the Value Stream Analysis Approach

Transcription

1 Improving Cath Lab Processes using the Value Stream Analysis Approach Michigan Lean Consortium Annual Conference August 9, 2013 Brian Vander Weele

2 Spectrum Health Hospitals at a Glance Non-for-profit health system in West Michigan Comprised of nine hospitals (1,370 licensed beds) Includes physician group totaling more than 700 providers Priority Health Plan with over 600,000 members Over 19,000 employees and 2,550 active volunteers

3 SH Cath Lab Initial Situation 8 Cath Labs (Coronary & EP) 24 prep/recovery rooms 5,957 Coronary/PV cases 2,376 EP cases Need to evaluate and readjust capacity of interventional cardiology services to respond to the growth in demand d for electrophysiology (EP) services Identify and eliminate waste throughout the process especially in the pre-procedure process steps

4 SH - Previous Project by Project Approach Great Starts t poor finishes i Boil the ocean list of action items too busy to implement No ownership or accountability for the improvements No way to sustain the changes Needed a More Structured Approach a standard way to do the work and manage it visually Needed to focus on the entire process from beginning to end to minimize sub-optimization

5 Spectrum Health Performance Improvement System Incorporate methods and tools from Toyota Production System / Lean Value Stream Analysis Safety & Quality Patient Experience True North Strategic Growth Financial Stewardship Developing Talent & Performance

6 VSA (Value Stream Analysis) A Value Stream is the flow of all activities or processes that provide care to the patient Value Stream Analysis is a structured approach for planning and linking improvements together within the Value Stream to prevent moving waste from one part of the system to another

7 VSA Approach Based on lean thinking and TPS Is Transformational Value must be specified from the patient s point of view Improvement becomes the work - not an added program Focuses on making it better, not perfect Don t Dela A 50% sol tion toda is better Don t Delay - A 50% solution today is better than an 85% solution six months from now.

8 VSA Structure for Improvement Value Stream Analysis Workshop Develop Prioritized Action Plan A3 Thinking VSA Steering Team 4-day Rapid Improvement Events (RIE) Standard Work Kamishibai Audit Process Managing For Daily Improvement (MDI)

9 A3 Thinking A structured cycle of improvement Framework for organized thinking Canbeusedfor: Strategy Deployment Value Stream Analysis (VSA) Rapid Improvement Events (RIE) Problem Solving Personal Development Business Case Current State Future State Gap Analysis Hypothesis if then Experiments 9 block approach Completion o Plan Confirmed State Lessons Learned

10 Cath Lab VSA A3

11 VSA Structure for Improvement Value Stream Analysis Workshop Develop Prioritized Action Plan A3 Thinking VSA Steering Team 4-day Rapid Improvement Events (RIE) Standard Work Kamishibai Audit Process Managing For Daily Improvement (MDI)

12 VSA Steering Team Responsibilities: Governance structure to manage improvement Determine Areas of Focus (VS Vision) Establish Targets/Measurement Systems Remove Organizational Barriers Capture Savings/Monitor it Results Create Accountability and Sustainability Leadership Standard Work, Auditing

13 VSA Steering Team Meetings Meet weekly (except during event weeks) Facilitated by Process Owner, PI Coach or Engineer Meet in Mission i Control Room Membership includes: Executive Sponsor and Physician Lead (monthly) Process Owner Process Engineer Process Improvement Coach Finance representative Quality Department t representative ti Other key stakeholders as necessary

14 Value Stream - Mission Control Board Used by Steering Team to : Track progress towards Goals Prepare for next (RIE) Events Track results and progress of previous RIEs Plan future meetings and events

15 VSA Structure for Improvement Value Stream Analysis Workshop Develop Prioritized Action Plan A3 Thinking VSA Steering Team 4-day Rapid Improvement Events (RIE) Standard Work Kamishibai Audit Process Managing For Daily Improvement (MDI)

