Lean in health care – crossing the hurdles final part 2

People asking questions… lost in confusion,

Well, I tell them there’s no problem… only lsolutions.

‐ John Lennon

EMBRACE IT !!!EMBRACE IT !!!

This may seem strange at first, but in fact many problems y g , y paren’t problems at all. In fact most problems are opportunities and many are actually ……

PINK BATS‐ unseen solutions just waiting to be found.

PINK BAT THINKING makes the impossible possible.

Usual major inefficiencies

Wasted motion

▪ Pharmacy tech

Rework

▪ X ray tech has to

Over production Excess inventory

▪ Admissionsspends 20 minutes looking in multiple places for a particular

▪ X‐ray tech has to re enter 10%‐20% of requests because of wrong

▪ Medicines held over in the wards excess than required

▪ Admissions paperwork having 7 redundant pages out in the

for a particular med

side indicationrequired .

16 page packet

Wasted transportation

Excess processing

Waiting time Wasted intellect

▪ 25% of patients admitted to 4M are transferred to a unit

ith i il l l

▪ Nurse records respiratory rate

4 diff t

▪ OR team waits 20 minutes for a case to b i d i t

▪ Numerous ideas are “lost” only to b di dwith a similar level

of care within 36 hours of admission

on 4 different forms in the chart

begin, and is not free to do other tasks

be rediscovered later

212 212120@S R M C@

Goal setting workshopWe as an organization are committed to being:

PATIENT CENTRIC‐ Being empathetic & transparent to patients by delivering timely, adequate care & sustainable processessustainable processes.

ETHICAL‐ Ensure transparency in all systems processes & servicessystems, processes & services.

COST EFFECTIVE‐ Delivering affordable care to patients by minimizing wastages and effective p y g gutilization of resources.

EMPLOYEE CENTRIC‐To go an extra mile to ensure t ff ti f ti t i i d l t dstaff satisfaction, training, career development and

overall safety.

INNOVATION‐To be an innovative organization byINNOVATION‐To be an innovative organization by the implementation of best practices and ownership of promised services through Team work. 212 degree @S R M C

212 Lean - Objectives

JCI Re accreditation & Sustenance of processes

Primary business focus on releasing capacity, increasing throughput and improving patient experience (e g lower waiting times)and improving patient experience (e.g., lower waiting times)

Improved utilization of assets

f d d fSuperior patient

3 key deliverables

Creation of a standard way of operating, processes, systems‐ IMPLEMENTATION OF BEST PRACTICES

Experience (visible improvements)

Superior clinician &Documentation of processes & creation of a STANDARD MANUAL

Training & skill development

Superior clinician & staff experience

Superior hospital

Visual management

In addition will take a 360º view to opportunistically identifying/

Performance (tangible financial benefits)

In addition, will take a 360 view to opportunistically identifying/ documenting other opportunities in areas we go deep in, but sequence out implementation

DDegreesReport on the P h d tPrephase‐ data

collection findingsbDecember 2010

ER

ORENDOSCOPY

2 CLINICAL SPECIALTITES

First PhaseOP

FOCUSIP

HOUSEKEEPING & STORES

RADIOLOGYADMISSIONS &

LABS

BILLING

212 degree @S R M C

DIALYSISPHARMACY

Overall Program Structure

LEADERSHIPDrive the initiative Monthly

reviews

Believe in the initiative & Sponsor it

Monthly reviews

Target Setting,Initiative roll outTrack milestones

CORE TEAM 10% of daily

timeDoctors ,

Nurses , & Admin ‐Track milestones

To ensure de‐bottlenecking and

10% of daily time Champions

OWNERSDepartment

TeamsOwn and drive implementation of initiatives

own and drive

80% of daily time

212 degree @S R M C

of initiativesEnsure debottleneckingSustenance of initiatives

25% of daily time

PRE PHASE 4‐6 weeksData collection by championsData collection by champions

MIRROR – MIRROR- One to One Interviews with Consultants, Nurses, staff and Patients

Organizational climate surveys

Patient Feedback mechanism changed to gNet Promoter Score

Collage competitions

Identify bottlenecks in processes

Draw Process Flow Analysis

Identify existing standards (baseline)

