DELIVERING OUTSTANDING IMPROVEMENTS AT CANADA S WILLIAM OSLER HEALTHCARE SYSTEM White Paper: William Osler Health System Diabetes Education Centre Brampton, Ontario
Diabetes clinic pilot project expands capacity, boosts efficiency and delivers sustainable results without adding resources. EXECUTIVE SUMMARY In July 2011, William Osler began a partnership with Medtronic s Integrated Health Solutions (IHS) on a pilot improvement project to optimize the performance of its Diabetes Education Centre at Brampton Civic Hospital. The plan was to apply a Lean Six Sigma approach and also adapt a diabetes clinic optimization model and process developed by the IHS group and used successfully in a number of clinics in Europe, particularly for the National Health System in the UK. The results of the pilot to date have been exceptional and the numbers are continuing to improve over time. Not only has the Diabetes Education Clinic vastly increased its capacity and efficiency in handling patients, but also it has done so while maintaining patient satisfaction scores and service delivery. To ensure a sustainable process, the entire project team earned their Lean Six Sigma Yellow Belts part of Medtronic s process with every Lean Six Sigma project. This has provided the Diabetes Education Centre with the capacity to be much more effective in improving internal processes on an ongoing basis. The project has demonstrated that partnerships between industry and health care professionals can lead to optimized service for patients while at the same time improving efficiencies and ensuring the sustainability of health services. Medtronic IHS was pleased to be one of Osler s key community partners, and looks forward to partnering with other health care providers to help address the needs of their communities. CHALLENGE Diabetes affects more than 75, 000 people living in the communities served by William Osler, and that number is growing rapidly each year. Peel Region, where William Osler is located, has one of the highest prevalence rates of diabetes in Canada. 10% versus the national average of just over 5%. All evidence suggests there is a predisposition to diabetes in the immigrant and ethno-culturally diverse population in the region and that the number of people with diabetes in the region will increase rapidly in the years ahead, creating a growing challenge for the healthcare system. As the healthcare provider for this high-needs diabetes area, William Osler has a responsibility to address the growing needs of its residents. William Osler needed to transform its operations so it could serve more people with diabetes and offer better care within its existing budget. The hospital s primary diabetes clinics were: Type II diabetes programs (80% of total annual patient visits) Type I diabetes programs (10%) Gestational diabetes management programs (10%) Pilot project goals: Improve the patient experience, clinic productivity and quality of care Demonstrate national leadership through a collaborative partnership and share learning within the institution APPROACH Identify solutions aimed at reducing or eliminating non-value-added clinical activities and administrative redundancies Operational issues to be addressed: Processing delays including missing referrals, lack of appointment time for followup and urgent appointments, and time delays in recieving reports from physicians. WOW THIS IS THE BEST WAY TO SEE THE ISSUES AND RESOLVE THEM WE ARE ANXIOUS TO IMPLEMENT. - NORINE, CLINIC MANAGER, ETOBICOKE ASTONISHING IMPACT As a result of the Lean Six Sigma project at Brampton Civic Hospital, the Diabetes Education Clinic experienced: A 58% increase in overall interactions per clinician A 20% increase in gestational diabetes management capacity A 45% increase in glucose tolerance class capacity
Over documentation, excess paperwork or scanning. Capacity problems. Fewer resources available to meet the increasing demand Problems with transfer assessment process including communication gaps and lack of standardized reporting to physicians. THE TEAM A steering commitee was put together to include senior management and executives from both Medtronic and William Osler as well as a working group consisting of registered nurses, registered dietitians, a clinic clerk, a program manager and other administrative staff. Medtronic s Morteza Zohrabi, a Lean Six Sigma Master Black Belt, led the project. METHODOLOGY Work began with a five-day workshop to review the main Diabetes Education Clinic processes. The working group reviewed the procedures and baseline metrics of the clinic, including its financial matrix, lead and wait times, and patient experience measures. Baseline measures were collected by analyzing a combination of electronic data, written notes and observations. A system was later developed to routinely record the