Creating the Michigan Quality System

Jack Billi, M.D.

jbilli@umich.edu

Michigan Quality System:med.umich.edu/mqs

Michigan Quality System:

• Quality

• Safety

• Efficiency

• Appropriateness

• Service

Lean Thinking in Health Care

Lean Thinking in Health Care at UMHS Summary A3 J Billi 1/9/09

• Background– UM has problems in quality,

safety, efficiency, service– Problems harm patients, raise

costs, frustrate workers– Economy: short & long term

• Current state– Inconsistent use of QI at UM;

varied models– Toyota Production System:

QI world standard (not health)-Brilliant process & outcome

• Goals– Ideal Pt Care Experience– Ideal Clinician Experience

Happy workers – healthy pts– Safest health system in US– Financial stability

• Analysis– Workers/mgrs: +/- trained in

problem solving; little std work– Problems complex, cross

silos/units; work often invisible– Unclear responsibility for

problems– Unclear priorities– Time, cost pressures: stress

• Strategies– Spread a consistent QI model

across UMHS-Build on our CQI base-Study and adapt lessons

learned from Toyota– 18,000 problem solvers

• Plan– Michigan Quality System

Burning Platform for Change?

Traditional Health Care …or, the way I was trained

• Frequency….……......Episodic• Initiation…….…..…....Patient• Coordination...…..…..Spotty (patients & doctors)• Communication……..Sporadic among clinicians• Patient education.......Inconsistent • Process of care……..Variable • Basis of decisions…..Clinicians’ opinions• Systems........…….....Not “Error-proofed”• Outcomes…….....…..Not measured• Cost……………….....Expensive

Gaps at UMHS (and most health systems):

• Quality: Not all CAD pts on statin, aspirin; DVT prophylaxis

• Safety:• Medication errors (10x infusion pump dose)• Labs labeled with wrong patient name • Results sent to wrong clinician • Hand sanitizing “in and out of rooms” less than 100%

• Efficiency: • Nurse, doctor searching for equipment, forms, pts…• Weeks waiting for appointment to the right physician• Higher LOS: fewer admissions/transfers, less $$, RIFs

• Appropriateness: • Antibiotics for URI, sinusitis; imaging for low back pain

• Service: Patients lost, staff look too busy to help

Where Do We Want to Go?

Our future state vision: The Ideal Patient Care ExperienceBased on Institute of Medicine Report“Crossing the Quality Chasm”

Care that is:• Safe• Effective• Patient-Centered• Timely• Efficient• Equitable

Crossing the Quality Chasm

• The IOM “Chasm” Report gives us a vision of where to go

• Lean Thinking gives us tools and business system to get there

• The IOM “Chasm” Report gives us a vision of where to go

• Lean Thinking gives us tools and business system to get there

Crossing the Quality Chasm

What is Lean Thinking?

“The endless transformation of waste into value from the customer’s perspective”.

---Womack and Jones, Lean Thinking

5 Step Process to Improve Value

1. Specify value from customer’s perspective

2. Identify the value stream for each product or service, and remove the waste

3. Make value flow without interruptions from beginning to end

4. Let the customer pull value from our process

5. Pursue perfection - continuous improvement- Do this every day in all our activities

Source: Womack & Jones: Lean Thinking

The Customer’s Perspective:A Clinic Appointment

• Call the clinic, voice prompts, on hold, leave message.• Clerk calls back and sets a date next week.• Arrive for the visit, check in, sit in waiting room.• Called into the exam room, wait for doctor.• Doctor sees you, saying she’s been waiting for you.• Diagnoses a URI, and BP is worse.• Doctor prints antibiotic prescription, walks to the

staffroom to get it. You are allergic to that drug. • Doctor says to return in a week for the BP.• Medical assistant does an EKG.• At check out you ask the cost – clerk says they’ll bill you, • No appointment is available next week.• Pharmacist says your insurance prefers a different drug.• Is there a problem?

Using the 5 Step Process in the Clinic Visit

• Specify value from customer’s perspective– A quick, effective clinic visit

• Identify the value stream for this service– Request > appointment > arrival > seeing doctor > check-out

…and remove the waste– Time on hold, callbacks, walking, wrong drug, unneeded test

• Make value flow without interruptions from beginning to end– Staff and patient move continuously from check-in to exit– Less waiting for patient and staff– Errors surface immediately

• Let the customer/worker pull value from the process– Physician pulls next patient to exam room; patient pulls med

refill when needed• Pursue perfection – continuous improvement

– Every day, every clerk, doctor, nurse thinks about how to redesign work to improve value to the customer, and ease for us

