Microsoft PowerPoint - Delivering Care in Efficient Environment - Medicall 2011 [Compatibility Mode]
Delivering Healthcare in Efficient Environment
Joy ChakrabortyDirector - Administration
Hinduja Hospital, Mumbai.
The Challenges & Transition in Healthcare
Controlling costs Government regulations Government regulations Increasing competition Implement new procedures and capabilities Treatment reimbursement rates are capped
based on diagnosis Number of uninsured
Contd..
New technologies are Expensive and adoption in questionStaff shortages in some areas continue to drive up Staff shortages in some areas continue to drive up costsReport Cards on providers quality, cost, number of procedures Role of the Private Sector in healthcare delivery Growth in the number of people age 65 and
older
Favorable patient outcomes
Patient safety
Implement new procedures and capabilities
What do our Patients want ?
Implement new procedures and capabilities
Controlling healthcare costs
Service with a smile
What does the hospital want?What that leads to:
Available and prompt care
Better patient outcomes
Increased patient satisfaction
Improved financial viability Smooth operations
Ensure patient safety
Provide quality care
Effective patient treatment
Utilized staff and resources
Improved financial viability
Improved patient throughput
Improved publicly reported information
Higher employee involvement and satisfaction
Reduced LOS
How do we achieve this? By Improving By Improving QUALITYQUALITY of health careof health care
Patient safety and risk management
Evidence-based practice
Continuous learning and improvement
Stimulate and improve integration and Stimulate and improve integration and Stimulate and improve integration and Stimulate and improve integration and management of health servicesmanagement of health services
Reduce variation in care and health care costsReduce variation in care and health care costs
Strengthen the publicStrengthen the publics confidence in the quality of s confidence in the quality of health carehealth care
How do we achieve this ?
MUDAMUDA
Waste
Examples of Waste
Inventory unneeded stock or suppliesMotion movement of staff and informationOverproduction - unnecessary testsExtra processing filling out extra paper workExtra processing filling out extra paper workTransportation movement of patients & equipment Defects duplicate work, medical errorsWaiting delays in diagnosis & treatment
What is Lean?
Lean means creating more value for customers with fewer resources & elimination of wastecustomers with fewer resources & elimination of waste
Vs
Six Sigma is:
A disciplined, data-driven approach and methodology for eliminating defects in any process
A statistical representation of Six Sigma describes A statistical representation of Six Sigma describes quantitatively how a process is performing
At many organizations Six Sigma simply means a measure of quality that strives for near perfection
6 Level Performance
Six Sigma standard of 3.4 problems per million opportunitiesopportunities
3 Sigma standard of 67000 problems per million opportunities
4 Sigma standard of 6200 problems per million opportunities
Nature of Healthcare Business
- Outcomes are Variable in Nature
Six Sigma in Health Care In a HOSPITAL, processes must run correctly
The best option for healthcare organizations is to implement Six Sigma because It focuses on total improvement with reducing costs,
Improving performance and productivity, and Improving performance and productivity, and
Ensuring the patient is entirely satisfied with the care he receives
It allows professionals to appropriately and successfully figure the inconsistencies within their operations
It allows medical professionals the ability to detail processes within the field and quickly adjust and standardize them
Lean
6
Lean Six Sigma
Total Quality Management
Quality Assurance
Quality Control
Inspection
Lean + Six SigmaLEAN SIX SIGMA is a business improvement methodology which combines tools from both Lean and Six Sigma.
Lean and Six Sigma are complementary in nature
Lean focuses on eliminating non-value added steps and activities in a process, Six Sigma focuses on reducing variation.
DMAIC: Basics
MeasureDefine ImproveAnalyze Control
What is important to the customer:
The process:
Analyze Data
The process gains:
Ensure Solution is to the customer:
Project Selection
Team Formation
Establish Goal
How well we are doing:
Collect Data
Construct Process Flow
Validate Measurement System
Analyze Data
Identify Root Causes
Ensure Solution is Sustained
The process performance measures:
Prioritize root causes
Innovate pilot solutions
Validate the improvement
Disruptive Innovation
Benefits of Lean Six Sigma
Improved patient experience and satisfaction Faster response to patient needs Increased job satisfaction & reduced stress for
caregiverscaregivers Improved, standardized & repeatable processes that are
more predictable Ability to focus resources on more value-added activities Improved asset utilization: people, equipment &
technology Reduced unit costs through increased capability
Benefits of Lean Six Sigma
Improved flow through elimination of bottlenecks (delays) and constraints (limiters)
Dramatic improvement in scheduling predictability Dramatic improvement in scheduling predictability better process management
Participative problem-solving
Engaging the people who know and do the work the team
Recognition of the need to manage change
Tools
Hypothesis testingFish Bone Analysis
RegressionVOC
Cause & Effect Matrix
Its not about tools to achieve Its not about tools to achieve success in Lean Six Sigma. Its about how to get leaders to believe in and
EMBRACE quality!
