1. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Clinical Process Analysis Program: Critical Tools for Improvement and Costing September 19, 2012 UT CS&E Pre-Conference Workshop

2. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Introduction Program history Team introduction Organization of content –Chronological use of tools by phases –Outpatient & Inpatient Practice sessions using tools Handouts

3. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center “This is an organization chart” said Dr. Deming (1947)!

4. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center HOW WE IMPROVE WHAT WE DO WHY WE DO WHAT WE DO HOW WE PERFORM OUR SERVICES PLAN TO IMPROVE DESIGN AND REDESIGN CUSTOMER KNOWLEDGE H.C. ENVIRONMENT COMMUNITY NEED SUPPLIERS PROCESSES Healthcare Organization As A System (Deming: Production as a System p.4; Adapted by Paul Batalden, MD 1990) OUTCOMES MEASURES INPUTSINPUTS OUTPUTSOUTPUTS Operations Finance Clinical Outcomes CUSTOMERS Satisfaction VISION

5. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center 1. WHY WE DO WHAT WE DO 3. HOW WE PERFORM OUR SERVICES MD Anderson Cancer Center as a System (Based on W. Edwards Deming “Production as a System”) INPUTSINPUTS Outcomes Costs = Value Needs of Society Relative to Cancer Needs of Cancer Patients and Families Vision: Making Cancer History Plan to Improve: Profound Knowledge Applied to: Education Patient Care Research Design and Redesign Education Patient Care Research OUTPUTSOUTPUTS 4. WHAT WE DELIVER Staff Equipment Supplies Partners Etc. Adapted From: A Framework for the Continual Improvement of Health Care. Batalden PB. Journal of Quality Improvement Vol 19 No. 10 1993 Processes 2. HOW WE IMPROVE WHAT WE DO

6. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Clinical Process Analysis Program

7. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Participants: Clinical Lead: Designated clinical point person for the project Content Experts: Frontline staff Clinical Leadership: Clinical Administrative Director; Center Business Manager; CPA Team: Clinical Process Analysis Team, Nurse Manager; Medical Director; Quality Officer Performance Improvement SOT: Senior Operations Team Process Flow Chart, Direct Labor Cost & Opportunities for Improvement Clinical Process Analysis Program

8. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center General Outpatient Center Case Study:

9. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center What is it? Why is it used? When is it used? What does it look like?

10. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

12. DATA DIAGRAM PACU Data Diagram

13. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Practice Session Develop a Data Diagram for your clinical area using either the Outpatient Template or the Inpatient Template Time = 10 min Questions?

14. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center What is it? Why is it used? When is it used? What does it look like?

15. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

16. Menu In-Patient

17. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center What is it? Why is it used? When is it used? What does it look like?

18. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Blueprint Outpatient

19. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Blueprint Inpatient

20. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Blueprint Inpatient

21. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Blueprint In-Patient

22. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Practice Session Build upon the Data Diagram you developed earlier by indicating which service/activity type or input/output you will focus on. Using the Menu Template for either Outpatient or Inpatient, select the rooms or activities that take place in your clinical setting. Develop a Blueprint for your multidisciplinary workgroup to use when building the process flow chart. Time = 10 min Questions?

23. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center General Outpatient Center Case Study:

24. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

30. What is it? Why is it used? When is it used? What does it look like?

31. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

32. A great Process Flow Chart is: Chronologically correct Mathematically accurate Artistically simple Rule of Thumb:

33. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Uses for Process Flow Charts Identify opportunities for improvement (OFIs) Calculate direct labor costs Orient new staff Standardize processes Educate and inform patients Select new electronic nursing documentation systems

34. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center BUTCHER PAPER MARKERS INVISIBLE TAPE The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center STICKY NOTES

35. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center JOB CODES: Employee positions linked to salary groups

36. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

38. NOTE: Employee doing the activity is in boldface

39. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center If all perform the activity equally: -Rectangle is white -Use “and” between each If different people perform the activity at different times: -Rectangle is white -Note percentages and utilize “/” (meaning “or”) If different people within the same job code perform the activity at different times: -Rectangle is color-coded to job code -Use “/” (meaning “or”) NOTE: Pharmacy is lightface because it isn’t part of the inclusion criteria.

40. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

44. Facilitated by Clinical Process Analysis Team (CPA Team) Attendees: Clinical Content Experts, including Clinical Lead(s), Frontline Staff, and Clinical Leadership (i.e. CAD) Leadership facilitates staff attendance at the appropriate weekly meetings Leadership promotes psychological safety, which encourages staff to share reality of current processes CPA Team creates process flow charts from the weekly meeting interviews Clinical Content Experts review charts each week and provide feedback/corrections to CPA Team Updated chart is utilized at the next weekly meeting, and so on… Weekly Interview Meetings

45. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Next Steps Capture the voice of the patient Associate processes with management data reports Capture variation

46. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Patient comments accessed here

47. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

48. The final process flow chart includes:

49. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Practice Session Time = 15 min Questions? Using the Case Study handout, create a process flow chart. Utilize flip charts, markers and sticky notes!

50. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center General Outpatient Center Case Study:

51. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center

52. What is it? Why is it used? When is it used? What does it look like?

53. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Transcription Spreadsheet Total Cost of direct labor activity job codes time estimate probabilities Total Cost of direct labor activity job codes time estimate probabilities Total cost = $11.21 per patient

54. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Transcription Gives an accurate representation of how much time a process takes and how much it costs The calculations take into account the probability of activities occurring Gives a clear picture as to how staff is being utilized Provides a good quality check of data from the process flow charts

55. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Costing Direct Labor Costs –The portion of the total cost of the fulfillment of a service that is associated with salaries, benefits, taxes, and other expenses related to the personnel needed for the process. The CPA program only provides data to calculate the Direct Labor Costs

56. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center “A good costing system… … tells you which areas are worth addressing and gives you confidence to have the difficult discussions with medical professionals.” - Dr. Jens Deerberg-Wittram, Schon Klinic

57. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center When the process is improved, the transcription can be used to discover the savings in direct labor costs and time. The example below illustrates how identifying an opportunity for improvement and streamlining the process can save on time and direct labor cost.

58. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Below is the transcription prior to the improvement. The opportunities for improvement are highlighted and illustrate which entries will be removed or replaced. Total time per patient : 19.19 mins Total direct labor costs per patient: $11.21

59. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center This is the transcription after the improvement is made. You can see the difference in the total expected time and the direct labor cost. Total time per patient : 15.175 mins Total direct labor costs per patient: $9.10

60. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Summary What is it? Why is it used? When is it used? What does it look like?

61. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Opportunities for Improvement (OFIs)

62. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Summary Report Report for Executive Leadership with a summary of: –Direct labor cost –OFI list –Program evaluation –Recommendations

63. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Workshop Wrap-up Electronic copies of slides and resources Blank templates Email questions to Jessica Melchor @ xwmelchor@mdanderson.org xwmelchor@mdanderson.org

64. The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center Conclusion It’s up to us… Flood the Court!