Creating the Michigan Quality System Jack Billi, M.D. [email protected] Michigan Quality System: med.umich.edu/mqs Michigan Quality System : • Quality • Safety • Efficiency • Appropriateness • Service Lean Thinking in Health Care
Dec 20, 2015
Creating the Michigan Quality System
Jack Billi, M.D.
Michigan Quality System:med.umich.edu/mqs
Michigan Quality System:
• Quality
• Safety
• Efficiency
• Appropriateness
• Service
Lean Thinking in Health Care
Lean Thinking in Health Care at UMHS Summary A3 J Billi 1/9/09
• Background– UM has problems in quality,
safety, efficiency, service– Problems harm patients, raise
costs, frustrate workers– Economy: short & long term
• Current state– Inconsistent use of QI at UM;
varied models– Toyota Production System:
QI world standard (not health)-Brilliant process & outcome
• Goals– Ideal Pt Care Experience– Ideal Clinician Experience
Happy workers – healthy pts– Safest health system in US– Financial stability
• Analysis– Workers/mgrs: +/- trained in
problem solving; little std work– Problems complex, cross
silos/units; work often invisible– Unclear responsibility for
problems– Unclear priorities– Time, cost pressures: stress
• Strategies– Spread a consistent QI model
across UMHS-Build on our CQI base-Study and adapt lessons
learned from Toyota– 18,000 problem solvers
• Plan– Michigan Quality System
Traditional Health Care …or, the way I was trained
• Frequency….……......Episodic• Initiation…….…..…....Patient• Coordination...…..…..Spotty (patients & doctors)• Communication……..Sporadic among clinicians• Patient education.......Inconsistent • Process of care……..Variable • Basis of decisions…..Clinicians’ opinions• Systems........…….....Not “Error-proofed”• Outcomes…….....…..Not measured• Cost……………….....Expensive
Gaps at UMHS (and most health systems):
• Quality: Not all CAD pts on statin, aspirin; DVT prophylaxis
• Safety:• Medication errors (10x infusion pump dose)• Labs labeled with wrong patient name • Results sent to wrong clinician • Hand sanitizing “in and out of rooms” less than 100%
• Efficiency: • Nurse, doctor searching for equipment, forms, pts…• Weeks waiting for appointment to the right physician• Higher LOS: fewer admissions/transfers, less $$, RIFs
• Appropriateness: • Antibiotics for URI, sinusitis; imaging for low back pain
• Service: Patients lost, staff look too busy to help
Where Do We Want to Go?
Our future state vision: The Ideal Patient Care ExperienceBased on Institute of Medicine Report“Crossing the Quality Chasm”
Care that is:• Safe• Effective• Patient-Centered• Timely• Efficient• Equitable
Crossing the Quality Chasm
• The IOM “Chasm” Report gives us a vision of where to go
• Lean Thinking gives us tools and business system to get there
• The IOM “Chasm” Report gives us a vision of where to go
• Lean Thinking gives us tools and business system to get there
Crossing the Quality Chasm
What is Lean Thinking?
“The endless transformation of waste into value from the customer’s perspective”.
---Womack and Jones, Lean Thinking
5 Step Process to Improve Value
1. Specify value from customer’s perspective
2. Identify the value stream for each product or service, and remove the waste
3. Make value flow without interruptions from beginning to end
4. Let the customer pull value from our process
5. Pursue perfection - continuous improvement- Do this every day in all our activities
Source: Womack & Jones: Lean Thinking
The Customer’s Perspective:A Clinic Appointment
• Call the clinic, voice prompts, on hold, leave message.• Clerk calls back and sets a date next week.• Arrive for the visit, check in, sit in waiting room.• Called into the exam room, wait for doctor.• Doctor sees you, saying she’s been waiting for you.• Diagnoses a URI, and BP is worse.• Doctor prints antibiotic prescription, walks to the
staffroom to get it. You are allergic to that drug. • Doctor says to return in a week for the BP.• Medical assistant does an EKG.• At check out you ask the cost – clerk says they’ll bill you, • No appointment is available next week.• Pharmacist says your insurance prefers a different drug.• Is there a problem?
