Effective Use of the Tool Box in Healthcare

November 6th, 2006

Effective Use of the Tool Box in Healthcare

Adrienne Elberfeld, Master Black Belt Virtua Health,

Marlton, New JerseyMarch 29th, 2007

November 6th, 2006

Virtua Facilities

November 6th, 2006

Virtua Health….TodayFour hospital system in Southern New JerseyTwo Long Term Care FacilitiesTwo Home Health AgenciesTwo Free Standing Surgical Centers (JVs)Two Medical Staffs (currently merging)Ambulatory Care - CamdenFitness Center7,100 employees + 2000 physicians7,752 deliveries8% Operating Margin - #1 in the state of NJSTAR Culture

November 6th, 2006

Virtua Locations

November 6th, 2006

Strategic Imperatives 2007 Continue to improve and sustain patient safety and clinical

quality, through evidence-based practices Improve and sustain patient satisfaction scores with an

increased emphasis on customer service Recognize and continuously develop best people and improve

employee satisfaction, with emphasis on leadership development

Continue implementation of medical staff development plan. Continue facility planning and development of ambulatory

sites and regional medical centers Advance Virtua’s Programs of Excellence development Continue rigor in expense management, revenue

enhancement, and reduced length of stay Begin implementation and integration of digital information

technology and clinical technology

November 6th, 2006

Virtua Health Challenges Today

A formula for a “perfect storm” Aging Work Force

Average age of Nurse = 49 years old Average age of Physician = 51 years old

Impact of Baby Boomer Generation to HealthCare Increasing Competition for Market Share Shorter Length of Stays/Payer Reimbursement Continual Shift to Electronic Work Flow

Processes Malpractice Costs Consumer Expectations Pressure from Government & Industry to Reduce

Costs

November 6th, 2006

Virtua Health Tomorrow

Greenfield Healthcare CampusComprehensive Ambulatory CentersContinued specialization of Marlton

CampusRedesign of Memorial Hospital

CampusDigital Healthcare StrategyPhysician Partnerships and

Recruitment Investment in Best People

November 6th, 2006

What Makes Virtua Different?

We are a Community Based Health System that has deployed the following: Relentless Measurement Rigor and Accountability Programs of Excellence Our Tool Box Partnerships with Industry Our People Our Results

November 6th, 2006

The Virtua STAR: The Backbone to Our Organization

CaringCulture

ExcellentService

Clinical

Quality &

Safety

ResourceStewardship

BestPeople

Outstanding

Patient Experienc

e

November 6th, 2006

Relentless Measurement

Everything we do is based on the 5 points of the STAR

Balanced ScorecardQuarterly Goals and Objectives

ReviewFriday BriefingVarious awards for Quality

November 6th, 2006

Score Card Snap Shot

November 6th, 2006

Quality

Winner of the Quality New Jersey Bronze Governor’s Award for Performance Excellence for 2005 (applied in 2006)

Balanced Score Card: The Star Report Joint Commission Constant ReadinessSustainability of Results Utilizing the

Virtua Tool Box Many of our Virtua Quality Goals exceed

national standardsParticipating in Regional and National

Quality Initiatives

November 6th, 2006

Best People

Incorporation of General Electric Human Resource tools into Virtua Best People Review Goals and Objectives Process Operating Calendar Talent Coaches Ranking of Talent Internal promotion

Annual Employee Opinion Survey

November 6th, 2006

Vitality Curve

“Valued Contributor”

“Top Talent” no more than 30%

“Needs Improvement”

10-15%

November 6th, 2006

Programs of Excellence

Programs of Excellence Women’s and Children’s Neurosciences Healthy Aging Orthopedics Surgery Cardio-vascular Oncology

Program Strategy is Delivered through a Planning Process of S1 and S2

November 6th, 2006

The S1 Components Definition of Core, Emerging and Crossover

Business Units Projected financial performance

Market share Patient inpatient and outpatient volume Revenue & CM projections

Market Dynamics Competitive Analysis Market Share Detail Payor Mix Legislative Impact Technology Impact – Sg 2 Physician Availability Market Intelligence

