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Ellis MedicineA Community
Hospital’s Quality Story
MARY ELLEN CRITTENDEN, RN, MS, CPHQVP, QUALITY SERVICES
May 11, 2011
2
Centralized location for outpatient services, primary and wellness care, and rehabilitation and long term care.
Centralized location for inpatient and emergency care.
Centralized location for inpatient OB/GYN services.
Ellis Medicine….
3
ELLIS HEALTH CENTER: ELLIS MEDICAL HOME – A MODEL OF PRIMARY CARE
Highlights: Services: family medicine, pediatrics, dental and insurance
enrollment, supplemented by full outpatient and emergency services; unique support for underserved
Community shuttle: 138 monthly average riders Health services navigators: 174 monthly average patient
encounters; 160 ED patients w/o a doctor were connected with primary care (Sept 2009-Sept 2010)
Community Partnerships – Ready. Set. Kindergarten! 114 children seen– Health Fairs, Farmer’s Market
The Importance of Quality in Medicine
Ernest Amory Codman, M.D. Franklin Martin, M.D.
1910“The End Result System of Hospital Standardization”
1913Founder of the
American College of Surgeons
Importance of Quality Monitoring in Medicine 1917 ACS Develops
The Minimum Standard for Hospitals
(Requirements fill one page)
1917The MinimumStandard for Hospitals1. Staff membership restricted to physicians who are (a) graduates of
medicine in good standing, legally licensed to practice in their states, (b) competent in their fields, and (c) worthy in character and in professional ethics; and that the practice of the division of fees, under any guise whatever, be prohibited.
2. Staff initiate, with approval of the hospital governing board, adopt rules, regulations, and policies governing professional hospital work. Staff meetings at least monthly. Staff review and analyze at regular intervals clinical experience in the departments, such as medicine, surgery, obstetrics, and other specialties; clinical records as the basis of review and analyses.
3. Accurate and complete patient records, filed in an accessible manner. A complete record being one which includes identification; complaint; personal and family history; history of present illness; physical examination; special examinations, such as consultations, clinical laboratory, X-ray and other examinations; provisional diagnosis; medical or surgical treatment; gross and microscopic pathological findings; progress notes; final diagnosis; discharge condition; followup and, in case of death, autopsy findings.
1917The MinimumStandard for Hospitals
4. Diagnostic and therapeutic facilities under competent supervision available for study, diagnosis, & treatment of patients, to include, (a) clinical laboratory providing chemical, bacteriological, serological, and pathological services; (b) X-ray department providing radiographic and fluoroscopic services.
5. Physicians privileged to practice in the hospital be organized as a definite group or staff. Such organization has nothing to do with the question of the hospital as “open” or “closed,” nor need it affect the various existing types of staff organization. The word “staff” is here defined as the group of doctors who practice in the hospital inclusive of all groups such as the “regular staff,” the “visiting staff,” and the “associate staff.”
1926Am. Coll. SurgeonsStandards Manual
18 pages
1951ACS Standards Manual
The American College of Surgeons (ACS)
The American College of Physicians (ACP)
The American Hospital Association (AHA)
The American Medical Association (AMA)
The Canadian Medical Association (CMA)
Joint Commission on Accreditation of Hospitals
(JCAH)
1964 begins charging for surveys1987 Name Change:
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO)
“JCAH”Joint Commission on Accreditation of Hospitals
1990 - 2006 Everyone just calls it: “The Joint Commission”
January 2007 Officially Changes Name to:“The Joint Commission”
11
Quality Today
THE AFFORDABLE CARE ACT (ACA) OF 3/23/2010
12
The Act provided for Mandatory Medicare Delivery System Reform: Reduce Inpatient Readmissions Institute Value Based Purchasing (VBP) Reduce Healthcare Acquired Conditions (HACS) Institute Meaningful Use (Electronic Healthcare
Record-EHR) An “incentive” program for hospitals accepting
Medicare reimbursement. Beginning in October 1, 2012, 1% of Medicare
reimbursement due to us for services already rendered will be withheld.
The amount withheld will increase by ¼ of a percent per year until 2% is reached.
We have an opportunity to earn back some or all of this money by demonstrating that we give quality care and have satisfied consumers.
