REDESIGNING ALLIED HEALTH OUTPATIENTS - Lean Thinking Applications to Allied Health

Transcription

1 REDESIGNING ALLIED HEALTH OUTPATIENTS - Lean Thinking Applications to Allied Health Josephine Kitch, Director, Allied Health Division,Flinders Medical Centre, SA Brenda Crane, RDC Clinical Facilitator, Allied Health Division,FMC, SA Prof. David Ben Tovim, Director, Redesigning Care, FMC Rebecca Daebeler, Manager, Podiatry Department,Allied Health Division,FMC, SA

2 BACKGROUND Flinders Medical Centre Approx 530 Beds Public teaching hospital Co located with FUSA & Flinders Private Hospital Within Southern Adelaide Health Service Full range of care from Perinatal to Palliative One of 2 Major Trauma Centres in SA Largely emergency driven work busiest ED workload/bed ratio in SA

3 WHY DID FMC UNDERTAKE REDESIGNING CARE? Winter 2003 Major crisis ensuring safe care Increasing our capacity did not work! - Had to search for unfamiliar solutions Learned about Lean Thinking British National Health Service Modernisation Agency Lean Manufacturing sources local & international Launched Redesigning Care Programme

4 REDESIGN IN FMC First 18 months Adult Emergency Dept Identified sequences of care -Value Streams Process made visible Big Picture Map Patients seen in order of arrival RESULT : Hospital Brought under control Can see extra 20 patients per day in ED Congestion decreased DNA fell 7% to 3-4% Improved ward turnover 1010 bed days saved Restored capacity for Elective Surgery Morale & recruitment improved Other streams Medical, Surgical, Mental Health, Older Patient

5 WHAT IS REDESIGNING CARE? Redesigning Care is : A systematic change programme Based on Lean Thinking philosophy & tools Focus on making visible the complexity of the Patient Journey through care

6 WHAT IS REDESIGNING CARE? It s about : The Patient Journey (not departments,divisions or professional silos ) Creating flow, maximising value and reducing waste Participation and ownership of staff,who initiate change Managers as enablers not decision makers & directors Can do culture -vs blame culture Ongoing improvement Sustainable change The Flinders House

7 WHAT IS LEAN THINKING? Based on the Toyota Production System Well established methodology to organise complex processes Initiate change from workplace Get the Right patient,to the Right place,for Right treatment, at the Right time IT IS NOT A project management philosophy A non specific QI process

8 FIVE PRINCIPLES OF LEAN THINKING Specify Value from the standpoint of the end customer Identify the Value Stream for each product family Eliminate Waste Maximise the Flow of the product or service Enable the customer to Pull or engage the service as needed Manage towards Perfection Adapted from The Toyota Way Jeffrey K. Liker

9 8 WASTES IN HEALTH CARE Waiting Queues Errors Transportation Motion Over Processing Over production Not using the skills & expertise of staff doing the job Adapted from The Toyota Way Jeffrey K. Liker 2004

10 REDESIGNING CARE Program phases P D A C Share key learnings P D A C Sustain new ways of working Project Phase 1 Intervention Phase P D A C 2 P D A C Diagnostic Phase P D A C

11 Project Phase REDESIGNING CARE PROJECT PHASE 1. Identify a piece of work that needs doing that is aligned with program goals / targets 2. Endorsement by the hospital executive 3. Steering Group / Leadership group 4. Defining the targets 5. Establishing the work-groups / resources 6. Lean education

12 Diagnostic Phase DIAGNOSTIC PHASE Understanding what is happening now.the good, the bad & the ugly! Big picture map- current state Identifying and acknowledging the mess Engagement and permission of staff Identify the value streams (or a value stream) Establish value stream work group Map specific value stream More detailed understanding of a specific patient journey Track the patient journey Is what we think happens, what really happens? Future state map

13 Intervention Phase P D A C REDESIGNING CARE INTERVENTION PHASE Work towards a future state through a series of PDCA cycles Targeted interventions revealed through mapping processes Sometimes it is important to get started Access to real time data on a weekly basis 3 month cycles

14 ALLIED HEALTH REDESIGN How does this apply to us? FMC Allied Health Outpatient Service is a large business operating in a complex hospital system

15 ALLIED HEALTH REDESIGN Project Phase Ever increasing demand on Allied Health Outpatient Services in FMC Explore Lean Thinking methodology to understand our services identify duplication and inherent waste learn how to improve processes. Steering Group formed and a Clinical Facilitator engaged in July 2006

16 ALLIED HEALTH REDESIGN Diagnostic Phase An initial survey of the FMC Allied Health OP Service showed: Complexity A large business ( the Allied Health Division ) comprised of 8 smaller individual enterprises No single Allied Health Outpatient entity and location No standard operating processes across the Division Diversity in size, staffing, funding and partnership arrangements Disparate referral processes Organic growth -adapting to department rather than organisation wide issues

17 ALLIED HEALTH REDESIGN Diagnostic phase Mapping:- Compare largest and smallest Departments ( Physiotherapy & Podiatry) in August September 06 Array of hidden roles and assumptions. Complexity and variation in clinic scheduling Embedded knowledge work in scheduling vulnerable PMA & Assistant & Admin roles Disjointed linking with other clinics or production lines across FMC Access issues for low risk patients in a context of shrinking community options

18 ALLIED HEALTH REDESIGN The Podiatry Dept. is.. another complex system quietly feeding into the main FMC pipes or streams..