Technology impact – Sg 2 Physician availability Market intelligence

November 6th, 2006

The S1 Components ContinuedStrategic initiatives

Specific strategies to achieve financial projections clinical quality and safety goals and service focus

Service venue: Inpatient and ambulatory strategy

Medical staff needs: Primary care, specialty care

Marketing strategy Workforce needs Investment requirement

November 6th, 2006

Operating plans and performance evaluation

Initial annual plan including timelines and accountability

Financial impact of planQuarterly assessment of actual

performance against the plan for: inpatient and outpatient volume and financial

performance program and service development and physician

recruitment goals quality and safety and service excellence goals

The S2 Components

November 6th, 2006

Resource Stewardship

Rigor in Expense Management Complemented by the Goals and

Objectives Process Fueled by the Friday Briefing Process Enhanced by our Tool Box Early and rigorous budgeting process Quality saves money

November 6th, 2006

Annual STAR Launch

G&O review & signoffPOE report & Final S1

G&O Review #1

QMM Meeting & celebration QMM

Best People UpdateG&O Review #3EOS

Budget Process

Best People Review

G&O Review #2

January 07

February

April

May

June

September

August

July

November

December

October

Outstanding Patient Experience

Stewardshi

pPatient Safety

Best People

Caring

CultureClin

ical

March

Virtua Values

1st Quarter

2nd Quarter

3rd Quarter4th Quarter

Virtua Health STAR Management System 2007

Resource

Service Excellence

Quality &

January/Feb 08

08 Star Launch07 4Q G&O Report Out

Strategic Imperative update for 2008 budget planning

QMM

POE S2 review & S1 draftQMM

November 6th, 2006

Virtua – GE History Bio – Med contract: 1998 Cultural change Post Merger: 2000 Six Sigma, CAP, Work Out: Oct 2000 Master Black Belts: 2002 ENTERPRISE CONCEPT IS BORN Work Out with GE Leaders: Feb 2003 Site Enterprise Representative: Sept 2003 Leadership and Management Systems: Nov

2003 Technology Assessment and Sg2: July 2004 S1 – S2: Fall 2004 DFSS and Personalized Healthcare: 2005 LEAN: 2006

GE

Virtua

Clinical & OperationalExcellence

Financial Performance Management

Technology Optimization

Strategic Planning

& Business Development

Learning &Leadership

Communication& Public Relations

The Basis for the Agreement

Partnership Today

GE

Virtua

Clinical & OperationalExcellence

Financial Performance Management

co

Technology Optimization

Strategic Planning

& Business Development

Learning &Leadership

Communication& Public Relations

• Greenfield planning• Hospital Workflow• Sg2 relationship• S1 & S2• POE Development

• Leadership and Mgmt Systems• G & Os/Best People • GE CXO site visits• S1 and S2• POE development

• GE Technology Assmt• Digital IDN• PACS• EMR• Exablate (Insightec)• Work Flow Evaluation

• World Health Congress• NBC 10

• Exablate• Women’s Health Tour

• Attaché• Women’s Health Symposium• Lean Symposium

• Six Sigma• DFSS• Lean• Personalized Healthcare

• GE Card Services• GE Capital• Healthcare Financial Services

November 6th, 2006

Partnerships 10 Year Strategic Partnership with General

Electric 3 years into the relationship Full time Enterprise General Manager dedicated to

Virtua Engagement with Jeff Immelt

“Virtua is a think tank of ideas” “In order for our business to continue to grow, our

customers need to be healthy and we want to help them get there”

Virtua does not need to make everything Has created the opportunity to work with

other appropriate industry partners

November 6th, 2006

Info Access + Process Reliability + Efficiency =

Safety, Quality

Paperless

Filmless Wireless

November 6th, 2006

A Very Complex Project…

November 6th, 2006

Information Technology

Partnering with GE on many fronts for this initiative

Creating new roles in Healthcare: Informaticists and Management Engineers

Need a combination of the Virtua Tool Box and great people to undertake this task

Most organizations will underestimate the amount of training that will need to take place over the next couple of years

The Application of Tools at Virtua

November 6th, 2006

Current State:

STAR Commitment

Desired State: STAR Performance

It’s Great to Have a Philosophy . . . But We Need a Strategy !!

