Let My Patients Flow! Patient Flow Summit 2015

Let My Patients Flow! Patient Flow Summit 2015 1

Agenda Background Approach Process Improvement Teams Simulation Model Results Q&A 2

Robert Wood Johnson University Hospital 965-bed Academic Medical Center located in New Brunswick, NJ Principal Teaching Hospital of Rutgers Robert Wood Johnson Medical School Flagship Hospital of multi-hospital system Centers of Excellence: Cardiovascular; Cancer; Women s & Neuroscience Center of Excellence; Level 1 Trauma Center Children s; Located mid-way between New York and Philadelphia, serving six county population of approximately 1.4 M Owner of Physician-Led Accountable Care Organization 3

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Situation at RWJUH Anticipated a significant increase in patient volume for the OR suite. As a major source of revenue for the hospital, the leadership team needed to make sure the OR suite was as efficient as possible while also minimizing costs. Due to the highly variable nature of work flow in the OR and the expenses involved in managing the projected increase of volume, as well as the introduction of case carts into the OR system, leadership requested that an objective data driven analysis be conducted in order to assure optimal performance of the OR suite. 5

Problem Statement Key Considerations/Potential Pitfalls when writing the Problem Statement Is the problem based on observation (fact) or assumption (guess)? Does the problem statement prejudge a root cause? Can data be collected by the team to verify and analyze the problem? Is the problem statement too narrowly or broadly defined? Is a solution included in the statement? Would customers be happy if they knew we were working on this? 6

RWJUH Problem Environmental factors driving a significant volume increase Introducing case carts to improve material flow and control OR utilization not acceptable Significant OR churn resulting in staff and patient stress Significant OR hold time due to PACU utilization issues 7

Problem Statement A well formed problem statement should answer specific questions and include specific information: What is the problem? When or under what conditions does this problem occur? Where does this problem occur? What is the extent of the problem? What is the impact of the problem? 8

9 Simulation

Goal Statement Identify Your Business Goal From Your Project Sponsor Identify Which of Those Goals Your Project Supports 10

Problem vs. Goal Statement The Purpose of the Problem Statement Is to Describe What Is Wrong The Goal Statement Defines The Team s Improvement Objective 11

The Goal Statement Defines the improvement the team is seeking to accomplish Starts with a verb (e.g., reduce, eliminate, control, increase) Tends to start broadly eventually should include measurable target and completion date Must not assign blame, presume cause, or prescribe solution! Example: Reduce the number of ER turnaround times for level 2 type patients beyond 1.5 hours by 50% from 500 to 250 by January 1 Goal = Project Improvement Objective 12

RWJUH Problem / Goal Problem - Old system processes and infrastructure made efficiency a daily challenge with a growing perioperative service line. Competing stakeholders with competing cultures and goals. Highly variable work flow in the OR, high cost inefficient set-up with the introduction of new systems and targeted expansion putting pressure on phasing and new work flow processes. Goal Improve overall efficiency of the OR Suite for both adult and pediatric services while also minimizing costs. Leadership requested that lean teams were deployed to ensure maximum return on investment of our new COE dedicated to pediatric surgery, new dedicated robotic suites, expanded PACU capacity and a new highly functioning case cart system. 13

Stakeholder Analysis A Stakeholder is any person or group of people who are: Responsible for the final decision Likely to be affected, positively or negatively, by the outcomes you want In a position to assist or block achievement of the outcomes Experts or special resources that could substantially affect the quality of your end product/service Can have influence over other stakeholders Identify those individuals with an interest in the process and what their positions on a particular Six Sigma Change might be. 14

Stakeholder Analysis SA MA N MS SS Stakeholder A X Stakeholder B X Stakeholder C X X Stakeholder D X X Stakeholder E X X Stakeholder F X X Stakeholder G X Stakeholder H X Stakeholder I X Stakeholder J X Stakeholder K X X 15

