Applying Lean Principles to a Continuing Care Patient Discharge Process Presenter: Valerie Maier-Speredelozzi Assistant Professor, Industrial and Manufacturing Engineering Graduate Students: Amy Thompson Paul Hossfield Stephen Abby
Topics Literature Review and Issues in Lean Healthcare Hospital Level Value Stream Continuing Care Current and Future Value Stream Map Post-Discharge Order Current and Future Value Stream Map Applied Lean Techniques Standardized Work Visual Display and Controls Summary Error-Proofing 5S
Project Scope New Graduate Level Course in Lean Manufacturing Systems Team Project Apply lean principles learned in class to a field other than manufacturing Healthcare Restaurant Retail Distribution Small Business Create current and future state maps Select at least 2 other lean techniques
Literature Review Womack and Jones, Lean Thinking,, 1996 Proposed how lean techniques could be applied to services Hospital should focus on effectiveness, rather than efficiency and utilization of resources [4] Hospital Board members with experience in manufacturing emphasize lean implementation [6]
Literature Review Lean can be applied to Ordering systems Lead time and throughput Admissions and Discharge Bed Availability Waiting rooms Linen distribution Metrics for hospital performance # infections per 1000 patients Direct care % by caregivers Overpayment by insurers # of complications # of forms Length of stay Value added time Throughput time [2, 3, 5, 6, 7]
Literature Review Lean apprehension [1] [5] Some healthcare practitioners associate lean with lean staffing Employees fear job cuts, layoffs, staff reduction As in manufacturing, a major goal of lean implementation is actually job security Touring lean manufacturing facilities can help
Int l. J. of Prod. Economics Article by Lluis Arbos,, 2002 Differential Characteristics of Products and Services Transfer of ownership Tangible vs. intangible nature of satisfaction Product can be stored, services generally can not High variability in service tasks, methods, length Productive process can coincide with enjoyment Customer can take part in delivery (self-service) service) In-situ services performed where client is located Degree of contact with customer Very low flexibility due to highly specialized employees
Hospital-Level Value Stream Map Flow Groupings and Layout by Process Unique patient treatments grouped by similarities Mostly One-Piece, Unbalanced Flow Non-Pull, Non-JIT, No FIFO Patient does not determine flow Can not pull from end of value stream Can not inventory wellness
Hospital-Level Value Stream Map Quality Feedback Built-In Quality ( (Jidoka)) in most individual pieces of healthcare equipment, instruments and tools Recursive Customer Interviews Recursive Physical Condition Checks Recursive Checks of Medical Records Customer Satisfaction Survey National Quality Auditing Agencies & Regulators
Hospital-Level Value Stream Map Measurements Length of Stay (LOS) Customer Satisfaction Issues in Hospital Value Stream Non-Deterministic Arrivals, Processing Times, and Outcomes Recursion and Parallelism on Critical Path Highly Specialized Employees
Supplier = Customer Hospital Support Services Facilities & BMET Services Hospital Support Services Shift = 8 hours Lunch = 1 hour (2) Breaks, 15 minutes each Uptime = 6.5/8.0=81.25% Supplier: Public Elective Surgical Patient Central Supply & Laundry Services Quality Management Diagnostic Test & Services Labs, EEG/EMG, Cardiac Testing, Radiology, PFT Information Services Case Management Dietary Nursing Support Social Work PT/OT Respiratory Services Total Throughput Time: 1935 minutes = 32.25 hours Value Added Time: 1800 minutes = 30 hours Non-Value Added Time: 135 minutes = 2.25 hours Target Waiting Rooms and Find Non-Value Added Time Within PACU, NCU, and the Discharge Process Nursing Estimated Arrival Rate: 48 per day Waiting Area Estimated Capacity: 10 Estimated Average Wait: 45 min. Waiting Area Estimated Capacity: 10 Estimated Average Wait: 30 minutes House Keeping Services Physicians Customer: Public Treated Patient I Pre- Admission Testing I Same Day Admission I Holding Unit Operating Room Recovery Room Nursing Care Unit Discharge: Case Management Waiting Area Estimated Capacity: 15 Estimated Average Wait: 60 min. 5 5 2 2 2 4 2 Estimated Capacity: 5 C/T: 75 min. Uptime:81.25% Estimated Capacity: 5 C/T: 105 min. Uptime:81.25% Estimated Capacity: 4 C/T: 90 min. Uptime:81.25% Estimated Capacity: 2 C/T: 180 min. Uptime:81.25% Estimated Capacity: 6 C/T: 240 min. Uptime:81.25% Estimated Capacity: 24 C/T: 1020 min. Uptime:81.25% Estimated Capacity: 2 C/T: 90 min. Uptime:81.25% 60 min. 45 min. 30 min. 75 min. 105 min. 1620 min.
