How will Healthcare Reform Impact Reengineering Strategies to Transform Healthcare Delivery? Learning from Experience Presents: David Belson, PhD, Editor-in-Chief,

How will Healthcare Reform Impact Reengineering Strategies to

Transform Healthcare Delivery?Learning from Experience Presents:

David Belson, PhD, Editor-in-Chief, Journal Society of Healthcare Improvement Professionals

&Imran Chaudhry, FACHE, Regional Executive, Operational

Excellence, Providence Health & Services

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Speaker’s Profile

Imran Chaudhry Imran Chaudhry is the Regional Director of the Operational

Excellence and Project Management Offices for Providence Health and Services, southern California. He is responsible for providing the overall leadership for the deployment and execution of the Lean, Six Sigma, Change Management and Project Management methodologies across the Providence southern California hospitals.

Dr. David Belson David Belson, Ph.D. has helped dozens of hospitals and clinics

improve their productivity. He applies his background of over 30 years as a professor in Industrial Engineering. He has developed classes on improving healthcare operations and written articles regarding Lean and other methods for radiology, surgery, emergency departments and other hospital functions. He has initiated research projects funded by the California HealthCare Foundation as well as the federal and California governments.

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“Insanity is continuing to do things the way you’ve always done them and expecting the results to be different.”Albert Einstein

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About Providence Health and Services

• Not-for-Profit faith based healthcare organization

• 2nd largest healthcare provider in the Los Angeles County

• 9th largest employer in Los Angeles County• 700 licensed beds in the region • 12000+ Employees and Medical Staff

Members • 2.7 Million Uninsured people in the county

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History of Six Sigma and Lean

1986Bill Smith originated Six Sigma as a metric

1980’sRolled out in Motorola

1988Malcolm Baldridge National Quality Award

1990’sGE and AlliedSignal

(Radical changes in products and services)

2002Providence Health System

2003Providence California

1970’sToyota Production System…”Lean”

Lean Six Sigma

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Commitment and Involvement of the Senior Leadership!!

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2011Certified first batch of 13 Change Facilitators

Introduced Design Thinking and Innovation to the organization

Expanded focus to include the Medical Institute.

Expanded team to include Project Management

OE OE GrowthGrowth

2006 6 Resources

2011120

Resources

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VOC VOP VOE VOM

• Reduce cycle time• Reduce turn around time• Reduce infection rate• Reduce medication errors

Process Y’s

• Reduce Days to Bill• Increase throughput / Decrease LOS• Patient satisfaction

Year Imperatives – Y’s

• Become Leaders in markets where we serve• High Performance Organization• Achieve Strong Financial Results

Providence Big Y’s

Dir

ecti

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of

Imp

act

Begin Investigating Here!

x1 x2 x4x3

Linking Business Y’s to Process Y’s

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Level 1Key Business Metric

Level 2 BusinessProcesses

Level 4High LevelProcess Map for Project

Level 5Detailed Subprocess Map –Sub Ys and Xs

Length of StayLength of Stay

Feeder to BedFeeder to Bed ProvideProvideInpatient CareInpatient Care

Discharge Discharge Planning ProcessPlanning Process

Execute Execute Discharge OrderDischarge Order

Nursing Care

Order Turn Around

Time

Physician Referral Process

Practice Patterns

Doc Order

Schedule Exam/Study

Prep Patient

Patient Transport

Lab OrdersPharmacy Orders

Imaging Order TAT

ReadTranscribe

Results Available

Complete Exam/Study

Level 3High-LevelProcesses

Probably Measuring L1

Usually Not Measuring L2s

and L3s

Six Sigma and WO Projects

Levels Of A Process

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Prioritize Opportunities

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Why Define a Standard Metric

What is the Definition of:• ED Door to Doc• OR First Case Start Time• Patient Discharge Time

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In Scope

As Necessary

Out of Scope

Define: Understanding the Scope

What’s in the scope of the project

Make Sure all team members are on the same page

What may be looked at

What will not be assessed or reviewed in this project

PROJECT SCOPING

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Discuss Resources and Time Commitment Upfront!

