delivering results in healthcare by marc baker, ian taylor and dr paul jarvis
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Shown at the Lean Summit 2013 - Lean Transformation: Frontiers and Fundamentals on 5th, 6th & 7th NovemberTRANSCRIPT
Delivering Results in Healthcare Marc Baker & Paul Jarvis
Doing the Right Thing for Every Patient
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Our Core Tenet
Our Core Tenet is a patient centred approach to re-design and has been the underlying principle of all our work in healthcare, we refuse to do local optimisation work. Over the years we have learned what works, and what does not, in healthcare (and why). This has been codified into our book ‘Making Hospitals work’.
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Making Hospitals Work How to improve patient care while saving everyone’s time and hospitals’ resources by Marc Baker and Ian Taylor Foreword by Daniel T. Jones A Lean Action Workbook from the Lean Enterprise Academy Version 1.0 Goodrich UK May 2009 www.leanuk.org
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Exercise
What is Takt Time?
How is it Calculated?
Why is it Important?
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Pull and Flow
We believe that our job in healthcare is to enable each individual patient to ‘pull’ themselves through the system and to ensure that our services ‘flow’ to provide exactly that which the patient needs exactly when they need it (pulled by the patient) during their journey through our system. There exists a natural pace or beat at which patients require our services and it is only when we can identify this pace or beat that can our services truly flow to meet the patient needs
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Staff/Departmental Availability V’s Opportunities for Patient Flow (Door to Door)
Example - Royal Gwent Staff Overflow Car Park
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We Are Obsessed by Demand (and crave to see it)
HRI’s Medical Demand Map
Where do they come from?
What happens to them?
Where do they go?
Lean Enterprise Academy
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Why is Demand so Important
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Because we can translate Demand into Takt time
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Takt Time comes from the German word for Pace or Beat & is used to describe the Rate at which Patients require a Service
Takt Time
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Takt Time is used to enable flow by matching the ‘Rate of Delivery’ with the ‘Rate of Demand’
Takt Time dictates how often one Request/Activity should be Completed – in line with Patient Demand
Why is Takt Time so Important?
Takt Time is used to scientifically calculate staffing levels
Everything in the System Must be Synchronised to meet Takt otherwise queues WILL form
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TAKT Time = 360 minutes 72 patients
TAKT Time Calculation Example Cont’d
One Patient Every 5 Minutes
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Using Takt to calculate the Number of Staff Required
Total Work Content Takt Time
=
=
=
120 30
4 staff
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ED Takt Example – Calderdale & Huddersfield
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It is quite normal in Acute Hospitals that during the busiest time of day, patients are presenting on average at A&E Majors Departments every ten minutes or so. Service Level Agreements (SLAs) are now commonplace in healthcare. For example the path lab may have a SLA to turnaround blood results to A&E within 90 minutes but is this good enough? If at the busiest time of the day, patients are arriving on average, at A&E Majors every ten minutes - but cannot be admitted or discharged until the results are available - we have to ask “is a SLA of 90 minutes good enough?”
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The diagram below illustrates that in this scenario with patients arriving every ten minutes and blood result ‘turn around time’ of ninety minutes Nine bays will be occupied by patients just requiring blood results alone.
10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170Patient 1 X X X X X X X X XPatient 2 X X X X X X X X XPatient 3 X X X X X X X X XPatient 4 X X X X X X X X XPatient 5 X X X X X X X X XPatient 6 X X X X X X X X XPatient 7 X X X X X X X X XPatient 8 X X X X X X X X XPatient 9 X X X X X X X X X
Minutes
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Takt at the Back Door
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JPUH Medical Takt Times
44 Mins
55 Mins
28 Mins
Due to Opening Hours the Back Door Must work to a quicker Pace than the Front Door
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Levelled Discharges being used in conjunction with the Visual Hospital
Levelled Discharges – Small Numbers ‘Drip Fed’ Throughout the Day (As Legitimate as the A&E Target)
HSJ Best Acute Hospital 2010
Commissioners saved £1.1 m
Trust saved £2.2 m from safely closing 100 medical beds
50% reduction in
Locum/ Bank and Agency spend
No compulsory redundancies
Calderdale & Huddersfield NHS Foundation Trust
Shortest Length of Stay
Static readmission rate
Continuing to improve
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What is Quality?
You want to go out for dinner with some friends
What constitutes a quality experience for you and your
friends?
You run a restaurant What would constitute quality now?
What is Quality?
Which is the more objective view of quality: Customer or Service Provider perspective?
Healthcare is a unique industry because a patient is both the customer and the product
Quality should always be viewed from the patient’s perspective
3 characteristics of quality: • Service • Product • Environment
For a quality patient experience all of these need to be right
Understanding Quality
• Would you go back to a hotel that wakes you up at 3am so they can move you to a different room?
