Process Improvement Tools and Methods

Paul Convery MD, MMM

February 6, 2016

First Day at Work for a New CMO• Dr. Pat Jones, a new CMO, is told by the Regional Hospital President, that the Board Chair is very

embarrassed by the report in the local paper that their CHF Readmission Rate from CMS Hospital Compare is one of the highest in the country. Dr. Jones is instructed to meet with Dr. Ronnie Everbrite, the chief of Cardiology, and “fix the CHF 30 day readmit rate, whatever that is.”

• Dr. Everbrite tells Dr. Jones that discharging CHF patients is very time consuming and filling out the multiple forms is tedious, and so usually left to the nurses. The nurses are also expected to schedule follow up appointments in Dr. Everbrite’s office, but they often do not schedule an appointment for four to six weeks. “It is the nurses’ fault that our rates of readmission are so high. I am very busy and cannot bother with this problem.”

• Nurse Chris Anderson tells Dr. Jones that Dr. Everbrite usually does not fill out the discharge forms and when he does the medication list is incomplete; the nurses’ instruction list is often left blank; and the social work follow up form is never completed. Also, when the nurses call Dr. Everbrite’s office for a follow up appointment for the patients, the earliest time is usually four to six weeks out. “Dr. Everbrite is a very busy physician and does not want to be bothered by the nurses.”

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What are the Problems that Dr. Jones is Facing in this New Role?

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“Systems” Definitions

• Macrosystem – defined by the coming together of parts, interconnections and purpose

• Microsystem – small and self contained with relatively few interconnections

• Mesosystem – contains numerous microsytems that are linked to achieve a purpose

• Process – sequence of activities that transform input into outputs; the way work is done

• Flow – describes the sequential steps in a process; e.g. workflow

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Most Process Improvement Work is at the Microsystem Level

• They are often the foundation of the patient experience – the “sharp” end

• They are more manageable• Easier to achieve success• Able to identify best practices• Spread the improvements• Link microsystems together to reach mesosystem and

macrosytem levels5

Dr. Jones Analysis of Problems1. Board and Senior Leadership not aware of

current quality metrics that impact the organization

2. Organization does not have system wide strategy, goals and metrics

3. Alignment of Leadership, Nursing and Medical Staff to achieve goals is not present

4. Readmission Results (Process) need improvement

5. Discharge Process needs improvement 6. Discharge Forms (Process) need improvement7. Appointment scheduling process in Dr.

Everbrite’s office needs improvement

Mac

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Micr

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Systems Approach to Process Improvement

Macrosystem Level

Baldrige Performance Excellence Program

• Award Established by Congress in 1987• Malcolm Baldrige was Secretary of

Commerce from 1981-1987• Health Care Category established in

1999• 20 Health Care winners • Projected that 65% of Hospitals will

use the Baldrige frame work and 41% will submit an application by 2018

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Baldrige Health Care Winners • 2002 -- SSM Health Care• 2003 – Baptist Hospital, St. Lukes Health System• 2004 – Robert Wood Johnson University Hospital• 2005 – Bronson Methodist Hospital• 2006 – North Mississippi Medical Center• 2007 – Mercy Health System, Sharp Health Care• 2008 – Poudre Valley Health Care• 2009 – AtlantiCare, Heartland Health• 2010 – Advocate Good Samaritan Hospital• 2011 – Henry Ford Health System, Schneck Medical Center, Southcentral Foundation• 2012 – North Mississippi Health Services• 2013 – Sutter Davis Hospital• 2014 – St. David’s Healthcare, Hill Country Memorial• 2015 – Charleston Area Medical Center Health System 10

Systems Approach to Process Improvement

Mesosystem and Microsystem Level

History of Process Improvement

• 1900 – Ford Assembly Line and Frederick Taylor• 1930 – Process Control - Shewart SPC (statistical process control)• 1950 – Deming in Japanese Automobile Industry; CQI and Toyota

