Ellis MedicineA Community

Hospital’s Quality Story

MARY ELLEN CRITTENDEN, RN, MS, CPHQVP, QUALITY SERVICES

May 11, 2011

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Centralized location for outpatient services, primary and wellness care, and rehabilitation and long term care.

Centralized location for inpatient and emergency care.

Centralized location for inpatient OB/GYN services.

Ellis Medicine….

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ELLIS HEALTH CENTER: ELLIS MEDICAL HOME – A MODEL OF PRIMARY CARE

Highlights: Services: family medicine, pediatrics, dental and insurance

enrollment, supplemented by full outpatient and emergency services; unique support for underserved

Community shuttle: 138 monthly average riders Health services navigators: 174 monthly average patient

encounters; 160 ED patients w/o a doctor were connected with primary care (Sept 2009-Sept 2010)

Community Partnerships – Ready. Set. Kindergarten! 114 children seen– Health Fairs, Farmer’s Market

The Importance of Quality in Medicine

Ernest Amory Codman, M.D. Franklin Martin, M.D.

1910“The End Result System of Hospital Standardization”

1913Founder of the

American College of Surgeons

Importance of Quality Monitoring in Medicine 1917 ACS Develops

The Minimum Standard for Hospitals

(Requirements fill one page)

1917The MinimumStandard for Hospitals1. Staff membership restricted to physicians who are (a) graduates of

medicine in good standing, legally licensed to practice in their states, (b) competent in their fields, and (c) worthy in character and in professional ethics; and that the practice of the division of fees, under any guise whatever, be prohibited.

2. Staff initiate, with approval of the hospital governing board, adopt rules, regulations, and policies governing professional hospital work. Staff meetings at least monthly. Staff review and analyze at regular intervals clinical experience in the departments, such as medicine, surgery, obstetrics, and other specialties; clinical records as the basis of review and analyses.

3. Accurate and complete patient records, filed in an accessible manner. A complete record being one which includes identification; complaint; personal and family history; history of present illness; physical examination; special examinations, such as consultations, clinical laboratory, X-ray and other examinations; provisional diagnosis; medical or surgical treatment; gross and microscopic pathological findings; progress notes; final diagnosis; discharge condition; followup and, in case of death, autopsy findings.

1917The MinimumStandard for Hospitals

4. Diagnostic and therapeutic facilities under competent supervision available for study, diagnosis, & treatment of patients, to include, (a) clinical laboratory providing chemical, bacteriological, serological, and pathological services; (b) X-ray department providing radiographic and fluoroscopic services.

5. Physicians privileged to practice in the hospital be organized as a definite group or staff. Such organization has nothing to do with the question of the hospital as “open” or “closed,” nor need it affect the various existing types of staff organization. The word “staff” is here defined as the group of doctors who practice in the hospital inclusive of all groups such as the “regular staff,” the “visiting staff,” and the “associate staff.”

1926Am. Coll. SurgeonsStandards Manual

18 pages

1951ACS Standards Manual

The American College of Surgeons (ACS)

The American College of Physicians (ACP)

The American Hospital Association (AHA)

The American Medical Association (AMA)

The Canadian Medical Association (CMA)

Joint Commission on Accreditation of Hospitals

(JCAH)

1964 begins charging for surveys1987 Name Change:

Joint Commission on Accreditation of Healthcare

Organizations (JCAHO)

“JCAH”Joint Commission on Accreditation of Hospitals

1990 - 2006 Everyone just calls it: “The Joint Commission”

January 2007 Officially Changes Name to:“The Joint Commission”

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Quality Today

THE AFFORDABLE CARE ACT (ACA) OF 3/23/2010

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The Act provided for Mandatory Medicare Delivery System Reform: Reduce Inpatient Readmissions Institute Value Based Purchasing (VBP) Reduce Healthcare Acquired Conditions (HACS) Institute Meaningful Use (Electronic Healthcare

Record-EHR) An “incentive” program for hospitals accepting

Medicare reimbursement. Beginning in October 1, 2012, 1% of Medicare

reimbursement due to us for services already rendered will be withheld.