The Virtua Tool Box is a part of our strategy

on our journey through the maze

The Virtua Tool Box is a part of our strategy

on our journey through the maze

November 6th, 2006

Usual pattern of process improvement (when improvement takes place!)

Process improvement with CAP and the Control Phase of Six Sigma

The Challenge…..

VIRTUA’S VIRTUA’S Performance Performance Journey Journey Continues…Continues…

WJ: Quality Circles: early - late 1980sMH: Morbidity and Mortality Reviews, Quality Audits

WJ: Quality Assurance: mid 1980’s

MH: Quality Assurance: mid 1970’s to mid 1980’s

WJ: Quality Assessment: late 1980’sMH: Quality Assessment mid to late 80’s (Leadership explores Total Quality Management Concepts with VHA 1988 - 1990)

WJ: Total Quality Management: early 1990s

MH: Total Quality Management 1990 - 1995

WJ: Re-engineering / Patient Centered Care: mid 1990’sMH: Metric Focused Quality Improvement (AQP) / Patient Focused Care: mid 1990’s

Virtua Health: STAR, Six Sigma/CAP/Workout, Becoming a Learning Organization - October 2000

Virtua Health: LEAN, Simulation, Management Engineering November 2003

Virtua Health: Leadership and Management Systems, DFSS-C 2004 - 2005

November 6th, 2006

The Tool Chest

Paths to Change•Strategic Decision

•Operational Issue Requiring a Decision

•“Wisdom of the Group” Problem

•Eliminate Delay/Waste

•Eliminate Defects

•Design Out Defects

Change Acceleration

WorkOut

Lean

Six Sigma

Execute

Design for Six Sigma

November 6th, 2006

Solid tools but….

Quality tool Vague goals No standard metrics Open-ended, unstructured Department-based Focus on product quality

Real results that matter to customers….

Business tool Clear goals/deliverables Clear, consistent metrics Rigorous timeline Business-based Focus on customer

Six Sigma builds on Lessons Learned from prior approaches

TQM Six Sigma

What Makes Six Sigma Different?Adapted with permission from Hamadi Said, US Mint Philadelphia, PA

November 6th, 2006

Financial ImpactOperations Improvement Annual Cost

$-$200,000$400,000$600,000$800,000

$1,000,000$1,200,000$1,400,000

2000 2001 2002 2003 2004 2005 2006

Year

Dol

lars

Operations Improvement Annual Benefits

$-

$1,000,000

$2,000,000

$3,000,000

$4,000,000

2000 2001 2002 2003 2004 2005 2006

Year

Dol

lars

Operations Improvement Net Benefit

$(2,000,000)

$(1,000,000)

$-

$1,000,000

$2,000,000

$3,000,000

$4,000,000

2000 2001 2002 2003 2004 2005 2006

Year

Do

llar

s

Drill Down on the Tools

Change Acceleration Process (CAP)WorkOut

LeanSix Sigma

Change Acceleration Process (CAP)

If we all know change is hard, why does resistance to change keep

sneaking up on us???

November 6th, 2006

When To Use CAP

DecisionsWorkOut

RecommendationsSix Sigma ProjectsAny Time Change is

Desired

November 6th, 2006

WorkOut

1 or 2 DaysTrained CoachesSponsor and Process OwnerSensing Session (Issues,

Participants, Boundaries, Deliverables)

Planned agendaChargeReport OutW W W

November 6th, 2006

CategorizeProblems/Barriers

Ease Implementation

Define the Problem

BrainstormProblems/Barriers

Define “Headers”for Categories

Prioritize Categories

2 10 9 1 6vo

tes

Brainstorm Potential Solutions

AssessPotential Solutions

Pa

y-o

ff

Develop Action Plans

Share Action Plans

Report-Out Action Plans

Kick-Off

Ground Rules, Introductions,

Roles, etc

Mission

What: Who: When: Resources

CategorizeProblems/Barriers

Ease Implementation

Define the Problem

BrainstormProblems/Barriers

Define “Headers”for Categories

Prioritize Categories

2 10 9 1 6vo

tes

Brainstorm Potential Solutions

AssessPotential Solutions

Pa

y-o

ff

Develop Action Plans

Share Action Plans

Report-Out Action Plans

Kick-Off

Ground Rules, Introductions,

Roles, etc

Mission

What: Who: When: ResourcesWhat: Who: When: Resources

What a WorkOut Looks Like….

