OAHHS LEAN WEBINAR OCTOBER 14TH,2014 · Frankford Hospital Patient Flow Cause and Effect Diagram ... Implementation plan is detailed 4. Results of Implementation are specified

Purdue Research Foundation© 1

OAHHS LEAN WEBINAR OCTOBER 14TH,2014


• A3 Analyze Key Components • Analyze Visual Presentation of TIPs • Multi-Level Pareto Analysis • Questions ?

Overview


A3 Analyze Key Components


Date: Project Title and Area: Organization:

Authors:

Defin

e M

easu

re

Impr

ove

Cont

rol

Project Y Project charter SIPOCS VOCS (SWOT; Affinity; CTS; Kano) Communication Plan

Pre-

Hoshin Kanri VOCS VSM

Data collection plan Gemba MSA Process flow charts Spaghetti diagrams Scatter plots

Set Goal – “SMART”

Quantifying the waste & variation Visual display of current process

Define the problem

Future State Map Hypothesis Testing Correlation Regression Gap analysis (current/future) Root cause – why gaps exist

Understanding the waste & variation Y = f(x)

Control Plan Visual controls Kan ban 2 bin systems Poke yoke

Preventing recurrence of the waste and variation

Select Project

Removing the waste & variation

Target state Prioritize solutions Impact/Effort Affinity Multi-voting List Reduction

Anal

yze

Pie charts; Bar graphs Control Charts Pareto Process capability (DPMO; Sigma score) Takt time; cycle time

Fishbone; 5 Why Opportunity prioritization Risk/Frequency Affinity diagram Multi-voting/List Reduction families of variation

Team Selection Exec sponsor Process owner

Gantt chart Kaizen newspaper Small tests of change PDCA Quick change-over Cellular layout 5-S

Gantt Chart

Standard Work

Analyze Tools


What is Analysis?

• Analysis is a process of inspecting, cleaning, transforming, and modeling data with the goal of highlighting useful information, suggesting conclusions, and supporting decision making.

• Analysis has multiple facets and approaches, encompassing diverse techniques under a variety of names.

“If you can’t measure it, you can’t manage it” - Peter Drucker


Two families of charts

Quantitative

Pie

Bar

Column

Line

Dot

Qualitative / Conceptual

Flow

Structure

Interrelationship

Action plan

Map

Text visual

Text table


Analyze Visual Tips Highlight The “So What”


City Hospital Medical Clinical Documentation Requests Current Trends

0

5

10

15

20

25

30

1-2009 2-2009 3-2009 4-2009 5-2009 6-2009 7-2009 8-2009 9-2009 10-2009 11-2009 12-2009 1-2010 2-2010 3-2010 4-2010 5-2010

Complete Medical Record Other Grand Total Trend (Complete Medical Record) Trend (Other) Trend (Overall)

Overall documentation requests trending downward, complete medical record requests flat

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

OT CM HP MN RR DN OR DM LR Other (15codes)Percent of Total Cumulative Percent

Improvement Opportunity

City Hospital Medical Records Volume by Type

13.8

17.714.8 17.6

73.6

211-365 days late

120-210 days late

61-120 days late

31-60 days late

9.7

0-30 days late

0-1 year late

0.53.7

22.3

3+ years late

2-3 years late

1-2 years late

Percentage of late Patient Accounts Receivables

36.8

20.415.4

10.2

93.6

211-365 days late

120-210 days late

10.6

61-120 days late

31-60 days late

0-30 days late

0-1 year late

Percentage of Accounts Count in 2010, by Claim Age

0.00.46.0

3+ years late

2-3 years late

1-2 years late

Over 26% of all receivable dollars linked to accounts that are more than 365 late (6.4% of receivables)

Focus the Viewer on The Key Aspects of The Data

EmergencyDepartment/Patient FlowDelays

Equipment

Environment

Process

Personnel

Communication Break Downs

Delays in Discharge Process

Sub-optimal ED registration Staff

Patient Traportation Delay's

Variations ED MD/RN Staffing RatiosLack flexibility Housekeeping staffing

Lack of set discharge timeSub-optimal discharge Communication

No Organizational statusLimited Ancillary testing on Weekends

Ancillary Order Issues

No Bed Tracking SystemSpeciman Rejections

Ineffective Pt. Transportatin ProcessUntimely MD Orders ED/Unit

Excessive Mangement Spans ofcontrol

Care Mgt. not Visable on Floors

Sub-optimal organizationalCommunication

Dept.Territorial OrganizationalCulture

Patient Assignment During Holding

Bed Design

Sub-optimal number ofPhones in ED

Sub-Optimal ED WorkStations

No of Bed Board

Inadequate PatientEquipment

Inadequate Number of CTScans

Priori ty& Timl iness of

MD Rounding

Sub-optimal Uni t Cl er k

D/C Noti fi cation

Sub-opt imal RN D/C

Not ifi cation

No D is charge noti ce

from MD

MD/RN/Case Mgt

Communicati on

MD/RN Comm uni cation

No Di scharge not ifi cation

Needs to more Pati ent

Focused

Oxygen Tanks

StrechersBeds

Frankford Hospital Patient Flow Cause and Effect Diagram

Top Root Causes • Patient assignment • Span of Control • Patient Transportation • Communication