A project SHOULD NOT TAKE more than 4 – 5 months to complete (few exceptions)

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All tools/processes are used synergisticallyAll tools/processes are used synergistically

MWork-OutTM

“Expert-driven”

Lean

“Data-driven”

H

MediumComplexity

HighComplexity

Six Sigma/Lean Six Sigma

“Waste Elimination”

Methodologies

Design for Six Sigma

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“Change in Paradigm/Futuristic”

CAP (“the glue”)

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Don’t Silo the Methodologies, its all about Continuous Improvement!!

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Change Acceleration Process

Q x A = R7 x 4 = 288 x 4 = 327 x 7 = 49

Quality x Adoption = Result

Focus on Q

Instead focus on A

Big Impact

It’s All About the Acceptance

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Leading Change

Changing Systems & Structures

CurrentState

TransitionState

ImprovedState

Creating A Shared Need

Shaping A Vision

Mobilizing Commitment

Making Change Last

Monitoring Progress

Change Acceleration Process

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Lean vs. Six Sigma

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Health Care Operations Improvement Work

David Belson, Ph.D.

USC Department of Industrial and Systems Engineering HCE Conference David Belson 2012

HCE Conference David Belson 2012 20

How do we improve healthcare performance?

Example projects

1. Emergency Department, Lean

2. Mammography clinic, simulation

3. Surgery patient flow, mapping

4. Primary care, doctor’s office, redesign

5. Technology solutions, RFID, EMR

Fixing the Emergency Department

with Lean


The most popular tool is LeanToyota method, Lean-Six Sigma, …

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• Hospitals, clinics, suppliers, hospital systems

• California Hospitals

• Providers nationally

HCE Conference David Belson 2012

Maximizes participation, reality (Kaizen)

2323HCE Conference David Belson 2012

LEAN Tools

• Kaizen, participation• Waste reduction• Mapping• 5 S• Value Stream

mapping• 5 Whys• Cause & effect• Pull

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• Standardize & simplify

• Visual Controls • Standard work• Kanban• Level & continuous

flow• A-3• PDSA / DMAIC

• & more …24HCE Conference David Belson 2012


Lean event;•ED department •“Lean” triage•Eliminated waste•Results; lower cost and

less waiting


Ideas from hands-on staff:

Results

ED’s Triage now:

• Fewer forms used

• Quicker handling of patient visit

• Less waiting time

• Fewer patients who left without being seen (the original objective)


Fixing the Patient Flowwith computer Simulation



Simulation

Computer Simulation

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No Show

GI Procedure

Recovery,Capacity 3

beds

Prep rooms and Procedure

room empty?Yes

(Exit)

93.9%

(Exit) no recovery

6.1%

No

Prep in Room

Proc bedsMon Tues

Scope to Sterilize

Patient

Check in

82.3%

(Exit) 17.7

Earliness Delay

Colo Scope

Endo Scope

Sterilize

(Exit)

Capture Scopes

Dummy Colo

Dummy Endo

Procedure not done

(Exit)

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daysComp

ScopeTech

0000

inRoom

Recovering in Room

Sterilize without batching

(Exit)

Get Procedure Room

Recovery Beds

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scopesPerDay

0000

scopesUsed

Decontaminate

Proc beds Tues-Fri

Set up(Prep)

PrepNursePrepNurseMorn

Inventory

Input Data

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• Observation & timing • Following patients and staff, interview• Hospital data


Steps Average room cycle (minutes)

1 Check-in 2 Registration 3 Waiting at reception area 4 Marsha- prep time 5 Room preparation 3

6 Tech out to bring patients and patient arrival 1

7 Patient changing 2

8 Questionnaire, cleaning etc. 3

9 Exam itself 5

10 Film processing, walk back and forth 7

11 Patient changing 2

12 Patient exit and tech back to room 1

13 Post processing, paperwork 4

Total at room 28 Minutes Average patients per day 19 Hours available 20 Hours Average time per patient 1 Hour

Analysis showed how mammography department could serve 50% more cases with no increase in staff or equipment.