The Broken Office Visit

UMHS Example: MedSport Consult

Long term problem:• Long delays to get an appointment• Frustrated referring physicians, patients, staff,

physicians• Incomplete records, phone tag• Physician review records prior to scheduling• Lots of hidden processes, errors, rework• Patients/referring physicians seek care elsewhere

Project scope:• MedSport consult – from request to scheduling

Using the 5 Step Processon MedSport Consults

1. Specify value from customer’s perspectivePatients, physicians and staff:

quickly scheduled appointments

2. Identify the value stream for the serviceRequest > review> schedule appointment

…and remove the wasteVariation in request, time on hold,

callbacks, physician reviews

MedSport AppointmentsCurrent State Map

Wednesday March 16, 2005 - Page 1

D R A F T - Orthopaedic Surgery MedSport - Current State Map

Summary

Total Processing Time : 11 31 minutes

Total Waiting Time: 1 - 36 days

% Complete and Accurate: %

Metrics

P/T: Processing Time

W/T: Wait Time

% C & A: % Complete and Accurate

Wait time (day)

Process Time (sec)

Mapping Icons

In

~~~ Service

Patient

Ref. Phys.Pt / ATC

Data Box

Information

OutsideSource

In Box(Queue)

ProcessStep

Wait Time

Mail

Phone

Fax

Email

5 min 10 min

0 - 3 d0 - 1 d

P/T: 5 min

W/T: 0-3 days

C&A: 100%

Call Ctr.

In

~~~Receipt &InspectRequest

P/T: 1 min

W/T: 0 days

C&A: 98%

Physician

In

~~~ClinicalReview

P/T: 3 min

W/T:0-3 days

C&A: 100%

Call Ctr. Sctry.

In

~~~TransportAppointment

Request

P/T: 2 min

W/T: 0-3 days

C&A: 95%

Ref. Coord.

In

~~~Business/ClinicalReview

P/T: 10 min

W/T: 0-14 days

C&A: 5%

Call Ctr.

In

~~~Re-workRequest

P/T: 1 min

W/T: 0 days

C&A: 98%

Ref. Coord.

In

~~~Denial/PriorSetting

P/T: 3 min

W/T: 0 days

C&A: 100%

Sctry.

In

~~~TransportAppointment

Request

P/T: 1 min

W/T: 0-1 days

C&A: 100%

Front Desk

Mail Itinary

P/T: 5 min

W/T: 0-1 days

C&A: 100%

Call Ctr.

In

~~~Scheduleand/or Notify

6 Requests28 Requests 6 Requests 6 Requests 28 Requests 30 Requests 29 Requests

1 - 14 d0 - 1 d

2 min

0 - 1 d0 - 3 d

3 min

0 - 1 d1 - 7 d

1 min

0 - 1 d

3 min

0 - 1 d

1 min

0 - 1 d

5 min

0 - 1 d0 - 1 d

1 min

0 - 1 d

Appeals

2 Rqsts2 Rqsts

Requests 30/Day

OPNotes

PhysicianNotes

Imaging

2 Rqsts

Lost Req1 Req

Using the 5 Step Processon MedSport Consults

3. Make value flow without interruptions from beginning to endStaff scheduling appointments on first

phone call

Uniform intake process

No waiting for appointments

Errors surface immediately

MedSport AppointmentsFuture State Map

Thursday March 17, 2005 - Page 1

D R A F T - Orthopaedic Surgery - Future State Map

Summary

Fast Track Slow Track

Total Processing Time : 6- 11 min 8 - 13 min

Total Waiting Time: 0 - 1 min 1 - 7 days

Lead Time: 6 - 12 min 1 - 7 days

% Complete and Accurate: 95% 85%

Metrics

P/T: Processing Time

W/T: Wait Time

% C & A: % Complete and Accurate

ConsultRequest

Guidelines onthe Web

BusinessReview

Ref. Phys.

OutsideOrtho

OPNotesED

Patient

Phone

Input byphone only.Faxes and

emails will befunneled to

phoneprocess

Clinic ReviewSchedule

AppointmentAppointment

Requirements

ItineraryPrinted &

Mailed

Entry Criteria

||||||||||||||||||||||||||||

Call Center Staff

Contact Schedule ReminderScheduling Patient Appointment:

StandardWork

3-5 Days Pre-Arrival Call

StandardWork

PatientRef. Phys.Pt / ATC

90%

LL

FailedRequests

areRedirected

Fast Track

2nd ReviewRotatingDesignee

10%

Slow Track - Exception Process

P/T: 6 - 11 min

W/T: 0 -1 min

C&A: 95%

P/T: 8 - 13 min

W/T: 1 - 7 days

C&A: 85%

Fast Track Slow Track

Mapping Icons

In

