1. Bariatric Value Stream
-Introduction of myself and Meagan
-Here to talk about our performance improvement event
-The Bariatric Value Stream
AASA
October 2015
Elspeth rogers
Meagan schuette

2. Agenda Introduction Charter review Background Process Key findings
Improvement projects
Metrics
Conclusion

3. -Fun fact
Busiest bike valet in the country, at the base of the tram and adjacent to the clinic

4. Oregon Health and Science University
Approximately 575 beds
Portland’s largest business
with over 14,000 employees
One of only two level 1 trauma centers in Oregon
Only academic medical center
-575 beds
-The city’s largest employer
-One of 2 level one trauma centers
-Only academic medical center in the state

5. Bariatric Surgery Overview
1.1 Clinical MD
1.4 NP
1.0 RN
1.0 RD
.8 Patient Navigator
2.0 Surgery Scheduler/Patient Scheduler (Pt Coordinators)
1.0 Program Coordinator
.35 Student
-Clinical team is composed of

6. Bariatric Surgery Overview (FY 2015)
Visits
955 MD
1,343 NP
1,689 RD
231 Procedures
11,496 wRVUS

8. Process Leading to Kaizen
Early Fall we identified need for process improvement
Held several pre-Kaizen meetings, and blocked the time well in advance
Data collection and analysis
Visited visibility board at Medical Staff Office as potential solution for tracking
Engaged staff, nurses, providers in 3 day Kaizen event
-I had a surgeon with too much extra time on his hands
-We reached out to performance excellence group for help
-13 hours of planning meetings Oct-March
-Conducted data analysis
-24 hour event with report out to the entire team, performance excellence team and VP of Ambulatory Care

9. Bariatric Surgery Value Stream Charter Scheduling
Project Sponsor(s): Meagan Schuette, DHC Director &
Dr. Samer Mattar, Bariatric Services Medical Director
Process Owner(s): Elspeth Rogers , Division Manager
Problem Statement: Bariatric Services within the Digestive Health Center provides warm, caring, high quality surgical weight loss procedures. The Bariatric surgery system is overly complex with undefined goals and expectations and we are not meeting patient demands nor consistently utilizing our capacity.
Goal/Target:
(SMART – Specific, Measurable, Action-Based, Realistic, Time-based)
Service:
Increase PG scores to a mean of 91.3 (Would you recommend & ease of scheduling)
Increase staff satisfaction scores (send surveys for baseline)
Affordability:
Increase ‘Follow-through’ rate from 18% to 40%
Increase surgery hour utilization per week by 25%
Process:
Reduce patient lead time (initial request to surgery) from 207 days to 121
Surgery on 91st day from Nurse Practitioner visit
Reduce process steps from 27 to 23
Objectives:
Service:
1a. Improve orientation process flow
1b. Implement DMS for optimal resource allocation
2a. Identify higher follow-through rate patients
2b. Create visual management system for patients in pipeline
3a. Create standard work
3b. Create visual management for task assignment
In Scope:
Process from initial request to surgery
Epic
Initial bariatric surgery
Dietician
Out of Scope:
Medical decision making
Revisions (procedure)
Capital/software requests
Additional FTE
Online orientation
Standard of care
-The charter was developed in the Kaizen and clarifies the team direction and goals
-We identified that the current system was overly complex with undefined goals and that we were not utilizing our capacity
-Main goals were to:
-increase patient experience goals to a mean of 91.3
-increase our surgical follow through rate from 18% to 40%
-increase surgery hour utilization per week by 25%
-reduce initial request to surgery from 207 days to 121 days
-reduce process steps from 27 to 10
-Main objectives were to:
-create a visual management system for patients in the pipeline
-create standard work
-identify higher follow-through rate patients (female age 30-50, commercially insured)
Improvement Team Members:
Cherie Scott, Patient Coordinator Surgery Scheduler
Kim Medic, Patient Coordinator
Leigh Ann McDonough, Program Coordinator
Elspeth Rogers, Division Manager
Meagan Schuette, DHC Director
Resource Representatives:
Dawn Rondeau, NP
Nicole Farber, MA
Samer Mattar, MD
Jessica Pham, Student
Sleep, Practice Manager, Candi Martinez
Psychology, Tanja Doss
Epic, HOS (Stephanie Winchester)
Epic, patient facing (patient entered data)
Patient A
Management Guidance Team:
Sally Rogers, Director Dept of Surgery
Samer Mattar, MD, Bariatric Services Medical Director
Kevin O’Boyle, VP Ambulatory Services
Judy Carlson, Manager Practice Optimization
Assessment: 02/07/2015 Planning: 03/15/2015 Go/No Go: 03/15/2015 Event: 04/08-04/10/2015
30-Day Check-In: 05/29/ Day Check-In: 6/30/ Day Check-In: 7/30/2015 Facilitator(s): Gretchen Landgraf, Travis Wilds, Hai Molinaro

