Industrial Engineering in an Unusual Healthcare Setting

Richard BlackwellProject Director, Process Quality

Cermak Health ServicesNovember, 2009

Summary

Brief history of IE and Quality Background on Cermak Clinic Describe the problem: distribution and

administration of medications to CCJ detainees Discuss the approach taken, results to date, and

expected outcomes Outline other IE projects being considered at

Cermak Discuss the potential impact of IE in healthcare

and other service industry applications

Goals

Discuss and demonstrate use of several IE techniques in an unusual healthcare setting Value Stream Analysis and process mapping Six Sigma process improvement (DMAIC) Quality Management System support of

accreditation audits Suggest possible career directions for IE

students

Who I Am

Graduated from U of I with MSIE in 1978 Career trajectory

Manufacturing and distribution applications of OR/MS techniques Owned my own consulting and software development company Telecommunications from 1997 to 2009; Project and Product

Management; Marketing; Quality Currently Project Director for Process Improvement at the Cermak

Clinic of Cook County Jail

After 30+ years in Industry, I still consider myself an IE; everything else is just what I

happen to be working on

Quality Management Systems - Quick Background

Industrial Engineers (as Scientific Managers) basically invented the Quality discipline – Walter Shewhart, Joseph Juran, W. Edwards Deming

Starting in the 1970s, traditional Quality Control shifted to more comprehensive Systems approaches Good Manufacturing Practice (GMP) driven by the FDA International Standards Organization (ISO) Certification Malcolm Baldridge Award (Motorola the first winner in 1988) Motorola’s Six Sigma methodology

During the 1990s, an expansion of formal QMS Certification into new areas Software Engineering Institute’s Capability Maturity Model ->

CMMI ISO “Variants” (TL 9000, QS 9000, AS 9000, …)

Our Approach

Starts with Six Sigma as a structured problem-solving approach Methods (e.g. DMAIC) Tools: statistical and process/problem

analysis Uses Quality Management System

certification as a goal and a club to drive organizational change

Cermak Health Services

Part of the Cook County, Illinois Health & Hospitals System

Located in the Cook County Jail The largest single-site correctional healthcare facility

in the US Provides comprehensive care for ~10,000 detainees 150,000 sq ft in 129 bed infirmary plus satellite facilities

within the jail Responding to Department of Justice findings from 2008,

Cermak is currently upgrading service delivery capacity and methods

Industrial Engineering in Healthcare

IEs (as Management Engineers) and other healthcare professionals have often used IE/OR/MS techniques Process simplification and re-engineering Process automation Patient safety

Both IIE and ASQ have divisions that focus on healthcare

Opportunities will expand as healthcare cost containment efforts ramp up

Case Study - Medications Administration

20% of detainees receive medication, with many receiving more than 1

Patients are dispersed 129-bed Infirmary for acute care 3 step-down intermediate care units General population is in 247 small living units

(~50 per unit) in 17 stand-alone Divisions A court has determined that detainees are

to receive all prescribed meds within 24 hours of prescription

Complications

Detainees move around Transferred at short notice, or may be in Court

or school at meds admin time Meds distribution methods vary

Dose by dose administration of TB, HIV, psychotropics, and controlled substances

7-day self-packs when appropriate Dispensed from central pharmacy and

also from meds rooms in some units

The Project

Develop a single, documented process that will be followed for all detainees in the system Eliminate non-Value Add steps Shorten the fulfillment cycle to 24 hours or less Reduce/eliminate missed or incorrect meds Institute control of drug inventory Reduce returns

New process is the basis for the implementation of a new campus-wide computer system

The Approach – Six Sigma

DMAIC process improvement Define the problem Measure the scope of the problem Analyze process data to understand the root

causes of the problem Improve the system performance Implement Control system to monitor

performance and prevent re-occurrence of the problem

Define Stage

Form project team(s) and develop project charter

Map & document current processes With groups of stakeholders By direct observation

Develop a measurement plan Anecdotal data from stakeholders not usually

sufficient Six Sigma requires independent data to ensure

objectivity Measurement allows you to develop and pre-test the

metrics employed in the Control plan

• Swimlane Map

• SIPOC• Value

Stream Mapping

A Process (“Swimlane”) Map

Dept

Process Logic

Sub-Process

Operation

Value Stream Analysis

A more elaborate form of process mapping used in Lean Any step that does not add customer value

is a candidate for elimination Rich vocabulary of symbols for process

steps Moves Delays Etc.