number of patients and wait times within the department. The clinic s processes were reviewed end to end to identify all bottlenecks and issues. The group recognized non value-added activities, redundant data entry and administrative process through value-stream mapping, Lean/Kaizen methodologies, and evidence-based learning. Outputs included: project charter problem statement high level process map (block diagram) value stream mapping root cause analysis waste analysis pros and cons analysis All ideas for improvement were captured in an ideas parking lot ensuring they could be discussed further to enhance the potential solution design. At the end of each workshop day, the steering committee attended a report-out session to review the progress of the project and share ideas and concerns. ACTION PLAN The group identified 81 potential solutions to reduce over-documentation, improve workflow efficiency, create more capacity and improve patient outcomes. The team reviewed solutions and used two levels of prioritization, span of control assessment and impact and effort analysis; to create a shortlist of 14 actionable items. The team then developed an action plan and assigned tasks to working group members. THIS WAS A GREAT OPPORTUNITY TO LOOK AT OUR ENTIRE PROCESS AND STREAMLINE THE WORKFLOW OF THE CLINIC. THE GROUP FACILITATOR REALLY ENCOURAGED US TO THINK OUTSIDE OF THE BOX TO COME UP WITH IDEAS - SHAISTA, REGISTERED NURSE, BRAMPTON As the project unfolded, clinic staff on the working committee held weekly performance huddles to review status and discuss any roadblocks to the action plan. Medtronic followed up monthly with the project coordinator and working group team lead to ensure the plan was moving forward and to help resolve any potential roadblocks. The project lasted 12 months, from initial stakeholder conversations through new process implementation and data collection.
RESULTS In surveying the clinic s processes, the team discovered that almost 40% of staff time was used to fill out required forms and databases. The team identified 10 forms, data collection tools, and checklists in the process, including three different databases that each generated different reports. Another significant discovery was that there was a 25% overlap in the information that registered nursess and dietitians were coiiecting during their patient sessions. Clinicians were able to find a better way of providing consistent information with patients all while providing the same high quality training, improving the patient follow up and seeing 25% more patients. Based on these findings, the clinic was able to: eliminate 10 redundant forms combine three databases into one electronic documentation system (a process that alone saved more than 2,300 working hours per year) eliminate redundancies and find better ways to improve the flow and consistency of high-quality iniormation and training delivered to patients The streamlined system and process saved significant clinician and administrative time and allowed staff members to focus less on paperwork and administration. OVERALL PILOT RESULTS 25% improvements in use of clinical time 33% increase in new patient visits per staff member 20% increase in gestational diabetes visits 58% increase in overall interactions per clinician 45% increase in impaired glucose tolerance class capacity 80% reduction in no shows (rate reduced from 45% to less than 5%) 2,600 hours of team time saved annually 60% reduction in data redundancy The pilot also evaluated patient experience using the Net Promoters Score measure before and after implementation. Patient satisfaction levels were sustained throughout the project. One issue worth noting is that there was no focus on patient outcome measures such as A1C during the pilot. As a consequence no conclusions can be made regarding the influence of this project on patient outcomes this is a suggested area for future study. ABOUT THE PARTNERS William Osler Health System is one of the largest community hospital systems in Ontario, serving a population of more than 1.3 million people living in one of the fastest growing and most culturally diverse regions of Canada. RESULTS THE STREAMLINED SYSTEM AND PROCESS SAVED SIGNIFICANT CLINICIAN AND ADMINISTRATIVE TIME, ALLOWING STAFF MEMBERS TO FOCUS LESS ON PAPERWORK AND MORE ON INTERACTING WITH PATIENTS. Medtronic is a recognized leader and innovator in medical devices, services and solutions, with expertise in cardiac, vascular, spinal and neurological science; minimally invasive technology and diabetic disease management. Medtronic has expanded its Integrated Health Solutions group in Canada. Leveraging its gloval knowledge and expertise, Medtronic uses its resources and capabilities help to improve the Canadian healthcare system by increasing efficiency and optimizing patient outcomes.