Using the 5 Step Process in the Clinic Visit
• Specify value from customer’s perspective– A quick, effective clinic visit
• Identify the value stream for this service– Request > appointment > arrival > seeing doctor > check-out
…and remove the waste– Time on hold, callbacks, walking, wrong drug, unneeded test
• Make value flow without interruptions from beginning to end– Staff and patient move continuously from check-in to exit– Less waiting for patient and staff– Errors surface immediately
• Let the customer/worker pull value from the process– Physician pulls next patient to exam room; patient pulls med
refill when needed• Pursue perfection – continuous improvement
– Every day, every clerk, doctor, nurse thinks about how to redesign work to improve value to the customer, and ease for us
UMHS Example: MedSport Consult
Long term problem:• Long delays to get an appointment• Frustrated referring physicians, patients, staff,
physicians• Incomplete records, phone tag• Physician review records prior to scheduling• Lots of hidden processes, errors, rework• Patients/referring physicians seek care elsewhere
Project scope:• MedSport consult – from request to scheduling
Using the 5 Step Processon MedSport Consults
1. Specify value from customer’s perspectivePatients, physicians and staff:
quickly scheduled appointments
2. Identify the value stream for the serviceRequest > review> schedule appointment
…and remove the wasteVariation in request, time on hold,
callbacks, physician reviews
MedSport AppointmentsCurrent State Map
Wednesday March 16, 2005 - Page 1
D R A F T - Orthopaedic Surgery MedSport - Current State Map
Summary
Total Processing Time : 11 31 minutes
Total Waiting Time: 1 - 36 days
% Complete and Accurate: %
Metrics
P/T: Processing Time
W/T: Wait Time
% C & A: % Complete and Accurate
Wait time (day)
Process Time (sec)
Mapping Icons
In
~~~ Service
Patient
Ref. Phys.Pt / ATC
Data Box
Information
OutsideSource
In Box(Queue)
ProcessStep
Wait Time
Phone
Fax
5 min 10 min
0 - 3 d0 - 1 d
P/T: 5 min
W/T: 0-3 days
C&A: 100%
Call Ctr.
In
~~~Receipt &InspectRequest
P/T: 1 min
W/T: 0 days
C&A: 98%
Physician
In
~~~ClinicalReview
P/T: 3 min
W/T:0-3 days
C&A: 100%
Call Ctr. Sctry.
In
~~~TransportAppointment
Request
P/T: 2 min
W/T: 0-3 days
C&A: 95%
Ref. Coord.
In
~~~Business/ClinicalReview
P/T: 10 min
W/T: 0-14 days
C&A: 5%
Call Ctr.
In
~~~Re-workRequest
P/T: 1 min
W/T: 0 days
C&A: 98%
Ref. Coord.
In
~~~Denial/PriorSetting
P/T: 3 min
W/T: 0 days
C&A: 100%
Sctry.
In
~~~TransportAppointment
Request
P/T: 1 min
W/T: 0-1 days
C&A: 100%
Front Desk
Mail Itinary
P/T: 5 min
W/T: 0-1 days
C&A: 100%
Call Ctr.
In
~~~Scheduleand/or Notify
6 Requests28 Requests 6 Requests 6 Requests 28 Requests 30 Requests 29 Requests
1 - 14 d0 - 1 d
2 min
0 - 1 d0 - 3 d
3 min
0 - 1 d1 - 7 d
1 min
0 - 1 d
3 min
0 - 1 d
1 min
0 - 1 d
5 min
0 - 1 d0 - 1 d
1 min
0 - 1 d
Appeals
2 Rqsts2 Rqsts
Requests 30/Day
OPNotes
PhysicianNotes
Imaging
2 Rqsts
Lost Req1 Req
Using the 5 Step Processon MedSport Consults
3. Make value flow without interruptions from beginning to endStaff scheduling appointments on first
phone call
Uniform intake process
No waiting for appointments
Errors surface immediately
MedSport AppointmentsFuture State Map
Thursday March 17, 2005 - Page 1
D R A F T - Orthopaedic Surgery - Future State Map
Summary
Fast Track Slow Track
Total Processing Time : 6- 11 min 8 - 13 min
Total Waiting Time: 0 - 1 min 1 - 7 days
Lead Time: 6 - 12 min 1 - 7 days
% Complete and Accurate: 95% 85%
Metrics
P/T: Processing Time
W/T: Wait Time
% C & A: % Complete and Accurate
ConsultRequest
Guidelines onthe Web
BusinessReview
Ref. Phys.