Continuing Care Arrange care for post-hospital recovery Educate family and patient on conditions, treatments, and care during and after hospital stay Assure patients are prepared to leave when discharged
Supplier = Customer Continuing Care (CC) Department Value Stream Map CARE UNIT DIVISION BY CCC WING A 18 EMERGENCY (ER) 15 HOLDING (AR) 4 NURSERY 16 PEDIATRICS 4 WING B (26) ICU 8 WING C (18) SAME DAY SURGERY (FLEX) CC Non-Value Stream Activities (Support) EXTERNAL CUSTOMERS Family Insurance Agency Continuing Care Services (Nursing Homes, Skilled Home Care Agencies, Community Resources) HOSPITAL Supplies Shift = 8 hours Lunch = 1 hour 2 Breaks, 15 minutes each Total Uptime on 24 hour Day = 27% AVERAGE LOS = 3.7 days Value Added Time: 133 minutes Non-Value Added Time: 165 minutes Wait Time = Rest/ Treatment Time =86.9 hrs. Assume Time Occurring Between CC Steps is Value-Added to Patient as Rest and Required Testing and Procedures Ave. Throughput Time = 3.71 days Supplier: Local Community A Continuing Care (CC) Patient AND MEDICAL CHART Admitting Performance Improvement Communications Risk Management Administration House Keeping / Infection Control Utilization Review Health Information Services MEDITECH Laboratory Patient Financial Services Medical Standards and Review Dietary KEY SYMBOL PATIENT MEDICAL RECORD CC FILE COMMUNICATION (ALL COLORS) REPEAT STEP Customer: Local Community Treated Patient Social Work Rehabilitation Average Arrival Rate: 13 per day Physical, Occupational, and Speech Therapy Cardio-Pulmonary Services 24 Hour Mark Physicians and Medical Staff Nursing Staff Identify Patient for CC CC Assesses CC Patient Status & Needs Assign a Level of Care, ID Screen, PASSR Create & Review CC Patient Discharge Plan Implement Discharge Plan Reassess Discharge Plan Periodically Perform Discharge Once Order Given 3 3 3 3 3 3 3 7 Patients Average Wait: 12 hours Capacity: 109 Ave. C/T: 1 min. Batch Process occurs once per day, Ave. Batch Size = 13 Uptime: 3.1% PR: CC Staff PROCEDURE SECTION I and II Forms: Demographics/ Face Sheet, Start Checklist 7 Patients Capacity: 109 Ave. C/T: 25 min. Min: 5 min. Max: 4 hrs. 1 Patients Capacity: 109 Ave. C/T: 12 min. C/T: 5 min. Lev. of Care C/T: 5 min. ID Screen C/T: 3 hours for PASSR Uptime: 27 % 1 Patients Capacity: 109 Ave. C/T: 15 min. 1 Patients Capacity: 109 Ave. C/T: 35 min. Uptime: 27% Uptime: 27 % Uptime: 27 % Uptime: 27 % PR: CC Staff PR: CC Staff PR: CC Staff PR: CC Staff PR: CC Staff Average Average Average Average Average Average Wait: PROCEDURE Wait: PROCEDURE Wait: PROCEDURE Wait: PROCEDURE SECTION VI Wait: PROCEDURE Wait: 4 hours SECTION III 1 min. SECTION IV and UR 1 min. SECTION V 1 min. Forms: Multi-Disciplinary 24 hrs SECTION VII 20 hrs. Forms: Multi- POLICY SECTION I Forms: Multi- Assessment, Continuity of (x 2) Forms: Any Necessary Disciplinary Forms: Level of Care Disciplinary Assessment Care Referral, Nursing Assessment, Mini- Assessment, ID Screen Facility Referral, Maternity Mental and PASSR Early Discharge Activities: Psychiatric Transfers, Abuse Services 1minute 25 minutes 12 minutes 15 minutes 35 minutes 15 minutes (x 2) 180 minutes 7 Patients Estimated Capacity: 109 Ave. C/T: 15 min. 7 Patients Estimated Capacity: 109 Ave. C/T: 3 hours Value Added: 15 min. Non-Value Added: 165 min. Min: When Family Max: When Transfer Uptime: 27 % PR: CC Staff PROCEDURE SECTION X Forms: Complete CC Checklist, Complete all CC Documentation and Forms