16 VSA Workshop Typically a 3 day event follows the A3 format Cross-functional team, which includes: Executive Sponsor, Physician Lead, Process Owner, Financial Analyst, staff, patient rep, PI Engineer and Coach Main deliverable is an Action Plan for the next 12 months

17 Cath Lab VSA Workshop - May 8-10, 2012

18 Cath Lab VSA Workshop - Summary Day 1 Analyze the Current State Day 2 Define the Ideal & Future State Day 3 Develop Action Plan & A3 s

19 VSA Structure for Improvement Value Stream Analysis Workshop Develop Prioritized Action Plan A3 Thinking VSA Steering Team 4-day Rapid Improvement Events (RIE) Standard Work Kamishibai Audit Process Managing For Daily Improvement (MDI)

20 Cath Lab VSA Prioritized Action Plan RIEs Projects 06/04/12 07/09/12 08/06/12 09/10/12 10/15/12 11/04/12 12/10/12 Jan /04/13 03/11/13 04/08/13 05/06/13 06/10/13 RIE #1 Implement MDI Board & Daily Huddle Conduct / update 6S system and audit process Reduce Table Scrap due to wrong access site preparation Improve On Time starts for all procedures (First Case & other proceures) Scheduling guidelines Block time rules One guideline shared w/ hosp. & offices Less down time betw cases reduce physician variability schedule consecutively Room Set Up /Turnover Flow Cell * Set up time & Room Turnaround time Reduction * Improve charge capture and documentation rework * Staff role rotation/ responsibilities *Standardization of physician workflow Complete Procedure Preparation * Standardize prep process to decrease delays (labs, etc.) **In Process * Informed Consent * Patient Education regarding procedure * Completeness of Pt. Chart NO RIE SCHEDULED Re tool the MDI Board and huddle process to highlight daily improvement / Solidify Golden Ticket process / Solidify the Kamishibai process Pre Encounter Flow Cell ("Planning RIE") * Physician Request * Gather Pt. demo. * Patient H&P * Medications * Wayfinding * Procedure Time * Pre auth * Procedure Instr. * Labs * Conversion to Epic * Capture Primry doc * PT transportation arrangements home *Corrrect Procedural Orders * Pre Reg for addons after 2:00 pm * Scheduling Rules & Standard Work * Sched. coordination btw computer systems complete coordination of preencounter (1 call) reduce errors in Med. Rec., Direct Patient Content Flow Cell (RIE#5A) * Scheduling date/time (smart phrase for "reserved time") * Verify Demographics * Cerner Med Reconcilliation * Address Med Needs (Labs, Holds, DM) * Education (procedure / expectations) * Wayfinding * Printed instructions and contact phone # to go with patient Confirmed Procedure Flow Cell (RIE #5B) "experimental RIE" / nontraditional * Finalize Future State *Experiments to include items from RIE #5A and proposed Futrue State Flow Cell #2 * Develop Implementation Plan Patient Transport COMPLETE NO formal RIE SCHEDULED Continue to implementthe the Pre Encounter Future State Pilot from RIE #5A and #5B Just Do Its (or Stop Its) 20 * 6S Procedure rooms, standardiz e and assess par levels using Lab #3 as template COMPLET Develop Standard of Care for prepping patientin in Prep/ Recovery COMPLETE Pre Planning meeting (2 4 hrs) review currentprocess and previous data / changes for Jan. event COMPLETE VSA Completion/ Transition Plan Indicates Complete Indicates Future Plan

21 VSA Structure for Improvement Value Stream Analysis Workshop Develop Prioritized Action Plan A3 Thinking VSA Steering Team 4-day Rapid Improvement Events (RIE) Standard Work Kamishibai Audit Process Managing For Daily Improvement (MDI)

22 Rapid Improvement Event (RIE) Typically a 4 day event Small team of people p focused on improving a part of a value stream Structured process follow A3 format Focused, team-based elimination of waste Design, test & implement improvements (results) by the end of the activity (week) Begin to change culture so that changes can happen daily