~~~ Service

Data Box

Information

OutsideSource

In Box(Queue)

ProcessStep

Wait Time LLLearningLoop

Using the 5 Step Processon MedSport Consults

4. Let the customer pull value from the processSame day appointments

After school sports, till 7PM

5. Pursue perfection – continuous improvementEvery day, every clerk, doctor, and nurse

thinks about how to redesign work to improve value to the customer

MedSport Project Results

• Goal: reduce time from request to scheduling

– Pre project: • process time = 27 min of work• wait time = 23 days

– Post project: • 91% of appointments made on first call in 2.5 min

– Physicians, nurses, and clerks:• Own the process, continue improvements• Freed to create more value

– Video www.med.umich.edu/mqs

Value Stream Mapping Workshop

Understanding how things currently operate. This is the foundation for the future state

Value Stream Scope

Designing a lean flow through the application of lean principles

Current State Drawing

Implementation Plan

Determine the Value Stream to be improved

The goal of mapping! 30, 60, 90 day follow-up

Implementation of Improved Plan

Future State Drawing

Developing a detailed plan of implementation to support objectives (what, who, when)

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From John Long

Why Draw Maps?

To find problems, we have to be able to see them!

• Ron Hirschl’s basement clean-up– If you make waste visible, it’s easier to remove– If you make problems visible, they’re easier to solve

• In healthcare: process steps are often invisible– Hard to find the non-value added steps

• We use Value Stream Mapping so we all can see the waste and find problems– How is work done now?– How could we make the job easier for workers and better for

customers?– What experiment should we try first?

Value Stream Mapping:Learning to See

Front-line workers:• Create the map as a team• Describe the way the work is actually done now

– Not how we think it is, or how it should be…

• Verify in the real workplace (“go and see”)

Managers support the effort

Value Stream Mapping:Learning to See

• “Aha” moments:– I never knew this is how it worked!– I can’t believe what a mess this process is!– No wonder we’re frustrated!– It’s a miracle a patient ever gets through it!

Improvements don’t have to wait for workshops…

We all can:

• Do our work every day in a standard way that we created

– Not just the way the work evolved!

• Be alert to things going wrong – They always do!

• Fix the problem now– For this patient or co-worker

• Find and fix the root causes of the problem– So it never happens again!

Modified after Spear; Billi

Lean Thinking:How To Get It “Right Every Time”Steven Spear, Institute for Healthcare Improvement

• Catheter-related sepsis – a lot of little things:– No sink, no soap, no doormat reminder or buzzer– Gloves missing, wrong size, old and rip, on other

side of patient, at bottom of kit– 92% of nurses faced with impediments

constructed ad hoc workarounds

Steven Spear. Fixing Healthcare from the Inside, Today

Lean Thinking:How To Get It “Right Every Time”Steven Spear, Institute for Healthcare Improvement

• Short on Time???• Can’t find time to fix root cause??? • Rather use the workaround every day for the

rest of your career? • Just take 10 minutes a day to fix root cause of

one problem – Frees up time, so next week it will be 20 min.– Then it will be 30 minutes…

Steven Spear. Fixing Healthcare from the Inside, Today

Lean is not about working harder or faster, it is about finding waste and transforming it into value our customers want.

How can we create (liberate)“18,000 problem solvers”?

• Help each worker take initiative to find and fix causes of problems he/she faces daily– This means each of us has two jobs:

• Do the work• Improve the work

• Managers role:– Support improvement work (time, mentoring)– Align improvements so value flows to the

customerModified from J Shook

“18,000 Problem Solvers”

Every worker applying the scientific method

to every part of daily work.

Turn all daily work into an experiment and every worker into an investigator. -Steven Spear

Lean Thinking as the Scientific Method Applied to Daily Work

Scientific Method• Observation• Hypothesis• Intervention• Results/reflection• Revise hypothesis• New intervention…• Structured abstract

Lean Thinking• Go see, ask why, respect• Plan P• Do D• Check/reflect C• Adjust A• Repeat PDCA cycle…• A3 report, Value Stream

Map

Lean Thinking - An analogy to great medical care

Tackle work problems with the rigor and systematic thinking we use for patient problems.

Help every worker become an expert clinician.