CC Department Level Activities A* NVA VA Continuing Care Wait # 1 720 Identify Patient for CC 1 Current Value Wait # 2 240 CC Assesses CC Patient Status & Needs 25 Stream Map Summary Table Wait # 3 1 Assign a Level of Care 12 Wait # 4 1 Create & Review Discharge Plan 15 Wait # 5 1 Implement Discharge Plan 35 *A is Treatment, Rest, and Wait Time ** NVA is Categorized Non-Value Added Activity ***VA is Value Added Wait # 6 2880 Reassess Discharge Plan Periodically Wait # 7 1200 Perform Discharge Once Order Given 165 15 Minutes 5043 165 133 Minutes 5208 133 30
Continuing Care Future Value Stream Map Reduce time from when the discharge order is given by the physician to when the patient is actually discharged Free-up bed sooner Less work for CC Coordinators to do the day of discharge Improve service quality and discharge speed to improve customer satisfaction
Customer Satisfaction Survey: Discharge Process Extent to which you felt ready to be discharged. Speed of discharge process after you were told you could go home. Instructions given about how to care for yourself at home. Help with arranging home care services if needed.
PHYSICIAN GIVES DISCHARGE ORDER (IN MEDICAL RECORD) FLAG THE PATIENT FILE IF THE PATIENT IS A CC PATIENT (COLORED FLAG) MEDICAL RECORD (using Yellow Mark for Visual Methods) PHYSICIAN DISCHARGES PATIENT FORM 851 NO IS PATIENT A CONTINUING CARE PATIENT? YES FORM 851 NON-CC PATIENT DISCHARGE FORM PULL CC PATIENT DOCUMENTS 1 CC PATIENT FILE ON EACH FLOOR PERFORM CHECKS: SERVICES DOCUMENTS INSURANCE CREATE A DISCHARGE CHECKSHEET FOR SERVICES DOCUMENTS AND COMPLETE ANY REMAINING EXTERNAL SERVICE ARRANGEMENTS, DOCUMENTS OR INSURANCE CHECKS NO EVERYTHING COMPLETE? CC PATIENT FILE YES Current Post- Discharge Order Process ALERT PATIENT OF DISCHARGE COORDINATE TRANSPORTATION CC PATIENT FILE
Current Post- Discharge Order Process (cont.) ALERT FAMILY ARRANGE SUPPLIES TO BE SENT WITH PATIENT MEDICAL RECORD DOES A FORM OR MATERIAL REQ NEED TO BE FILLED OUT? NO CC PATIENT FILE CC PATIENT FILE NURSING HOME NURSING HOME OR HOME CARE? HOME CARE NOTIFY NURSING TO COMPLETE PAPERWORK COPY RECORDS NEEDED FOR TRANSMISSION & PLACE IN ENVELOPE IN MEDICAL RECORD DELIVER ENVELOPE WITH RECORDS TO AMBULANCE DRIVER WHAT HAPPENS TO CC PATIENT FILE? HOW IS IT RETURNED FROM NURSE? NURSE COMPLETES PAPERWORK AND COPIES RECORDS NEEDED FOR TRANSMISSION NURSE FAXES COPY OF DOCUMENTS TO AGENCY MEDICAL RECORD CC PATIENT FILE COPY OF RECORDS FROM CC PATIENT FILE
Current Post- Discharge Order Process (cont.) DOES A COPY OF DOCUMENTS GO TO MEDICAL STANDARDS AND REVIEW? YES SEND COPY OF DOCUMENTS TO REVIEW BOARD COPY OF RECORDS FROM CC PATIENT FILE NO ADMINISTRATOR INPUTS PATIENT INFO INTO CC DATABASE CC PATIENT FILE CC PATIENT DOCUMENTS FILED IN CC DEPARTMENT IN HOME CARE FILE OR NURSING HOME FILE ALPHABETICALLY CC PATIENT FILE End
Improvements to Post-Discharge Order Process Transportation & Communication Materials Quality Assurance: Services & Equipment Final Documentation Processing
Transportation & Communication Agreements with Transportation Suppliers Currently must wait until discharge order is given to schedule/arrange for patient transportation Currently a delayed response for pickup Negotiate quicker response to request for transport Intent to Discharge notice the day before Push lean/jit concepts back to transportation suppliers Family Transport: Incorporate Beeper Service
