Lean Implementation at Jefferson Healthcare Earll Murman LAI Annual Conference March 25, 2010
Rural Healthcare Case Study Jefferson County, WA Population 29,542 (2008 est.) Photo by Earll Murman Source: Google 2010 MIT Murman LAI Annual Meeting 2
Jefferson Healthcare Overview History 1890 Sisters of Providence founded St John s Hospital 1975 Jefferson County Public Health District takes ownership and establishes Jefferson General Hospital 2002-2007 Acquired 5 primary care clinics 2003 Designated Critical Access Hospital 2004 Renamed Jefferson Healthcare Governed by 5 elected Commissioners Largest employer in Jefferson County, 489 employees Annual budget approximately $45 million Over three quarters of business is outpatient 2010 MIT Murman LAI Annual Meeting 3
Seattle Hospitals Medivac Jefferson Healthcare Swedish MC Seattle Harrison Hos. Bremerton Acute Cardiac Drive to Stroke Telemedicine In Patient Family Birth Center Surgery East Jefferson Fire & Rescue ED and Express Care 25 Bed s Five Primary Care Clinics Home Health & Hospice PT and Rehab Port Ludlow Fire & Rescue Medical Short Stay Diagnostics 2010 MIT Murman LAI Annual Meeting 4
JHC Drivers for Lean Grow activity and contain costs while achieving: Purpose To assure appropriate healthcare services are available to support the health of all people of Eastern Jefferson County Values Jefferson Healthcare is: Intentionally Patient Centered Committed to the highest possible quality healthcare for all An employer that recognizes the quality of its employees and helps them to reach their potential Committed to a health community that encourages individual responsibility A prudent steward of healthcare resources Mission Jefferson Healthcare... excellence with compassion and innovation Source: http://207.56.191.254/web/aboutjeffersonhealthcare/purposevaluesmission/tabid/89/default.aspx 2010 MIT Murman LAI Annual Meeting 5
JHC Lean History Early 2000 As one of 20 rural hospitals affiliated with Virginia Mason in Seattle, JHC CEO was aware of lean Exploratory: 2003 2006 Four staff attended Lean training brought tools home Conducted RPIW for patient registration Difficult implementation but good results (45 5 min) Island of success no traction across JHC commitment: 2006 present CEO and other directors received 1 week training Strategic decision to make Lean the JHC Performance Improvement system Contracted with Joan Wellman & Associates Formed Lean Resource office Budgeted $1M annually for lean implementation ~ 200 improvement opportunities identified 2010 MIT Murman LAI Annual Meeting 6
Lean Organization Lean Resource Office reports to CEO Lead is member of JHC Strategic Leadership Group Three Lean Fellows and one admin support Lead is RN with experience in ED, OB, IT Joan Wellman Associates under contract to provide lean expertise - the JHC Sensei Associate spends 1 week/month on site The 5 lean team members support 30 events/year as coaches, experts, facilitators 2010 MIT Murman LAI Annual Meeting 7
JHC Lean Events Primary tools employed are 5S, RPIW, VSMA 2007 7 events 2008 30 events Photo by Earll Murman 2009 30 events Examples: OP Clinic VS, ED VS, AMI RPIW, Stroke RPIW, Laundry RPIW, Safety Office 5S, Pt discharge 2010 MIT Murman LAI Annual Meeting 8
Time is critical for treating major heart attacks. Greatest loss of heart muscle is in first 2 hours Recommended treatment is catheter insertion of balloon within 90 min of presentation Alternate treatment clot busting thrombolytic drug Acute Myocardial Infarction RPIW Situation Closest Cat Lab is in Bremerton minimum 55 min drive time No clear boundary for when patients go to Bremerton or when they require thrombolytics at JHC Average as is treatment or process time at JHC is 165 min RPIW Targets Reduce Lead Times for AMI response 2010 MIT Murman LAI Annual Meeting 9
Pt Value Stream Intersects Multiple Organizations Common process required for 6 different organizations 2010 MIT Murman LAI Annual Meeting 10