Guides the development of a desired “Future State” from the “Current State”

Measure Stage

Based on Define stage results, Mean Prescription Flow Time and Delivery Errors per Encounter selected as targets In order to meet 24-hour requirement, need to

know current state Analysis of Flow Time will support

determination of root causes for delays Delivery Errors cause rework, increase mean

flow time, and affect patient safety

• Measurement System Analysis

• Descripive Statistics

• ANOVA• Variance

Reduction• Process Costing• Process

Capability

Unfortunately…

No data is available in current computer systems

Current paperwork inconsistently filled out, results not tabulated

Measurement plan – limited sampling Observe meds pass and note results Work backwards through pharmacy records to

determine what was prescribed and when Analyze monthly nursing records for actual

delivery

Analyze & Improve

DMAIC is not strictly linear; phases often overlap

In this case, some of the required improvements are known We can use the data analysis to validate

required process improvements after we start them

“Surprises” can be leveraged as they occur

• Descripive Statistics

• “Fishbone” & “5 Whys”

• ANOVA• Variance

Reduction• Design of

Experiments• Process Re-

Engineering• FMEA

Process Results to Date

Pharmacy capacity is limited by several bottlenecks Manual entry of Prescriptions Label printing & manual sort Staging of meds for delivery to Divisions

Administration in the Divisions contains significant non-Value Added steps Redundant manual data transcription “Unnecessary” validation of delivered meds against patient’s

medical profile Impossible with current processes to verify that correct meds

have been administered Improvement approach is to document and implement one

standard process

An Implementation Plan

Present plan to Senior staff Form Working Group – CQI, Pharmacy, Nursing, Medical

Draft Context document, review with staff and Software Vendor for accuracy

Combine existing documents and process flows and adapt Eliminate non-value adding steps Leverage Software capabilities Define and implement metrics support elements in Software

Review and revise with Senior staff Pilot

Review with Dept of Corrections and revise as required Final approvals Develop training materials Train Monitor & mentor

• Process Design

• Metrics System Design

• Change Management

Why Is Implementation So Hard? Most Process Improvement Efforts Fail

One study shows that 60% of Six Sigma projects end in partial or complete failure

The reasons are not surprising People don’t like to change Organizations change all the time, making

long-term committed efforts difficult Management commitment is hard to get

and keep Some projects just don’t make sense

Improving the Odds

Techniques exist to improve the odds Stakeholder & Force Field analysis:

understand the management setting and risks before starting a project

Scope Management: Avoid over-commitment and “creep” by clearly

documenting realistic objectives and goals Avoid projects lasting > 6 months

Change Management: a toolkit for overcoming resistance to change

The Control Phase

Implemented using standards-compliant process documentation Must be supported by senior AND line management Will face scrutiny by employee unions

Includes key elements of a standard Quality Management System A performance measurement system Internal Audit (Self-monitoring) Management Review; Corrective/Preventive Actions

Verified by an independent accreditation body (NCCHC)

• Process Control Charts

• Metrics measurement systems

• Troubleshooting

Management Involvement Management commitment to all aspects

of the Quality System

Customer Focus Management is focused on Customer

satisfaction, relationship development and communication

Documented Management System Documentation is available that provides

policy, responsibilities and records in accordance with the Quality System

Internal Audit Periodically conducted to verify

effectiveness of Quality System Document / communicate audit plan and

ensure independence of auditors Reviewed by Management

Improvement Processes Monitor, measure and analyze processes

for conformity and improvement to products

Corrective/Preventive Actions

Continual Management Dynamics

Other IE Projects

Map & Streamline the sick call process Map & Streamline the Mental Health care

delivery processes Design meds administration automation

processes Analyze and optimize layout and

throughput of a proposed detainee admitting facility

Common IE Skills Used

Process analysis Statistical analysis of process data Process design, documentation &

implementation Design of management metrics systems Support of certification/accreditation Design & implementation of process

automation Cross-disciplinary team leadership

Career Ideas for New IEs

Healthcare – it’s exploding Public Sector – Lord knows they can use

us… Software/Consulting – draw on IE training,

& gets you into the game Project Management – a natural step up

from entry-level, and there are never enough PMs

Six Sigma – a natural for IEs; you already know most of this stuff

Lean – IE with a different name

Links and Resources

www.punshui.com: my slides and other materials www.lean.org: lots of ideas and resources re Lean

methods and tools www.asq.org: starting point for Six Sigma and many

other directions in Quality http://www.iienet2.org/SHS/Community/Default.aspx

: IIE Society for Health Systems http://www.asq.org/healthcare-use/why-quality/over

view.html: ASQ Healthcare Division

www.pmi.org: professional certification for Project Managers and lots of tools

Questions?