The amount withheld will increase by ¼ of a percent per year until 2% is reached.

We have an opportunity to earn back some or all of this money by demonstrating that we give quality care and have satisfied consumers.

BEGINNING THE LEAN JOURNEY AT ELLIS

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REASON FOR LEAN NOW…..

• Achieve a top performing organization• A mindset of clinical quality• Accountability of managers• Keeping patients first when considering change• Increasing financial pressures – declining

reimbursement• Consistent monitoring of results and data• The status quo is no longer acceptable• Collaboration between departments is

expectation

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LEAN is a methodology that is used to accelerate the speed and reduce the cost for any process by removing waste (non-value-added activities)

“Re-examine the way you think about waste, as it is often difficult to recognize. Start by making waste obvious to everyone.”

Taiichi Ohno, Founder Toyota Production System

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WASTE REDUCTION – 120 DAY CYLE

• Kick Off - COMPLETED• 30 Day Check-In - COMPLETED• 60 Day Check-In - COMPLETED• 90 Day Check-In- APRIL 26th 9-11 Auditorium• Summation – MAY 24th 9-11 Auditorium _________________________ 120 Days X 3 Cycles =360 Days

THE NEXT 120 DAY CYCLE BEGINS ON THE SUMMATION DAY.

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ROLE OF WORKOUT COORDINATORS

• Assist the exec champion in managing the logistics of the 120 day Workout

• Support for timely development of the 120 day action plans

• Identifying potential successes and failures

• Providing support to stimulate ideas and discussions

• Act as a coach for the lean process

Additional Training for LEAN workout coordinators is scheduled.

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LEAN -WORK OUT COORDINATORS

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EXCELERATOR

All managers with a LEM - have access to Excelerator.

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EXCELERATER RESULTS TO DATE:

• 640 PLANS ENTERED SO FAR• $400,000 Savings identified for 2011• $1.2 Million Savings identified for 2012 The Finance Data Sheet is posted on the

portal to assist you with valuing your cost savings.

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SUMMARY OF 7 TYPES OF WASTE:

1. “In Quality Staffing” (Over Capacity) 2. Over‐Correction 3. Over‐Processing 4. Excess Inventory 5. Waiting & Delays 6. Motion/Transport 7. Movement of Materials & Information

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RAPID CYCLE TEST TEMPLATE

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RAPID CYCLE TEST TEMPLATEPRE       POST              

Data into grey columns only.                            

Count Data Avg   Count Data Avg.   Rapid Cycle Testing Instructions              

1 132 112  1 69 82  1. Determine the measure to test & the source of data (manual or IT system).      

2 99 112  2 101 82  2. Create the plan to test the change (date to begin test, training, data collection, etc.)    

3 102 112  3 63 82  3. Obtain/ collect baseline data (25-30 data points or more if not manual.)      

4 99 112  4 73 82  4. Train/orient staff (if needed) & train data collectors (if needed) & conduct 1 "dry run".    

5 78 112  5 89 82  5. Run the test for 25-30 data points over 1-shift, 1-day, 3-days, collecting data along the way.  

6 106 112  6 79 82  6. Analyze results. If improvement, "hardwire" the change. If not, cease the change.    

7 119 112  7 78 82  7. Repeat the Rapid Cycle Test process.            

8 89 112  8 83 82                     

9 100 112  9 77 82        Pre Post          

10 102 112  10 78 82      Average 112 82          

11 150 112  11 89 82      St. Dev. 27 10          

12 146 112  12 95 82                     

13 123 112  13 94 82                     

14 132 112  14 90 82                     

15 176 112  15 78 82                     

16 102 112  16 84 82                     

17 89 112  17 90 82                     

18 95 112  18 69 82                     

19 96 112  19 69 82                     

20 97 112  20 101 82                     

21 98 112  21 63 82                     

22 102 112  22 73 82                     

23 142 112  23 89 82                     

24 165 112  24 79 82                     

25 132 112  25 78 82                     

26 123 112  26 83 82                     

27 172 112  27 77 82                     

28 69 112  28 78 82                     

29 85 112  29 89 82                     

30 84 112  30 95 82                     

31 76 112  31 94 82                     

32 98 112  32 90 82                     

33 99 112  33 78 82                     

34 100 112  34 84 82                     

35 120 112  35 90 82                     

36 130 112  36 69 82                     

                                   

Source: Manual 7-7-09

Automatic

Calculation

TWO CHANGES PER MONTH

ASK STAFF – What processes are interfering

with our ability to provide excellent care?