23 RIE - Agenda Day 1 Analyze the Current State Day 2 Determine Future State & Hypotheses Day 3 Run Experiments Day 4 Develop Standard d Work

24 Cath Lab VSA Summary of RIEs RIE #1 On Time Starts, 6S, Implement MDI, Reduce set-up scrap RIE #2 Cath Lab Scheduling Guidelines RIE #3 Set-up/Room Turn Over Flow Cell RIE #4 Complete Procedure re Preparation RIE #5 / 5B Pre-Encounter Process Redesign

25 Cath Lab Pre-Encounter Process Redesign Physician Requests Patient sits with WMH Scheduling WMH schedules in WMH Scheduling Procedure / scheduler and gets calls MHC Scheduler NextGen. completes E Boarding Patient In Yes Standard Required date / time and Labs for tentative appt. Professional Auth. Slip Office? Data From Physician obtained by WMH [1] [3] [4] Scheduling [5] [6] No Virtual task to WMH Scheduling. Call to patient. Set up time / date / lab. Instructions mailed [2] Scheduling Pre Arrival Registration WMH Scheduling sends virtual task to MHC Scheduling [7] Once appt. confirmed falls into Pre Arrival work queue [12] MHC Sheduling Confirms appt. in Cerner [8] Pre Arrival contacts patient for demographics, insurance info. and wayfinding (Cerner) 13] WMH PPP tasks MHC Scheduling to print NextGen Documents [9] Face sheet to verification for auth check & eligibility (Health Quest) [14] MHC Scheduling pulls indicated documents from NextGen for MHC Patient Chart [10] END MHC Scheduling build Cath Lab Chart / Sent to MHC PPP (day prior) [11] Extra procedure specific document added to Pt. Chart. Thank you cards / stickers / face sheet END [27] Physician requests procedure and completes the Appropriateness form [1] Patient In Office? No (virtual patient) H&P completed within 30 days? No Yes Yes Patient Touch Flow Cell 1 S 6 P [6, 7, 8] [12] MHC Scheduling receives task w/ Boarding Slip and Appropriateness Document and confirms Appt. (fax or electronic) Pre Arrival is tasked with confirmation of appointment Confirmed Procedure Flow Cell 1 S 6 P MDI MDI Invite patient for RN visit or * Schedul. date/ time [3,4] Clerical perform (Patient * Verify demographics [13] *Print Documents [9, 10] * Pre authorization [5] Touch flow cell) * Verify documentation * Cerner (Med Recon.) [23] & follow up tasks over the * Address Med Needs: [23] * Assemble Chart [11, 21] phone with labs * Vendors patient holds * Equipment DM * Anesthesia [2] * Education (Procedure [19,23] * Thank you Cards [27] & Expectations * Wayfinding [23] Clinical * Printed instructions * Confirm lab results [19] & contact # go w/ pt. follow up if needed Shdl Schedule H&P * Med Review visit in WMH * Create smart phrase document changes Office (physician for staff to say about or mid level "reserved" time provider) Not assigned from Current State MHC PPP WMH Pre Procedure Planning Task drops into RN/PPP box (WMH PPP) [15] Tasks processed by chronological need [16] Reviews task for "Red Flag" patients [17] WMH PPP reviews patient chart [18] Day prior MHC PPP MHC PPP RN prints schedule MHC Chart goes to RN receives Cath / calls patient (med rec.) / Prep/Recovery night Chart reviews meds / Inpatient prior profile / Anesthesia / Adv. [22] Directives, Tobacco [23] [24] Call patient to review meds, labs and education [19] Prep/Recovery performs quality check [25] WMH PPP identifies needed NextGen documents [20] Patient "Check In" / Verify demographics or Register if not already / Name Band / Sign Hospital Consent form / Confirm referring (Primary doc) [26] Current State WMH PPP task to MHC clerical/ scheduling [21] END END From Feb. Planning Session [24] [25] Future State [13] [14] [15] [16] [26] Registration Verifies demographics [17] checks in / registers patient Name Band [18] Consent for Tx form [20] Confirm Referring / Primary doc. 3 designed patient contacts 1 designed patient contact 5 Process Flow Lines 2 Flow Cells 2 designed Med Rec 1 designed Med Rec Lack of standard work Standard Work Implemented

