Implementing Process Improvement In Healthcare By Gagan Rajpal With Craig A. Stevens PMI Nashville Symposium

Creating a Team Focused Improvement Program Agenda Goals/Objectives General PI Processes ✓ Process Analysis Value Chain Analysis Layout Analysis and Spaghetti Diagrams SPIOC 88 Summary of PI Program Approach This is an example text. Go ahead and replace it 3 3 PI Assessment and Performance Measures

Process Improvement is all about implementing changes; many times these are small, requiring no project management. However, other improvements require major changes that become projects. The biggest problem with many of the process improvement programs is that you have to have a degree in statistics or engineering to understand them. However, it does not have to be that way. During this presentation, we will apply a simple three- phase Process Improvement process using PM, LEAN, Six Sigma, and TQM approaches to real Healthcare examples as applied by University of Tennessee’s Industrial and Systems Engineering Department. Implementing Process Improvement In Healthcare 1/7/20133

Reinforce the Simple Three Phases To Show Some Examples of Process Improvement using Healthcare Goals and Objectives This Presentation Improvement Focused Teams 4

Creating a Team Focused Improvement Program Agenda Goals/Objectives General PI Processes ✓ Process Analysis Value Chain Analysis Layout Analysis and Spaghetti Diagrams SPIOC 88 Summary of PI Program Approach This is an example text. Go ahead and replace it 3 3 PI Assessment and Performance Measures ✓

Three Easy to Understand and Use Improvement Phases 6 A = Assessments P = Problem Solving I = Implementation Using Project Management Tools/Support

Westbrook Stevens, Seven Attributes of Excellent Management Model, 1990 © People and Team Building 7 From Book Geronimo Stone

Step 1 –Build the Assessment Candidate Portfolio Example

Hospital Service Doctor’s Office/ Department Patient Admissions Life cycle of a patient needing services at East Tennessee Children Hospital Incoming Patients A f t e r A d m i s s i o n s Resource Allocation

Step 2 –Assessment Phase 10 A = Assessments P = Problem Solving I = Implementation Using Project Management Tools/Support

Creating a Team Focused Improvement Program Agenda Goals/Objectives General PI Processes ✓ Process Analysis Value Chain Analysis Layout Analysis and Spaghetti Diagrams SPIOC 88 Summary of PI Program Approach This is an example text. Go ahead and replace it 3 3 PI Assessment and Performance Measures ✓ ✓

Hospital Service Doctor’s Office/ Department PatientAdmissions Incoming Patients PART I : Incoming Patients Applicable Lean Principle : Consistent incoming patient flow Incoming patient flow and trend

Hospital Service Doctor’s Office/ Department PatientAdmissions Incoming Patients PART I : Incoming Patients Applicable Lean Principle : Consistent incoming patient flow Incoming patient flow and trend

Number of patients in year 2007 & 2010 are extrapolated Is there any “trend” in number incoming patients over the years?

Is there any “trend” in number incoming patients over the years?

Is there any “trend” in “number” of incoming patients within an year?

Is there any “trend” in “type” of incoming patients within an year?

Is there any “trend” in “number” incoming patients within a week?

Is there any “trend” in “type” of incoming patients within a week?

Is there any “trend” in “number & type” of incoming patients within a day?

Creating a Team Focused Improvement Program Agenda Goals/Objectives General PI Processes ✓ Process Analysis Value Chain Analysis Layout Analysis and Spaghetti Diagrams SPIOC 88 Summary of PI Program Approach 3 3 PI Assessment and Performance Measures ✓ ✓ ✓

Hospital Service Doctor’s Office/ Department Patient Admissions Incoming Patients Is staffing logistics appropriate? Is patient registration a smooth process? Current layout PART II : Patient Admission Applicable Lean Principle : Efficient, effective and reliable admissions process

Hospital Service Doctor’s Office/ Department PatientAdmissions Incoming Patients Is staffing logistics appropriate? Is patient registration a smooth process? Current layout PART II : Patient Admission Applicable Lean Principle : Efficient, effective and reliable admissions process

Step 2 –Assessment Phase 24 A = Assessments P = Problem Solving I = Implementation Using Project Management Tools/Support

Is staffing logistics appropriate?

3-4 registrations/ hr Is staffing logistics appropriate? Temporary solution will be to move one of the evening personnel to the peak hours

Doctor’sOffice PatientRegistration Pre-Cert # Order Patients Name Date of birth Diagnosis Tests to be done Doctor’s Sign Legal guardianship House Address Is patient registration a smooth process? Rarely on Order Bad Faxes No signature Legal guardianship paper No diagnosis on order Not having insurance card No Order Grand parents or Neighbors Step parents Interpreter

Admissions Doctor’s Office/ Department Insurance Company Parents Operator Is patient registration a smooth process? (Continued)

Step 3 – Build the Problem Solving Portfolio 29 A = Assessments P = Problem Solving I = Implementation Using Project Management Tools/Support

Recommendations  Pre-screening orders and have more proactive approach Creating a Kanban system for orders that need attention  Having Pre-cert # already on the order  Having a “complete” & “readable” order Better fax machines “Standard format” for orders (Website access to input patient data) No need for faxes Direct upload onto the database Can be easily read Time & Money saved  Pre-registration on phone  In case of surgery, doctor could send order directly to surgery  In case of standing order, direct admit

Creating a Team Focused Improvement Program Agenda Goals/Objectives General PI Processes ✓ Process Analysis Value Chain Analysis Layout Analysis and Spaghetti Diagrams SPIOC 88 Summary of PI Program Approach 3 3 PI Assessment and Performance Measures ✓ ✓ ✓ ✓