ASK STAFF – Is there a better way?

POOR QUALITY AND PATIENT SAFETY RISKS

ARE OFTEN CREATED BY VARIATION IN OUR

PROCESSES

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LEAN TEAM KAIZEN EVENT

Application of Lean concepts and tools to rapidly improve the process through the removal of waste in the system

Project charter: Opportunity exists to improve the process of timely medication delivery to new post-op patients.

Scope: From when physician signs order to when medication is administered to patient in A3

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WHAT IS LEAN??

Philosophy– Focus on value-added elements in process, drive out

waste in system

Tools– Throughput time, five Ss, simple visual control systems,

spaghetti diagrams, standardized work, smooth flow….

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29Documenting and studying the actual process

PACU PROCESS AND ISSUES

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Med recSign/dated

Scanned to

pharm by

clerk

Scanned to

pharm by RN

RN revieworder

Post op orderSign/dated

Incomplete

Orders

15 minutes

PHARM PROCESS AND ISSUES

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Messages

ScanArrived

Scan put into MAK by

RX

Robot retrieval

and bagging

Meds put in tube

Meds sent via tubes

Batch wait time

No trace = rework

10 minutes 3012

0

20 minutes

A3 PROCESS AND ISSUES

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Nurse Verifies

MAK entry

Nurses time

spent on non-

patient care

Meds put in Med room

Nurse retrieves med from

room

Meds to patient

Hunt and gather

Did meds arrive

?

Unattended Meds!

Pyxis underus

ed

CURRENT PROCESS

Example: 6/23 total knee surgery

– Antiemetic (Zofran) ordered at 1745– Patient received at 2226

– Total time 4 hrs 41 minutes from order to delivery

– BUT – Zofran is a PYXIS item. Available immediately on over-ride on A3 unit!

– Patient could have had it in minutes!

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OPPORTUNITIES TO REMOVE WASTE

PYXIS use up Time/date MORE orders Tube system alert Tube system tracking board Tubes cleared by non clinical staff Supply room reorganize – hunt and gather Room-side cabinet Runner?

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35Spaghetti diagram – RN checking on missing med

36Part of the improved tube management system

37Increase PYXIS use!

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Minimize hunting and gathering - - Utilize and organize Nurse cabinets

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Tubes in que For system

Report Parameters: 6/22/2009 12:00AM to 6/23/2009 12:00AM

Graph displays orders received by hour and priority for a specified date range to show the demand within a 24 hour time period.

SUMMARY

This Lean activity, with its focus on waste reduction, eliminates unnecessary processes, provides better service to patients, and increases both patient and employee satisfaction

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EXTRAORDINARY CHANGE– Catalyst for change: NYS health care reform (Berger law)

– Ellis assumed responsibility for the services of two hospitals in a short seven month period.

– Thousands of details involved …

– Consider what was added to Ellis: Employees 1,133

Expense Budget $118 MDischarges 10,600Days of Care 43,000Surgeries 8,400ER Visits 39,000

– Financial Turnaround 2007 – 3 hospitals lost $7 M collectively 2008 – newly unified Ellis posted $4.6 M operating margin

INTRODUCTION

Schenectady, NY Three campus hospital system 455 licensed beds 3,300 employees (850 RNs) 600 affiliated physicians 2009 projected volume: 550,000 patients 2009 projected births: 2,700 babies 2009 operating budget $343 million 2008 operating margin: $4.6 million