Images from AMI RPIW Planning training ED RN Lean Fellow BEFORE 165 min CNO Cardiologist ED MD AFTER 20 or 60 min Writing new protocols Lean Fellow Photos by Earll Murman House Coordinator Jefferson Healthcare Acute Myocardial Infarction RPIW April 20-24, 2009 Process Owner 2010 MIT Murman LAI Annual Meeting 11
Key to RPIW was the focus on Pt and Pt value stream Six different organizations working collaboratively to provide the best care possible given constraints Clear geographic boundaries delineate treatment pathway based on time-to-treatment constraints Process time measured by stopwatch strapped to Pt Medics certified to administer thrombolytic drugs in EMS van Future State AMI Algorithm The hospital is where the patient is. 2010 MIT Murman LAI Annual Meeting 12
Value Stream Event for JHC Situation Five legacy outpatient clinics Few standard processes Little coordination between clinics and with other parts of JHC Patients per day per doctor under national norms Poor flow and facility layout Primary Event Focus: Identify standard patient flow for clinic encounters; improve patient access and provider productivity Outpatient Clinics Photos by Earll Murman 2010 MIT Murman LAI Annual Meeting 13
Jefferson Healthcare Clinic - Current State Map OVERALL CLINIC DATA - Blocked Hours 67/day Receive call & Send registration packet Reg Pkt V1 Wait for pt to return packet Request Med History records EXTERNAL PROVIDERS Wait for ex prov to return info Med History Receive Med History & Call to Schedule Input Med History - Cost per visit - $125.39 - Avg. Pts per hour - 1.83 - Available hours per day 67 ROS V1 - Contact Hours 59/day - Utilization 88% Phone call Phone call Visit Clinic PATIENT EXTERNAL PHARMACIES PATIENT DATA - Volumes - 131 visit/day - Market share - Hospital 46.7% - Cancel by reason - see chart A - Payor mix commercial 38% - Satisfaction overall 74.4 - Volume by Diagnosis See chart B - Schedule on 1 st call 0% - # of Pts on panel 5997 - Days out for first 3 rd visit 3.75 - Days out by provider - See C Reg Pkt V2 Obtain Demographics mini-reg & Send packet Call patient to schedule Hot Document delays 2% Input Med History ROS V1 2.2 Check-in patient for visit Interface 19.1 Phone call Room & perform vitals, etc. RN Med list 31.2 Salmon reminder (PTFP) Scripts Routing Slips Educ. Orders See patient MD, PA 4.4 Check-out patient Referrals Discharge Walk to hospital Referral Coordinator 4.8 walk or return Scripts Discharge MediTech Register for Ancillary Services Hospital Registration Discharge Rad film Interface 14.0 MediTech HOSPTIAL Ancillary Services L/T 1.6 9.7 20.7 2.1 2.3 3.1 C/T - Schedule on 1 st call 0% - # of Pts on panel - 5998 - No shows 2% - On-time starts 37% - Referral volume 14.5 % - Volumes by service 13.0% - Days out for first 3 rd visit 2.00 - On-time starts 37% - Time by diagnosis Chart D - Lead-time by service - varies - Days out by provider- see chart C - Document delays 12% - Volume by hour Chart E Pre-reg, Schedule, & Send packet Reg Pkt V2 ROS V2 Input Med History following Check-in LEGEND = PTFP Scheduling = Hospital Services = OPC Scheduling = Patient - Schedule on 1 st call 100% - Document delays 30% = JMPG Scheduling = Patient on schedule - # of Pts on panel 5886 - Days out for new visit - 15.01 = Clinic flow (all sites) - Days out by provider See Chart C Days out for first 3 rd visit 1.16 Source: Jefferson Healthcare, Port Townsend, WA 2010 MIT Murman LAI Annual Meeting 14