26 Experiments/Key Changes Provide standardized patient education in the office when scheduled for procedure from a physician office visit - if possible ( warm hand-off from scheduling to PPP) If patient is scheduled for procedure over phone soft hand-off from scheduling to PPP (still one patient contact) Eliminate the patient phone call 2 days prior from MHC PPP, by incorporating all education in initial patient contact

27 Results Successfully tested validity of Patient Contact Flow Cell (PPP) at the provider office patients seem very supportive Eliminated the redundancy of patient education & wayfinding by eliminating it from the MHC PPP role Able to reduce an FTE (through attrition) by reducing role of MHC PPP (elimination of redundancy)

28 Results Reduced amount of print-outs at MHC Scheduling Streamlined patient education and documentation at provider office PPP Performing Physician: Fred and Lena Meijer Heart Center Kresge Heart Catheterization Lab 100 Michigan St. NE, Grand Rapids Pre Procedure Instructions Date: Arrival Time: Procedure Time: No Solid Foods After: Then, only clear liquids, until arrival time Developed Standard Work for all roles within the process scope How to get here: Maps are available on our website, (spectrumhealth.org) under the following tabs. Patients and Visitors Parking and Directions This will take you to Yahoo maps where you may enter your address. Parking: 221 Michigan N.E. Grand Rapids, MI (Parking Ramp 7) Patients and visitors should park in Ramp 7, entrance is on Michigan Street, one half block east of Barclay Avenue. The skywalk is located onlevel3 of theparking structure, take skywalk to hospital elevators, to the Meijer Heart Center lobby on level one. Parking validation is available for patients and visitors on the 1 st Floor of the Meijer Heart Center at either the registration desk, or the information desk. Valet parking is available at the front door of the Meijer Heart Center (Located on Barclay Ave.) The fee for valet parking is $8, or free with a handicap sticker. Where to go when you arrive: Proceed to the 3 rd Floor of the Meijer Heart Center. Bring your insurance cards with you. What to expect: You must be driven home from the hospital and will not be permitted to drive the day of your procedure. Plan to be at the Meijer Heart Center approximately 4 6 hours. Most procedures are performed as an outpatient, however your physician may decide to have you stay overnight if appropriate. Please come prepared with an overnight bag and your prescribed medications in their original bottles, except narcotics. If you have any questions, please contact West Michigan Heart, Bradford (616) , Holland (616) Last Update 3/13/2013

29 Time spent with patient or chart prior to procedure Current State t = 130 min. Pilot = 95 min. -27% Net Result is reducing 1 FTE (by attrition)

30 Challenges Along the Way Technology challenges: (contingencies i of one application affecting another, conversion from NextGen to Epic, printing reports to scan back into another application, etc.) Uncovering the hidden exceptions or work- arounds thinking you have current state and standard work defined Multiple locations with Provider having unique differences in process (new types of patients homegrown processes

31 First Case On Time Starts Prior to VSA: < 25% on time starts 90% 80% Cath Lab First Case On Time Starts - Coronary/PV Target = 75% or higher 70% 60% 50% 40% 30% 20% 10% 31 0% Jun '12 Jul Aug Sep Oct Nov Dec Jan '13 Feb Mar Apr May Jun

32 First Case On Time Starts Tools Used: Pareto Chart Plot Daily results on MDI Board Standard Work 32 Process Control - Visual