Sources of Resistance Source of Resistance Definition/Causes of Resistance Some Strategies for Overcoming Resistance Technical Habit and inertia Difficulty in learning new skills Lack of skills Provide education and training Provide coaches, green belts, tools / job aids Get people involved Political Threat to status quo See Initiative as a loss Power and authority imbalance or selfpreservation Empathize with the loss and show WIIFM Do a political map to understand influence patterns Provide safe exits and/or alternate job designs New measures and rewards -- customer driven Clarify roles and responsibilities -- accountabilities Cultural Control Issues Locked into old "mindset Afraid of letting go Do a cultural audit: what beliefs drive us? Articulate desired mindset and gaps Give resistor control over the initiative Give the resistor credit for the change 16

Approach Form clinical based process improvement teams Teams define the processes Teams gather data on the processes Teams to recommend process changes Teams to guide change implementation Need arose to verify process changes prior to implementation and define which changes worked well together in combination 17

18 Charter Development

ANALYZE Define Measure Analyze Improve Who are the customers and what are their priorities? How is the process performing and how is it measured? What are the most important causes of the defects? How do we remove the causes of the defects? Control How can we maintain the improvements? 19

An approved charter establishes the purpose and plan for the project. The key elements of the charter are: Problem Statement Project Timeline Goal Project Scope Milestones Develop Team Charter - Objectives Team Members, Stakeholders and Roles A charter: Clarifies what is expected of the team Keeps the team focused Keeps the team aligned with organizational priorities Transfers the project from the Project Sponsor to the project team 20

Process Improvement Teams Formed steering team of clinical personnel who manage the work in the area affected Formed process oriented clinical teams for each major process Team supported by training and central quality improvement resources Started team and asked team if others were required to ensure all stakeholders involved Teams set goals for process improvement 21

Team Member Roles How do you want the Project Sponsor to work with the team? Is the team s role to implement or recommend? When must the team go to the Project Sponsor for approval? What authority does the team have to act independently? What and how do you want to inform the Project Sponsor about the team s progress? What is the role of the team leader (Black Belt) and the team coach (Master Black Belt)? Are the right members on the team? Functionally? Hierarchically? 22

Process Improvement Teams Teams created a flowchart of the process under study Teams measured current performance Teams brainstormed changes and selected those rated most effective in reaching the goal Team reported to central steering committee Team and steering committee agreed on implementation What How Time Frame 23

ROLE RESPONSIBILITIES BEHAVIORS Executive Sponsor Project Owner Team Leader Improvement Team (Typically 3-8 consistent members) Facilitator 24 Team Member Roles Strategic guidance Active participation (Regular mtgs, event kick offs & report outs) Eliminate barriers Communication to admin staff & organization Oversight & results of project Team selection Hold team accountable Communication: Report status (up and down) Monitor progress & attend regular progress mtgs Sustain improvements after project completion Recognize achievements Content expert & team member, Provide data as needed, coordinate observations Recommend team members Manage team focus / progress / follow-up, help lead meetings Communication (Work with facilitator & project owner) With project owner, own process & sustain changes Includes subject matter experts Participate in observations and data collection as appropriate Attend project meetings & improvement events (contribute ideas & execute action items) Communication with coworkers Guide the team (scope project, assist with team selection, provide structure for project) Lead pre-work w/ project owner / team leader incl. analysis Lead improvement events (e.g. Kaizen, Work-Out) Communication with entire project team Hand off of project including metrics to project owner Highlight achievements Committed to success of project Trusts process Fosters feeling of unity Respect for team Empowers team Mentors team members Inspires team members Utilizes listening skills Maintains team focus Positive (Trust) Motivated and motivates others (Commitment) Listens (Learning) Open to suggestions (Respect) Respectful of each other Holds self and others accountable Actively engaged Promotes positive environment Influential among coworkers Confident Committed to success of project Understanding of team s needs Inspires team Respect for team Supportive of improvement efforts throughout the project Objective

Approach Some processes were highly interdependent making process change effectiveness difficult to predict Some changes needed their effectiveness demonstrated to engage all stakeholders Needed to test alternatives quickly and quantify their relative effectiveness Collaborated with ProModel Corp. to construct a simulation model of the entire OR suite This model used to analyze and verify changes prior to implementation 25

Lean in the OR PI teams tasked with applying lean principles to the OR Eliminate waste! Excessive movement Excessive waiting Pull instead of push Paradigm shift for OR 26