Materials Move on-line activities to off-line: stage materials to be sent home with a patient the day before expected discharge 5S supply closets on each unit Remove unneeded/outdated materials Organize and Sustain Make space for staging soon-to to-be-discharged patient s discharge materials Use Visual Displays and Controls Quality feedback: Check items pulled for patient against Multi-Disciplinary Assessment Form
Quality Assurance Currently No Assurance Methods to verify All services are arranged All equipment and materials are arranged Transportation is arranged Patient has received necessary information for continuing care Quality Assurance would reduce delays, improve customer satisfaction and care
Documentation Eliminate Waste Standardized Work Error-Proofing 5S Visual Displays and Controls Streamlined a Data Entry Process
Remove Non-Value Added Activities CC Department Level Activities Wait # 1 720 Identify Patient for CC 1 Post Discharge Order Current A* NVA VA Activities NVA VA Curent Total Removed New On- Line Off- Line Pull CC Patient File and Perform Checks 9 1 10 9 1 - Complete Remaining Tasks 15 0 15 15 0 - Wait # 2 240 Alert Patient 3 2 5 3 2 - CC Assesses CC Patient Status & Needs 25 Alert Transportation 11 1 12 11 1 - Wait # 3 1 Wait for Transport 90 0 90 85 5 - Assign a Level of Care 12 Alert Family 0 1 1 0 1 - Wait # 4 1 Arrange Supplies 0 10 10 10 0 10 Create & Review Discharge Plan 15 Process Documentation 0 20 20 20 0 20 Wait # 5 1 Implement Discharge Plan 35 Patient Leaves with Docs 0 5 5 0 5 - AA Records Stats and Files 10 2 12 10 0 2 Wait # 6 2880 Minutes 138 42 180 15 32 Reassess Discharge Plan Periodically 30 Hours 2.30 0.70 3.00 0.25 0.53 Wait # 7 1200 Days 0.10 0.03 0.13 0.01 0.02 Perform Discharge Once 165 15 Order Given *A is Treatment, Rest, and Wait Time Minutes 5043 165 133 ** NVA is Categorized Non-Value Added Activity Minutes 5208 133 ***VA is Value Added
Future Value Stream Map CARE UNIT DIVISION BY CCC WING A 18 EMERGENCY (ER) 15 HOLDING (AR) 4 NURSERY 16 PEDIATRICS 4 WING B (26) ICU 8 WOMENS WING (18) SAME DAY SURGERY (FLEX) Supplier: Local Community A Continuing Care (CC) Discharged Patient AND MEDICAL CHART W ith a Discharge Order Supplier = Customer Post-Discharge Order Future Value Stream M ap EXTERNAL CUSTOMERS Transportation Services Fam ily Insu rance Agency Continuing Care Services (Nursing Homes, Skilled Home Care Agencies, Com munity Resources) HOSPITAL Physicians and MedicalStaff Shift = 8 hours Lunch = 30 minutes 1 Break, 20 minutes Total Uptime on 24 hour Day = 27% Ave. Throughput Time = 15 minutes KEY SY M B O L PATIENT MEDICAL RECORD CC FILE COMMUNICATION (ALL COLORS) REPEAT STEP PHYSICAL ACTIVITY ( ALL COL O R S) Customer: Local Community Treated Patient Average Arrival Rate: 13 per day (1) Pull CC F ile and Check for C om pletion (2)Alert Patient (3) Alert Transportation (5) A lert F am ily (6) Patient Leaves with Documents 3 3 3 3 3 Capacity: 109 Ave. C/T: 1 min. Value Added: 1 min. Uptime: 27% PR: CC Staff PROCEDURE SECTION X.b.i.-ii. Forms: Capacity: 109 Ave. C/T: 2 min. Value Added: 2 min. Uptime: 27% PR: CC Staff PROCEDURE SECTION X.b.iv. Forms: Capacity: 109 Ave. C/T: 1 min. Value Added: 1 min. Uptime: 27 % PR: CC Staff PROCEDURE SECTION X.b.v. Forms: 7 Patients (4) A verag e Wait for Transport 5 min. Capacity: 109 Ave. C/T: 1 min. Value Added: 1 min. Uptime: 27 % PR: CC Staff PROCEDURE SECTION X.b.vi. Forms: Estimated Capacity: 109 Ave. C/T: 5 min. Value Added: 5 min. Uptime: 27 % PR: CC Staff PROCEDURE SECTION X.b.viii.-x. Forms: Any Necessary Total: 15 m in. Wait Time: 5 min (Target to reduce w ait to 0 in future) 1 minute 2 minutes 1 minute 1 minute 5 minutes