BEGINNING THE LEAN JOURNEY AT ELLIS
13
REASON FOR LEAN NOW…..
• Achieve a top performing organization• A mindset of clinical quality• Accountability of managers• Keeping patients first when considering change• Increasing financial pressures – declining
reimbursement• Consistent monitoring of results and data• The status quo is no longer acceptable• Collaboration between departments is
expectation
14
LEAN is a methodology that is used to accelerate the speed and reduce the cost for any process by removing waste (non-value-added activities)
“Re-examine the way you think about waste, as it is often difficult to recognize. Start by making waste obvious to everyone.”
Taiichi Ohno, Founder Toyota Production System
15
WASTE REDUCTION – 120 DAY CYLE
• Kick Off - COMPLETED• 30 Day Check-In - COMPLETED• 60 Day Check-In - COMPLETED• 90 Day Check-In- APRIL 26th 9-11 Auditorium• Summation – MAY 24th 9-11 Auditorium _________________________ 120 Days X 3 Cycles =360 Days
THE NEXT 120 DAY CYCLE BEGINS ON THE SUMMATION DAY.
16
ROLE OF WORKOUT COORDINATORS
• Assist the exec champion in managing the logistics of the 120 day Workout
• Support for timely development of the 120 day action plans
• Identifying potential successes and failures
• Providing support to stimulate ideas and discussions
• Act as a coach for the lean process
Additional Training for LEAN workout coordinators is scheduled.
17
LEAN -WORK OUT COORDINATORS
18
EXCELERATOR
All managers with a LEM - have access to Excelerator.
19
EXCELERATER RESULTS TO DATE:
• 640 PLANS ENTERED SO FAR• $400,000 Savings identified for 2011• $1.2 Million Savings identified for 2012 The Finance Data Sheet is posted on the
portal to assist you with valuing your cost savings.
20
SUMMARY OF 7 TYPES OF WASTE:
1. “In Quality Staffing” (Over Capacity) 2. Over‐Correction 3. Over‐Processing 4. Excess Inventory 5. Waiting & Delays 6. Motion/Transport 7. Movement of Materials & Information
21
RAPID CYCLE TEST TEMPLATE
22
RAPID CYCLE TEST TEMPLATEPRE POST
Data into grey columns only.
Count Data Avg Count Data Avg. Rapid Cycle Testing Instructions
1 132 112 1 69 82 1. Determine the measure to test & the source of data (manual or IT system).
2 99 112 2 101 82 2. Create the plan to test the change (date to begin test, training, data collection, etc.)
3 102 112 3 63 82 3. Obtain/ collect baseline data (25-30 data points or more if not manual.)
4 99 112 4 73 82 4. Train/orient staff (if needed) & train data collectors (if needed) & conduct 1 "dry run".
5 78 112 5 89 82 5. Run the test for 25-30 data points over 1-shift, 1-day, 3-days, collecting data along the way.
6 106 112 6 79 82 6. Analyze results. If improvement, "hardwire" the change. If not, cease the change.
7 119 112 7 78 82 7. Repeat the Rapid Cycle Test process.
8 89 112 8 83 82
9 100 112 9 77 82 Pre Post
10 102 112 10 78 82 Average 112 82
11 150 112 11 89 82 St. Dev. 27 10
12 146 112 12 95 82
13 123 112 13 94 82
14 132 112 14 90 82
15 176 112 15 78 82
16 102 112 16 84 82
17 89 112 17 90 82
18 95 112 18 69 82
19 96 112 19 69 82
20 97 112 20 101 82
21 98 112 21 63 82
22 102 112 22 73 82
23 142 112 23 89 82
24 165 112 24 79 82
25 132 112 25 78 82
26 123 112 26 83 82
27 172 112 27 77 82
28 69 112 28 78 82
29 85 112 29 89 82
30 84 112 30 95 82
31 76 112 31 94 82
32 98 112 32 90 82
33 99 112 33 78 82
34 100 112 34 84 82
35 120 112 35 90 82
36 130 112 36 69 82
Source: Manual 7-7-09
Automatic
Calculation
TWO CHANGES PER MONTH
ASK STAFF – What processes are interfering
with our ability to provide excellent care?