19 PODIATRY INTERVENTION - Diagnostics Baseline data analysis Incomputable complexity of scheduling 12 specialised Podiatry clinics. Tracking of Podiatrist and PMA/Administration roles high value adding by podiatrists team dependence upon multitasking PMA /Clerical role Valuable information continual motion of PMA PMA activity & overburden Information flow Patient wait times

20 PODIATRY INTERVENTION Diagnostic phase Podiatry PMA Activity (one clinic ) VA NVA NDV BREAK Staff Cover for PMA (one clinic) Instances AM set up Calls Bookings Cleaning Dressings Activity Podiatry PMA Instances of Activity ( one clinic) Movement Operations Info. flow Interruptions Cleaning Assist Pod. Assist Dr Tracking Podiatry PMA activity instances noted

21 PODIATRY INTERVENTION Diagnostic Phase Tracking Podiatrist Podiatrist Activity Value Chart (one clinic) Podiatrist instances of Activity (one clinic) VA NVA NDV Break Patient Wait Time (one clinic) Minutes Waiting Movement Operations Interruptions Info flow Rework Patient

22 PODIATRY INTERVENTION - BOOKING TEMPLATE REDESIGN Aim : Simplify the complex booking & triage system through redesign of clinic booking template Release capacity for IP work and OP High Risk service from gains made from improved OP Clinic flow. Work Group - October 2006 Trial Intervention -Feb ongoing

23 PODIATRY INTERVENTION BOOKING TEMPLATE REDESIGN Method: Move bookings from computer template Single large hand written daily template sheet All staff to see all patients No named clinics Book to time needed, treatment room, & Podiatrist Multiples of 20 min (later10) slot units - not set appointment length Book patients in order to next available appointment Pre allocated emergency slots in each session Plan Do Check (Study) Act cycles for review and planning

24 PODIATRY INTERVENTION BOOKING TEMPLATE REDESIGN Booking Model Referral Slots in Order All staff see all pts No named clinics Next available appt See pts in order Emergency slots Podiatrist Triage & Assessment & Decision re Follow up V a r i a b l e S l o t s 10 10

25 PODIATRY INTERVENTION -Cycle checks Check- 1/2/07 20 min to 10 min slots Increased flexibility Written sheets to book Check - 30/3/07 Helps in staff vacancy. + ve use of small gaps Template to computer Check- 20/4/07 Visible template Aids time management Easy to use Immediate access to info Visual control tool for scheduling work Adjustment to variable slots takes time Some set clinic times for specialist link up Check 28/5/07 Capacity freed for IP work Consider optimum,rather than set time slots,for New pts Increasing patient variety in Specialist Clinic. Now consider workplace redesign - 5S

26 PODIATRY BOOKING INTERVENTION Staff Feedback Template easy to use -visual control Flexibility of 10 minute slots Adjustment required to anticipating right time for booking Positive use of small gaps Improved range of appts across week for patients Benefits of move away from specialist clinic structure Patients easing away from familiar clinic & day Enhanced capacity for inpatient work Now possible to see IP s on same day Enhanced rapport with ward staff All staff get IP experience now Generalist and Specialist Podiatrist skills confirmed across team Helpful in time of vacancy, not lost when staff leave

27 PODIATRY INTERVENTION Results Demand Tally Pre Intervention Post Intervention % offered appts 15 days Av.wait to appt Range 2-27 days % offered appts 10 days Av.wait to appt Range 5-16 days Wait cut by one week Compressed range of wait advantages ALL patients

28 PODIATRY INTERVENTION Results- Activity Data Comparison-Pre & Post Intervention 2007 Staff instability & leave significantly greater than 06 Activity Maintained DNA rate fell steadily over both periods Podiatry DNA 06 & 07 Feb Mar April DNA 06 DNA 07 But lower in 2007

29 PODIATRY INTERVENTION -Laboratory 5S Sort Identify what s needed and not Sometimes used Rarely used Never used Red Tag Eliminate clutter Set in Order For access & to relate to process Analyse status quo Allocate items a space Decide how things should be stored Labels Shine Clean, inspect & maintain work area Identify hazards Standardise Make work areas with similar function look the same Visual techniques Quick identification Place for everything Easy retrieval of frequently used items Check list for putting things away Safe storage height & weight considerations Sustain Ensure 5S is not just a quick clean up Team responsibility 5min maintenance daily Standard operating procedures 5S teams

30 PODIATRY LAB 5S Before After

31 PODIATRY LAB 5S Before After

32 PODIATRY LAB - 5S Before After

33 Ongoing Planning in Podiatry Consumer feedback and satisfaction Investigate patient outcome data 5S all areas of podiatry area Consolidate changes made in the department Continue to improve Continue to share

34 ADDITIONAL ALLIED HEALTH WORK Big Picture Maps completed for all AH OP Services Booking Intervention - Audiology Dept since May 07 Hand Therapy Service mapped in June Links with Division of Surgery -hospital wide OP Referral Data Base pilot site Dietetics AH key member of Hospital Outpatient Steering Group and in some areas leading the way

35 Hospital wide Outpatient framework Principles Metrics Predicated outcomes Across the outpatient journey points (referral, triage, booking, intervention and discharge) Endorsed by Management Executive Now the fun begins!! Standardization is possible across the hospital

36 SUSTAINING NEW WAYS OF WORKING Culture of perpetual improvement Make friends with your data! Team ownership of the process Develop Lean Leaders in each department Staff coaching and Lean knowledge Learning by sharing - success and failures Workplace organisation 5S & shared responsibility