Healthcare Finance Management Association: Continuous Improvement Foundations

Transcription

1 Like us on Facebook and enjoy some helpful downloads and connections Continuous Improvement Solutions, LLC 8801 Bethnal Rd., Bella Vista, AR

2 Chad Smith: Trainer, Facilitator, Practitioner of Continuous Improvement, ASQ Master Black Belt #8

3 Chad Smith: Pilot, Builder, Aviation Nut

4 Chad Smith: Musician

5 Chad Smith: Husband and Dad

6 Leaning Objectives Explore the Need See the Improvement Cycle in Action Discuss cultural challenges that stand in the way of changing healthcare processes Discuss courage and fear impacting success Walk away with good ideas to help you inspire others

7 The Background Large Regional Hospital System: 827 bed facility Provides tertiary care to large city System is third largest employer in State Hospital System is a non-profit organization Their objective is to serve more people in the local metropolis

8 The Need Wanted to drive more consistent service and reduce patients Leaving Without Being Seen (LWBS) Wanted more capability to accommodate additional patients Wanted to improve service to their customers by reducing door to Doc time

9 Team Members VP Clinical Services Unit Supervisor ED & Medflight Director PI Senior Systems Analyst Night Shift ED Charge Nurse Business Manager for ED ED Medflight Nurse Educator/Charge Nurse Nurse Educator/Charge Nurse Paramedic Central Processing Supervisor Nurse Educator/Charge Nurse

10 Problem Statement Prolonged wait times to be triaged LWBS (2015): 4.6 / day Avg 10 / day for April 2016 Not a clear understanding of Arrival-to-Doc time LOS (2015): min.

11 Project Goal Objectives: Reduce LWBS to less than 2% Reduce LOS to 60 min for acuity level of 4-5

12 Are we adding value for our Customers? We discussed the idea of Value-Add and Non-Value Add activities and assessing if they are adding value for our customers Value Added Any activity that increases the market form or function of the product or service. (These are things the customer is willing to pay for.) Non-Value Added Any activity that does not add market form or function or is not necessary. (These activities should be eliminated, simplified, reduced, or integrated.)

13 Established the Project Customers Internal Customers (the Floors, Physicians, Radiology, the Laboratory, Surgical Services, Bed Board) External Customers (Patients, EMS, outside facilities)

14 Completed Process Map and 8 Wastes Training A Process Map is a graphic display of steps, events, and operations that constitute a process. Includes Value Added AND Non-Value Added Activities Activity Start the car Activity Check your fuel gauge Delay Activity Wait for Put in defroster gear to clear Go FAST! Review 8 Wastes Transportation Over Production Motion Defect Delay Inventory Processing People/Information

15 Completed Current State Process Map Started with initial training on Process Mapping Determine the Start and Stop Start: Patient Arrives Stop: Doctor sees Patient Silent Brainstorm to get all the process activities quickly

16 Cause & Effect Manpower No one at Mini-Reg MD shift change Call Ins Distractions in waiting room delaying triage nurse Dr interruptions Measurement Patient acuity Patient volume Ambulance volume High acuity patients Method No beds available (hospital or ED) Rising Transfers Zero beds in hospital Registration Slow triage nurse Zero techs for triage Staffing vs Patient load Triage nurse has to take very sick patient straight back Several EKG/CT at once Mother Nature Mondays Holidays Days off Manpower Several EKG/CT needed at once Staffing versus patient load Staffing - not enough techs for triage Slow triage nurse Calls - insurance, incoming, transfer calls (charge nurse) Distractions in waiting room delaying triage nurse Shift change for doctors (staffing) Registration Material MD shift change LR Patient Arrival to Hospital and ED treatment.igx No one at mini reg Mother Nature Mondays - higher volume Sometime people come to get doctor excuse for another day off after a holiday Holidays - increase volume No beds available in hospital No beds available in ED Transfers out of hospital ED Transfers into hospital Method Measurement Doctor time in a room for high acuity Patient volume Ambulance volume Patient acuity Slow test turnaround times (lab) Slow documentation time per Dr Pauls - EPIC Machine Rising Door- to- Door to Doc time too high Doc Time

17 Go to Gemba! Gemba simply means the place where Value is Created Imperative to see what is really happening in the process! Critical Time to engage the Docs- the are integral to driving the improvements and must be on board

18 Current State Data Patient Arrival by Day and Hour Monday is the highest volume day of the week 9am 7pm are the highest volume hours of the day

19 Current State ED Process Map

20 Improvement Ideas Add NP/APN to assist at triage Provider gives rapid medical evaluation and begins orders Fast Track / Flex Bed Quick-Reg Process (did not address at this time) MD shift change (did not address at this time)

21 Acuity Levels: Refresher

22 Future State Fast Track Patient Arrives Move Patient to Waiting Room (Family Rm) Quick Reg Lab/X-Ray get Patient from Waiting Rm. Acuity Level 4 and 5 no longer going to main ED!!! Triage Is Patient a 4-5? yes Medical Screening (APN) no Main ER Move Patient to Waiting Rm (Family Rm) Nurse gets Patient Order any req d tests Dispo / Discharge

23 Future State Pilot Wednesday Pilot - RTU Dr. Purvis up front Used rooms near triage Streamlined flow to minimize walking Thursday Pilot Dr. Pahls acted as an APN Saw all acuity levels and que test orders immediately Run 10:00 12:00 Saw 8 Patients Remainder of Thursday is same process as Wednesday s pilot with Dr. Chaffin up front

24 Dr Desk Healthcare Finance Management Association: Rapid Treatment Unit Pilot RTU Waiting POC Rm-25 Discharge Rm-26 Assessment 4 Rm-3 Blood Draw Quick Reg 2 Rm-2 Triage Nurse 3 8 Rm-1 Registration/ Financial Security 1