ASK STAFF – Is there a better way?
POOR QUALITY AND PATIENT SAFETY RISKS
ARE OFTEN CREATED BY VARIATION IN OUR
PROCESSES
24
25
LEAN TEAM KAIZEN EVENT
Application of Lean concepts and tools to rapidly improve the process through the removal of waste in the system
Project charter: Opportunity exists to improve the process of timely medication delivery to new post-op patients.
Scope: From when physician signs order to when medication is administered to patient in A3
26
WHAT IS LEAN??
Philosophy– Focus on value-added elements in process, drive out
waste in system
Tools– Throughput time, five Ss, simple visual control systems,
spaghetti diagrams, standardized work, smooth flow….
27
28
29Documenting and studying the actual process
PACU PROCESS AND ISSUES
30
Med recSign/dated
Scanned to
pharm by
clerk
Scanned to
pharm by RN
RN revieworder
Post op orderSign/dated
Incomplete
Orders
15 minutes
PHARM PROCESS AND ISSUES
31
Messages
ScanArrived
Scan put into MAK by
RX
Robot retrieval
and bagging
Meds put in tube
Meds sent via tubes
Batch wait time
No trace = rework
10 minutes 3012
0
20 minutes
A3 PROCESS AND ISSUES
32
Nurse Verifies
MAK entry
Nurses time
spent on non-
patient care
Meds put in Med room
Nurse retrieves med from
room
Meds to patient
Hunt and gather
Did meds arrive
?
Unattended Meds!
Pyxis underus
ed
CURRENT PROCESS
Example: 6/23 total knee surgery
– Antiemetic (Zofran) ordered at 1745– Patient received at 2226
– Total time 4 hrs 41 minutes from order to delivery
– BUT – Zofran is a PYXIS item. Available immediately on over-ride on A3 unit!
– Patient could have had it in minutes!
33
OPPORTUNITIES TO REMOVE WASTE
PYXIS use up Time/date MORE orders Tube system alert Tube system tracking board Tubes cleared by non clinical staff Supply room reorganize – hunt and gather Room-side cabinet Runner?
34
35Spaghetti diagram – RN checking on missing med
36Part of the improved tube management system
37Increase PYXIS use!
38
Minimize hunting and gathering - - Utilize and organize Nurse cabinets
39
Tubes in que For system
Report Parameters: 6/22/2009 12:00AM to 6/23/2009 12:00AM
Graph displays orders received by hour and priority for a specified date range to show the demand within a 24 hour time period.
SUMMARY
This Lean activity, with its focus on waste reduction, eliminates unnecessary processes, provides better service to patients, and increases both patient and employee satisfaction
41
EXTRAORDINARY CHANGE– Catalyst for change: NYS health care reform (Berger law)
– Ellis assumed responsibility for the services of two hospitals in a short seven month period.
– Thousands of details involved …
– Consider what was added to Ellis: Employees 1,133
Expense Budget $118 MDischarges 10,600Days of Care 43,000Surgeries 8,400ER Visits 39,000
– Financial Turnaround 2007 – 3 hospitals lost $7 M collectively 2008 – newly unified Ellis posted $4.6 M operating margin
INTRODUCTION
Schenectady, NY Three campus hospital system 455 licensed beds 3,300 employees (850 RNs) 600 affiliated physicians 2009 projected volume: 550,000 patients 2009 projected births: 2,700 babies 2009 operating budget $343 million 2008 operating margin: $4.6 million
BTS 8 FRAMEWORK FOR SUCCESS
Aim statement Plan – Do – Study – Act PDSA Cycles Identify BTS 8 Team Garner Physician Champion(s) Engage Senior Leadership/Management Perform tests on changes and processes
leading to implementation Monthly Conference Calls Update Data for Premier ~ My Community Attendance at all three BTS8 Learning
Sessions
TEAM MEMBERS
Director Surgical Services (Jonathan Blank)
OR Manager (Pam Margas)
PACU Manager (Judy Symolon)
Physician Champions (Dr. Iftikhar Syed & Eric Aronowitz)
Purchasing Manager (Coleen Norberg)
Surgical Supply Manager (Donna Cafaldo)
Vice President of Operations (Patti Hammond)
AIM STATEMENT
Improve OR supply chain expense by $125,000 through standardization, utilization, contracting and increased efficiencies across a 3 campus perioperative system by 12/31/09.