BTS 8 FRAMEWORK FOR SUCCESS

Aim statement Plan – Do – Study – Act PDSA Cycles Identify BTS 8 Team Garner Physician Champion(s) Engage Senior Leadership/Management Perform tests on changes and processes

leading to implementation Monthly Conference Calls Update Data for Premier ~ My Community Attendance at all three BTS8 Learning

Sessions

TEAM MEMBERS

Director Surgical Services (Jonathan Blank) 

OR Manager (Pam Margas)

PACU Manager (Judy Symolon)

Physician Champions (Dr. Iftikhar Syed & Eric Aronowitz)

Purchasing Manager (Coleen Norberg)

Surgical Supply Manager (Donna Cafaldo)

Vice President of Operations (Patti Hammond)

AIM STATEMENT

Improve OR supply chain expense by $125,000 through standardization, utilization, contracting and increased efficiencies across a 3 campus perioperative system by 12/31/09.

STRATEGIES

Identify Perioperative Opportunities for Supply Chain Savings.

Identify Operational Efficiency Opportunities.

Identify Standardization Initiatives.

Utilize the BTS 8 “Formula for Success”– Aim statement– Persistent PDSA Cycles– Measuring, Performing Tests on Changes and Evoking Process

Evolution– Garnering Physician Champion Support (General and Orthopedic)– Engaging Senior Management– Communication

METHODOLOGY

Structured Focus on Aim Statement PDSA Cycles Monthly Premier Perioperative Conference

Calls Premier Consultation Senior Management Engaged Communication Updates Physician Champion Support Attendance at BTS 8 LS1-3 Conferences

CONTRACT OPPORTUNITY

Reprocessing – Shavers, Trocars, Tourniquet Cuffs, OPCAB Devices – SAVE $40K

Utilization Custom Pack Changes– Knee Arthroscopy – SAVE $14K– Total Knee - SAVE $ 7K– Total Hip –SAVE $16K– Physician Eye Packs – SAVE $19K

Standardization– Disposable Clean Up Kits SAVE -$45K– Foot Compression Garments SAVE-$2K– Shoulder Drape SAVE - $3K– PortaCath SAVE – $8K

Premier - Yankee Alliance Contracts & Capitated Pricing– Cardinal Custom Procedure Packs SAVE -$69K– Orthopedic Implant Capitated Contract –SAVE $651K

BTS 8 SAVINGS $1,157,170.00

Cumulative Dollar Savings from all BTS 8 Initiatives

$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09

CONCLUSION

Premier (BTS 8) - Framework for Success

Reprocessing – Conservative Approach

Operational Efficiency – Global Initiative

Contracts and Capitated Pricing – Persistence WINS

Capture all SAVINGS – Opportunities Abound

Change theory – Embrace with Leadership/Mentoring

LESSONS LEARNED

Framework for Success: Communication

Persistence

Savings

Global Operational View

Senior Leadership and Physician Champions

PROJECT INITIATIVES

Operational Efficiency Component– PACU Expansion– Enhanced Communication – CSuite Task Force– Information Technology

Material Management Component– Reprocessing– Contracts– Custom Packs– Standardization of Product

AIM

Improve OR supply chain expense by $125,000 through standardization, utilization, contracting and increased efficiencies across a 3 campus perioperative system by 12/31/09.

