Redefining Workflows with Lean and Simulation

10100.015\314516(pptx)-E2

SIMUL8 Corporation | SIMUL8.com | [email protected] 1 800 547 6024 | +44 141 552 6888

SIMUL8 Corporation | SIMUL8.com | [email protected] 1 800 547 6024 | +44 141 552 6888

Presenters

Sean Hartzell

Senior ManagerECG Management Consultants, Inc.

John Budd

Senior ConsultantECG Management Consultants, Inc.

SIMUL8 Corporation | SIMUL8.com | [email protected] 1 800 547 6024 | +44 141 552 6888

SIMUL8 Corporation | SIMUL8.com | [email protected] 1 800 547 6024 | +44 141 552 6888

Housekeeping

• Audio

• Q and A

• Recording available on simul8healthcare.com

Agenda

I. Introduction and Industry Overview

II. Large Primary Care Case

III. Orthopedics Case

IV. Conclusion

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5

I. Introduction and Industry Overview

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I. Introduction and Industry OverviewEvolving Economics

Traditional Organizations High-Performing Organizations02468

1012

CostCost

Profit

Profit

Pricing pressures from patients and payors will continue to push healthcare organizations to change the way they view their business model.

Fixed Price

An organization’s ability to manage costs through continuous improvement is currently a valuable competitive advantage but will soon be necessary for organizational survival.

Cost + Profit Margin = Price Price – Cost = Profit Margin

Old Equation New Equation

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I. Introduction and Industry OverviewWaste in the System

In September 2012, the Institute of Medicine (IOM) published its findings on waste in the healthcare system.

Optimize processes and establish a Lean culture that focuses on continuous improvement.

Develop and implement standard work and care protocols.

Conduct analysis of variance between providers in order to identify best practices.

Streamline processes to minimize unnecessary expenditures.

These areas will be the target of continued governmental and payor pressures. Organizations with strong continuous improvement programs will be the best prepared.

Emphasize a business model that views profit as a function of cost reduction.

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At their center, both methods encourage a systematic team-based approach to problem solving and an organizational focus on continuous improvement of key processes.

I. Introduction and Industry OverviewLearning From Other Industries

Lean • Emphasizes

continuous generation of value to the customer.

• Continuously seeks to reduce waste.

• Views improvement as a job responsibility of all employees.

Six Sigma• Emphasizes the

elimination of defects.• Heavily relies on statistical

analysis and tools.• Focuses on structured

projects with defined teams, led by improvement experts.

Lean Six Sigma has been used in countless other industries to eliminate waste from systems. It is now gaining traction within healthcare.

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Customer Focus

I. Introduction and Industry Overview Lean Production System

Origins

• Beginning in the 1950s, the Lean Production System was developed over the course of 30 years by the Toyota Manufacturing Company.

• Built on necessity in post-World War II Japan, it is a product of resource and capital scarcity experienced during the period.

• These economic pressures lead to many of the system’s foundational elements:

– Just-in-Time.

– Waste reduction.

– Changeover time reduction.

Themes

• Continuous reduction of waste.

• Respect for people.

• Create value to the customer.

• Economies of flow versus economies of scale.

• Seek improvement over perfection.

Lean has proven to be a product of its environment as it was developed and has thrived within organizations where change was the only alternative to failure.

“Improvement usually means doing something that we have never done before.” – Mr. Shigeo Shingo

The pinnacle of the Lean Production System is a customer focus. This is supported by Just-in-Time and Jidoka production methods. Finally, the entire system is built on a foundation of process standardization and stability.

Just-in-Time Jidoka

Standardization

Stability

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I. Introduction and Industry OverviewIntroduction to Lean Six Sigma

Origins

• Six Sigma methods were founded in the statistical analysis of manufacturing processes developed by Mr. Walter Shewhart and further refined by Mr. W. Edward Deming.

• Deming’s methods were initially adopted in Japan and were said to play a key role in the country’s rise to manufacturing prowess in the 1980s.

• Early U.S. adopters include Motorola, Raytheon, Kodak, and GE.

Themes

• Any variation from the goal is a loss to society.

• Defect reduction through fact-based root cause analysis.

• Process results are a function of its inputs.

“Processes are perfectly designed to produce the results that occur.” – Mr. Deming

Six Sigma seeks defect reduction through fact-based, data-driven problem solving tools that rely heavily on data analysis and statistical methods.

The Six Sigma standard aims to preserve six standard deviations from the mean before reaching the process output defect threshold. Process defects are reduced to less than or equal to 3.4 defects per million opportunities.

1s 2s 3s 4s 5s 6s1s2s3s4s5s6s xI

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I. Introduction and Industry OverviewSystematic Approach

• Determine scope, goals, and key stakeholders.