STRATEGIES
Identify Perioperative Opportunities for Supply Chain Savings.
Identify Operational Efficiency Opportunities.
Identify Standardization Initiatives.
Utilize the BTS 8 “Formula for Success”– Aim statement– Persistent PDSA Cycles– Measuring, Performing Tests on Changes and Evoking Process
Evolution– Garnering Physician Champion Support (General and Orthopedic)– Engaging Senior Management– Communication
METHODOLOGY
Structured Focus on Aim Statement PDSA Cycles Monthly Premier Perioperative Conference
Calls Premier Consultation Senior Management Engaged Communication Updates Physician Champion Support Attendance at BTS 8 LS1-3 Conferences
CONTRACT OPPORTUNITY
Reprocessing – Shavers, Trocars, Tourniquet Cuffs, OPCAB Devices – SAVE $40K
Utilization Custom Pack Changes– Knee Arthroscopy – SAVE $14K– Total Knee - SAVE $ 7K– Total Hip –SAVE $16K– Physician Eye Packs – SAVE $19K
Standardization– Disposable Clean Up Kits SAVE -$45K– Foot Compression Garments SAVE-$2K– Shoulder Drape SAVE - $3K– PortaCath SAVE – $8K
Premier - Yankee Alliance Contracts & Capitated Pricing– Cardinal Custom Procedure Packs SAVE -$69K– Orthopedic Implant Capitated Contract –SAVE $651K
BTS 8 SAVINGS $1,157,170.00
Cumulative Dollar Savings from all BTS 8 Initiatives
$0
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09
CONCLUSION
Premier (BTS 8) - Framework for Success
Reprocessing – Conservative Approach
Operational Efficiency – Global Initiative
Contracts and Capitated Pricing – Persistence WINS
Capture all SAVINGS – Opportunities Abound
Change theory – Embrace with Leadership/Mentoring
LESSONS LEARNED
Framework for Success: Communication
Persistence
Savings
Global Operational View
Senior Leadership and Physician Champions
PROJECT INITIATIVES
Operational Efficiency Component– PACU Expansion– Enhanced Communication – CSuite Task Force– Information Technology
Material Management Component– Reprocessing– Contracts– Custom Packs– Standardization of Product
AIM
Improve OR supply chain expense by $125,000 through standardization, utilization, contracting and increased efficiencies across a 3 campus perioperative system by 12/31/09.
BTS 8 TEAM PERIOP RESULTS
TOTAL SAVE of $1,157, 170.00
OPERATIONAL EFFICIENCY SAVINGS OR/PACU PATIENT THROUGHPUTSTANDARDIZATION –EMR/FORMS
Labor and Anesthesia Expense Reduction : SAVINGS $19,599
Collaboration - BIOMED Equipment Transfer: SAVINGS $199,940
Forms Standardization: SAVINGS $3,000
Information Technology Specialist: SAVINGS $55,000
$277,940
PATIENT FLOW AND OPERATIONAL EFFICIENCY OPPORTUNITIES
PATIENT FLOW AND OPERATIONAL EFFICIENCY OPPORTUNITIES
OR AND PACU LABOR COST TREND
Total Save = $13,677
0
500
1000
1500
2000
2500
3000
3500
4000
4500
NOV DEC JAN FEB MAR APR MAY
OR Labor Cost
PACU LaborCost
ANESTHESIA LENGTHENED TIME COST
0
500
1000
1500
2000
2500
November December J anuary February March April May
Anesthesia Lengthened Time - Costs
Total Save = $5,922
920000850933
690670
200000
400000
600000
800000
1000000
Old $ New $ Save
Cardinal Custom Procedure Pack Contract
PREMIER & YANKEE CONTRACT WORK
Premier – Custom Procedure Pack Contract
Yankee – Benchmark for Ortho Capitation Contract
3031777
2380332
651445
0
1000000
2000000
3000000
4000000
Old $ New $ Save
Orthopedic Implant Capitated Contract
UTILIZATIONCUSTOM PACK CHANGES
29376
19988
14388
0
5000
10000
15000
20000
25000
30000
Old $ New $ Save
Knee Arthroscopy
143562127210
16352
0
50000
100000
150000
Old $ New $ Save
Total Hip
144621 137101
75200
50000
100000
150000
Old $ New $ Save
Total Knee
149223129393
19830
0
50000
100000
150000
Old $ New $ Save
Physicians' Eye Pack
SUPPLY CHAIN BARRIERS
Reprocessing – Surgeon’s previous experience created concern regarding inclusion of harmonic scalpel.