Project Scope What process will the team focus on? What are the boundaries of the process we are to improve? Start point? Stop point? What resources are available to the team? What is out of bounds for the team? What constraints must the team work under? What is the time commitment expected of team members? What will happen to our regular jobs while we are doing the project? 27

Tools to Define Project Scope In/Out of the Frame Visual tool based on the analogy of a picture frame It challenges the team to identify those aspects of the project (the type and extent of end results or deliverables, the people impacted, timing, product lines impacted, sites involved, etc.) which are : in the frame (meaning clearly within the scope of work) out of the frame half-in-half-out (meaning this is either up for debate, or some aspects are in the scope of work but only in a partial way) 28

Milestones A high-level project plan with dates Tied to phases of the project management process (define, measure, analyze, improve, and control/sustain) Aggressive (don t miss window of opportunity ) Realistic (don t force yourselves into band-aid solution) Documented, shared with all project team members and Champion, and updated regularly 29

Pediatric Suite Elevator Changes Scenario Patient Type Total Exits Average Total Cycle Time Differenc Class P Patients Above 120 Min Wait (/Year) Case Cart Utilization Time In Pre-Op As Is with Class P peds patient 58 293.70 22.00 57.00% 57.58 Seventh Floor Peds Proposed Opening Day Configuration peds patient 243 382.51 30.24% 3.00 72.00% 89.69 Seventh Floor Peds Proposed Opening Day Configuration With Elevator Policy peds patient 243 352.51 20.02% 3.00 61.00% 58.02 30

Histogram Represents data to evaluate: Central Tendency Spread Patterns in data ID sources of variation Summarizes large data sets into frequency intervals 31

Pediatric Room Use Effect Increased Time Spent in Pre-Op versus Current State Increase of 32 minutes 32

Cause and Effect Diagram Helps to ID possible causes related to a problem or a condition The team focuses on the content of the problem not the history Creates a snapshot of collective knowledge Builds support for resulting solutions 33

Fishbone Diagram Example * NOT RWJUH DATA 34

35 Nursing Staffing Requirements of Various Changes

Investigation into Three Possible Pediatric Configurations The majority of this extra time occurs due to patients spending extra time in pre-op and 1 st stage recovery due to contention for beds when these two stages are occurring in the same space. This is shown by the chart of patient time in stage shown below. 36

Run Charts * NOT RWJUH DATA Displays data in time order sequence 37

Throughput Affect of Various Changes As Is As Is with Class P Class P Bump Own Service Only Class P with Peds Recovery Total Exits Average Time In System (Min) Total Exits Average Time In System (Min) Total Exits Average Time In System (Min) Total Exits Average Time In System (Min) MOR patient 1502 457.759915 1502 475.017964 1502 475.017964 1502 466.596929 peds patient 117 279.553803 116 293.697336 116 293.6973362 116 297.772465 SDS patient 1348 386.533171 1348 372.123897 1348 372.1238976 1348 374.340928 38

Helps team focus on causes Based on the Pareto Principle 80/20 Rule Displays the relative importance of problems Shown by frequency or size in a descending bar graph Pareto Analysis 20% of the sources cause 80% of any problem 39

Need for Simulation Many processes interdependent Patient care processes too critical to experiment requiring proof of change effectiveness Case cart processes totally new to the OR suite All of these factors make it necessary to have a safe trial environment to test changes, investigate processes, and prove effectiveness BEFORE their introduction into the patient care process 40

Simulation Collaborated with a trusted consultant Model constructed on floorplan (Autocad) of OR suite and scaled to drawing One year+ of data used to construct time and arrival distributions Model driven by Excel frontend for quick update and scenario creation Multiple scenarios created to test the introduction of case carts by itself and multiple process change combinations 41

42 Simulation

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IMPROVE... determine and confirm the optimal solution... How can we fix the process? Generate alternatives Assess the risks Test the alternatives Select the best alternative Can we confirm the problem by turning it off and on? Process X s or Factors X 1 X 2 X 3 PROCESS Outputs Y 1 Y 2 X 4 Y 3 The after curve shows a more standardized practice with reduced variation a more predictable model Before Improvements After Improvements 44