November 6th, 2006

WorkOut Issues

Ambulatory Surgery Workflow Community Acquired Pneumonia

SOPS Visitor Access to LTC Center FMEA Infant Abduction Rental Equipment Safety Inspections OR Case Cart Accuracy Patient Complaint Process Registration and Billing Accuracy in

Dental Center

Work Out: MedSurg Supply CostsWhat the Team Did … Why They Did It …

Extraordinary financial impact, gratifying cultural change, from two days work (and a year of

implementation!!!)

• Six teams of 8-10 people each met for two days to reduce supply costs by $821,000

Total savings? You decide!WorkOut on Feb 10, 2003

Challenge: $347,000 removed from budget with no plan for achieving

Came in under budget by $121,000

Total hard savings $468,000 by 12/31/03

Projected over spending: $473,000

? Total benefit of $941,000

• Six Sigma project on Supply Cost was terminated – wrong tool!

Teams from OR, Amb Surg, EndoCysto, MedSurg, ICU, ER all worked together

Learned from each other

No “victim” mentality

A true team success for the facility

• Used numerous strategies to communicate costs and waste to peers

• Quantified challenge as per-patient reduction

• Focused team on high volume low cost items

• Spread the awareness, recruited support

November 6th, 2006

What is Lean? Increasing customer value by eliminating waste

throughout the value stream*

* Based on definition in the book Lean Thinking, Womack & Jones, Simon & Schuster

In healthcare, Lean is about shortening the time between the patient entering and leaving

a care facility by eliminating all non-value added time, motion, and steps

We Spend 75-95% of Our Time Doing

Things That Increase Our Costs and Create

No Value for the Customer!

November 6th, 2006

The Lean Process

The continuous movement of products, services and information from end to end through the process

Define value in from the customers perspective and express value in terms of a specific product

Nothing is done by the upstream process until the downstream customer signals the need

The complete elimination of waste so all activities create value for the customer

Map all of the steps…value added & non-value added…that bring a product of service to the customer

2 Map the

Value Stream

3Establish

Flow

4Implement

Pull

5Work to

Perfection

1Specify Value

Using Lean to Improve a Process …Start Time: End Time: Total Cycle Time: 0:00

TAKT 22.65 minObserver: Sylvia Konopka Date: 12/7/04 Mark:

Step Description Time (secs.) Dist.(Ft.) VA VE Wait Travel Inspect NVA-OtherSame Day Surgery Admission

Pre-Surgical Screening (One-Week Prior to Surgery)0 Patient Arrives 0 01 Person at desks notifies Corrinne (screening person) 8 28 12 Corrinne walks to desk and checks off pt on sign in sheet 11 30 1 13 Corrine walks toward patient in waiting area to introduce herself 6 18 14 Corrine introduces herself to patient 1 0 15 Corrinne takes patient back to room 11 30 16 Patient Signs Paperwork 89 0 17 Corrine walks patient to per-surgical screening 84 137 18 Patient waits in pre-surgical surgical screening 577 0 19 Nurse takes patient into exam room B 20 28 1

10 Nurse asks questions/has pt sign papers 1670 0 111 Nurse takes blood pressure 168 0 112 Nurse takes temperature 14 0 113 Nurse draws blood 178 0 114 Nurse completes assessment 350 0 115 Nurse walks to phone to call anesthesia to come down 5 13 116 Nurse calls anesthesia 82 017 Patient waits for anesthesia, respiratory, and house doctor 108 0 118 House doctor arrives to do assessment 0 019 Respiratory arrives 0 020 Respiratory stamps forms, grabs pt bag, and leaves to come back later 128 23 121 Anesthesia enters room 0 022 Anesthesia completes assessment 313 0 123 House doctor completes assessment 596 0 124 Pt waits for respiratory to return 80 0 125 Pt is moved from exam room B to exam room A 17 20 126 Respiratory returns 1045 0 127 Respiratory completes assessment/instructions 109 0 128 Patient leaves building 138 147 1