• Estimate timeline, budget, and resources.

• Map the current state through interviews and observation.

• Define key process metrics.

• Identify waste.

• Locate internal and external sources of variability.

• Ascertain causes of redundancy and errors.

• Prioritize potential changes.

• Implement process changes.

• Review outcome and CTQ performance in order to understand the impact of changes.

• Establish ongoing accountability and measurements.

• Monitor performance.

Define

Measure

Analyze

Improve

Control

• Define the problem.

• Measure current state.

• Analyze for root causes.

• Generate, prioritize, and implement improvements and countermeasures.

• Measure to confirm improvement.

• Standardize the new process.

• Respond to the need for further modifications.

• Restart problem solving process over again as appropriate.

Plan

Do

Check

Act

Together, Lean and Six Sigma utilize a systematic approach toward problem solving and process improvement that is based on the scientific method.

It is important to note that neither of these approaches are linear in practice, as improvement generally requires multiple cycles.

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I. Introduction and Industry OverviewSummary of Lean Six Sigma Tools

Define Measure Analyze Improve Control

Purpose

Frame the project and position it for success.

Collect and summarize data to understand the current state.

Determine root causes of variation and waste.

Identify, develop, and implement solutions.

Put strategies in place to assure improvements are sustained.

Tools

• Project charter.

• Voice of the customer.

• Critical to quality (CTQ) assessment.

• SIPOC.

• Current-state VSM.

• Fishbone diagram.

• Minitab (summary statistics, control charts).

• Paretto charts.

• Hypothesis testing.

• ANOVA.

• Correlation and regression.

• 8 wastes.

• 5 whys.

• Future-state VSM.

• 5S/visual management.

• Pull systems.

• Workload balancing.

• Single-piece flow.

• Standard work.

• FMEA.

• Training plan.

• Visual controls.

• Daily management.

While there are a multitude of tools available, the key to project success is appropriate selection and effective deployment.

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I. Introduction and Industry OverviewLean Six Sigma in Healthcare

The number and size of organizations engaging in Lean Six Sigma practices have continued to grow as they increasingly experience positive results.

• Thedacare reduced patient wait time and throughput in one family practice clinic in order to shift financial results from an annual operating loss of $400,000 in 2006 to a profit in 2009. – On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry

• The Pittsburgh Regional Health Initiative cut the amount of reported central line-associated bloodstream infections by more than 50%. The rate per 1,000 line days (the measure hospitals use) plummeted from 4.2 to 1.9. – ASQ.org (American Society for Quality)

• A major hospital in the U.S. was able to reduce inpatient mortality rates by 47.8%. – iSixSigma.com

• North Mississippi Medical Center reduced the number of prescription errors in discharge documents by 50%. – ASQ.org

• The Mayo Clinic’s Rochester Transplant Center reduced the cycle time from when a new patient made initial contact to setting up an appointment from 45 days to 3 days. – iSixSigma.com

• Mercy Medical Center decreased in-hospital mortality rates from 6.7% to 3.5%, a 47.8% reduction. – Medical News Today

In 2012, a study funded by the American College of Healthcare Executives found a 7:1 return on investment from Lean and Six Sigma projects.

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II. Large Primary Care Case

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II. Large Primary Care Case Situation

ECG Management Consultants, Inc., was asked to assist a large primary care clinic in developing and implementing performance improvement strategies,

while leveraging Lean tools and patient-centered medical home concepts.

The clinic had previously identified numerous areas of improvement throughout the year with a long-term goal of improving health

outcomes, increasing efficiency, and reducing costs.

• Develop an optimal patient flow. • Optimize scheduling processes.• Design a team-based care model. • Provide patient-centered care.• Define standards of care for preventive medicine and care management

processes.• Develop a culture of improvement, initially through daily huddles.

Conduct a value stream analysis and develop a future-state model and implementation plan.

Objectives

ECG Scope of Work

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II. Large Primary Care CaseValue Stream Analysis Overview

The Value Stream Analysis (VSA) is a Lean technique that enables organizations to gain a solid understanding of their current state, identify critical process areas

that need improvement, and begin the process of continuous improvement.

Key Considerations• Requires a team of dedicated staff to commit to participating in an uninterrupted 1-day to week-

long retreat to conduct the VSA.• Substantial work is required pre- and post-VSA retreat. • The VSA will be far more effective if the facilitators “go to the gemba.”• The VSA provides organizations with the improvement plan. The next struggle lies in

implementing the future-state plan and truly sustaining the changes and a culture of continuous improvement beyond implementation.

• Organizations embarking on VSAs need a strong leadership committed to a culture of change.