Model Benefits Explain what the model provided Explain how it let us know the unknowable Explain how it let us experiment with the processes to define those changes that are effective 45

Hypothesis Testing Helps us determine whether observed differences are: statistically significant or due to chance (random variation) 46

Identify Improvement Strategy Utilize different methods to identify solutions: Brainstorming Creative Thinking Best Practice Should Be Process Map Run A Pilot Study Full Implementation Design of Experiments 47

IMPROVE Define Measure Analyze Improve Who are the customers and what are their priorities? How is the process performing and how is it measured? What are the most important causes of the defects? How do we remove the causes of the defects? Control How can we maintain the improvements? 48

Objective and Solution Objective To increase throughput while optimizing staff and plan for the necessary actions required to further accommodate a rise in patient volume. Solution The leadership team for the OR needed to understand; The overall constraints on throughput in the OR Suite The cycle time for patients flowing through the system Where patient flow problems existed, managers needed to determine if they were being caused by a lack of space or insufficient staff. The team was tasked with determining whether the OR suite could accommodate a 30% increase in patient volume without changing the OR s physical environment or adding additional space. Additionally, case carts were being introduced into the system and the team needed to make sure that the carts were properly resourced to keep up with patient flow through the OR. To deal with the effects of high variability in the OR it was decided that a simulation solution was the only way to reliably predict the impact of changes to the work and/or workflow. 49

Objective Objective and Solution To increase throughput while optimizing staff and plan for the necessary actions required to further accommodate a rise in patient volume. Solution Particular attention was paid to the two patient recovery (PACU) areas in the OR System, the Main PACU and Cardiac PACU. Expansion areas were also added to the model to help understand if they could potentially add capacity and improve patient flow through the OR, or if they were sources of further constraint to the system. The model was also designed to be fully costed, incorporating financial elements and reporting on how much profit is generated with each patient flow scenario. The output data of the model allowed the leadership team at RWJUH to design an optimal workflow process that consisted of adjusting their staffing levels to ensure maximum throughput with minimum patient delay and at minimum cost. 50

Objective Investigation into Three Possible Pediatric Configurations This study was to investigate the three different configurations under consideration for the Pediatrics department operating suite on the seventh floor of Robert Wood Johnson University Hospital. 51

Investigation into Three Possible Pediatric Configurations The analysis was performed using the RWJUH OR Suite flexible simulation model previously defined and validated. Data covering OR cases from November 1, 2012 to January 30, 2013 was used for all runs during this study. Any patient below eighteen years of age was considered pediatric for use in this study. This study also used the updated case cart washer configuration where the washer capacity is: Two large carts Four small carts One large and two small carts 52

Prioritize Solutions Some solutions are easier to implement than others Some solutions are more expensive than others Some solutions have a bigger impact than others It is impossible to implement everything at once Tools: Pay-off Matrix (Benefit VS Effort) N/3 Voting (30 items/each person votes for 10 items) Must/Want Matrix (assign weights/quantify) 53

Prioritize Solutions A Pay-Off Matrix looks at the relationship of benefit and effort to reduce the number of solutions to address High Pursue Rescope / Reconsider Benefit Low Eliminate Eliminate Low High Effort 54

Pay-off Matrix Example Example: Improving Admission Cycle Time Redo admission into simpler form Develop new software system for registration/admission desk High Streamline packet completion step Benefit Low Call patients before completing admission Develop new training course for all employees Low Effort High 55

Pilot Pilots are important when: The scope of change is large Change could cause far-reaching unintended consequences Implementing the change will be a costly process Change would be difficult to reverse Test part or all of a proposed solution on a small scale It helps to better understand the effects of a change We learn how to make full scale implementation more effective 56