Fixing Surgerywith Mapping



Lean Value Stream Map from Focus Group

Kaizen



Value Stream Map – Hospital Discharge

Spaghetti Diagram


Operating Rooms

Admitting, registration

Pre Op Pre Op Holding Recovery(PACU)

Inpatient Bed

Entry from outside Hospital

Inpatient Bed

Exit, return home

Basic Surgery Flow

Q

QQ

Q QQQ

Q

Improve with pull 38HCE Conference David Belson 2012

Surgery SurgerySurgeryRoomTurnover

1. Surgery end to wheels out

2. Room turnover, wheels out to wheels in

3. Wheels in to surgery start

RoomTurnover

Room Turnover Time, includes:• Wheel-out prior patient• Move out equipment from prior case• Clean room• Move in equipment for following case• Interview patient in Pre Op• Transport patient to operating room• Wheel-in following patient• Potential causes of delay:• Patient not ready in Pre Op• Patient paperwork not ready• Transport staff not available• Room not clean• Surgeon, anesthesiologist or nursing not available

Move not ordered

1. Surgery end to wheels out, includes:• Extubation of patient• Move patient to transport bed• Completion of paperwork• Disposal of drugs

Wheels in to surgery start, includes:• Assembly of clinical staff

(surgeon, anestheologist, surgeon)

• Confirmation of plan, “time out” step

• Move patient from transport bed to surgery bed

• Prep of patient• Intubation of patient

Surgery SurgerySurgeryRoomTurnover

1. Surgery end to wheels out

2. Room turnover, wheels out to wheels in

3. Wheels in to surgery start

RoomTurnover

Room Turnover Time, includes:• Wheel-out prior patient• Move out equipment from prior case• Clean room• Move in equipment for following case• Interview patient in Pre Op• Transport patient to operating room• Wheel-in following patient• Potential causes of delay:• Patient not ready in Pre Op• Patient paperwork not ready• Transport staff not available• Room not clean• Surgeon, anesthesiologist or nursing not available

Move not ordered

1. Surgery end to wheels out, includes:• Extubation of patient• Move patient to transport bed• Completion of paperwork• Disposal of drugs

Wheels in to surgery start, includes:• Assembly of clinical staff

(surgeon, anestheologist, surgeon)

• Confirmation of plan, “time out” step

• Move patient from transport bed to surgery bed

• Prep of patient• Intubation of patient

Wheels Out Time

Wheels In Time

USC 39HCE Conference David Belson 2012

Typical Surgery Patient Flow

Problems

Pre Op delays

Physical Layout constraints

Pull system needed

Scheduling inaccurate &

ineffective

Communicat ions lacking

Charge Nurse ineffective

Report Card lacking

Utilization of staff and rooms low

Surgery Operational Problem AreasIssues are similar among hospitals.


Fixing the Primary Care Doctor’s Office with Redesign


Old Process


New Process


Fixing Patient Waiting with Technology


Patient wristband with RFID chip



Staff can see what patient is where and how long they have been there.

Who does Healthcare improvement?Who does Healthcare improvement?

• External consultantsExternal consultants• Designated internal departmentDesignated internal department• Responsibility of managersResponsibility of managers• Certified or uncertifiedCertified or uncertified• Corporate vision (or not)Corporate vision (or not)

HCE Conference David Belson 2012HCE Conference David Belson 201247

• Time for a given activity reduced by over 50 %• Amount of human effort needed reduced by > 50

percent.• Defects reduced by > 90 %• Injuries and sick days reduced by over 50%• Cost of a given activity reduced by 30 – 50 %• Work force dissatisfaction and turnover reduced

dramatically.

Results are significant


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David Belson, Ph.D.

USC Department of Industrial and Systems Engineering

HCE Conference David Belson 2012

http://healthcareengineering.usc.edu

[email protected]

http://www.jship.org/home/

http://healthcareengineering.usc.edu/

mailto:[email protected]



How will Healthcare Reform Impact Reengineering Strategies to Transform Healthcare Delivery? Learning from Experience Presents: David Belson, PhD, Editor-in-Chief,

Documents

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