Develop project goals

and objectives.

Define process and

outcome measures.

Map current state.

Identify barriers and

opportunities.

Design future state and

improvement goals.

Develop training and

transition plan.

Implement. Sustain.

VSA Process

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II. Large Primary Care CaseApproach

A team of physicians, nurses, administrative assistants/schedulers, and other administrative staff spent 2 days conducting a VSA.

• Developed and concurrently managed two work streams focused on processes identified as priority improvement areas.

– Work Stream I – Team-based care, huddle processes, patient flow, and care management. – Work Stream II – Scheduling process, preventive care, staffing model, and patient navigators.

• Leveraged patient-centered medical home concepts as a foundation for developing the future-state plan.

• Mapped out the current-state patient flow, including identifying areas of waste, decision points needed, and opportunities for improvement.

• Developed recommendations for future-state model, addressing all activities in Work Streams I and II.

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II. Large Primary Care CaseResults

Check and stock rooms for the day.

Review schedule for the day and any

patient notes.

Bring patient back from

waiting room.

Review patient reason for visit,

snapshot, and care team notes.

Pend any orders for M.D./NP.

RN or L.P.N./M.A. administers

any approved vaccines or injections.

M.D./NP conducts visit with patient and submits

orders.

Care team conducts daily

huddle.

Room patient – vitals, chief complaint,

allergies, med list, medical/social history, and other data entry.

M.D./NP reviews medication list that

RN previously reconciled.

M.D./NP documents visit

in Epic, including care

plan, goals, and follow-up

instructions.

Print patient AVS to nursing station

and bring to patient.

AOA enters patient room with AVS and

assists check-out and

scheduling follow-up.

AOA provides patient with care team

phone number for other follow-up

needs and referrals.

AOA walks patient out of

clinic.

Patient Visit – Future-State Value Stream

The clinic retreat team developed a future-state value stream for pre-visit, prior day of patient visit, patient visit, and post-visit.

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II. Large Primary Care CaseResults (continued)

The clinic optimization retreat resulted in an improvement plan that ultimately helps improve efficiencies and reduce waste, allowing clinical staff to work at “the top of

their license” and provide high-quality, patient-centered care.

Recommendations

• Optimized patient flow, restructured huddle processes, simplified scheduling process, developed care teams, improved medication reconciliation process, and redesigned clinical space for improved efficiency and a collaborative environment.

• Establish a Primary Care Optimization Team and delegate a Physician Champion. • Initiate and expand upon the 6-month implementation plan for the future-state model with a

phased-in approach over time.• Develop and track measures of success – process, clinical, quality, and service.• Invest in improving and optimizing the IT infrastructure.

Lessons Learned

• Representation from various roles is crucial during the VSA.• Everyone has a different perception of the current state. • When planning the future state, set high expectations but also be realistic.• Spend the time prior to the VSA to walk through the “gemba” and understand the current state

yourself.

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III. Orthopedics Case

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III. Orthopedics CaseSituation

ECG was asked to assist an orthopedics group in designing and refining future-state provider and clinic master schedules via the use of simulation software.

Clinic Statistics

• 16 providers.

• 9 exam rooms.

– 2 swing rooms.

• 1 cast/bracing/splinting room.

• 2012 volumes = 14,121.

• 4 nurses.

• 1 medical assistant.

• 2 registration clerks.

• 10% unfilled appointments.

Project Objectives

• Optimize use of staff and room resources.

• Reduce bottlenecks in the distribution of clinic volume across sessions.

• Increase patient throughput and overall clinic volume.

• Reduce patient wait time.

• Improve access to available appointments.

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Operating Rooms

Emergency Departments

Clinic Operations

Space Planning

Disaster Planning

Identify Work Queues

Monitor Resource Utilization

Measure Event Duration

Optimized Platform

III. Orthopedics CaseOverview of Simulation Applications in Healthcare

Simulation models can be used to test changes in a risk-free environment to identify and implement the best solution.

CommonApplication

Areas

Simulation Capabilities

Evaluate Financial Outputs

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III. Orthopedics CaseProject Methodology and Client Results

• Operating hours.

• Provider schedules.

• Support staff.

• Exam rooms.

• Work flow processes.

– Check-in.

– Rooming.

• Visits = Increased 19%.

• Wait time = Decreased 40%.

• Physician utilization = Decreased 17%.

• Nursing utilization = Unchanged.

• Exam room utilization = Unchanged.

Findings

• Providers were the bottleneck resource.

• Work flows created inefficiency in deployment of providers.

Recommendations

• Redistribution of clinic sessions across days to reduce wait time for patients.

• Work flow modification to reduce rework by providers and increase clinic capacity.