Investigation into Three Possible Pediatric Configurations Results - The key metrics of patient cycle time and PACU closing times are shown in the table below. Monthly Through put Patient Cycle Time Normal PACU Close Time Normal Late Close Time Scenario Name Current State MOR patient 732 479 11:30 PM Midnight Current State SDS patient 436 376 6:30 Current State peds patient 62 349 11:30 AM 1:00 PM All Recovery Seventh Floor MOR patient 736 481 10:30 PM 11:30 PM All Recovery Seventh Floor SDS patient 437 378 6:30 PM All Recovery Seventh Floor peds patient 249 341 3:00 PM 4:00 PM 1st Stage Recovery Seventh Floor MOR patient 734 519 11:45 PM 1:00 AM 1st Stage Recovery Seventh Floor SDS patient 435 385 6:30 PM 1st Stage Recovery Seventh Floor peds patient 248 368 4:30 PM 5:30 PM 1st Stage Recovery Seventh Floor With Revised Elevator Assignments MOR patient 734 515 11:30 PM 12:30 AM 1st Stage Recovery Seventh Floor With Revised Elevator Assignments SDS patient 435 385 6:30 PM 1st Stage Recovery Seventh Floor With Revised Elevator Assignments peds patient 248 359 3:45 PM 4:40 PM 57

Investigation into Three Possible Pediatric Configurations The most effective performing scenario is that with all Pediatric recovery occurring on the seventh floor. This scenario avoids contention for pediatric PACU beds between pre-operative and postoperative patients. Splitting the pediatric recovery between the first and seventh floor so that stage two occurs in the main OR floor increases the patient cycle time and the PACU closing times due to the transport for pediatric inpatients and the effect of reducing the ability to flex PACU to beds in this space. Reassigning the elevator transports to alleviate the elevator congestion reduces some amount of the impact but does not eliminate this reduction in efficiency versus having all pediatric recovery in one space. 58

Investigation into Three Possible Pediatric Configurations These configurations also affect the number and utilization of the case carts. This result is shown below. Scenario Large Carts Small Carts Cart Utilization Current State 36 22 69% All Recovery Seventh Floor 36 24 89% 1st Stage Recovery Seventh Floor 42 28 88% 1st Stage Recovery Seventh Floor With Revised Elevator Assignments 40 26 84% 59

Control / Impact Matrix High Medium Low Implementation of standardized order sets Turnaround time of echo Documentation of ACE/ARB In Control Selection of correct CareMap Consultations Initiation of D/C planning Documentation of echo Discharge disposition Out of Control Compliance of MD to utilize standardized order set Comorbidities Compliance of use of CareMap Necessity of needing echo during hospitalization Patient compliance to follow-up care Patient resistance to D/C Support system 60

Investigation into Three Possible Pediatric Configurations The split recovery configurations also take a higher level of labor due to the extra inefficiency of the transport. This is shown in the table below. Scenario Name Work Time (HR/Month) Difference (Hr/Month) Difference (%) All Recovery Seventh Floor ORRN 1769.711683 All Recovery Seventh Floor PACURN 1750.139175 All Recovery Seventh Floor PreOpHoldingRN 24.75219583 All Recovery Seventh Floor Stage1RN 210.2421708 All Recovery Seventh Floor Stage2RN 284.1366333 All Recovery Seventh Floor PreOpRn 168.4124917 All Recovery Seventh Floor pedsor rn 503.7172042 All Recovery Seventh Floor pedspacu rn 447.3996583 Total Direct Work Hours 5158.511213 1st Stage Recovery Seventh Floor ORRN 1933.453766 163.7420825 9.25% 1st Stage Recovery Seventh Floor PACURN 1955.386574 205.2473992 11.73% 1st Stage Recovery Seventh Floor PreOpHoldingRN 34.21132917 9.459133333 38.22% 1st Stage Recovery Seventh Floor Stage1RN 227.6355263 17.39335542 8.27% 1st Stage Recovery Seventh Floor Stage2RN 308.7912758 24.6546425 8.68% 1st Stage Recovery Seventh Floor PreOpRn 184.9787271 16.56623542 9.84% 1st Stage Recovery Seventh Floor pedsor rn 546.7629521 43.04574792 8.55% 1st Stage Recovery Seventh Floor pedspacu rn 477.2634808 29.8638225 6.67% Total Direct Work Hours 5668.483631 509.9724188 9.89% 1st Stage Recovery Seventh Floor With Revised Elevator Assignments ORRN 1865.26964 95.55795661 5.40% 1st Stage Recovery Seventh Floor With Revised 61 Elevator Assignments PACURN 1886.428978 136.2898028 7.79% 1st Stage Recovery Seventh Floor With

