5 1 5 99%

Print PDSA's 6 5 6 5 99%

Print Education Plan 6 5 6 5 100%

EMS CODE STROKE PI

PROJECT - IMPROVE

• Innovative new workflow that placed

patient at the center of attention

• Core Value Stream flows through

patient not the clinical team

• Patient may never enter the ED helping

reduce arrival time to treatment

• Full implementation took approx. 1

month beginning June 5, 2017 and

ending July 17, 2017

EMS CODE STROKE PI

PROJECT - IMPROVE

Post-Implementation Data Analysis

Improvements Observed (Change Between Pre and Post)

Door to ED

Physician

Door to Code

Stroke Activation

Door to CT

Performed

Door to CTA

Performed

Door to IV

tPA Bolus

Door to

Puncture

Door to Final

Revascularization

Average6.8 14.1 25.6 37.4 49.4 90.5 113.3

Median3.0 7.0 17.0 26.5 41.5 79.0 111.0

Door to ED

Physician

Door to Code

Stroke Activation

Door to CT

Performed

Door to CTA

Performed

Door to IV

tPA Bolus

Door to

Puncture

Door to Final

Revascularization

Average

1.3 6.2 3.9 8.9 9.7 20.8 23.7

Median

1.0 5.0 5.0 9.5 10.5 29.0 23.5

*All values in minutes

CONTROL

Last Phase

Goal: Maintain your solution

• Important to document the process,

apply what you learned to other

areas, ensure management is aware

of the new solution, and

share/celebrate your work

Phase Tool Box:

• Control plan

• Control chart

CONTROL TOOLBOX

• Control Plan

• Describes what must happen at each step of the process to ensure a

quality output

• Holds the group accountable to ensure the success of the new process

• Can include a multitude of information that is generated throughout

the project

Process Flowchart

Process FMEA Control Plan

CONTROL TOOLBOX

• FMEA: Failure Mode Effect Analysis

• Analysis of your product or process finding failure modes,

measuring their effect, and mitigating risk

• By identifying the largest risks for failure you can systematically

focus your control plan

• Most analysis rank failure modes by level of severity, frequency, and

detectability

Process Step/Input Failure Mode Failure Effect Sev

erit

y

Causes Freq

uen

cy

Current State Control Det

ect

ion

Ris

k P

rio

rit

y N

um

ber

(R

PN

)

Corrective Action Responsibility Actions Sev

erit

y

Freq

uen

cy

Det

ect

ion

Ris

k P

rio

rit

y N

um

ber

(R

PN

)

1

2

3

4

5

https://goleansixsigma.com/failure-modes-effects-analysis-fmea/

EMS CODE STROKE PI

PROJECT – CONTROL/RESULTS• Door to IVtPA Bolus improved by 9.7 mins

• Door to Final Revasc. Improved by 23.7 mins

• Average savings of 45.03 million neurons per patient with LVO

• Average savings of 73.47 weeks of life expectancy per patient with LVO

• Patient population observed a decrease Length of Stay on average of 2,603 mins

(approx. 1.8 days) saving an estimated cost of $1,940 per patient

• NIHSS at discharge improved 1.94 points

• mRS at discharge improved by 0.50 points

• Mean lifetime cost of an ischemic stroke was $140,048 (est. in 2010)

• Improved function prior to discharge can drastically impact overall cost

WHY WE DID IT

• Stroke is the 5th leading cause of death in the U.S.

• Stroke is the leading cause of disability in the U.S.

• Close to 800,000 strokes occur in the U.S. every year

• Finding the right problem to solve for this population allowed

us to have the greatest impact for this important clinical

population

*All statistics from American Stroke Association Website

REVIEW

• Lean Methodology Goal : process that results in perfect value

that has zero waste

• Six Sigma Methodology Goal : improving output quality by

removing defects and minimizing variability

• PDSA/PDCA and DMAIC are two major ways to organize a

project with different steps for each part of the project

• There exists a large toolbox for process improvement projects

that can help organize a team around a central goal that

produces results

CONCLUSION• Process Improvement can be a powerful tool in any business

setting

• There’s a large array of different tools that can be applied to a

variety of different projects

• When used properly there can be a profound impact on a process

or product

• While expertise and experience can be beneficial, anyone can

make an impact through process improvement

QUESTIONS?