Production System• 1990 – Motorola introduced Six Sigma• 1990 – CQI introduced to Healthcare; “Curing Health Care” Berwick, et al• 1991 – The Institute for Healthcare Improvement • 1992 – Brent James started the Advanced Training Program for Health Care

Delivery Improvement (ATP) in Intermountain Healthcare• 2000 – LEAN Manufacturing in USA• 2002 – Virginia Mason – Toyota Production System

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CQI, LEAN, TPS were Designed to Improve Organizational Finances

• LEAN comes out of the industrial engineering world• Taiichi Ohno – Toyota Production System.

• 1940s-1950s company was on verge of bankruptcy• Dynamics of industry were changing – moving from mass production to more

flexible, shorter, varied batch runs (people wanted more colors, different features, more models, etc).

• Ohno was inspired by 3 observations on a trip to America• Henry Ford’s assembly line inspired the principle of flow (keep products moving

because no value is added while it is sitting still)• The Indy 500 – Rapid Changeover• The American Grocery Store – led to the Pull system – signals when and how stock

needs to be replenished

Goal was to eliminate wasted steps and production!! 13

LEAN Uses the Flow Diagram to Identify Opportunities to Reduce Waste

ED Registration Forms contain errors and need to be corrected prior to moving to triage

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Nurse must return to the med room each time she administers a different medication

Some LEAN Terminology and Tools• Kaizen Events - a small group to improve some aspect of their work quickly• 5 S - reduces workplace waste by Sort, Store, Shine, Standardize and Sustain• Kanban - a Japanese term that can be translated as “signal,” “card,” or “sign.”• Gemba Walk - observe the process first hand• Muda - “waste” – goal is to eliminate activity that does not add value • Jidoka - immediately stop work to correct a process defect – “stop the line”• Spaghetti diagram - a hand drawn map of your process including: tasks,

location and distance

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Opportunities to Eliminate Waste in Healthcare

Wastes Healthcare ExamplesTransport 1. Moving patients from room to room

2. Poor workplace layouts, for patient services3. Moving equipment in and out of procedure room or operating room

Inventory 1. Overstocked medications on units/floors or in pharmacy2. Physician orders building up to be entered 3. Unnecessary instruments contained in operating kits

Motion 1. Leaving patient rooms to: Get supplies or record Documents care provided

2. Large reach/walk distance to complete a process step

Waiting 1. Idle equipment/people2. Early admissions for procedures later in the day3. Waiting for internal transport between departments

Over-Production 1. Multiple signature requirements2. Extra copies of forms3. Multiple information systems entries4. Printing hard copy of report when digital is sufficient

Over-Processing 1. Asking the patient the same questions multiple times2. Unnecessary carbon copying3. Batch printing patient labels

Defects 1. Hospital-acquired illness2. Wrong-site surgeries3. Medication errors4. Dealing with service complaints5. Illegible, handwritten information6. Collection of incorrect patient information

Skills 1. Not using people’s mental, creative, and physical abilities2. Staff not involved in redesigning processes in their workplace3. Nurses and Doctors spending time locating equipment and supplies4. Staff rework due to system failures

Systems Approach to Process Improvement - CQI

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Continuous Quality Improvement

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To Start a Quality Improvement Project

• Identify a problem; an opportunity to improve; or a source of unnecessary variation

• Observe and understand the situation; make some preliminary assessments and measurements

• Identify the reason that the improvement is necessary….the “burning platform”

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Understand the Work as a Flow Chart

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Form a Team / Importance of Team Size and Roles

• 2 Person Group• coaching, reinforcement, simple problems

• 3 Person Group• Two on One, Majority Rule• Most Ruthless of All

• 5-9 Person Group• Less Tension• Problem Solving, Avoid Deadlocks

• Larger Groups for Information Sharing, etc.• Roles: Executive Sponsor, Team Leader, Facilitator, Staff and Technical

Experts

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Aim Statement

• S – specific• M – measurable• A – actionable• R – realistic• T – time bound

Example: We will increase the number of correct patient information forms from 60% to 90% within thirty days in one PCP office. 22

Put Together a CQI Team and Write an AIM Statement

Describe the members of the team and your message to them. Write and AIM Statement.The improvement projects are:1. Improve the discharge process2. Improve the discharge forms process3. Improve the appointment scheduling process in Dr.