Jefferson Healthcare Clinic - Ideal State Map OVERALL CLINIC DATA - Blocked Hours 67/day - Cost per visit - $125.39 - Contact Hours 59/day EXTERNAL PROVIDERS Med History History Request Appt Request Jefferson Website - Research Providers - Input Medical History - Input Registration Data - Initiate requests for Med Hx from external Reg Pkt Reg Pkt providers Pt Info Reminder History Request Reminder Appt Request Patient Info Reg Pkt Pre Visit Check-in - Avg. Pts per hour - 1.83 - Available hours per day 67 Reminder Internet Reg Pkt - Utilization 88% Visit Clinic EXTERNAL PHARMACIES PATIENT PATIENT DATA - Volumes - 131 visit/day - Market share - Hospital 46.7% - Cancel by reason - see chart A - Payor mix commercial 38% - Satisfaction overall 74.4 - Volume by Diagnosis See chart B Phone call Schedule Pt Schedule & Initiate Pt Registration & Initiate Registration Same Day (urgent) 2-Wks (non-urgent, no preference) Mail or Appt Walk-in Request Phone call MediTech Complete Pre-Reg & Demographic Documentation Reg Pkt 1 Wk prior Reschedule E-mail reminders Call Pt for Visit Reminder Reschedule Call Pt to Reschedule due to incomplete records 2 days prior for limited patients Phone call reminder Hold daily Check-in huddle Check-in Patient Check-in Patient Check-in Clinic Patient Patient Team n n n n n Pt Info Clinic Kiosk Pre Visit - Check-In Check-in Interface Check-in Room & Patient ROS perform vitals, etc. MA E-mail reminders Pod Med list Scripts Scripts Routing Slips Educ. See patient See See Orders patient Care patient Providers, Team Providers, RN, MA RN, MA Discharge Referrals Check-out patient Referral Coordinator MediTech Interface Rad film HOSPTIAL Ancillary Services E-orders Follow-up care n n n n Recall Patient 10-15 min - Schedule on 1 st call - No shows - On-time starts - Referral volume - # of Pts on panel - On-time starts - Time by diagnosis - Days out for first 3 rd visit - Days out by provider - Document delays - Volume by hour - Volumes by service 13.0% - Lead-time by service - varies Source: Jefferson Healthcare, Port Townsend, WA = Scheduling ist = Clinic ist = Referral Coordinator LEGEND = MA = MD/PA = RN = Hospital Services = Patient = Patient on schedule n = Queues (Inventory) 2010 MIT Murman LAI Annual Meeting 15
Jefferson Healthcare Clinic Future State Focus (2008) OVERALL CLINIC DATA - Blocked Hours 67/day Receive call & Send registration packet Reg Pkt V1 Wait for pt to return packet Request Med History records EXTERNAL PROVIDERS Med History Receive Med History & Call to Schedule Wait for ex prov to return info Input Med History - Cost per visit - $125.39 - Avg. Pts per hour - 1.83 - Available hours per day 67 ROS V1 - Contact Hours 59/day - Utilization 88% Address safety measures & gaps by 10-31-08 Phone call Phone call Establish Pt focus group by 4-1-08 Improve staff satisfaction by (TBD) Visit Clinic PATIENT EXTERNAL PHARMACIES PATIENT DATA - Volumes - 131 visit/day - Market share - Hospital 46.7% Improve Pt - Cancel by reason - see chart A satisfaction - Payor mix by (TBD) commercial 38% - Satisfaction overall 74.4 - Volume by Diagnosis See chart B - Schedule on 1 st call 0% - # of Pts on panel 5997 Develop standard Reg Pkt scheduling template by 4-1-08 V2 Obtain Demographics mini-reg & Send packet Develop standards for scheduling & reception by 4-7-08 - Days out for first 3 rd visit 3.75 - Days out by provider - See C Develop standard registration Call packet patient by 12-31-07 to schedule Hot Document delays 2% Input Med History Develop process ROS for capturing V1 Hx pre-visit by 7-1-08 Hire/train MA resources 2.2 Check-in patient for visit 19.1 Implement daily huddle by 11-1-08 1.6 Develop clinic service standards by 12-31-07 Interface Phone call Room & perform vitals, Develop etc. standard room by 4-1-08 RN 9.7 Med list Align Educ. to care teams in pods by Orders (TBD) See patient MD, PA Salmon reminder (PTFP) Scripts Routing Slips 31.2 Develop pre-order 4.4 & future lab capabilities in by 7-1-08 20.7 Check-out patient Referral Coordinator 2.1 Discharge Develop postvisit standard Referrals work by (TBD) Walk to hospital Standardize 4.8 visit walk documentation by (TBD) or return Scripts Discharge MediTech Register for Ancillary Services Discharge Hospital Eliminate need to Registration re-register in hospital 