• Would you return to a shop that makes you wait several hours before they serve you?
• How would you feel if the person serving you talked to you like you were an idiot?
• Would you carry on using the same garage if your car had to go back in because the work done was inadequate 10% of the time?
These are everyday examples – Why are they tolerated in healthcare?
Why do we need Quality Improvement in Healthcare?
We’re not a hotel, a shop or a garage, but we do provide a service.
Patients tolerate poor care because there
is very little alternative (and it’s free) Huge initiative throughout health service
on improving the patient experience
Need for Change
X Y Patient encounter Healthy & satisfied with Dr patient
Sadly, life isn’t this simple?
How Complex is one patient’s Journey
Reality is more like this…
This is one patient’s real hospital journey!
Old System
Traditional ED System
Treatment CT = 20 min
Disposal CT = 3min
Triage CT=6 min
Dr Review
CT = 37 min Investigations CT = 63 min
Nurse Assessment CT= 27min
Dr Review
CT = 15 min
Walking
Ambulance Consultant
Old System
Traditional ED System
Treatment CT = 20 min
Disposal CT = 3min
Triage CT=6 min
Dr Review
CT = 37 min Investigations CT = 63 min
Nurse Assessment CT= 27min
Dr Review
CT = 15 min
Walking
Ambulance
Consultant
32 41 9 32 7 201
28
15
What is the problem?
• System designed to make patients wait (Triage is a step to decide how long you should wait) • Two access points to the service • Investigations requested late • Potential for inexperienced staff to order unnecessary investigations
34
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ED Takt Example – Calderdale & Huddersfield
9am – 9pm Takt is 12 mins
Old System
Traditional ED System
Treatment CT = 20 min
Disposal CT = 3min
Triage CT=6 min
Dr Review
CT = 37 min Investigations CT = 63 min
Nurse Assessment CT= 27min
Dr Review
CT = 15 min
Walking
Ambulance
Consultant
32 41 9 32 7 201
28
15
9am – 9pm Takt is 12 mins
Exercise: Draw Bar Chart of Delay/ CycleTimes v Takt for walking patients
Takt Time
201
EDIT CT= 16 min
ED Dr CT = 37min
Treatment CT = 20min
Disposal CT = 3min
Ambulance
Walking
Consultant 1 Consultant 2
Emergency Dept Intervention Team System
Redesign ED Process
201
9am – 9pm Takt is 12 mins
7 8 4
Exercise: Draw Bar Chart of Delay/ CycleTimes v Takt
Takt Time
201
2 x Resource
3 x Resource
Phase 1 – Evaluate the performance of the traditional ED model - 1st April to 24th May 2013 (3835 patients)
Phase 2 – Evaluate introducing POCT into traditional ED model - 28th May to 29th September 2013 (7033 patients)
Phase 3 – Evaluate POCT and EDIT model together – 30th September to 18th October 2013 (1200 patients)
3 Phase Trial
Before Trial Median Blood Results being available: 63 minutes Trial Results Median: 3 minutes Able to do 60% of ED bloods using iStat
Point of Care Testing
Effect of the 3 Different Working Models on the Median ED Times
68% Overall
Reduction
40% Overall
Reduction
60% Overall
Reduction
Tim
e hh
:mm
Results
• Introduction of Point of Care Testing (POCT)
•
• i-Stat® System
Introduced Point of Care Testing
With traditional model 9 patients are undergoing ED Care in the ED central area at any one time (Monday to Friday 9-5) EDIT & iStat reduces this to 5 due to quicker processing of patients
45
Results
Reduces Overcrowding
Frees up time to Care
With Traditional Model 3% of patients seen in ED Central Area Monday to Friday 9-5 are discharged with 30 minutes of arriving. With EDIT & iStat this is increased to 10% with the additional benefit of being seen by a consultant.
Results
Reduces Overcrowding
Frees up time to Care
With Traditional Model 11.4% of patients seen in ED Central Area Monday to Friday 9-5 return within 7 days of their initial presentation With EDIT & iStat this is 9.1% Shorter patient journey times do not equate to more patients having to return to the ED within 7 days
Results
48
Results
* - only 1 consultant
When only 1 consultant causes special cause variation in performance r = -0.8
UCL
*
*
Before Trial Median Blood Results being available: 63 minutes Trial Results Median: 3 minutes Able to do 60% of ED bloods using iStat
Point of Care Testing
360 ED attendances per day cross site
2.5% reduction = 9 few admissions per day
Rates of Admission
Introduction of a consultant-led assessment process (EDIT) and POCT provides a 40% reduction in the time from patient arrival to
being declared ‘ED Ready’ and 2.5% reduction in the number of patients admitted
Conclusion