Presentation of facts and findingsSmart Service Desk

Presentation of facts and findings

HALL WALK212 degree @S R M C

To drop in your ideas

Root Cause AnalysisRoot Cause Analysis

CO‐ CREATE solutions

De‐bottlenecking processesDe bottlenecking processes

Implementation of best practices

Building capacity & capabilities

Parallel implementation of 4th

Edition JCI standards

Reviewing & monitoring phase

212 degree @S R M C

Reviewing & monitoring phase

INVESTIGATIVE PHASE FINDINGSINVESTIGATIVE PHASE FINDINGS

212 degree @S R M C

Operation Theatre

250 ENT

200

OG

PEAD.S

PLAS.S

GEN.S

NEURO

Average Utilization is 78%

100

150

SGE

ORTHO

OPTHAL

URO

VASCULAR

50

OMFS

DENTAL

CTVS

PSYCHIATRIST

SMILE TRAIN

0May‐10 Jun‐10 Jul‐10 Aug‐10

SPINE

ARTHROSCOPY

OTHERS

212 degree @S R M C Data collected from previous reports

Operation Theatre: Cancellation analysis Insurance not approvedPatient not fit

Patient not admittedNon availability of compatible

421

0

8

3

63 623

00

142

15

100%

Cancellation Analysis BloodTheatre busy

24

42

7

21

17

211

9

8

62

63

76

39

62

6

2 7

13

28

12

5

2

11

4

15

17

15

40%

60%

80%

28

36

2

8

23

21

0

228

60

61

60

76

4

2

0

6

7

24

11

10

11

12

16

0%

20%

40%

D RY N H E D E N R S G ON E S

September

August

July

T APPROVED/ C

ATEGORY N

OT PAID

NNO LO

NGER W

ARRANTS SURGER

Y

3. AW

AITING CONSU

LTATIO

N

4. PATIE

NT DEA

TH

5. WORK –U

P INCOM

PLET

E

6. PATIE

NT NOT A

DMITT

ED

EDIC

ALLY N

OT FIT

FOR PR

OCEDURE

OOD FOR IN

TRA‐

OP TRANSF

USION

9NON A

VAILABILI

TY O

F ATTE

NDER

MEN

T ISS

UES\IN

STRUM

ENT ISS

UES

11. PATIE

NT NOT W

ILLIN

G

ME U

NSUITA

BLE FO

R THE SU

RGEON

WITH

PREVIO

US/EM

ERGENCY C

ASE

14. M

ISCEL

LANEO

US

June

1. INSU

RANCE NOT A

2. PATIE

NT CONDITION N

7. MED

AVAILABILI

TY O

F COM

PATIB

LE BLO 9.

10. EQUIPM

12. ALL

OTTED TIM

E

13. SU

RGEON H

ELD U

P W

8. NON A


Endoscopy Maximum cases done are private in Medical Gastroenterology

Case Mix

Gastroenterology

196

PVT Ward Free OPD NB Ward Total No. of Cases

9262

190 3 3 9 4

19 7 2 0 0 9

MedicalGastroenterology

SurgicalGastroenterology

General Surgery


Endoscopy 81% of the endoscopies are done by two doctors

No. of Cases Performed by doctors 8%

2%6% 2% 1%0%

Dr. A

Dr. B

Dr. C

Dr. D

53%

28%Dr. E

Dr. F

Dr. G53% Dr. G

Dr. H


ENDOSCOPY An average of 345 endoscopies are done every month

ENDOSCOPY PROCEDURES

400

500

200

300

400

otal

(No.

)

0

100

200

Gra

nd T

o

Series1 331 405 363 284

AUGUST, JULY,2010 JUNE, 2010 MAY, 2010


Total TAT is about 75 min (even for a 15 min procedure)

212 degree @S R M C

AVERAGE TIME TAKEN BY A PATIENTIN ER20% OF ER CASES ARE

FEVER FOR

EMERGENCY

AVERAGE TIME TAKEN BY A PATIENT IN ER FEVER FOR EVALUATION & 13% FOR RTA.

617.4ALOS in ER is about 8 hours

451.2

617.4

600

700

Total TAT for Patient in ER is about 10 hours

400

500

600

Series1

100

200

300Series1

0

100

TOTAL LENGTH OF STAYIN ER (MIN)

TOTAL TAT FOR APATIENT IN ER(MIN)

212 degree @S R M C Data collected by observation

Cause of increased LOS is waiting for the investigative reports or bed unavailability

Patients routinely interact with 7‐9 different nurses during their stay in wards

Patient exposure to nurses

IN PATIENTS

Bed number shift 15-09-10 16-09-10 17-09-2010 18-09-10 19-09-10 20-09-10 21-09-10

A m

p

B m

C m

D m

E m

F e

G e

H e

I e

J e

K n

L n

M n

N n

O n

Different colours represent different nurses Data collected by observation212 degree @S R M C

212 degree @S R M C

MIRROR ‐MIRROR

212 degree @S R M C

MIRROR ‐MIRROR‐ EMPLOYEES

28 %

How many years you have been working with the hospital?