Patient Wait to Pre-Op Holding29 Arrive in reg and get in line 6 36.6 130 wait in line 65 6 131 talk with ladies at front desk 15 0 132 sit down 13 20 133 wait in line 10 0 134 person at front desk walk to pt 5 0 135 lady at front desk with pt 20 0 136 Walk from Reg to OR Wait Rm Desk 59 172 137 Wait for clerk to show up to OR Wait Rm Desk 360 0 138 Check in at OR desk 0 0 139 OR desk to waiting area 0 73.0 140 Wait to be called to front desk for consult 365 0 141 Walk to front desk 8 73.0 142 Walk to consult room (1 or 2) 5 20.0 143 Clerk walks from desk to consult rm 1 or 2 87 16.0 144 Consult 108 0 145 Pt walks to seat in wait area 10 93.0 146 Clerk walks to desk 0 16.0 147 Wait until staff calls pt for bloodwork (if necc) 0 0 148 Pt walks from wait area to OR desk (if necc) 0 0 1

49 Pt and phlebotomist walk from OR desk to bloodwork area in pre-op room (if necc) 0 0 150 Bloodwork (if necc) 0 0 151 Pt walks from bloodwork area back to waiting area (if necc) 0 0 152 Wait until staff calls pt for pre-op 2767 0 153 Pt gets up 0 0 154 Pt walks from seat to pre-op door 15 30 1

STREAM: Same Day Surgery AdmissionValue Stream Map

1.0 Detailed process observations

2.0 Validated process map

Day of Surgery:

Distance = 4127.6 ft.

Patient

Nurse

3.0 Spaghetti analysis

5.0 Process improvement plan

4.0 Value analysis and improvement opportunity

November 6th, 2006

Lean: Making the Very Best use of the Resources We Have

Only the right work…. Only the right way….

Everywhere.…All of the Time!

November 6th, 2006

Before Kaizen After Kaizen

Operation Problem Actions Taken Results

Kaizen ImpactED physician workspace

Multiple locations for physicians to check for results leads to patient care delays

• Re-Organized physician work area

• Increased visual cues• Consolidated work space• Standardized work roles for US

and physician• Designated area for charts by

status• Piloted Biometric login

• One location for results• Consolidated physician area

for improved workflow access to resources

• Standard process for d/c mgmt

• Better visual cues• Fewer delays with system

November 6th, 2006

Before Kaizen After Kaizen

Operation Problem Actions Taken Results

Kaizen Impact

Fast Track Patient Flow

Fast Track delayed due to acute patient overflow

• Created dedicated Fast Track space• Added 2 acute beds!• Poke yoked beds for Fast Track

patients• 5S rooms to create standard

inventory of supplies• PA dedicated to Fast Track

• Clearer focus on the Fast Track patient and business

• Faster cycle time for Fast Track patients

• Fewer delays• More space for Acute

patients

November 6th, 2006

Before Kaizen After Kaizen

Operation Problem Actions Taken Results

Kaizen Impact

Fast Track Nursing Station

Congested, disorganized workspace

• Remove clutter and clean new area

• Moved DC Instruction printer to PA area

• Added Label printer and fax for rads

• IBEX monitor

• Better access for ED staff to resources

• Improved work area for PA

• Better IBEX status visibility

What measurements will the process owner use to confirm

sustained improvements? What system and structure changes

support sustained gains?

Define

Project Scoping

Operations Plan

Strategic Plan

Control

ImproveAnalyze

Measure

What is the right operational area for a project?

What is the right process result to address? What

does the customer expect? How is the current process

performing?

What are the most important factors driving the process results? What changes will deliver the desired process

result?

How well did the changes improve the process?

Project Conclusion

The DMAIC Process

Six Sigma

Acute Anticoagulation ServicesWhat the Team Did … Why They Did It …

Complex Clinical Processes Require Simplification and Error Prevention!