33 Table Scrap Reduction RIE #1 Prior to RIE: $770 / week After RIE (post 90 day): $0 / week Annual Savings of $40,040

34 Table Scrap Reduction Tools Used: Plot Daily results on MDI Board Audit the Standard Work until hardwired Develop Standard Work

35 Reduction in Documentation Errors Tools & Methods Used: Plotting on MDI Board Review with staff at daily huddles Pareto Charts by equipment types and staff Standard Work Prior to RIE: 3/day Current: <1/day Kamishibai Auditing

36 VSA Structure for Improvement Value Stream Analysis Workshop Develop Prioritized Action Plan A3 Thinking VSA Steering Team 4-day Rapid Improvement Events (RIE) Standard Work Kamishibai Audit Process Managing For Daily Improvement (MDI)

37 Waste Reduction (over processing) Provided end user electronic access to desired information Eliminated printing and scanning of XIM log into Medical Record for down stream use Annual savings of $25,400

38 Waste Reduction (excess motion) Before: Location of charts for #9-12 at either desk depending on staffing, etc. After: Kamishibai Audit Card Less searching for charts and Physician frustration

39 Waste Reduction (excess motion) Procedure rationale not Ensure Rationale available always readily available prior to scheduling procedure Inconsistent organization of Patient Chart Create standard Chart Index Before: After: Improved Physician satisfaction and process Improved Physician satisfaction and process efficiency & quality

40 6S Standardization of 5 Cath Labs Standardized location of supplies Reduced par levels based on usage One time credit of $10,346

41 Golden Tickets Ideas for Improvement The purpose of the golden ticket (GT) is to provide a standard way to document an improvement idea Any one can have a great idea for improving their work area, or one of the key measures on the MDI board. Keep scope narrow so staff in the area can work on implementing them in a timely fashion. Ideas are best tried and implemented by the person(s) who had the idea.

42 Golden Ticket Flow VALUE High Value / Effort Grid 1 Reviewed in Huddle Low 2 Easy Hard EFFORT 3 Top 3 New Golden Ticket Completed

43 Staff Suggestions 6S EP Equipment Cart Room 8 Stretcher Rotablator Flow Cardia CSI Lead Panel Open Area Room 1 Stretcher W.O.W. Ivus Radi/Adenosine OCT/FFR OCT/FFR West Ha allway Sonosite Room 7 Stretcher Room 2 Stretcher Sonosite llway East Ha Angiojet Volcano Accist Accist Core Valve Cart Lead Skirt Pyxis Programmer Ivus Programmer Room 6 Programmer Stretcher Programmer Overhead Light Open Rep Equipment Area Room 3 Programmer Stretcher Stockert sign-out board Published Equipment Map Infrared X Programmer Programmer Programmer Room 4 Contents IABP Laser IABP Tandem Heart Carto3 Tandem Heart ESI/Velocity Impella Cryo Impella Cryo Zero Gravity Room 10 Stretcher

44 Staff Suggestions - Supply Usage Based on identified suggestion use contrast from Acist machine instead of 50 ml bottle, for a 10ml need. Annual savings of $12,673

45 VSA Structure for Improvement (sustain) Value Stream Analysis Workshop Develop Prioritized Action Plan A3 Thinking VSA Steering Team 4-day Rapid Improvement Events (RIE) Standard Work Kamishibai Audit Process Managing For Daily Improvement (MDI)

46 Sustaining the Improvements VSA / RIE Standard Work MDI (Managing for Daily Improvement) Kamishibai Audits Leadership Standard Work Gains Impro oveme ent Time

47 Standard Work The currently known best method to perform the work A living document

48 Sustaining the Improvements VSA / RIE Standard Work MDI (Managing for Daily Improvement) Kamishibai Audits Leadership Standard Work Gains Impro oveme ent Time

49 Managing for Daily Improvement (MDI) MDI is a system for managing and sustaining process improvement initiatives. Major Components of MDI: Visual Management Boards Performance Tracking Daily Huddles Daily Problem Solving Daily Assessments Daily Gemba Walks Daily Standard Work for all Roles Can you tell in 5 seconds what s going on?