OutsideOrtho
OPNotesED
Patient
Phone
Input byphone only.Faxes and
emails will befunneled to
phoneprocess
Clinic ReviewSchedule
AppointmentAppointment
Requirements
ItineraryPrinted &
Mailed
Entry Criteria
||||||||||||||||||||||||||||
Call Center Staff
Contact Schedule ReminderScheduling Patient Appointment:
StandardWork
3-5 Days Pre-Arrival Call
StandardWork
PatientRef. Phys.Pt / ATC
90%
LL
FailedRequests
areRedirected
Fast Track
2nd ReviewRotatingDesignee
10%
Slow Track - Exception Process
P/T: 6 - 11 min
W/T: 0 -1 min
C&A: 95%
P/T: 8 - 13 min
W/T: 1 - 7 days
C&A: 85%
Fast Track Slow Track
Mapping Icons
In
~~~ Service
Data Box
Information
OutsideSource
In Box(Queue)
ProcessStep
Wait Time LLLearningLoop
Using the 5 Step Processon MedSport Consults
4. Let the customer pull value from the processSame day appointments
After school sports, till 7PM
5. Pursue perfection – continuous improvementEvery day, every clerk, doctor, and nurse
thinks about how to redesign work to improve value to the customer
MedSport Project Results
• Goal: reduce time from request to scheduling
– Pre project: • process time = 27 min of work• wait time = 23 days
– Post project: • 91% of appointments made on first call in 2.5 min
– Physicians, nurses, and clerks:• Own the process, continue improvements• Freed to create more value
– Video www.med.umich.edu/mqs
Value Stream Mapping Workshop
Understanding how things currently operate. This is the foundation for the future state
Value Stream Scope
Designing a lean flow through the application of lean principles
Current State Drawing
Implementation Plan
Determine the Value Stream to be improved
The goal of mapping! 30, 60, 90 day follow-up
Implementation of Improved Plan
Future State Drawing
Developing a detailed plan of implementation to support objectives (what, who, when)
Sta
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ard
ize
for
late
r im
pro
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From John Long
Why Draw Maps?
To find problems, we have to be able to see them!
• Ron Hirschl’s basement clean-up– If you make waste visible, it’s easier to remove– If you make problems visible, they’re easier to solve
• In healthcare: process steps are often invisible– Hard to find the non-value added steps
• We use Value Stream Mapping so we all can see the waste and find problems– How is work done now?– How could we make the job easier for workers and better for
customers?– What experiment should we try first?
Value Stream Mapping:Learning to See
Front-line workers:• Create the map as a team• Describe the way the work is actually done now
– Not how we think it is, or how it should be…
• Verify in the real workplace (“go and see”)
Managers support the effort
Value Stream Mapping:Learning to See
• “Aha” moments:– I never knew this is how it worked!– I can’t believe what a mess this process is!– No wonder we’re frustrated!– It’s a miracle a patient ever gets through it!
Improvements don’t have to wait for workshops…
We all can:
• Do our work every day in a standard way that we created
– Not just the way the work evolved!
• Be alert to things going wrong – They always do!
• Fix the problem now– For this patient or co-worker
• Find and fix the root causes of the problem– So it never happens again!
Modified after Spear; Billi
Lean Thinking:How To Get It “Right Every Time”Steven Spear, Institute for Healthcare Improvement
• Catheter-related sepsis – a lot of little things:– No sink, no soap, no doormat reminder or buzzer– Gloves missing, wrong size, old and rip, on other
side of patient, at bottom of kit– 92% of nurses faced with impediments
constructed ad hoc workarounds
Steven Spear. Fixing Healthcare from the Inside, Today
Lean Thinking:How To Get It “Right Every Time”Steven Spear, Institute for Healthcare Improvement
• Short on Time???• Can’t find time to fix root cause??? • Rather use the workaround every day for the
rest of your career? • Just take 10 minutes a day to fix root cause of
one problem – Frees up time, so next week it will be 20 min.– Then it will be 30 minutes…
Steven Spear. Fixing Healthcare from the Inside, Today
Lean is not about working harder or faster, it is about finding waste and transforming it into value our customers want.
How can we create (liberate)“18,000 problem solvers”?
• Help each worker take initiative to find and fix causes of problems he/she faces daily– This means each of us has two jobs:
• Do the work• Improve the work
• Managers role:– Support improvement work (time, mentoring)– Align improvements so value flows to the
customerModified from J Shook
“18,000 Problem Solvers”
Every worker applying the scientific method
to every part of daily work.
Turn all daily work into an experiment and every worker into an investigator. -Steven Spear
Lean Thinking as the Scientific Method Applied to Daily Work
Scientific Method• Observation• Hypothesis• Intervention• Results/reflection• Revise hypothesis• New intervention…• Structured abstract
Lean Thinking• Go see, ask why, respect• Plan P• Do D• Check/reflect C• Adjust A• Repeat PDCA cycle…• A3 report, Value Stream
Map
Lean Thinking - An analogy to great medical care
Tackle work problems with the rigor and systematic thinking we use for patient problems.
Help every worker become an expert clinician.