WBH protocol performance fully characterized

Successful transition to LMWH

Improved Lab-Nursing communication

Bed scales, new pumps, MAR

• Reduced process complexity from 92 to 21 steps

• “Catastrophic” failures were drivers of adverse outcomes

• Variation in approaches was creating opportunities for error

Project Results …

• Transitioned UFH to LMWH for DVT/PE and Acute Coronary

• Mistake-proofed UFH and LMWH administration processes (inc WBH MAR)

• Created SOPs for weighing patients and for communicating critical lab results

Labs were obtained, reported and addressed appropriately in the vast majority of cases

Rare failures were gross deviations from protocols

Simplification and Mistake-proofing are critical to patient safety

Learning's …

Revenue Generation ProjectWhat the Team Did … Why They Did It …

A successful project by any measure - productivity, revenue, sustained impact!

Medicare Length of Stay

• Developed SOP’s for billing carve out items

Agreement with MCOs on a simplified carve out billing documentation

Elimination of many unnecessary steps in billing process

Found and corrected over 22 procedures with carve outs which were not being billed

• Improve consistency of billing process

Year Billed Received

2000 $1,275,445 $498,410

2001 $2,585,151 $2,519,707

2002 $2,053,370 $1,740,604

2003 (YTD 6/03) $1,105,020 $834,316

Total (w Rx) $7,830,944 $6,305,348

• Revised Charge Master

• Restructured IS system for billing carve out items

• More accurate charges available for carve outs

• Eliminate non-value added steps, increase reliability and timeliness

Cardiac Meds: A PRO/CMS Quality Indicators Project

What the Cardiac Meds Team Did …

Why They Did It …

Project started in 7/02. All PRO indicators were achieved for Q4 ‘02. Project closed out in July ’03,

Success is sustained to date!

• Gaged current data collection system

Project requested by physician leadership

Documentation was more of a problem than the actual delivery of care

Major progress in achieving physician support for process improvement (including physicians firmly addressing physician outliers!)

• Improve quality and consistency of data

• Created a cardiac discharge instruction sheet

• “Contained” defects immediately while implementing more sustainable systems and structures to support improvements

• To obtain immediate results to achieve aggressive system targets

• Increase compliance from docs and support accurate data collection

Indicator Results

AMA ASA < 24 hrs >95%

AMI ASA at Discharge >95%

AMI Beta Blocker < 24 hrs

>95%

AMI Beta Blocker at DC >95%

CHF ACE at DC >90%

November 6th, 2006

CAP WorkOut Lean Six Sigma

ProblemI know the answer but I’m going to meet a lot of resistance

I have a rough idea of where we need to go. I want my team to work together to improve the process quickly.

I have to do more, faster with less. I want to be sure my team is as productive as possible

The process is important and it isn’t working. I’m not sure why. I need to understand my process better and pick the right solutions.

Deliverable

- Change management- Dealing with resistance- Maintaining the gains

- Helping those who do the work come up with and own great solutions

- Speed - Efficiency- Productivity- Removing waste

- Meeting customer expectations- Eliminating defects

Catch phrase

“Why are we always surprised by resistance”

“The people who do the work know

it best”

“We need to do more with less…. and faster too!”

“We need to get it really right for our customers!”

Turnaround

< 1 day 1 – 2 days 3.5 - 5 days 6 – 9 months

Facilitator CAP/WorkOut CoachCAP/WorkOut

CoachInformaticist/

Black BeltBlack Belt

Matching the Tool with the Task

Design forSix Sigma

This process is so broken we might as well start from scratch and we have new programs we are just starting – I need to build in my customers expectations

- Meeting customer expectations- Eliminating defects in the design phase of the process

“We need to design this

process correctly before we let our

customers experience it.”

6 – 9 months

Black Belt

Project Selection

November 6th, 2006

First Wave Projects Selection…Boiling the Seven Seas!

Employee RecruitingEmployee RetentionPatient Satisfaction in

Voorhees EDMarlton ORVoorhees ORCHFLessons Learned

What makes a good projectBite-sized projectsMultigenerational plan

November 6th, 2006

Subsequent Project Selection

Portfolio 3:1 Financial Return Non-Financial Projects

Alignment with Strategic Imperatives Operations Choice Deployment as our “Antennae”

MBBs propose to Operations Leadership Executive VP has final decision

November 6th, 2006

Project Selection Lessons Learned“Tripping over dollars”Where the money lives

Bad debt – “discoverable” Charge capture – invisible (and huge!)

