System redesign in Primary Care

Transcription

1 System redesign in Primary Care A focus on Lean Anthony Behm, D.O. Chief of Staff, Erie VAMC Primary care(pc) satisfaction: up and down Satisfaction rates for PC s started dropping in the late 90 s. Physicians i who would still choose a career in PC*: 28% in % in % in 2010 However, only 25% satisfied with time spent on administrative tasks. *Medical Economics,

2 So, why are we unhappy with how we spend our time? Hamster health care: Across the globe doctors are miserable because they feel llike hamsters on a treadmill. They must run faster just to stand still But systems that depend on everyone running faster are not sustainable. The answer must be to redesign health care. Morrison and Smith; BMJ. 2000;321: Changing roles of PC More time spent: working on the computer for patient care (EMR) reviewing current preventative measures on a panel of patients trying to remember which plans pay for what in whom caring for patients with multiple comorbid conditions on multiple medications(chronic disease management) coordinating care with multiple specialists To have this time you and I will need to. Redesign the system, your office, how your staff and others work. 2

3 AOA Policy on Integrated Delivery Models We are especially supportive ofnew delivery models that enhance and promote the role of primary care physicians as the foundation for the health care system and place emphasis on the promotion of coordinated care across the health care spectrum. *From AOA National Webinar 1/5/12 System redesign How the parts of the system work with each other and how to improve their performance. The secret is small improvements in a process get repeated over and over that translate over time into big changes across a system. Lean is just one method that has been used Lean is just one method that has been used with some success to facilitate system redesign. 3

4 Lean as a method of system redesign Lean is managed as a system, not individualized tools. Core meaning is to maximize i the customers value while minimizing waste. For healthcare workers, most have not been trained to look for waste. It involves looking at process flow maps and creating processes that t require less human effort, less space, less cost. Lean at Toyota Lean was a term coined to describe Toyota s business in the late 1980 s*. Mainbeliefs grounded in the invention of the automated loom by Sakichi Toyoda in Further refined after the defeat in WW2 where Japan had to survive on scant resources and innovation. America studied the Toyota Production System (Lean s origin) in the 1980 s and discovered superior processes and techniques. *James Womack, Lean Thinking 4

5 Importance of the Toyota Background We are not really trying to teach you about manufacturing. We are teaching lean principles and understanding these principles requires: Knowledge of the history and context. Developing understanding of why these principles work in all complex settings, including healthcare. Awareness that it is working in healthcare settings across the United States. Lean in the Healthcare Setting My main message to you is that dramatic improvements in Healthcare are not only possible, but inevitable if you commit to change and diligently apply Lean thinking, principles and tools. John Black; The Toyota Way to Healthcare Excellence Virginia Mason Medical Center (Seattle) Seattle Children s Hospital ThedaCare, Wisconsin Akron Children s Hospital Cleveland Clinic 5

6 Akron Children s Hospital Radiology Department An A3, Green Belt and Kaizen project slashed MRI appointment wait times from 25 days to within 2 days. As a result, the improvements boosted the number of MRI exams performed and increased hospital revenue. Lean in PC at Virginia Mason Took PC from $ loser to profitable. Analyzed how supplies and teams flowed through the day. Changes resulted in shorter work days and btt better quality for docs. TAT for labs results went from 25 days to

7 So, how might you look to apply LEAN principles to the work in your office, clinic or hospital? Healthcare workers have not been trained to see waste in processes so many work harder than they should to overcome broken processes with superhuman efforts Seeing the entire process flow map, not just one isolated step or problem is something that can be learned. Consider learning how to identify waste in a systematic, standardized way. Definition of waste Any human activity that absorbs resources but does not add value to you or your staff or the patient and their hifamily. Also known as muda. Death or injury due to poor healthcare is the worst type of waste. The healthcare system itself creates most of the waste There are 7 types or broad categories of waste in healthcare. 7

8 Examples of Waste in Healthcare Type of Waste Transportation Overproduction Motion Defects Waiting Inventory Processing Example (Erie VAMC) Long distance between processes and storage locations Performing more frequent, not recommended or unnecessary lab tests Supplies and cabinets remote from work area (e.g. outpatient room); non-standard Room Errors by provider and non-provider departments; incorrect paperwork System down time; waiting for approvals; waiting for the next process to be ready Purchasing excess medical record folders; buying excess drugs or medical supplies that might expire Duplicate forms; duplicate questions; unnecessary data entry; excess testing Process flow map analysis A pictorial representation of the current state 8

9 Toast making video current condition Toast making video target condition 9

10 Lean Tools Waste identification 5S Standard problem solving Visual management 5S in the office 5S is the term used to describe a system for keeping an orderly workplace. The purpose is to make it an effortless task to perform certain tasks important to the patient. 10

11 Example of 5S Before After 21 Standard Problem Solving Process A structured, scientific, data driven problem solving process will be used to systematically analyze opportunities for waste elimination and process improvement. The effort works toward an ideal state and includes 4 concepts: 1) Clearly specify all activities of work. 2) All steps in the request for a service are as simple and direct as possible. 3) The pathway (or flow of steps) required to produce the request is simple and direct. 4) All problems are addressed as close in time and person as possible (as soon as possible by the people doing the work). 11

12 A3 problem solving Breakdown the Problem 12

13 Target & Root Cause See Countermeasures Through 13

14 Visual Management Helps everyone see problems quickly. Includes the use of redyellow green indicators or line markers to show position or quantity of an item. Allows one to view a process from a distance away and see right away that something is amiss. More examples of visual management 14

15 More examples of visual management Displaying our work, also part of visual management 15

16 A little about our experience in implementing Lean at the EVAMC It has required a clear message and similar use of the tools (training) for all staff involved. It is difficult to jump in with the tools described above and try to change the entire system at once. Lean lends itself to starting in a model area, with one clinic, one provider if necessary. Start small, use problems identified by staff, standardize after successful changes and monitor for sustainment. If you are interesting in learning more 16

17 Parting thoughts Insanity is doing the same thing over and over againandexpecting and a different result Albert Einstein 17