The current layout 1.4 Miles/ shift

Recommendations  Change the current layout  Apply principles 5 S in patient admissions office Sort (Seiri), Straighten (Seiton), Shine (Seiso), Standardize (Seiketsu) and Sustain (Shitsuke)

Step 6 – Select the Solutions and Build a Project Portfolio 34 A = Assessments P = Problem Solving I = Implementation Using Project Management Tools/Support GFR

The “current” layout Front Desk Call Center Fax Room Marty’s Office The “new” layout

The Achievable Target 5-6 registrations/ hr

Creating a Team Focused Improvement Program Agenda Goals/Objectives General PI Processes ✓ Process Analysis Value Chain Analysis Layout Analysis and Spaghetti Diagrams SPIOC 88 Summary of PI Program Approach 3 3 PI Assessment and Performance Measures ✓ ✓ ✓ ✓ ✓

Hospital Service Doctor’s Office/ Department PatientAdmissions Incoming Patients A f t e r A d m i s s i o n s Resource Allocation PART III : After Admission Patient flow Alignment between admissions & services provided Lean Principle Applicable : Customer satisfaction due to the reduction in wait time via Just In Time system/ pull system

Hospital Service Doctor’s Office/ Department PatientAdmissions Incoming Patients After Admissions Resource Allocation PART III : After Admission Patient flow Alignment between admissions & services provided Lean Principle Applicable : Customer satisfaction due to the reduction in wait time via Just In Time system/ pull system

Step 2 –Assessment Phase 40 A = Assessments P = Problem Solving I = Implementation Using Project Management Tools/Support

Focus Areas

Focus Areas

Value added Vs Non-value added time Patient registration Explaining the procedure Taking history Actual procedure Redundancy Waiting Walking/ transportation Excessive processing Errors

Current state 38.7 % Non-value added time

Current state 70 % Non-value added time

Current state – OPS Ear Tube Lead time: 233 min VA/ T: 85.3 min WIP: 168 min 63.4 % Non-value added time

Current state 55.6 % Non-value added time

Current state 46.6 % Non-value added time

 Redundancy in paper work  Waiting for technician  Waiting for room  Same questions asked by several personnel  Orders lost  Delay in bringing patients from the floor lack of transporter technician being busy with other patients sometimes lack of technicians Types of waste

Current state – OPS Ear Tube 4 th Floor 6 th Floor

Creating a Team Focused Improvement Program Agenda Goals/Objectives General PI Processes ✓ Process Analysis Value Chain Analysis Layout Analysis and Spaghetti Diagrams SPIOC 88 Summary of PI Program Approach 3 3 PI Assessment and Performance Measures ✓ ✓ ✓ ✓ ✓ ✓

Hospital Service Doctor’s Office/ Department PatientAdmissions Incoming Patients After Admissions Resource Allocation PART IV : Resource allocation model

Hospital Service Doctor’s Office/ Department PatientAdmissions Incoming Patients After Admissions Resource Allocation PART IV : Resource allocation model

Step 3 – Build the Problem Solving Portfolio 54 A = Assessments P = Problem Solving I = Implementation Using Project Management Tools/Support

1.To increase service/ patient satisfaction 2.To minimize cost Depends on- - Number of people - Time/ Schedule of different departments Allocation of resources to patient admissions

SIPOC - Department - Doctor Patient -Time - Schedule Admissions to the entrance of the service Service -Time - Quality Patient Supplier InputProcess Output Customer Logic : Ability to provide resources to serve the customer Resources are provided in the process, therefore, they should dictate the schedule Our approach

InsuranceInsurance OrderOrder Relation to PatientRelation to Patient Social Security #Social Security # AddressAddress Doctor’s nameDoctor’s name Service RequiredService Required Availability of serviceAvailability of service # of patients in queue for service# of patients in queue for service Avg. time required for serviceAvg. time required for service Input

Admissions X-ray Pulmonary Lab Neurology Surgery Type - 1 Type - 2 Type - 3 Type - 4 Type - n Patient QAQAQAQA Q S1 Q S2 Q S3 Q S4 Q S5 Q S11 Q S12 Q S13 Q S14 Q S1n Output = Min: ∑ Q A + Q S1 + Q S Output

1.To increase service/ patient satisfaction 2.To minimize cost Depends on- - Number of people - Time/ Schedule of different departments Allocation of resources to patient admissions

SIPOC - Department - Doctor Patient -Time - Schedule Admissions to the entrance of the service Service -Time - Quality Patient Supplier InputProcess Output Customer Logic : Ability to provide resources to serve the customer Resources are provided in the process, therefore, they should dictate the schedule Our approach

Insurance Order Relation to Patient Social Security # Address Doctor’s name Service Required Availability of service # of patients in queue for service Avg. time required for service Input

Admissions X-ray Pulmonary Lab Neurology Surgery Type - 1 Type - 2 Type - 3 Type - 4 Type - n Patient QAQAQAQA Q S1 Q S2 Q S3 Q S4 Q S5 Q S11 Q S12 Q S13 Q S14 Q S1n Output = Min: ∑ Q A + Q S1 + Q S Output

Creating a Team Focused Improvement Program Agenda Goals/Objectives General PI Processes ✓ Process Analysis Value Chain Analysis Layout Analysis and Spaghetti Diagrams SPIOC 88 Summary of PI Program Approach 3 3 PI Assessment and Performance Measures ✓ ✓ ✓ ✓ ✓ ✓ ✓