ED Analyze: Initial Cause and Effect Analysis


Pareto Analysis “Key Considerations”


Pre POST

Pareto Charts Before and After Improvement “ Confirm the change really improved the process”


“It May take two or more pareto charts to narrow the focus to an actionable level”


Count 300 250 200 150 100Percent 30.0 25.0 20.0 15.0 10.0Cum % 30.0 55.0 75.0 90.0 100.0

Num

ber

of P

atie

nts

Perc

ent

Reason for Re-admission

Missed

follow

-up

appo

intmen

t s

Weig

ht Lo

ss

No D

/C In

st ruc

tions

MED n

on-co

mplian

ce

No IP

T Prot

ocol

as In

pat ie

nt

1000

800

600

400

200

0

100

80

60

40

20

0

St.Stanton HF Patients Re-admitted W/N 30 days Reason

Level 1 Pareto


Count 100 80 50 40 30Percent 33.3 26.7 16.7 13.3 10.0Cum % 33.3 60.0 76.7 90.0 100.0

Num

ber

of P

atie

nts

Perc

ent

Inpatient Unit 4 South4 North2 SouthICU3 East

300

250

200

150

100

50

0

100

80

60

40

20

0

St. Stanton Heart Failure Patients with No Inpatient Protocol

Level 2 Pareto


Count 40 30 20 10Percent 40.0 30.0 20.0 10.0Cum % 40.0 70.0 90.0 100.0

Num

ber

of P

atie

nts

Perc

ent

Inpatient MD Dr. BrownDr.GormanDr.VeaseyDr. Weamer

100

80

60

40

20

0

100

80

60

40

20

0

St. Stanton Heart Failure Patients with W/No Inpt protocol MD Drill Down

Level 3 Pareto


Num

ber

Perc

ent

Comment Type

Count 4 4Percent 21.7 13.3 12.0 10.8 9.6 9.6 8.4

184.8 4.8 4.8

Cum % 21.7 34.9 47.0 57.8 67.5 77.1

11

85.5 90.4 95.2 100.0

10 9 8 8 7 4

Other

Disch

arge

Instr

uctio

n

Commun

icatio

n Fam

ily

Delay

Disc

harg

e

Wait T

ime

Attitud

e/Beh

avior

Skill

IVMea

ls

Nursi

ngRoo

m

90

80

7060

50

4030

20

10

0

100

80

60

40

20

0

PHCC 4th Quarter Opportunity Comments

Level 1 Pareto


Num

ber

Perc

ent

Comment TypeCount

16.7Cum % 50.0 66.7 83.3 100.0

9 3 3 3Percent 50.0 16.7 16.7

TempCleanlinessCall LightTV Malfunction

20

15

10

5

0

100

80

60

40

20

0

PHCC 4th QTR Opportunity Comments RM Drill Down

Level 2 Pareto


Date: Project Title and Area: Organization:

Authors:

Defin

e M

easu

re

Impr

ove

Cont

rol

Pre-

Set Goal – “SMART”

Define the problem

Understanding the waste & variation

Preventing recurrence of the waste and variation

Select Project

Removing the waste & variation

Anal

yze

What x’s and processes were measured to understand the stated problem?

Why this problem?

How does this project move the organization to its goals?

Quantifying the waste & variation

1. Business case has been explained 2. Problem statement in measureable terms 3. Data provided to describe the problem 4. Performance gap is described 5. Metrics are specified

1. Current state performance is described 2. Visual representation of process is shown 3. Data describing problem/process is provided 4. Project objectives/goals are specified

1. Proposed changes are specified 2. Visual representation of Target State is shown 3. Implementation plan is detailed 4. Results of Implementation are specified 5. Spread is in Implementation Plan if applicable

1. Primary obstacles and barriers are specified 2. Root causes are specified 3. Method of identifying root causes is shown 4. Goals regarding root causes are shown

1. Process owner is specified 2. Plans for follow up monitoring is detailed


Anthony Veasey, MA,CPHQ , LSSBB | Senior Advisor – Lean Six Sigma

708-790-5541 (office) | 708-790-5541 (mobile) | [email protected]

Purdue Healthcare Advisors | Purdue University

mailto:[email protected]


LEAN HEALTHCARE: “HAC” Project

Sky Lakes Medical Center


About Us…….