Standardized Work: Alignment of Procedures 45 total existing Work Procedures for CC 7 for CC procedures and policies Remaining are detailed guidelines for specific tasks Align 7 Work Procedures to VSM Remove redundancies, including conflicting segments Organize and order methods and procedures to VSM Added a detailed procedure for post-discharge order
Standardized Work: Results Keep Separate Work Procedures (A-F) Maintains original philosophies for categorization and separation of work Consolidates Seven Procedures into One Master Procedure Orders and organizes work by Value Stream Final procedure reduces 23 pages to 14 pages Further CC consolidation possible in the future
Existing Lean Techniques Visual Displays and Controls Status Boards Patient Board Discharge Board Binder Carousel of Medical Records Status Indicator Dial Discharge Flag
Existing Lean Techniques Error-Proofing CC Coordinator Checks Continuity of Care Referral Continuous Improvements (CI) Performance Improvement Department CI teams meet twice per year
Continuing Care Checklist Existing Wastes Defects Motion Over-Processing Waiting Inefficiency: Waste of Capacity Lean Methods Applied to Eliminate Wastes Error-Proofing Standardized Work 5S Visual Control
The PATIENT INFORMATION Name: Physician: Admit Date: Discharge Date: UNIT Wing A Pediatrics Emergency Wing B Holding Same Day Surgery ICU Wing C Nursery Other: Continuing Care Checklist FORMS Complete N/A Demographic Face Sheet Mini Mental Multidisciplinary Form Level of Care I.D. Screen PASSR Continuity of Care (Interagency) Nursing Facility Referral SRS Waiver Maternity Early Discharge Alcohol / Drug Facilities Psychiatric Transfer DISPOSITION Nursing Home Transfer Home w/ Skilled Nursing Home w/ Family Expired Other: INSURANCE Blue Chip Blue Cross / Blue Shield Federal Medicare Medical Assistance Neighborhood Health Plan PHS Private Insurance Self Pay United Health Care / Metra Health Other: SPECIAL SERVICES Discussed Options Distributed Info Arranged Service Service Declined Durable Medical Equipment Hearing & Speech Services Durable Power of Attorney Heating Assistance Meals on Wheels Home and Community Care Medical Assistance Home Equity Mortgage Mental Health Hospice Care Nursing Homes Housing Substance Abuse Identification Cards Adoption Independent Living Adult Day Services Legal Services Advocacy Medicare Agencies for the Blind Medical Savings Alzheimer's Disease Nutrition Arthritis Foundation Ombudsman Case Management Prescription Programs Community Action Protective Services Community Diversity Publications Community Elder Specialists Respite for Children Dental Services Respite Care Early Response Senior Centers Education Opportunities Sr. Citizen Advocates Eldercare Locator Sr. Workforce Development Emergency Response Social Security Family Caregiver Supplemental Security Friendly Visiting Tax Information Geriatric Assessments Transportation Health Centers Volunteers Health Insurance Counseling Other: Discussed Options Distributed Info Arranged Service Service Declined
Continuing Care Patient File Book Existing Waste Over-Processing Waiting in Main Value Stream Motion Defects Lean Methods Applied to Eliminate Wastes Error-Proofing Standardized Work 5S Visual Control