Lean Thinking is Like Great Medical Care

for Daily Work

Great Medical Care• Collect data personally,

systematically, at the bedside

(H&P)• Impression and plans• Tests and treatments• Assess results & reflect• Revise impression & plan• Std write-up, presentation

Lean Thinking• Go see, ask why, respect

• Plan P• Do D• Check/reflect C• Adjust A• Value Stream Map, A3

Lean means seeing problems as interconnected:

5 admissions on “call day”, none for next 2-3 days

• Waste: -Muda– Errors (no beds on home unit)– Worker motion (patients scattered on 5 floors)– Inventory (patients waiting for rounds, orders, D/C)– Workers waiting (for the COW to arrive from last floor)

• Uneven workload, variability -Mura– Busy call day, “recovering” next day– Batch orders till end of rounds (none -> rush)

• Stress of overburden -Muri– Physicians, nurses, clerks rushing through work– Duty hour limits; nurse and PA shortages

Michigan Quality System:Strategy for Lean Transformation

1. People Development - Leaders

-Managers- Frontline Staff

• “Just-in-time” training: Learn Lean by Doing• Coaching and mentoring• Courses, talks, web resources, book club

2. Process Improvement- Focused on institutional priorities

• Value stream analyses and workshops• Rapid-cycle improvement and “Just do it” activities• Lean in daily work

MQS Learning Project Results

Radiation Oncology (6 teams – over 70 faculty & staff)

• Patients referred for brain metastases required 3 visits over 5 days (consult, simulation, treatment)

• After mapping the process, the team redesigned the process, removing unnecessary steps

• Now 95% of patients have all 3 parts within 24 hours

• Billing process first-time-quality increased0% to >95%

– Video www.med.umich.edu/mqs

MQS Learning Project Results

Results Reporting ~ 99,000 lab results had no ordering physician, radiology requisitions lost, extensive rework

• Preprinted labels on requisitions implemented (12/06)• Imaged requisitions increased by 880% (from 957 to 9380)• 50% drop in orphan lab results

MQS Learning Project Results

Emergency Dept. and CPU• Acute coronary syndrome:

• Goal is “Door to Balloon” within 90 min.• Go and see, mapping: time spent on EKG, serial

paging• Redesign patient flow, parallel paging• Within 90 min. – Increased from 75% to 85%

• Time to ED discharge decreased 10 minute

Before, nurses prioritized sickest, never got to discharges.

MQS Learning Project Results

Care Transitions: MFH discharge from 5B

– Timely appointments in hand at discharge– Management until the first follow-up visit– Mapped the discharge process, MLine pilot– Pilot results:

• Decreased 14 day readmissions by 33% • Decreased visits to ED within 72 h. by 81%

MQS Learning Project Results

Cardiovascular Center32 projects and analyses over 2 years• Non-value-added time during device clinic visit

reduced from 100 to 10 minutes – Tech & nurse visits simultaneously

• Time for new medication delivery decreased from 90 to 41 minutes with implementation of “cart-less” system

• Standardized bedside stocking in ICU reduced extra supply runs from 4.5/bed/month to 1.7/bed/month

MQS Learning Project Results

Vascular Access

• Doubled PICC lines placed within 12 hours by nurses from 35% to 71%; reduced by 46% cases needing interventional radiology

• Nurses standardized their cart, saved 1 hour/day

CT scheduling and throughput

• In by 9, out by 5 for inpatients; no longer a weekend bottleneck

VAS Supply Cart 5S

Drawer: Pre-5S

Drawer: Post- 5SSaved each nurse an hour a day!

Engaged team: front line workers

and managers

Questions and Discussion

Michigan Quality System & Lean References Books:• Womack J, Jones D. Lean Thinking.• Liker J. The Toyota Way; Liker J, Meier D. The Toyota Way Fieldbook.• Shook J. Managing to Learn.• Dennis P. Getting the Right Things Done.• Rother M, Shook J. Learning to See.• Womack J, Jones D, Roos D. The Machine That Changed The World.• Sobek D, Smalley A. Understanding A3 Thinking.• Marchwinski C, Shook J, eds. Lean Lexicon.Articles:• Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: what can hospitals learn from a

world-class automaker? J Hosp Med. 2006;1:191.• Bush R. Reducing Waste in the US Healthcare System. JAMA 2007;297:871.• Spear S. Fixing Health Care from the Inside, Today. HBR. 9/05.• Spear S. Learning to Lead at Toyota. HBR 4/04 • Spear S. Decoding the DNA of Toyota Production System. HBR 9/99• IHI Whitepaper: “Going Lean in Health Care”

www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm Web: • Michigan Quality System at UMHS: med.umich.edu/mqs• Lean Enterprise Institute: www.lean.org webinars, books, meetings…• Ideal Patient Care Experience at UMHS www.med.umich.edu/i/acs/ipe.htm • Crossing the Quality Chasm (IOM): newton.nap.edu/catalog/10027.html • Lean Enterprise Academy (UK): www.leanuk.org • National Health Service (UK): www.networks.nhs.uk/networks.php?pid=211 • Wikipedia: en.wikipedia.org/wiki/Lean_manufacturing