14.0 2.3 Rad film Interface MediTech HOSPTIAL Ancillary Services 3.1 L/T C/T - Schedule on 1 st call 0% - # of Pts on panel - 5998 - No shows 2% - On-time starts 37% - Referral volume 14.5 % - Volumes by service 13.0% - Days out for first 3 rd visit 2.00 - On-time starts 37% - Time by diagnosis Chart D - Lead-time by service - varies - Days out by provider- see chart C - Document delays 12% - Volume by hour Chart E Pre-reg, Schedule, & Send packet Reg Pkt V2 ROS V2 Input Med History following Check-in LEGEND = PTFP Scheduling = Hospital Services = OPC Scheduling = Patient - Schedule on 1 st call 100% - Document delays 30% = JMPG Scheduling = Patient on schedule - # of Pts on panel 5886 - Days out for new visit - 15.01 = Clinic flow (all sites) - Days out by provider See Chart C Days out for first 3 rd visit 1.16 Source: Jefferson Healthcare, Port Townsend, WA 2010 MIT Murman LAI Annual Meeting 16
Standard Rooms and Central Supplies 5S Events in each Clinic Source: Jefferson Healthcare 2010 MIT Murman LAI Annual Meeting 17
Lean Events Targeting Each Step in the Clinic Value Stream Standard Work creates a foundation to build on FIW Dec 2007 FIW Mar 2008 FIW Mar 2009 RPI Jun 2008 RPI Mar 2009 RPI Sep 2008 Source: Jefferson Healthcare FIW = Focused Improvement Workshop 2010 MIT Murman LAI Annual Meeting 18
Daily Management System Implement daily huddle Photos by Earll Murman 2010 MIT Murman LAI Annual Meeting 19
Results Project Access RPI (Feb 2009): Reorganized Medical Staff Structure Consolidate Provider meetings reducing meeting hours. Revise scheduling guidelines (20 min vs. 40 min vs. 60 min) 6000 5500 5000 4500 4000 3500 3000 2500 2000 1500 1000 Cumulative Available Clinic Hours 2007, 2008, 2009 Project Access RPI January February March April 2007 CML 2008 CML 2009 CML Create schedule management strategies using daily huddle Source: Jefferson Healthcare 2010 MIT Murman LAI Annual Meeting 20
Results Source: Jefferson Healthcare 2010 MIT Murman LAI Annual Meeting 21
JHC Accomplishments Laundry RPIW was early success Saved laundry from being outsourced Stabilized staff at 3 FTE from 4 FTE budgeted Customer satisfaction went from 70% to 100% Most MDs get it, are on board, and are driving process improvement Launching the Clinic VS was a tipping point OR daily on time start went from 14% to 96% Culture beginning to change Community now has excellent stroke and acute cardiac care response for rural hospital 45% employee participation in at least one event Source: Jefferson Healthcare 2010 MIT Murman LAI Annual Meeting 22
Success Factors CEO leadership, commitment, engagement -wide process improvement method Commitment of resources Engaging consultant on long-term contract Lean Resource office Tiger teams from IT, EVS, facilities, materials mgmt support rapid change during RPIWs Getting MDs involved and on board Active participants in process improvement No layoffs for productivity improvements The lesson learned by the MDs from the clinical value stream RPI was that lean focuses on what to do to make them, the patients, and the staff happy. Vic Dirksen, CEO 2010 MIT Murman LAI Annual Meeting 23
Challenges and Opportunities Lean fatigue 30 events per year for 489 employees and 4 lean resource office staff is at capacity of organizational rate of change Changing culture opens opportunities for bottom-up implementation Transforming Care at Bedside is an example Making everyone a problem solver all the time Biggest gains still to come Lean is an effective way for me to make systemic, not charismatic, change in process improvement at Jefferson Healthcare. Vic Dirksen, CEO 2010 MIT Murman LAI Annual Meeting 24
Acknowledgements Terri Camp Jefferson Healthcare Teresa Deason Joan Wellman Associates Vic Dirksen Jefferson Healthcare Paula Dowdle Jefferson Healthcare John Nowak Jefferson Healthcare Matt Ready Jefferson Healthcare 2010 MIT Murman LAI Annual Meeting 25