10. Kaizen – Current State Value Stream Map
Overly Complex
Where is the patient?
Over processing of ‘Green Sheet’
-Current state value stream
-27 steps!
-Patient is lost in the process
-Over processing of patient intake and form was a visual que

11. Kaizen- Current State Value Stream Map
-This is how I felt trying to follow current state
"Comical Processing" features drawings by award-winning cartoonist Jerry King.

12. Key Findings - Opportunities
Improve orientation process flow
Implement daily management system
Identify and expedite higher follow-through rate patients
Create visual management system in pipeline to eliminate bottlenecks
Create standard work for scheduling staff
-Key findings of the event

13. Future State Value Stream Map
Patient-centered
10 steps
Parallel processing
Standard Work
-Future state mapping is patient centered
-Ten steps, the 11th is surgery completed
-Parallel processing to get patients through the system faster

14. Post Kaizen Improvement Projects
Visibility board and daily management system to track patient progress and identify abnormalities
Eliminate new patient intake form as pace setting barrier
Increase orientation class frequency (and add on-line class)
Daily readiness huddles and weekly patient progress huddles
Staff work re-alignment
Standard work for scheduling staff
-Main improvement projects:
-visibility board and daily management system to track patients progress through pipeline
-eliminate patient intake form as pace setting barrier
-increase orientation class frequency
-daily/weekly huddles
-create standard work

15. Journey to Transformation Board
-Photo of visibility board
-Pt names at top covered by blue stickys
-Green check completed
-Red is either in process or not complete
-The team huddles at the board weekly to identify bottlenecks

16. How are we doing? Metric Pre-Kaizen Event 120 Day
Time from orientation to NP visit
61 days
30 days
Orientation to Surgery
221
107
Hours of operating room time (per week)
9.7
11.7
Overall Patient Satisfaction Mean
91.6
89.6
-Positive results in almost all areas

17. Bariatric Surgery Hour Utilization (%)
-Kaizen took place April 8th-10th
-21.6% increase in surgery hour utilization per week

18. Next 120+ days Continue to refine Epic episodes (patient checklist)
Create standard work for entering episodes
Electronic Journey to Transformation visual board
Analyze abnormality tracker and how to use it
Track and measure outcomes/metrics
Focus on patient experience goals
On-boarding new surgeon
-We have just built episodes, checklists and reporting workbench

19. Lessons Learned
Kaizen did not magically improve patient experience scores as initially thought
Not everyone buys into the Kaizen process
OR capacity and pipeline are greatly improved, now we are starting to experience access issues

20. Conclusion/Outcomes
Task realignment to set clear understanding of workflow
Less barriers to scheduling patients initial appointment
Daily communication/prioritization
Visual Board is key – made it possible to see where bottlenecks occur
This is a continual process, can still slip into ‘old ways’

21. My Babies

22. Meagan’s Babies

23. The End
Questions?
Thank you!!!