Continuing Care Statistics Performed by Administrative Assistant Existing Method: Manual Search for Data Manual data entry Manual calculations for totals Separate MS Word document Print and distribute
Continuing Care Statistics Proposed Method: Semi-automated Use Checklist to avoid searching for data Ease of data entry Checkboxes Drop-downs Automatic Generation, Printing, and Emailing
Sample Form Entries
Sample Report
Accomplishments Future State Map Projected time savings Standardized Work Instructions Reduced from 23 to 14 pages Eliminated redundancies Improved training process for new hires or floats Checklist Created checklist that previously did not exist Provided quality control mechanism for standard care
Accomplishments Patient File Books Provided hospital with a sample binder that all units could adopt Organized all required forms into one location Separated forms for each room and patient into pocket folders to ensure quality Data Reporting Method Programmed MS Access Database for Daily Entry of Discharges Automated Monthly Report Generation Projected Time Savings and Procedure Simplification
Accomplishments Successfully Introduced Lean Healthcare Benefits for training, reduced learning curves, patient and employee satisfaction, improved quality, and decreased length of stay Student Team Worked with Hospital Staff Provided perspective of outsiders Translated manufacturing principles to healthcare Low cost consultants Students see applications of engineering to service industries and alternate career options
Conclusions Follow-up Binders are in use with the checklist as the first component in each patient s section Database programming was further tailored by the hospital s in-house programmers and is now in use Improved procedures are now part of the hospital s accreditation process Acknowledgements Thank you to the nurses and administrators at the New England hospital who shared their time and opened their facility for this student project
References [1] Leah L Curtin. 1997. Lean, mean and stupid! Nursing Management.. 28 (5) (May): 7-9. 7 [2] Laubrass Inc. Timely Care. www.laubrass.com/uploads/documents/corpinfo_article/ [3] Patricia Panchak.. 2003. Lean Health Care: It Works. Industry Week 252 (11): 34-40. 40. [4] James P. Womack and Daniel T. Jones. 1996. Lean Thinking.. New York: Simon & Schuster. [5] Lucette Lagnado.. 1997. Nearby Clinic Thrives on Streamlined Approach. Wall Street Journal February 12, 1997: B1.
References [6] Bernard Wysocki Jr.. 2004. Industrial Strength: To Fix Health Care, Hospitals Take Tips From Factory Floor; Adopting Toyota Techniques Can Cut Costs, Wait Times; Ferreting Out an Infection; What Paul O Neill s Been Up To. The Wall Street Journal.. April 9, 2004: A1. [7] David E. Bowen and William E. Youngdahl.. 1998. Lean service: In Defense of a Production-Line Approach. Int l. Journal of Service Industry Management 9 (3): 207. [8] Lluis Cuatrecasas Arbos.. 2002. Design of a Rapid Response and High Efficiency Service by Lean Production Principles: Methodology and Evaluation of Variability of Performance. Int l Journal of Production Economics 80 (2): 169-183. 183. [9] Charles B. Stabell and Oystein D. Fjeldstad.. 1998. Configuring Value for Competitive Advantage: On Chains, Shops, and Networks. Strategic Management Journal 19 (5) (May): 413-437. 437.