25

30 27 % 28 %

20 %

20 16 %

20 %

10

15

9 %

0

5

0 ‐ 2 years 2 ‐ 4 years 4 ‐ 6 years 6 ‐ 8 years > 8 years

Data collected by feedback 212 degree @S R M C

MIRROR ‐MIRROR‐ EMPLOYEES

%

The organization cares for me

35

40

45

31.8 %

41.9 %

25

30

35

10

15

20

9.48 % 7.95 % 8.87 %

0

5

Strongly Agree I am Disagree Strongly Strongly Agree

Agree I am indifferent

Disagree Strongly Disagree


MIRROR ‐MIRROR‐ EMPLOYEESNeed of the day at this hospital today is About 45% of the

staff feels that the processes need to be

40

45

45 % improved

30

35

4030.67 %

15

20

25

10 %

6 %8.33 %

0

5

10 6 %33

Better processes

Better infrastructure

Better technology

Better people Better IT


MIRROR ‐MIRROR‐ EMPLOYEESHave you visited the hospital before? It is 7 times easier

to retain anexisting patient

120 104

g pthan getting a new one

80

100 78

40

60

26

0

20

Total Yes NoTotal Yes No


MIRROR ‐MIRROR‐ EMPLOYEESNeed of the day at this hospital today is

Alarming‐ as there are about 23%

120 104of the patients who are DETRACTORSThey would never refer the hospital

to anyone

80

100

56

40

60

1912 12

0

20

Total 1 Never 2 3 4 5

5 12 12

Total 1 Never 2 3 4 5 Definitely


Next Steps

Solution designing & implementation

D il 30 i i b 212 D L dDaily 30 min reviews by 212 Degree Leader

Monitoring dashboards

5S WORKSHOP

212 degree @S R M C

REPORT CARD – Month Every patient Delighted

Score ‐

Asset Metric Unit Apr '09 May' 09 June' 09 Target OPD Patients waiting beyond 15 mins of appnt % 3% 5% 3% <5%PHC %age PHCs completed within defined TAT % 63% 76% 78% 90%ER Pts with LOS > 4 hrs in triage % 1% 0% 0% <5%

ER Ambulance response outside 10 mins % 0% 2% 0% <10%Score ‐Wards Discharges before 11 am % 34% 44% 43% 75%

IPD ALOS Days 4 3.75 4

OT & Cath Lab Procedure / Surgeries starting within 30 mins of scheduled time % 85% 91% 91% 90%

Lab Med Short lead test completed with in 1hour 30 mins % 77% 91% 90% 90%mins

Radiology USG reports within 15 minsX-ray reports within 30 mins % 38% 45% 46% 90%

Asset Metric Apr '09 May' 09 June' 09 Target OPD Calls Dropped % <5%

Score –ER Ambulance calls turned back % 0% 4% 3% <5%IPD Admissions denied % 0% 0% 0% 0%

OT & Cath Lab Surgeries rescheduled % 7% 5% 4% <5%

A t M t i A '09 M '09 J ' 09 T tAsset Metric Apr '09 May '09 June' 09 Target ICUs % Step downs planned % 46% 47% 63% 80

Billing Patients with final bill more than 5% of estimate % 10% 7.3% 5.8% <5%

Wards % discharges planned % 63% 78% 82% 80%Wards Length of discharge process Mins 203 202.5 180 120

Score –

Score = 1 = 2 = 3

House keeping TAT for room cleaning post discharge Mins 20 23 25 30

Score 67% 75% 81%

LAB – IDENTIFIED PROBLEMS & AND POTENTIAL SOLUTIONS

IDENTIFIED PROBLEM POSSIBLE SOLUTION ACTION TAKEN

“Frequent delay in transport of samples from ward to lab because of long waiting time

Provision of Pneumatic systemor prioritized lifts

Feasibility studies and installation

Blood collection &

t t because of long waiting time for the lifts

or prioritized lifts installationtransport

One Phlebotomist is assigned for wide area for collection. This leads to

Ward Nurse / Secretary to strictly follow the schedule

Education to be given to the ward nurses /

t idelay in collection after request creation especially during peak hours”

secretaries

Blood samples are Frequently lysed To increase the number of

Phlebotomists HR staffing plan reviewq y yespecially from ICU Phlebotomists g p

ICU staff nurse to be trained periodically in blood collection techniques

Structured education sessions with periodic

l tiD ring net ork in blood collection techniques evaluation--During network breakdown samples are dispatched to lab without hospital number and with only the name of patient. This causes confusion in processing and results of

All samples can be received with hand written hospital number from ward / ICU Th b ti b f

Education and information dissemination To improveprocessing and results of

samples Frequent Run time error necessitates shut down and restart of machines

They can be continuous numbers for easy verification

dissemination To improve network efficiency

212 degree @S R M C

5 S Workshop

212 degree @S R M C

Background

C RMCProject Title:5SCompany Name:

SRMC

Gemba: Ist Floor to 7th floor

Date: 07 05 2011

Preliminary Objectives

To implement 5S concepts in Admission Billing Lab Radiology Cardiology and

Date: 07.05.2011 8 GEMBAS for 7 floors

Concerns / Issues Needing Attention from one

Admission, Billing, Lab ,Radiology,Cardiology and EndoscopyTo stream line process for better efficiencyTo optimize output in each area

Concerns / Issues Needing Attention from one team

Find a place for scrapped itemsMaintain orderliness in change rooms/ cleaning

Team Name: TEAM BMembers: Lean members present‐Dr. UmaSekar, Dr. K.S.Sridharan, Dr. Naveen, Ms.Latha, Mr.Gunasekaran, Mr.Thikkaram, Ms. rooms

Educating all Gemba staffs on 5S principles, Retention period for documents not specified for Radiology

, , , ,Anuradha, Ms. Baghyalakshmi, Ms.Manimekalai, Ms.P.Sudha, Ms.Sheela, Sr.Devi, Sr.Mohana, Sr.Mythili,Core Team members‐Mr.Alagumuni, Ms.Gunasundari, Ms. Kokilavani, Ms.Jeyanthi, Ms.Sowbaghyalaksmi, y , g y

Action taken during workshop5 S Steps Actions takenSeiri – Sort Sorting of files, papers, consumables and stocks

Seiton Set in Identified suitable places for keeping the items andSeiton – Set in Order

Identified suitable places for keeping the items and labelling done for easy retrieval, floor mapping in radiology

Seiso –Cleaning

Extensive cleaning, dusting and mopping done

Before After Photos / Sketches Red tagRed tag

Red tag

Before After Photos / Sketches-Lab

Before After Photos / Sketches-Endoscopy & Star Health

What has changed…………………

WHAT CHANGES WILL THE PATIENT’S NOTICE IN YOUR GEMBA?

Area found to be more neat and clean than before

WHAT CHANGES WILL THE DOCTOR’S NOTICE?WHAT CHANGES WILL THE DOCTOR S NOTICE?

‐Things are well organized

WHAT CHANGES WILL THE GEMBA STAFF NOTICE?

ff f‐Staff will find easy to work when things are organized well

212 DEGREES

LabsLabs

iIIntroduced new tests and combined test panels ‐ average revenue 3.62 lakhs per

thmonth

Reduced lysis of samples in ICU’s from 0.3% to 0.07%

Reagent wastage minimized per month ‐ saving of 32,000 INR

Number of samples increased 25% of the times

The outliers for number of tests that are reported (>90 min) reduced form 30% to 3%

Pharmacy

iIReduced waiting time for OP prescriptions .

Dispensing TAT from 1hr 20 minutes to 50 minutes

Medical and Surgical Dispensing at one counterg p g

OROR

iINumber of surgeries per day increased from 35 to 38

Capacity released

% surgeries scheduled a day before (Gen Surg) increased from 65% to 100%g y ( g) 5

Cancellations (Gen Surg) reduced from 23% to 12%

Delay in first case starts (8:00 am) reduced to only 10% delays from 32% for Gen SurgDelay in first case starts (8:00 am)‐ reduced to only 10% delays from 32% for Gen Surgand OBG

ERER

iIPatients with length of stay more than 4 hours reduced from an average of 77 patients

d t ti t dper day to 10 patients per day

Cash collection in ER‐Average of 1.2 lakhs is increased due to release of capacity.

TAT Radiology investigations‐ reduced considerably

Dialysis

iI75% of the patients coming with appointments

Average TAT per dialysis chair increased from 2 to 2.3

Endoscopy

iIAppointment system in place

Slots for different consultants

Endoscopy utilization went up from 18‐ 48%py p 4

Release of capacity‐more cases can be done easily

IPIP

iIActivity card updations including implant costs, category fee etc – updated within 24 h f t t l d b tt i tihours of surgery to prevent losses and better communication

Cohorting in process

Room TAT decreased form 180 min to 45 mins

OPDsOPDs

iINumber of Gen Surg OP per day increased from 25 to 28

First OP case delays (9:00 am) reduced form 30 min to 15 min

Centralized Appointment system startedpp y

Number of repeat patients (OBG and Gen Surg) increased from 41 to 71

Radiology

iIVoice Recognition Software used for all reports‐ Saves time and errors

Separate IP and OP Slots‐ Streamlined processes and better visibility (All IP’s done on the same day and more OP’s are done)

Capacity released

Increased Equipment utilization

MRI scans increased from 21 to 26

Success Mantra……

Communication

Implementation of all solutions

Improved tracking mechanism‐Targets review & scorecard

Mirror Mirror‐Top 15 initiatives to be finalized for patient and employee satisfaction

Involvement of DoctorsInvolvement of Doctors

capacity released

Continuous internal reviews (daily, weekly, monthly)

Lean ‐212 degree is a journey, not a destination

Lean in health care – crossing the hurdles final part 2

Health & Medicine