25 Future State Pilot Results

26 Future State Pilot Results KAIZEN REPORT CARD DATE: RTU, Acuity level of 4-5 LEADER: AREA: ED BEFORE GOALS AFTER % IMP 2 WEEKS 1 MONTH 3 MONTHS 1 YEAR Arrival-to-Doc (min) % LWBS (Pilot run 11am-11pm) % LOS (Acuity=4-5) % Arrival-to-Dispo % LOS (Overall) % REMARKS: "BEFORE" data is based on 1 wk prior to trial

27 Future State Pilot Results Door to Room Door to Doc Door to Room Door to Doc Before After Before After ED LOS LWBS ED LOS LWBS 0 Before After Before After

28 Tools We Used Kaizen Philosophy Process Mapping GEMBA Silent Brainstorming Parking Lot Affinity Diagrams

29 Action Items Action Item Register Meeting: Improvement Group Team Members Date 4/22/2016 Action Item Owner Category Due Date Progress Comments Team leader is the person that will keep the champion updated,set up team meetings, push for completion, Progress etc. Key Progress Key 1 2 Install 1 workstation for Physician and 1 workstation for Scribe Work with team to develop go-fwd plan after admin evaluation % Complete 25% Complete 3 Map physicaian's computer to printer in new location Move existing PACS to new physicaion location Change 7 Flex Beds to monitored ED beds % Complete 75% Complete 100% Complete 6 Determine APN long-term strategy Map nurses printer After determination of go-forward is confirmed, work with team to finalize plan

30 What it Takes to Drive Daily Improvement Deming s Principle #8: Drive Out Fear Drive out fear, so that everyone may work effectively for the company Fortunately for this team, the culture of open and honest communication was developed during the event In fact, they had embraced a saying often repeated by Donnie Smith, Former CEO of Tyson Foods Say it in the room!!!

31 Power of a Fear Free Organization Deming s Principle #8: Drive Out Fear Let s press pause and discuss: Why is it critical that Fear be eliminated in your organization?

32 Power of a Fear Free Organization Deming s Principle #8: Drive Out Fear Let s press pause and discuss: What are reasons for fear in businesses? What can we do to overcome?

33 Power of a Fear Free Organization Deming s Principle #8: Drive Out Fear Let s press pause and discuss: How does the Process Improvement Event reduce the likelihood of being fearful?

34 Final Thoughts Be willing to establish a big challenge Be OK with adapting approaches and tools to meet the business need Practice Say it in the room Make it your standard work Do everything you can to eliminate FEAR This can best be done by working as a team! Lead by Example!

35 Leaning Objectives- Recap Explore the Need See the Improvement Cycle in Action Discuss cultural challenges that stand in the way of changing healthcare processes Discuss courage and fear impacting success Walk away with good ideas to help you inspire others

36 Questions What Questions do you have? I d Love to Hear from You!!! Link with me on Linked In, Twitter and Facebook Chad Smith, MBB (ASQ #8) Continuous Improvement Solutions, LLC 8801 Bethnal Rd. Bella Vista, AR cisolutionsllp@gmail.com

37 Appendix Provider-in-Triage Industry Study Palomar Medical Center ED Parma Community Hospital. James J. Augustine, MD, FACEP Scientific Assembly Seattle, WA GW School of Medicine & Health Sciences St Joseph Mercy Hospital Ann Arbor, MI Background Patient volume spiked after relocating to a new hospital and ED. Rising Wait times, triage delays, increased LWBS Prolonged wait times and LWBS. Overcrowding ED. Placed a Physician Assistant (PA) in triage. To see all patients EXCEPT those placed on Fast- Track area of ED Provider-in-Triage (PIT) Results Door-Doc = 15 min (34% reduction) LWBS reduced by 64% 35% increase in revenue from ED patients in first 5 months Overall ED patient satisfaction increased from 80 to 86 percentile (Press Ganey) 42 min decrease in ALOS (with 10 hr long PIT) Improved Physician & Nursing satisfaction Press Ganey results improved from 30 to 90 th percentile LWBS decreased by almost half resulting in increased revenue LWBS decreased by 43% to less than 1% Length of stay decresed 9 min Reduction in LWBS more than covered the cost of the Provider Originally started PIT for 7 hr/day, but extended to 16 hr/day because financial viability

38 Appendix Provider-in-Triage Industry Study A Long-term Analysis of Physician Triage Screening in the Emergency Department Jonathan G. Rogg, MD, Benjamin A. White, MD, Paul D. Biddinger, PhD, Yuchiao Chang, MD, and David F. M. Brown, MD Journal of Hospital Administration 2014, Vol. 3, No 1 Improving patient satisfaction by adding a physician in triage Background Compare ED performance metrics over 4 year period ( ) to evaluate PIT benefits Study compares patirnt satisfaction 6 months before and after PIT implemented. (Approx 500 patients in each sample group) PIT Results LWCA decresed from 4.8% to 2.9% Door-to-room decreased from 18.4 to 9.9 min (46% reduction) LOS reduced from 362 to 306 min (15% reduction) Study shows a small but statistically significant improvement in the absolute patient satisfaction scores (Press Ganey) after adding a PIT

39 Appendix Current State Data 1 MD at 6am- 7am Patient-RN ratio is above 3.5 from 8am- 10am Patient-MD Ratio is above 12 from 6am- 12pm

40 Appendix Current State Data Staffing vs Patient Volume Patient-RN ratio is above 3.5 from 8am-10am Patient-MD Ratio is above 12 from 6am-12pm