Everbrite’s office

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CQI Tools for Problem Solving

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Using CQI Tools to Model Process and Plan Interventions

CQI Tools: Process Flow Chart

Patient arrives at front desk

Receptionist asks for patient’s name & searches database for his/her file

Patient in system?

Receptionist asks patient to complete paperwork for new clients

and return it to front deskNO

Ask patient to be seated in the Waiting room

YES

Medical assistanttakes patient into

exam room

ETC.

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CQI Tools: Brainstorming

• Everyone participates• Group activity• First to come to mind• Take the time• Defer judgment• Do not jump to solution• Withhold criticism• Welcome unusual ideas• Combine and improve• List possible solutions

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CQI Tools: Fishbone or Ishikawa Diagram

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Some Categories to Fill Out the Fish Bone Diagram (Cause and Effect Diagram)

• Methods, Materials, Machines, Manpower• Place, Procedures, Policies, People• Surroundings, Suppliers, Systems, Skills• Equipment, Environment

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CQI Tools: Pareto Chart to Prioritize Improvement Efforts

Reasons for CHF Readmits in One Month

I No Appt Rx Error Rx Missing Missed Appt Medical

Reason

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CQI Tools: Histogram

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CQI Tools: Multi-Voting Technique to Prioritize

• Use when improvement efforts are not quantifiable• Multiple options for improvement may exist• Each person votes for top three choices• Align by number of votes with three for first choice, etc.• Improvement efforts are prioritized• Move from highest to next, etc.

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Next Step: Plan the Intervention

• Using the information from the analysis (the PLAN stage)• Select one or two interventions to test (the DO stage)• Collect metrics for feedback (the CHECK stage)• Revise the plan based on feedback data and repeat the

cycle (the ACT stage)

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Use at Least Two of These CQI Tools to Plan an Intervention and Describe It (the Do Stage)

• Flow Chart• Brainstorming• Histogram• Fishbone Diagram• Pareto Chart• Multi-voting Technique

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Check Stage: Data Collection

• Keep the collection tools simple; a check list, not a spread sheet

• Collect useful data, not everything• It does not have to be perfect or

scientifically accurate; you will not publish this data

• Do not make this a burden for your staff

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Check Stage: Run Charts for Data Display

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Check Stage: Run Charts for Data Display

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Rea

dmis

sion

Per

cent

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan

Intervention

1 Intervention

2Intervention

3 Intervention 4

Control Charts: Upper and Lower Control Limits

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PDCA Model For Continuous Improvement

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PDCA Cycles: Lead to Continuous Improvement

Standardize the Process across the

clinics

A PS D

A PS D

D SP A

DATAD SP A

Cycle 1A: Achieved 70% correct information forms

Cycle 1B: Requirement to verify information in the system improved correct number to 85%

Cycle 1C: Double checking the forms filled out by patients improved rate to 95%

Cycle 1D: Repeat in each PCP office and then move across the clinic

“The shorter the timeframes between test cycles, the more tests can be conducted and therefore, more opportunities for learning will emerge.” - HIVQUAL Workbook

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Questions to Ask of the Improvement

• Is the AIM Statement satisfied?• Is the improvement feasible and possible?• Did the improvement make the difference?• Is the improvement embedded or “hardwired”?• Is the improvement quantifiable?• Is the improvement sustainable?• Is the improvement spreadable?

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“Where there is no standard ( or goals), there can be no improvement. For these reasons, standards (or goals) are the basis for both maintenance and improvement” Masaaki Imai

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