Investigation into Three Possible Pediatric Configurations Conclusions The configuration with pediatric pre-op in the main OR area and all pediatric recovery occurring on the seventh floor is the most efficient since it minimizes the elevator use and avoids contention for bed space in the seventh floor complex between incoming preoperative patients and outgoing post-operative patients. This option demonstrates superior metrics in the following areas versus the other two options: Lower overall patient cycle time for all patients including Pediatric patients Lower number of Class P patients that exceed the 120 minute threshold Lower patient hold times due to higher efficiency of Phase I and II recovery in the same physical space Lower number of case carts required to support the ORs in total The revision to the case cart process showed a marked decrease in the number of case carts required to support the ORs using the most recent volumes. This analysis shows that approximately 40 large carts and 26 small carts are required to ensure no delays due to unavailability of case carts. The case carts and case cart washer remain an area of concern. All possible measures need to be taken to ensure the reliability and uptime of the cart washer. 62

63 Simulation

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Simulation Model found that the cart washer was an important point of failure Model found the best set of PACU changes to reduce OR hold time Model verified multiple staffing changes Model found the optimum set of changes to OR assignments Model verified smoothed OR schedule to improve patient flow through the OR suite and into inpatient units Model verified that current and next year projected volumes could be handled by the new configuration Model determined the volume increase that could be tolerated without further changes Model found the elevators to Seventh Floor to be problematic without usage policies in place 65

66 Simulation Inputs

Pediatric Suite OR Close Time Five Rooms Close at 1:30 PM Four Rooms Close at 3:00 PM Three Rooms Close at 5:00 PM 67

Investigation into Three Possible Pediatric Configurations 1. Pediatric patients would check into Pre-op on the first floor complex, then are transported Main OR area on the seventh floor using the back elevators, receive their procedure in seventh floor OR suite, recover in the seventh floor PACU for Phase I & Phase II and either depart home or move to an inpatient room from the seventh floor PACU. 2. Pediatric patients would check into the Pre-Op Area on the seventh floor complex using the back elevators, receive their procedure in seventh floor OR suite, then from the OR Suite patients will move to the Phase I PACU on the seventh floor, then be transported downstairs via the back elevators to Phase II recovery on the first floor. Finally, patients will either depart from Phase II PACU to inpatient unit or home. 3. Pediatric patients would check into the Pre-Op area on the seventh floor complex using the main elevators, receive their procedure in seventh floor OR suite, then from the OR Suite patients will move to the Phase I PACU on the seventh floor, then be transported downstairs via the back elevators to Phase II recovery on the first floor. Finally, patients will either depart from Phase II PACU to inpatient unit or home. 68

Results of project Learned which patient types and surgery types caused the most disruption in flow and the length of OR hold times by patient type. In particular, the model indicated that the PACU areas were the major limiting factor and constraint to OR flow. The OR suite simulation output significantly affected the decision making process and was used to determine which actions were needed to take regarding the PACU areas. 69

Investigation into Three Possible Pediatric Configurations Results The most effective performing scenario is that with all Pediatric recovery occurring on the seventh floor. This scenario avoids contention for pediatric PACU beds between pre-operative and postoperative patients. Splitting the pediatric recovery between the first and seventh floor so that stage two occurs in the main OR floor increases the patient cycle time and the PACU closing times due to the transport for pediatric inpatients and the effect of reducing the ability to flex PACU to beds in this space. Reassigning the elevator transports to alleviate the elevator congestion reduces some amount of the impact but does not eliminate this reduction in efficiency versus having all pediatric recovery in one space. 70

71 Appendix

Problem Statement Examples Poor Example: Under skilled staff takes too long to prepare and distribute Radiology reports. Updated training is needed. Improved Example: 60% of all Radiology reports over the past year have been delivered beyond 24 hours after exam at Speedy Medical Center. The result has been delayed diagnosis by our Radiologists and delayed treatment for our patients. Poor Example: ER is understaffed, causing patients to wait too long for treatment. This is making ER turnaround too long. Improved Example: ER patients are spending about 3 hours in ER before either being released or admitted. Time in ER is especially long during the hours between 10 AM and 1 PM. The long time issue is causing many patients & physicians to complain. 72