Waste Form –Not implemented across three campuses.
Orthopedic Implant – working through vendor resistance and influence.
Supply Chain Focus versus Clinical –
disconnect between clinical side and supply chain initiatives.
65
THE IMPORTANCE OF LEAN SIX SIGMA PROCESS TRACKING TO ACHIEVE IMPROVEMENT AND MAINTAIN IT.
Lean at Ellis– Change the way of thinking / culture– Consulting firm to assist in laying the foundation– Focus on quality
Improve patient flow Increase patient volume Eliminate non-value added activities Improve staffing
WHAT IS LEAN?
A philosophy & improvement methodology focused on eliminating waste & improving workflow
Focus on value stream analysis In Lean, costs exist only to be reduced Flow optimization Pull versus push (“Chocolate Factory”) Perfection (zero waste)
Mobilize the entire organization
– Board– Senior Leadership– Middle Management– Physicians– Front line staff• Set targets and deadlines up front• Set financial targets• All levels held accountable• Include front-line staff
Basic set of standardized terms– Posted on intranet
Discuss at Open Forums– Open discussion with all employees– Ask staff for brainstorming
Communication cascades
69
GETTING STARTED / INFRASTRUCTURE
1. Sr Management Oversight Committee for project selection & overall stewardship of activities
2. Consultant for initial education, teaching materials & coaching
3. Administrative support for scheduling & clerical functions: Critical Need!
4. System for tracking projects & results5. Strong ties to and support from Finance
70
120-day cycle with 30-day check-ins
Disciplined, focused engagement
Built database tracker to promote accountability & adherence to timelines
71
Activate engagement
• Set targets and deadlines up front• Set financial targets• All levels held accountable• Include front-line staff
Sort, Straighten, Shine,
Standardize, Sustain
7:00 AM anesthesia arrives
7:45 AM OR starts
Large Bariatric growth over last 5 years
Have PACU holds increased since the closure of B2
Anesthesia does not see the patients prior to the day of surgery (except for some cardiac cases)
How can we improve
– Patient tracking system in the PACU/OR
“BEFORE SURGERY” TEAM MEETING What is working:
Diligent staff that keeps on top of things (in relation to scheduling and paper work)
Having extra staff for turnovers helps move the cases along
Teamwork
Pick sheets have been improved
Moving towards an enterprise wide pick sheet.