Move to integrated planning via Wing-to-Wing Value Stream Mapping and Multi-Generational Planning

We don’t know our processes in sufficient detail to identify our biggest opportunities…..

We don’t know our processes in sufficient detail to identify our biggest opportunities…..

November 6th, 2006

Functions:The Reasons

Customers Seek Us Out

Processes: How we use our

Resources to deliver the Functions

Resources: The People and Things we use to make our

processes work

Sup

port

Depend

ence

What Makes a Health System Work?

AccessEmergent

CareSurgical

CareMedical

CareGuest

ServicesOther

November 6th, 2006

Planning &

Metrics

?

Operations

How Deep Is Our Knowledge?

Functions

Processes

Resources

AccessEmergent

CareSurgical

CareMedical

CareGuest

ServicesOther

November 6th, 2006

POEs & Strate

gy

Process – The

Missing Link

Budget

Where Do We Spend Our Time and Attention?

Access

EmergentCare

SurgicalCare

MedicalCare

GuestServices

Other

November 6th, 2006

POEs & Strate

gy

Process – The

Missing Link

Budget

The Impact of Resource Allocation with Inadequate

Process Knowledge

Access

EmergentCare

SurgicalCare

MedicalCare

GuestServices

Other

Failure of Processe

s

Failure in the Eyes of

the Customer

Wasted Resource

s!

November 6th, 2006

Functions:The Reasons

Customers Seek Us Out

Processes: How we use our

Resources to deliver the Functions

Resources: The People and Things we use to make our

processes work

Sup

port

Depend

ence

Enlightened Project Scoping

AccessEmergent

CareSurgical

CareMedical

CareGuest

ServicesOther

Lean

Six Sigma

WorkOut

November 6th, 2006

Virtua Levels of Training

White Belt: Foundation Team members (500-800)

CAP and WorkOut Coaches (206)Yellow Belt: Leaders Using the Toolkit

(356)Green Belt: Full Training with a “day

job” (56)Black Belt: Our Six Sigma Experts (22)Master Black Belt: Teaching,

Mentoring, and Continuity (5)

November 6th, 2006

Site Visits Leading

Practice Research

Peer to Peer Surveys

Photo Journaling

Technology Roadmaps

From-to Adjacency

High LevelFlow

ARENASimulation

IT Enablers

Evidence Based Design

Patient Experience

Desi

gn

Desi

gn

FutureState

FutureState

TransformationTransformation

DesignIntelligence

Move In

Move In

SafetyChecklists

Use of Tools in Hospital Design/Integration

November 6th, 2006

Use of Critical Pathway Program Output

Ante-partu

m

Post-partu

m

WHMSMed/ Surg

ICU

Tele-metry

NICU

Nursery

PCUPedia-trics

PICU

SPU

Mother/ Baby

L&D

Pts. From ED

Direct Admits

Mapping of patient flow to and from all inpatient units for each service line

November 6th, 2006

Lean Thinking Principles

Lean is all about simplifying processes Identifying which parts of a process add value Enabling care to flow more effectively by

eliminating wasteThe Five Principles

Define what value is to the patient or customer Identify where that value exists in a value stream Make the value steps flow by removing all obstacles Pull the patient along their journey, avoid the push Perfect and strive to standardize and improve

November 6th, 2006

Key Characteristics in Extreme

November 6th, 2006

Surgery

November 6th, 2006

Spaghetti Diagram – Pharmacy Schematic Design II

I.V. Pharmacist

Tech

I.V. Tech

Buyer

Total Miles Walked annually - 1st Shift (within pharmacy)

I.V. Pharmacist

Tech

I.V. Tech Buyer

64

127

124

205

Majority of picking and IV prep

contained in work cell

Drug storage/inventory is accessed often by IV

Tech

Med cart prep located centrally to IV prep and PO prep

November 6th, 2006

Buyer Space Relationship Diagram

Pickstation

Workstation 2

Refrigerator

Workstation 1

Back

Door

Workstation 3

Front

Inve

ntor

y

Room

Back Room

21-42

< 68-17

*Frequencies of movement are per 1st shift observed (6/12)