Real Life ApplicationOrganization Project Outcome Achievement
Charleston Area Medical Center
Supply chain for surgical supplies
Lower inventory, Improved supplier relations
Saved:$163,410 immediately $841,540 future
CommonwealthHealth Corporation
Radiology Decreased time between dictation and signature, Improved wait times and staff scheduling
$800,000 savings, 25% better throughput and eliminated 14 positions
Froedtert Memorial ICU lab times Reduced turnaround Cut turnaround times from Lutheran Hospital times 52 to 23 minutes
Mount Carmel Hospital
Medicare+ Choice Plan reimbursement
Redefined coding working-aged Medicare recipients
Profit $857,000
Wellmark Inc. Physician addition to managed care network
Reduced time for adding physicians to medical plan
Savings: $3 million per year
Scottsdale Healthcare
Over crowded ED
Improved transfer time from ED to inpatient hospital bed
Profits: $600,000
381 beds, including 53 ICU beds; 19 Short Stay Service;
11 Operation Theatres and 6 EICU beds
Not for Profit Hospital
140 Consultants; 510 nurses and other support staff
Exclusive area for Preventive Health Checks
An Overview
Exclusive area for Preventive Health Checks
Promoting Medical Education along with attached Nursing College
State of the Art Technology Application
Group is entering into For Profit Segment in Healthcare
Well stocked library with over 417 latest online and
offline journals. 26
PioneeringBest Practices movement @ HNH
College of American Pathologists (CAP) (1st hospital laboratory to be accredited among the SAARC region countries);
ISO certification in 1996
Recipient of Ramakrishna Bajaj award for healthcare quality.
Participation in Best prax Club competition
ISO 27001 for IT Department for Information Security
Hospital accreditation
Hinduja hospital six sigma Hinduja hospital six sigma
success story
FIRST HOSPITAL to adopt six sigma in Healthcare in India
Recently, concept of Lean Six Sigma has been applied too.
Some Studies :
Turnaround time for patient discharges Outpatient Satisfaction Outpatient Satisfaction Turnaround time for Imaging reports Satisfaction for Peri - operative care Average Length of Stay Operation Theatre support services OPD waiting time Discharge waiting time X Ray turnaround time Pharmacy items turnaround time
Case Study # 1
Short Stay Services.
1. 300 identified surgeries across 8 surgical specialties 1. 300 identified surgeries across 8 surgical specialties in scope.
2. 19 bedded dedicated self dependent unit with two units
3. Preoperative investigations and post-operative follow-up done at home.
4. 24 hrs in house dedicated call centre managed by nursing personnel.
Care @ Home Services
1. Expansion of reach.
2. Range of services provided
Measurable Outcome
Year Installed Bed
Capacity
No. of Surgeries
done
Avg Lengthof Stay
Capacity done
09 -10 383 11089 4.9 Days
10 - 11 372 12149 4.7 Days
Lean Six Sigma Process Improvement Project at Hinduja Hospital
Project Name : Reducing the Turn Around Time for Outpatient (OPD) Services
Case Sudy # 2
Project Goal : To reduce the Idle Waiting time in the Outpatient process by 30-50%
Define PhaseProblem Statement: Over the past few months it has been observed that the Turn Around Time for patients to avail OPD services has been an issue of concern for the patients and Hinduja Hospital.
Voice of CustomerVoice of Customer
Selection of the project on Reducing the waiting time in Out Patient Services is based on the concern raised by patients on waiting time in the regular OPD feed back forms & verbal communication to our customer care.
Voice of the customer was used to determine the acceptable Idle Waiting Time.
Measure Phase
Data collection : The entire process flow for consultation / investigation was tracked throughout the OPD working hours using tracking sheets.
The activity was divided into sub processes & the overall findings were :
Queue Time : 5-7 min Queue Time : 5-7 min
Vouchering Time : 3-4 min
Travel Time : 5-7 min
Idle Waiting Time : 40-50 min
All TAT other than the Idle waiting time are within their respective acceptable limits and hence not taken up for further study
Acceptable limit for the Idle Waiting Time is considered to be 30 minutes.