– Currently working with purchasing and the OR buyer to standardize supplies
– Will have an electronic system for inventory contro
What is not working:
Paper
– Large amount of un-needed paper in the scheduling / PAT phase
– Duplication of work
– Missing documentation
– Would like to move to a central scanning system
Process to notify patient in regards to OR time changes
– Going to start reminder calls to patients with the arrival time, not the OR time Once up and running, MD office will no longer need to call patients with time
– Gives more flexibility in moving cases around
Patients that come in early for blood work wind up sitting in Day Surgery without having the blood drawn
– A facilitator position has been approved and will be posted soon
Missing pre-op antibiotics
– These are either not ordered or ordered at the last minute Can OR nurses have access to the PACU Pyxis
Outdated H+Ps
– Same day surgery is checking the charts the day prior
– Looking at having the PA update the H+P
Process
MD has set block time
– ~ 90% of block time is utilized
Case is scheduled by Joanne once the paperwork is received from the MD’s office
Schedule PAT appointment
– 7 - 30 days prior to OR date
Return completed booking sheet to the MD
Worksheet is generated and sent to PAT to secure the financials, pre-certs
Patient arrives for surgery
– 1 ½ hours prior to OR time
– Patient is escorted to Day Surgery, blitzed by staff, then waits for surgery
75
What is working:
Staff works hard
Teamwork
What is not work:
Patient not ready
– Blocks - RNs not available to assist
– Incomplete charts
PACU holds at 9:30 AM
– Is this due to staffing
Add-ons
– Stresses the staff / anesthesia
– Extra rooms running at 5 PM
Payer mix
– ~ 50% government funded
– Increasing bariatric patients but most are on Medicaid with minimal reimbursement
On time starts
76
DURING SURGERY” TEAM MEETING “What is working:
Teamwork
Dedicated staff
Positive outcomes
Patient comes first most of the time
Much talent in the OR
They have the needed tools to get the job done
What is not working:
Cost savings by the MD
– MD will require a certain product that is more expensive than a similar product
– Opening all products that could possibly be used for the procedure
Start times of first cases
Schedule of OR has expanded past the blocked time
– Rooms are running later in the day
– No room for the add-ons
Underutilization of EHC for ambulatory cases
No enforcement of the un-utilized block time
OR holds caused by no PACU beds
Reciprocation for the hard work of the staff
Redundancy in steps
– Assessment, chart check, ect.
Patients brought into the OR that are not ready
Process
Introduction and visual assessment of the patient in the holding area
– Seen by anesthesia
Chart review for missing documentation
Universal protocol
Update missing documentation
Patient is brought into the OR
Surgeon arrives
Anesthesia begins
Time out
Surgery
Case closed
Room turn over
Next case begins
77
AFTER SURGERY” TEAM MEETING What is working:
Send the surgical PA to the floor earlier
What is not working:
Long LOS
Crunch time for beds in PACU is Noon
– Peak time for hospital discharges is 4PM
Delay to PACU admission
Nursing units are at capacity
Room turnover on floors
No reports to floors during shift change
Unit nurse is needed for patient transfer to ICU
Anesthesia purges patients from PACU
Process
Call from OR to PACU for space
– Does not always happen
Patient arrives in PACU
Moves to Phase II recovery
Patient is transferred to the floor or discharged home
78
79
Goal– Achieve an annual tangible cost recovery
Goal - $3 Million– Conservative estimate with savings
expected to greatly exceed goal
Institution Orientation
Redefine Quality in relation to waste Define expectations
– Managers responsibility» Eight changes during 100 day cycle / 2 per
month» One change must include collaboration with
another department– Every employee is involved
80
Surgical Services Breakout
Identified as an area for substantial waste reduction and savings
Three teams – Prior to surgery– During surgery– After surgery
Cross section of specialties on each team to maximize results
81
Focus on the 7 categories of waste
“In Quality/ Out of Quality” Staffing; Overcapacity Correction / inspection Over-processing / redundancy Over-inventory Waiting Motion of patients / staff Material / information movement
Encourage process changes, not just simple waste reduction
82
– Rapid cycle testing PDSA 25-30 data points prior to and after change Facilitate change for new and innovative ideas
supported by data prior to implementation Eliminate long evaluation periods
83
KEY ROLES– Senior leaders
Buy in and support– Attend monthly check-ins when plans are presented by stake
holders– Workout coordinators
Managers broken up into approx 12 member teams Role of the workout coordinator is to offer guidance/advice, not ideas.
– Ownership of plans is placed on managers– Finance Liaison
Support in assigning actual savings when not readily identifiable Verify tangible savings when in question
– Communication Coordinator Announcement emails News letters Intranet
84
Challenges– Changing old school ways of thinking– Reducing staffing / supplies without compromising patient
care– Staying the coarse
This will not go away in a couple of weeks Owning the process and maintaining momentum after
consultants leave
85
Change Examples• B/W vs color printing• Stop unneeded reports• Consolidate deliveries• Fax vs mail reports• Eliminate face to face meetings: use technology• Reduce over time• Contracts/supplies: better pricing options• Control purchase options
86
Tracking progress– Consultant offered software package
Overview of projects Results
– Goal - $3 Million To Date - Planned $2.5 Million To Date - Actual $1.5 Million
87
88