WHITE PAPER Transforming the Healthcare Organization through Process Improvement
The movement towards value-based purchasing models has made the concept of process improvement and its methodologies an important component of healthcare s future. Whether Lean, Six Sigma, Total Quality Management or Re-engineering, a scientific, methodological approach to becoming a performance-driven organization will be vital to achieving success in the new model. In the following pages, using some lessons gleaned from Virginia Mason Medical Center and the Virginia Mason Institute, we will examine: Some basic concepts for process improvement. What your organization can do to set up the infrastructure for process improvement. How to identify opportunities to accelerate improvement. Some examples that can better help you understand the concepts and implementation. Some questions to consider: How receptive is your organization generally to change and innovation Is your organization quick to adapt to new ideas and/or processes What problem(s) are you trying to solve Is it a design issue, process, variation or specific business need Is it a narrow or cross departmental/corporate issue BASIC CONCEPTS: Choose the Method That s Right for Your Organization At the core of process improvement is finding a process or method that is the right fit for your organization. While all focus on engaging organizational involvement to improve quality, operational and financial performance through implementing stable processes, there are some general differences. All are based to some degree on data, standardization and reducing process variation, but Lean and Six Sigma are much more grounded in this foundation than some other methods. For example, each of the systems might have a bit of a different primary focus Six Sigma is mainly about reducing variation, Lean about removal of waste and a system like Theory of Constraints, removing obstacles or roadblocks from a process. Once you get past the main focus, these methods seem to look very similar or aspire to the same things in many cases. So how to choose The culture of your organization will be a major determining factor in what method you choose. If your organization places a high value on data and is highly analytical, Six Sigma may be the way to go. If your culture is more process oriented, finds more visual change important and likes to move a bit more quickly, Lean could be the best option. In situations where the change is more departmentally focused, or there is not a need to involve the entire organization, then something similar to the Theory of Constraints model may work best. 2 INTALERE.COM
Lean and/or Six Sigma may be most helpful in complex healthcare settings where there are a high number of transactions or mistakes can be very expensive. These methods can also be very well matched to these settings because of the increased focus on never events and the potential for medical errors. In smaller settings, or where processes are generally simple, these methods may not be as necessary. Any process improvement method can offer valuable resources, theories and practices. The challenge is to ask the right questions in determining the best fit and making sure that the program you choose is sustainable and flexible enough to adapt as the needs of your organization evolve. Whole Organization Buy-In Once the method is chosen, there must be organizational alignment and accountability that begin at the very top. Leadership must first exhibit a commitment to organizational transformation and continued alignment in all areas. They must also communicate a clear strategic framework with explicit goals, timetables and accountability/ownership. This framework must foster an environment in which people feel free and safe to engage in improvement. Encouragement of innovation is key, as is constant communication. During their careers, many middle managers and staff may have been saddled with quality initiatives that seem like a flavor of the month. If your efforts are to be successful, they must be continued and sustained for a period of years, ultimately becoming ingrained in the culture of your organization. New programs take time to understand and staff must use the processes on a reiterative basis in order to gain the experience to make projects and reporting requirements truly successful. If there are frequent changes to terminology or reporting requirements, for instance, then the programs become more of a burden than a tool. Finally, communication of unit-based results against goals, such as posting charts, illustrates definitive progress to all stakeholders. Outcomes tracking evaluates adherence to approved programs, quantifies goals and builds credibility by identifying possible issues and can establish a new baseline for the next project. For example, structural requirements for the Virginia Mason Production System include: Process improvement programs/leaders aligned with operational executive leadership. Executive sponsorship with accountability for sustained results. Education. Standardization of tools, results reporting and communication. Getting Started In the early parts of any process improvement program, it is important to not be overly aggressive, but to initially concentrate on what is called in the Lean process, point improvements. The focus should be on key areas and learning how to use and apply the tools. Be deliberate it is a journey, not a sprint. Root out basic problems, make improvements and build a foundation. Focus on point improvements - try to choose initial projects that are: Important because of customer demand build a foundation Core to the overall facility strategy make improvements root out basic problems Ripe for improvement in cost or process 3 INTALERE.COM