Lean Thinking is Like Great Medical Care
for Daily Work
Great Medical Care• Collect data personally,
systematically, at the bedside
(H&P)• Impression and plans• Tests and treatments• Assess results & reflect• Revise impression & plan• Std write-up, presentation
Lean Thinking• Go see, ask why, respect
• Plan P• Do D• Check/reflect C• Adjust A• Value Stream Map, A3
Lean means seeing problems as interconnected:
5 admissions on “call day”, none for next 2-3 days
• Waste: -Muda– Errors (no beds on home unit)– Worker motion (patients scattered on 5 floors)– Inventory (patients waiting for rounds, orders, D/C)– Workers waiting (for the COW to arrive from last floor)
• Uneven workload, variability -Mura– Busy call day, “recovering” next day– Batch orders till end of rounds (none -> rush)
• Stress of overburden -Muri– Physicians, nurses, clerks rushing through work– Duty hour limits; nurse and PA shortages
Michigan Quality System:Strategy for Lean Transformation
1. People Development - Leaders
-Managers- Frontline Staff
• “Just-in-time” training: Learn Lean by Doing• Coaching and mentoring• Courses, talks, web resources, book club
2. Process Improvement- Focused on institutional priorities
• Value stream analyses and workshops• Rapid-cycle improvement and “Just do it” activities• Lean in daily work
MQS Learning Project Results
Radiation Oncology (6 teams – over 70 faculty & staff)
• Patients referred for brain metastases required 3 visits over 5 days (consult, simulation, treatment)
• After mapping the process, the team redesigned the process, removing unnecessary steps
• Now 95% of patients have all 3 parts within 24 hours
• Billing process first-time-quality increased0% to >95%
– Video www.med.umich.edu/mqs
MQS Learning Project Results
Results Reporting ~ 99,000 lab results had no ordering physician, radiology requisitions lost, extensive rework
• Preprinted labels on requisitions implemented (12/06)• Imaged requisitions increased by 880% (from 957 to 9380)• 50% drop in orphan lab results
MQS Learning Project Results
Emergency Dept. and CPU• Acute coronary syndrome:
• Goal is “Door to Balloon” within 90 min.• Go and see, mapping: time spent on EKG, serial
paging• Redesign patient flow, parallel paging• Within 90 min. – Increased from 75% to 85%
• Time to ED discharge decreased 10 minute
Before, nurses prioritized sickest, never got to discharges.
MQS Learning Project Results
Care Transitions: MFH discharge from 5B
– Timely appointments in hand at discharge– Management until the first follow-up visit– Mapped the discharge process, MLine pilot– Pilot results:
• Decreased 14 day readmissions by 33% • Decreased visits to ED within 72 h. by 81%
MQS Learning Project Results
Cardiovascular Center32 projects and analyses over 2 years• Non-value-added time during device clinic visit
reduced from 100 to 10 minutes – Tech & nurse visits simultaneously
• Time for new medication delivery decreased from 90 to 41 minutes with implementation of “cart-less” system
• Standardized bedside stocking in ICU reduced extra supply runs from 4.5/bed/month to 1.7/bed/month
MQS Learning Project Results
Vascular Access
• Doubled PICC lines placed within 12 hours by nurses from 35% to 71%; reduced by 46% cases needing interventional radiology
• Nurses standardized their cart, saved 1 hour/day
CT scheduling and throughput
• In by 9, out by 5 for inpatients; no longer a weekend bottleneck
Michigan Quality System & Lean References Books:• Womack J, Jones D. Lean Thinking.• Liker J. The Toyota Way; Liker J, Meier D. The Toyota Way Fieldbook.• Shook J. Managing to Learn.• Dennis P. Getting the Right Things Done.• Rother M, Shook J. Learning to See.• Womack J, Jones D, Roos D. The Machine That Changed The World.• Sobek D, Smalley A. Understanding A3 Thinking.• Marchwinski C, Shook J, eds. Lean Lexicon.Articles:• Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: what can hospitals learn from a
world-class automaker? J Hosp Med. 2006;1:191.• Bush R. Reducing Waste in the US Healthcare System. JAMA 2007;297:871.• Spear S. Fixing Health Care from the Inside, Today. HBR. 9/05.• Spear S. Learning to Lead at Toyota. HBR 4/04 • Spear S. Decoding the DNA of Toyota Production System. HBR 9/99• IHI Whitepaper: “Going Lean in Health Care”
www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm Web: • Michigan Quality System at UMHS: med.umich.edu/mqs• Lean Enterprise Institute: www.lean.org webinars, books, meetings…• Ideal Patient Care Experience at UMHS www.med.umich.edu/i/acs/ipe.htm • Crossing the Quality Chasm (IOM): newton.nap.edu/catalog/10027.html • Lean Enterprise Academy (UK): www.leanuk.org • National Health Service (UK): www.networks.nhs.uk/networks.php?pid=211 • Wikipedia: en.wikipedia.org/wiki/Lean_manufacturing