OutputsInputs Over 500 variables were

needed!

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III. Orthopedics CaseSIMUL8 Screen Views

Simul8 captures wait time distributions for selected

processes in real time.

SIMUL8 provides graphical representation

of resources as they move along designated

pathways.

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Metric 1

Status Quo

Scenario 1:

Standardize

Provider Start

and End Times

Scenario 2:

Extend Clinic

Hours

Scenario 3:

Schedule

Providers for

Three 3-Hour

Sessions

Scenario 4:

Implement New

X-Ray Process

Scenario 5:

Implement New

X-Ray Process

and Reduce

Unfilled

Appointments

Scenario 6:

Extend Clinic

Hours and

Implement New

X-Ray Process

Patient StatisticsUnfilled Appointments 10% 10% 10% 10% 10% 0% 10%

Patients Registered 1,358 1,445 1,622 1,475 1,358 1,504 1,622

Patients Requiring X-Ray 60% 60% 60% 60% 20% 20% 20%

Total Patients Sent to X-Ray 813 865 972 883 269 298 321 Average Wait/Process Times (Minutes)

Wait Time at Registration 0 0 0 0 0 0 0Wait Time for Exam Room 4 5 6 5 3 4 3Wait Time to See Provider 7 7 7 7 6 7 6Median Time Spent in Clinic 98 98 103 98 57 59 59

Room StatisticsNumber of Exam Rooms 9 9 9 9 9 9 9Usage Rates 47% 50% 58% 45% 35% 44% 43%Average Hours Open Per Day 7.9 7.6 8.0 9.0 7.9 7.9 8.0 Cast Room Visits 544 579 649 592 408 453 487Nursing Procedures 339 361 405 368 339 375 405

Physician Statistics .Number of Providers 16 16 16 16 16 16 16Available Capacity (Hours) 658 679 769 693 658 658 769Total Utilization 106% 106% 105% 106% 90% 99% 89%

Planned Utilization 2 71% 71% 71% 72% 71% 79% 71%Rooms Per Provider 2 2 2 2 2 2 2

Support StaffNumber of Nursing Staff 4 4 4 4 4 4 4

Available Nursing Capacity 896 900 900 900 896 896 900 Capacity Used 44% 47% 49% 44% 41% 45% 46%Number of MAs 1 1 1 1 1 1 1 Available MA Capacity 225 225 225 225 225 225 225 Capacity Used 40% 42% 45% 38% 33% 37% 39%Number of Clerks 2 2 2 2 2 2 2 Available Clerk Capacity 456 456 450 458 456 456 450 Capacity Used 17% 18% 18% 17% 17% 18% 19%

ResultsProjected Annual Visits 14,121 15,032 16,873 15,344 14,121 15,639 16,873 Volume Change 0% 6% 19% 9% 0% 11% 19%Projected Change in Revenue -$ 96,958$ 328,927$ 132,970$ -$ 168,167$ 328,927$ Increase in Physician Capacity 0% 3% 17% 5% 0% 0% 17%Increase in Nursing Capacity 0% 0% 0% 0% 0% 0% 0%Increase in Non-Licensed Staff Capacity 0% 0% 0% 0% 0% 0% 0%

III. Orthopedics CaseOverview of Modeling Results

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Trial Calculator

Customizable to Situation

Varying Levels of Modeling

Financial Outputs

Current- and Future-State

Capture

Scenario Management

III. Orthopedics CaseSIMUL8 Analytics Capabilities

• Performance measure for all objects in simulation.

• Interactive P&L statements.

• Ability to track carbon footprint.

• Gantt chart generation of processes.

• Detailed log results for further analysis.

• Time graphs for visual insight.

• Results segregation to filter by label type.

– I.e., trauma patients versus fast-track patients in an ED.

• Trials for simulations to validate results.

Sample Reports Available

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IV. Conclusion

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Conclusion

As the healthcare sector continues to look for opportunities to reduce waste, SIMUL8 can act as a tool to weigh a wide

range of performance improvement opportunities.

• ECG has been able to marry SIMUL8 with its traditional performance improvement strategies.

• Substantial work is required pre- and post-VSA retreat.

• The VSA will be far more effective if the facilitators “go to the gemba.”

• The VSA provides organizations with the improvement plan. The next struggle lies in implementing the future-state plan and truly sustaining the changes and a culture of continuous improvement beyond implementation.

• Organizations embarking on VSAs need a strong leadership committed to a culture of change.

SIMUL8 Corporation | SIMUL8.com | [email protected] 1 800 547 6024 | +44 141 552 6888

SIMUL8 Corporation | SIMUL8.com | [email protected] 1 800 547 6024 | +44 141 552 6888

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