Waiting time for the OPD Services (in mins)
ServiceQueue Time
Vouchering Time
Travel Time
IdleWaiting
Time
Total Waiting
Time
Pulmonology 5 4 5 19 33
Cardiology 3 3 4 10 20
Neurology 4 4 10 45 63
Measure Phase
Neurology 4 4 10 45 63
Laboratory 6 3 2 10 21
X Ray 8 1 3 17 29
Physiotherapy Retrospective billing 8 8
Urodynamics Retrospective billing 29 29
Scopy (UGI, LGI) Retrospective billing 47 47
Bronchoscopy Retrospective billing 28 28
Consultation 4 4 3 33 44
Analyze Phase
A further investigation was done of the services which have Idle Waiting Time beyond 30 minutes
Neurology
UGI / LGI Scopy
Consultation
Neurology services Idle Waiting Time
EMG 101
EEG/ BERA/ VEP/ SSEP 21
EMG
Analyze Phase
Idle Waiting Time EMG is done in 2 steps : 1.NCV 2.Complete EMG
First step is conducted by the Neurology Technician & the second step is done by the Consultant. The increased Idle waiting time was observed in specific cases of pediatric neurology wherein the patients were uncooperative & had to wait for patient to settle down.
Wrong Date
Wrong Dr.'s Name
WRONG APPOINTMENT
Wrong HH no.
Wrong Time
Wrong details captured at time of giving Appointment
BILLING
Wrong HH no. entered at time of vouchering
Conversion of EX patient to HH patient
MRD FILE NOT RECEIVED
File not requested
File archived
DR NOT AVAILABLE
Dr. on Rounds / Procedure
Dr. in OTDr. gone for Emergency
Dr. Delayed for miscellaneous reasons
Appts after 8pm not reflected in appt list since list printed before 8pm
Analyze Phase : Consultation
Requested file not reflecting in MRD Delta report
WRONG APPOINTMENT
Dr.'s Instructions
Slot not available
Wrong Appointment
DOUBLE APPOINTMENT
BILLING
PATIENT LOST
Patient cannot find location
Wrong Instructions given
Training of new staff
NURSE NOT AVAILABLE
Nurse busy with Dr. or Patient
Tea Break
Shortage of Nursing Staff
MRD FILE NOT RECEIVED DR NOT AVAILABLE
PATIENT DELAYED
Emergency Patient
Previous patient taken in late
Patient came lateDr.'s
Instructions allowing Non Appointment Patients Walk-ins
Improve Phase : Solution Matrix Consultation Idle Waiting Time
Process Step Constraint Cause Solution
Appointment Checking Slot Patient called as Slot not available
Non appointment patients to be seen after the appointment patients as per Dr. instructions
Non appointment patients taken in advance only if the next Appointment
SchedulingChecking Slot Availability
Patient called as non appointment patients
advance only if the next patient has not arrived
Reserve specific slots in between appointment slots for non appointment patients
Slot is available but cannot take appointments on same day due to system limitations for file retrieval
System change to reflect the file request for same day appointments
Process Step Constraint Cause Solution
Printing of Appointments could not be taken on
File request not reflected in the MRD report for the same
System change to reflect the file request for same day
Improve Phase : Solution Matrix Consultation Idle Waiting Time
File retrieval in MRD
Printing of Delta report
not be taken on same day
report for the same day
for same day appointments
Printing of Appointment list
Updated appointment list not available
Appts after 8pm not reflected in appt list since list printed before 8pm
Any additional appointments after the list is printed are added by the Nurse in the appointment list and informed to the Doctor
Wrong Date
Wrong Dr.'s Name
WRONG APPOINTMENT
Wrong HH no.