• Located in Klamath Falls • 300 days of sunshine per year! • Licensed for 176 beds • Average Daily Census around 62 • We serve approx 80,000 people in Klamath and Lake counties

in Oregon, and Modoc and Siskiyou counties in California

23


Our Lean Project

Bedside Report…..

Is the time when responsibility and accountability for the care of a patient is transferred from one nurse to another.

Journal of Perinatal and Neonatal Nursing December 2010


Bedside Report Project Team • Jeremy Westover RN Quality • Claire Jambalos RN front-line Post-Surgical • Sarah Freitas RN front-line Post-Surgical • Tiffani Boehnen RN front-line Post-Surgical • Shannon Mason RN front-line PCU • Karen Wright Doty RN front-line PCU • Chantry Forney RN front line Post-Surgical • Sabrina De Vall RN front-line Medical • Stacey Mathis RN front-line Emergency Department • Christie Wiles RN Unit manager PCU/Medical • Justin Jannicelli RN Unit manager Post-Surgical • Katie Singleton RN Nursing Education • Cindy Neubauer RN Director Nursing education

8 front-line nurses! (even a few naysayers)


Sky Lakes Medical Center: Patient and Family Engagement: Bedside Shift Report: May 29th 2014 Authors: Jeremy Westover, Katie Singleton, Cindy Neubauer, Jodie Grohs, Justin Jannicelli, Christie Wiles

Defin

e M

easu

re

Anal

yze

Impr

ove

Cont

rol

Background: Bedside report provides an opportunity to improve patient safety and increase patient involvement through collaboration and coordination of the patient’s plan of care. It also reassures patients that caregivers work as a team, therefore providing professional transfer of responsibilities. Problem Statement: Sky Lakes Medical Center has a poor shift to shift patient hand-off process. Often, crucial information such as fall risk, pain control, or pressure ulcer concerns are missed because they are not systematically discussed between caregivers at the bedside at shift change. The patient is rarely involved in their own care. Aim: Bedside report Small test of change on 12 bed 2A Post-Surgical Unit , July 7th 2014. After 3 weeks of PDCA, then spread process to each unit for a 3 week period. All inpatient floors utilizing bedside report by October 1st 2014. Daily and nightly audits will be performed for two months and then weekly thereafter. Voice of the Customer (Staff) Survey

This is a copy of the hand-off tool we will use on our July 7th Post-Surgical small test of change

Project: Bedside Report, Sky Lakes Medical Center

Daily BSR audit sheet

Scenario #1

Scenario #2


Define

• No early interaction with patient

• No formal introduction of oncoming staff

• No confirmation of details or concerns from the patient

• No discussion of goals, discharge plan, tests or procedures with patient

• No standardization in quality or consistency of report

• Propagation of bias at the nurses station outside of earshot of the patient (“crazy, drug seeker”, etc).

Why we chose bedside report…The problem:


Define

• Improving patient safety and quality • Improving the hand-off communication process • Improving time management (reducing OT) • Improving accountability between nurses • Increasing staff satisfaction with hand-offs • 100% compliance with the new process

Our Aim….

We began with a small test of change on a 12 bed Post-Surgical Unit on July 7th 2014 with the goal of:


Measure

Prior to bedside report…


Measure

• Sub-point one – content. • Sub-point two – content.

Voice of the Customer (staff)

Top Responses

BSR: Staff concerns with old process BSR: Staff concerns with new process

BSR: Benefit to the patient BSR: Benefit to the staff


Analyze

Measure


Analyze


Improve

• Sub-point one – content. • Sub-point two – content.

Main point


Going to the Gemba


Bedside Report skills stations • Offered several different dates and times

• Three patient scenarios each • Mandatory attendance • Fed them well for attending

Improve


Two weeks of auditing per department,

random thereafter



Control (Sustainability/Spread)

• AM and PM weekly random shift audits • Bedside Report Team meets weekly


Advice to Others & Lessons Learned

• Front-line involvement every step! • Go visit a hospital that does it really well • Regular updates to staff on successes and opportunities • Don’t discount your naysayers for the BSR team (they

can change and others will follow) • Meet regularly (monthly is not enough) • Give out lots of food tied to BSR efforts • Incorporate a unit huddle just before BSR • Random Audits for the rest of your life


Contact Information

Jeremy Westover RN Nursing Quality Coordinator Sky Lakes Medical Center Klamath Falls, Oregon 541-274-2961 [email protected]


QUESTIONS?

Documents

OAHHS LEAN WEBINAR OCTOBER 14TH,2014 · Frankford Hospital Patient Flow Cause and Effect Diagram ... Implementation plan is detailed 4. Results of Implementation are specified