Buyer travels from to drug/storage inventory room

frequently, therefore adjacency is critical for buyer but not

critical for othersIV Tech, Pharmacist and Tech

have high frequency adjacencies that are within their work cells

Owner High Frequency Task Frequency

Tech Pick station to Tray 34

IV TechWorkstation I to

Inventory 39

IV PharmacistWorkstation to

Computer 30

November 6th, 2006

Comparison of Schematic Designs

Distance traveled annually (miles)

1st ShiftCurrent Design Option I Option II

IV Pharmacist

149 62 64

Tech 124 106 127

IV Tech 172 95 124

Buyer 123 205 205

Total 568 468 520

8'- 6

3/1

6 "

2'-1

0 1/

16"

November 6th, 2006

Leadership Implications

What a Black Belt learns: Who is the customer? What do they want? What is the process that leads yields our

product/service? How often do we disappoint our customer? What factors drive our process

performance (defects)? How to mobilize those who do the work to

improve the process Locking in the gains

And, these competencies/training/development are

delivered at a cost of…..

November 6th, 2006

Financial Impact

Operations Improvement Net Benefit

$(2,000,000)

$(1,000,000)

$-

$1,000,000

$2,000,000

$3,000,000

$4,000,000

2000 2001 2002 2003 2004 2005 2006

Year

Do

llar

s

A Profit!

November 6th, 2006

Leadership Implications

Recommended Educational Outcomes1

Change Management Finance and Reimbursement Populations- based organizational management Information systems and technology Quality improvement Standardization Consumer satisfaction Market and regulatory

strategic management of health services lifelong learning

1 PL Davidson et al. A Framework for Evaluating the Impact of Health Services Management Education The Journal of Health Administration 18:1 1-48 2000

November 6th, 2006

Tool Kit Summary

The right tool for the right taskTransparencyCommon languageHighly teach-ableThe people who do the work fix it bestProgress is easy for leadership to

monitorEveryone becomes an agent for

changeA highly plausible path to success

November 6th, 2006

Physicians and Hospitals:A Unique Business Relationship

Physicians:Drive clinical processesHeavily influence financial

performanceAre generally not employedAre difficult to influenceAre both Customers and

Stakeholders

November 6th, 2006

Physician Perspectives on Process Improvement

“Nothing ever

changes around here”

“Sure, I’ll be there. We’ll meet for months and

nothing will change”

“Didn’t we solve that two years

ago?”

“Administration never

delivers on their

promises”

“A meeting at 2PM!!! Are you

kidding?”“It’s just another Flavor of

the Month”“Admin is great at

saying no to things that will really

help”

“Oh no, not another

“Sticky Note” session - I’m outta here”

November 6th, 2006

Hospital Staff Perspectives on Physician

Involvement

“They only care about getting in

and getting out”

“They don’t have any idea how much work we put in on this”

“All they do is attack the data”

“Can’t someone

make them come to the meetings?”

“Yeah, they no- show then veto the plan!”

“You can’t get a

decision from the

docs” “This is a physician

issue”

November 6th, 2006

How is Six Sigma Different?

Projects start with Customer Requirements Process Average is only half the story

Variation must be evaluated and addressed

Prioritizes interventions based on basis of failures

Ambitious, quantifiable goals (3.4 DPMO) Focus on quantifiable, practical, business-

relevant results Rigorous Control measures assure

sustained benefit

November 6th, 2006

When Physicians Need to Change

Fix hospital “owned” systems first Fix hospital-physician interface

problems next Encourage complaints Improve the physician experience Demonstrate the “physician driven

delta” when it is Number One on the Pareto Chart

Go for the outliers The data better be good!

November 6th, 2006

ResultsNothing else mattersThis will win the docs supportMake them visibleMake them stickCelebrate the docs’ support and

success (don’t underestimate the power of this step!)

November 6th, 2006

What have we learned? Healthcare needs to act more like a

business We are doing that….

Healthcare needs to focus on what they do best

Consumerism will “consume” healthcare Data, data, data

Translates into increased outcomes decreased liability

The Virtua – GE learning has produced great results……