Think about instituting what the Virginia Mason Institute refers to as everyday Lean ideas (ELI). ELI is about small, quick-to-implement improvements made by staff in a local work unit. They often focus on improving safety, reducing defects, organizing materials or information and saving time and money. The beauty of ELI thinking is that it immediately delivers small improvements while embedding Lean thinking into staff. Ideas are fully tested and proven before they are implemented. Safe, simple yet effective examples include placing a stop sign in a pharmacy work station that reads, No interruptions during chemo reviews, eliminating a potential source of medical error. In a patient financial services department, paperwork was reduced by scanning all referrals upon receipt, then shredding the documents. This step saved 30 minutes of staff time per day storing documentation. Another example focused on adding valuable nursing time at the bedside, but brings to light many pieces of the workflow that are also applicable to other tasks and processes. Using a process called 5S, a continuous improvement cycle built on Sort, Simplify, Sweep, Standardize and Self Discipline, teams set about organizing common areas, nursing stations and medication rooms. They sorted, simplified and standardized the areas, so that everything was clean and placed in its proper location so they could find what they need without delay. Extra shelves and cabinets were taken away so they would not fill up with unnecessary items. They next worked on the patient rooms, simplifying the supplies and moving equipment to designated locations so that staff would not waste time searching. They also made sure that linens and the most-needed supplies were available for just-in-time use, saving time and footsteps in search of supplies. Central Supply and Housekeeping took the lead to replenish items throughout the day. Previously, nurses and patient care technicians (PCTs) cared for patients whose rooms were scattered across the unit. They reconfigured their workstations into nursing zones so that the nurse and the PCT were clustered near their assigned rooms, improving communication and saving footsteps. At Virginia Mason, 5s is defined as a strategy that helps to keep our workplace safe and organized - it is a foundational element of the Virginia Mason Production System (VMPS). Sort Simplify Sweep Standardize Self Discipline separates necessary from unnecessary makes places for necessary items a form of inspection that ensures everything is returned to its proper place makes places for necessary items maintains standards through training, empowerment, commitment and discipline 4 INTALERE.COM
Nursing also sought to eliminate medication errors and falls. The nurses began documenting their care in or near the patient s room and paired two nurses together at the bedside to double-check the physician s order for high-risk medications. Nursing also implemented a bedside handoff for their shift-change report, involving the patient and family in the discussion and improving safety. The goal was for the oncoming nurse to be clear about the patient s physiological status, plan of care and patient-safety risks. A whiteboard was posted in the room to enhance communication, flagging key information that was important for nurses, patients and families to know. These steps, along with some other processes, improved bedside care time to 78 percent over time. Nurses and PCTs took many fewer steps to do their job (from 5,818 to 846) and nearly halved the cycle of time it took to complete their work. Call lights were illuminated less often and patient satisfaction increased. Standard work generally involves: Collaborate together with resources and projects aligned to support strategic objectives for both organizations. Leverage the strengths of both organizations to provide added resources. Use data to reduce variation. Develop a communication and integration model that is flexible, focused on strategy and tactics, but also leaves room for innovation. Sustainability and Growth In time, the transition in process improvement will move to the next step that the Virginia Mason Institute refers to as line improvement, which begins to link processes across departments and develops more standard operations and standard work for leaders. What is standard work At Virginia Mason, standard work is defined as an agreed upon, repeatable sequence of work assigned to a single operator at a pace that meets customer demand. It is generally the foundation of continuous improvement and should be used in some way in your process so that any gains through process improvement are not lost over time. As your organization gets better at getting better, more shared priorities will lead to further alignment of systems measuring performance, alignment of accountability across diverse stakeholders and partnerships that drive a higher level of care. In conclusion, it is important to emphasize an aligned, accountable, process-driven improvement program is not necessarily about the size of the healthcare organization or complex IT systems needed to harness the data on which some projects can depend. It s about listening to the customer and the employees, uncovering, implementing and tracking opportunities and creating stakeholder value while creating knowledge all rooted in metric-based accountability. Healthcare s new model will demand consistent, ongoing and measurable improvement for providers to maximize reimbursement and protect their margins. Adopting a process improvement model promptly will benefit any size healthcare entity in staying ahead of the curve. Learn how data analytics and an information-rich environment support cost/ quality initiatives and the implementation of best practices. 5 INTALERE.COM
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