50 Daily Huddles All staff and clinicians i i attend Anyone can lead a Huddle Same time, everyday 5 to 10 minutes in length Initiate problem solving Review suggestions (GT) Sustain the gains

51 Sustaining the Improvements VSA / RIE Standard Work MDI (Managing for Daily Improvement) Kamishibai Audits Leadership Standard Work Gains Impro oveme ent Time

52 Kamishibai Auditing Visual Audit Cards are the foundation of the Kamishibai System Cue cards for auditing a process Ensure that a new process is routinely followed (accountability) Can be used hourly, daily or weekly Audits need to be short (< 5 minutes) Audits need to be valuable critical few vs. important many

53 Audit Cards Name of Audit Audit Question(s) Audit Details Corrective Action Details Instructions

54 Kamishibai Audit Board Used as simple and effective visual control in performing daily process audits & assessments of Standard Work 54

55 Sustaining the Improvements VSA / RIE Standard Work MDI (Managing for Daily Improvement) Kamishibai Audits Leadership Standard Work Gains Impro oveme ent Time

56 Leadership Standard Work (LSW) Provides a structure and routine that helps leaders shift from a results focus to a process and results focus. Go to the Gemba and observe MDI Board. Reinforce visuals, what is normal? Is corrective action effective? Attend a daily huddle and/or perform an audit. Engage staff in improvement discussions.

57 Summary of Benefits Cath Lab VSA Improvements (annual savings): Date Description of Improvement / Action Implemented Source Anticipated Savings Comments July '12 6S - savings in not searching for equipment (10min/week) = $286 / year RIE 1 $ 286 Aug. '12 Revision to Set-up Scrap cost savings (actual coming in at $0/week vs. $110 ) RIE 1 $ 40,040 Re-audited in February '13 Aug. '12 Oct. '12 Revised process of using 50 ml bottles of Contrast to using 10 ml from Acist machine for balloon use (was wasting 40 ml / case). Reduction of 242 bottles/month to 64 bottles in September. 178 * $7.49 = $1333/month or $16,000/year Reduction in supply levels due to 6S and inventory reductions in Cath Labs (central corridor stock returns = $6,025) (returns from cath lab rooms = $ ) Just-Do-It $ 12,673 Validated in January '13 RIE 3 $ 10,346 One time credit Jan. '13 Eliminate printing and scanning of XIM Log RIE 4 $ 25,400 Go-live (2/1/13) Feb. '13 Added EP capacity from Coronary 3 months earlier than without RIE 2. Contribution margin =$36,425/day x 13 days (3 months) = $473,520. RIE 2 $ 473,520 Steering Team approval 2/21/13 May '13 Reduction of one FTE (job transfer - position not filled at WMH) due to elimination of second PPP phone call to patient (redundancy waste) from MHC. RIE 5/5B $ 48, TOTAL: $ 610,430

58 Summary of Benefits - Intangibles Improved patient satisfaction with improvements in procedure start times. Staff more engaged in improvement ideas through participation in daily huddle at MDI Board. Improved patient satisfaction and safety by performing dual procedures (TEE & cath) together in cath lab reduces transport, prep & recovery from 2 places to 1 & one sedation.

59 Lessons Learned What Went Well... What Could be Improved... Prep work prior to RIE workshops Pre-experimenting when possible Having standard work defined Having a patients t & fresh eyes Having experts involved Being open minded Having the structure of Agendas Having more solid attendance in RIE More patients for experiments More areas represented as needed Getting more Physician i involvement What Did We Learn... What Would We Do Differently... This is a very personal process Difficulty getting out of our normal thinking to develop future state Conference room experiments work Limited it scope for RIEs work best Preparation (pre-work) pays dividends 59 How complex the process really is Hold regular updates with staff Schedule Test patients for experiments if volume is low for RIE

60 Questions?