Wrong Time
Wrong instructions given
PATIENT NOT PREPARED
Training of Call Centre Staff
PROCEDURE DELAYED
Dr. Delayed
Emergency patient taken
Dr. on Rounds
Dr. in ProcedureDr. gone for
Emergency
Dr. Delayed for miscellaneous reasons
Patient Delayed
Endoscopy Suite not available
Patient misunderstood instructions
Patient did not follow given instructions
Aerated Lime drink not available
Patient arrived late for preparation
Analyze Phase :UGI/LGI Scopy
WRONG APPOINTMENT
Outpatient Wilkins
Inpatient sent randomly
DOUBLE APPOINTMENT
PREPARED
DR.'S PRESCRIPTION NOT AVAILABLE
Patient forgot Dr;'s prescription
Dr. not available to give fresh prescription
SCOPY SUITE NOT AVAILABLE
Cleaning
PROCEDURE DELAYED
Non Appointment Patients- Wilkins
DR NOT AVAILABLE
PATIENT DELAYED
Emergency Patient
Previous patient taken in late
Patient came late
Inpatients sent randomly
Previous patients procedure ongoing
No Appts given to inpatients
Previous patients procedure ongoing
U. P. patient taken previously
Consecutive slots for Multiple procedures not available
Overlapping Appointments
Improve Phase : Solution Matrix Scopy Idle waiting Time
Process Step Constraint Cause Solution
Appointments taken for Inpatients
Reserve slots specifically for Inpatients / Inpatients only
Appt for Procedure
In patient Appt
Inpatients being taken randomly in between scheduled patients
No appointments taken for Inpatients
Inpatients / Inpatients only taken in vacant slots
Inpatient taken after all Out patient Appts
Assign point of contact in Scopy who will co-ordinate with Floor Nurses to ensure the Inpatients are taken in a scheduled manner
Process Step Constraint Cause Solution
UGI is a shorter procedure than LGI but the same single slot (of 30 min) is given
Only single slot allotment done in system: Overlapping
Changes in slot scheduling : 1 Slot 30 minutes for shorter procedures and 2 slots of 30 minutes each for longer procedures e.g. Colonoscopy
Improve Phase : Solution Matrix Scopy Idle Waiting Time
Appt for Procedure
Appt Scheduling
(of 30 min) is given when scheduling all the appointments
Overlapping appointments
procedures e.g. Colonoscopy will be given 2 slots instead of 1 slot
Separate slot timings given for multiple procedures on same patient when If continuous slots not available but procedure done consecutively
Slot not available consecutively for multiple procedures
Multiple process should be given consecutive slots and if required rescheduling of next patient
Process Step Constraint Cause Solution
If Scopy
Delay for next patient when patient is ready
Patient came late for preparation / Patient did not follow Dr.
When preparation to be done in Hospital, Appointment Cell to ask patient to follow Dr.'s instruction at time of giving appointment and call a day prior to confirm
Improve Phase : Solution Matrix Scopy Idle Waiting Time
If Scopy patient is not prepared
Patient given preparation at Hinduja Hospital
when patient is ready for procedure
did not follow Dr. instruction
and call a day prior to confirm the same i.e. patient to come to Hospital at least 2 hrs earlier /as per requirement
Requisite preparation solution not available
Patient did not bring along the requisite aerated drink required for preparation
Cafeteria to deliver the aerated drink for the patient
Performance: Consultation and Scopy
Idle Waiting Time
(in min)
Mean SD Sigma Level
BEFORE TARGET AFTER BEFORE TARGET AFTER BEFORE TARGET AFTER
Consultation 33 15 14 36 5 11 -0.06 3 1.45
Scopy 47 30 25 35 5 21 -0.07 3 1.70
Waiting time for the OPD Services (in mins) - YR 2010 vs YR 2011
Service
PRE LSSIdle
Waiting Time2010
POST LSSIdle
Waiting Time2010
FOLLOW UP Idle
Waiting Time2011
Pulmonology 19 19
Cardiology 10 10
Neurology 45 25
Laboratory 10 05
X Ray 17 09
Physiotherapy 08 01
Urodynamics 29 46
Scopy (UGI, LGI) 47 25 30
Bronchoscopy 28 35
Consultation 33 14 18
Case Study # 3
Project Name : Reducing the Turn Around Time for Patient Discharge
Project Goal : To reduce the Patient Discharge Time by 30-50%
Average TAT for Patient Discharge beyond 2 hours is considered as a defect.
Average Times (in minutes)
BEFORE AFTER
y1= Written order to Finance folder sent
85 18
y2 = Finance Folder sent to received in Billing9 7
y3= Finance folder received to taken for billing8 88 8
y4= Finance folder taken for Billing to Discharge Slip given to relative
50 48y5= Discharge Slip given to relative to receipt by nurse
21 19
y6= Discharge Slip received by nurse to patient physically leaves bed 22 21
Y = Written Intimation to Patient leaves floor 194 121
Performance: Discharge Process
Mean Max SD
BEFORE TARGET AFTER BEFORE TARGET AFTER BEFORE TARGET AFTER
y1 (in min)
85 40 18 385 50 45 94 5 9
y4(in min)
50 30 48 188 50 89 36 5 16
Y (in min)
195 120 121 525 150 205 108 5 22
DID YOU KNOW.....??
..Do you Know ?
Hospitals report that the biggest challenges in implementing lean or six sigma include sustaining improvements, competition from other initiatives, leadership commitment and availability of resources
- American Society for Quality, 2009
The Week The Week IMRB Exclusive IMRB Exclusive survey ranks Hinduja Hospital as survey ranks Hinduja Hospital as survey ranks Hinduja Hospital as survey ranks Hinduja Hospital as
no. 1 in the region for the 4th no. 1 in the region for the 4th year consecutivelyyear consecutively
54
Thank You