BTS 8 TEAM PERIOP RESULTS

TOTAL SAVE of $1,157, 170.00

OPERATIONAL EFFICIENCY SAVINGS OR/PACU PATIENT THROUGHPUTSTANDARDIZATION –EMR/FORMS

Labor and Anesthesia Expense Reduction : SAVINGS $19,599

Collaboration - BIOMED Equipment Transfer: SAVINGS $199,940

Forms Standardization: SAVINGS $3,000

Information Technology Specialist: SAVINGS $55,000

$277,940

PATIENT FLOW AND OPERATIONAL EFFICIENCY OPPORTUNITIES

PATIENT FLOW AND OPERATIONAL EFFICIENCY OPPORTUNITIES

OR AND PACU LABOR COST TREND

Total Save = $13,677

0

500

1000

1500

2000

2500

3000

3500

4000

4500

NOV DEC JAN FEB MAR APR MAY

OR Labor Cost

PACU LaborCost

ANESTHESIA LENGTHENED TIME COST

0

500

1000

1500

2000

2500

November December J anuary February March April May

Anesthesia Lengthened Time - Costs

Total Save = $5,922

920000850933

690670

200000

400000

600000

800000

1000000

Old $ New $ Save

Cardinal Custom Procedure Pack Contract

PREMIER & YANKEE CONTRACT WORK

Premier – Custom Procedure Pack Contract

Yankee – Benchmark for Ortho Capitation Contract

3031777

2380332

651445

0

1000000

2000000

3000000

4000000

Old $ New $ Save

Orthopedic Implant Capitated Contract

UTILIZATIONCUSTOM PACK CHANGES

29376

19988

14388

0

5000

10000

15000

20000

25000

30000

Old $ New $ Save

Knee Arthroscopy

143562127210

16352

0

50000

100000

150000

Old $ New $ Save

Total Hip

144621 137101

75200

50000

100000

150000

Old $ New $ Save

Total Knee

149223129393

19830

0

50000

100000

150000

Old $ New $ Save

Physicians' Eye Pack

SUPPLY CHAIN BARRIERS

Reprocessing – Surgeon’s previous experience created concern regarding inclusion of harmonic scalpel.

Waste Form –Not implemented across three campuses.

Orthopedic Implant – working through vendor resistance and influence.

Supply Chain Focus versus Clinical –

disconnect between clinical side and supply chain initiatives.

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THE IMPORTANCE OF LEAN SIX SIGMA PROCESS TRACKING TO ACHIEVE IMPROVEMENT AND MAINTAIN IT.

Lean at Ellis– Change the way of thinking / culture– Consulting firm to assist in laying the foundation– Focus on quality

Improve patient flow Increase patient volume Eliminate non-value added activities Improve staffing

WHAT IS LEAN?

A philosophy & improvement methodology focused on eliminating waste & improving workflow

Focus on value stream analysis In Lean, costs exist only to be reduced Flow optimization Pull versus push (“Chocolate Factory”) Perfection (zero waste)

Mobilize the entire organization

– Board– Senior Leadership– Middle Management– Physicians– Front line staff• Set targets and deadlines up front• Set financial targets• All levels held accountable• Include front-line staff

Basic set of standardized terms– Posted on intranet

Discuss at Open Forums– Open discussion with all employees– Ask staff for brainstorming

Communication cascades

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GETTING STARTED / INFRASTRUCTURE

1. Sr Management Oversight Committee for project selection & overall stewardship of activities

2. Consultant for initial education, teaching materials & coaching

3. Administrative support for scheduling & clerical functions: Critical Need!

4. System for tracking projects & results5. Strong ties to and support from Finance

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120-day cycle with 30-day check-ins

Disciplined, focused engagement

Built database tracker to promote accountability & adherence to timelines

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Activate engagement

• Set targets and deadlines up front• Set financial targets• All levels held accountable• Include front-line staff

Sort, Straighten, Shine,

Standardize, Sustain

7:00 AM anesthesia arrives

7:45 AM OR starts

Large Bariatric growth over last 5 years

Have PACU holds increased since the closure of B2

Anesthesia does not see the patients prior to the day of surgery (except for some cardiac cases)

How can we improve

– Patient tracking system in the PACU/OR

“BEFORE SURGERY” TEAM MEETING  What is working:

Diligent staff that keeps on top of things (in relation to scheduling and paper work)

Having extra staff for turnovers helps move the cases along

Teamwork

Pick sheets have been improved

Moving towards an enterprise wide pick sheet.

– Currently working with purchasing and the OR buyer to standardize supplies

– Will have an electronic system for inventory contro

What is not working:

Paper

– Large amount of un-needed paper in the scheduling / PAT phase

– Duplication of work

– Missing documentation

– Would like to move to a central scanning system

Process to notify patient in regards to OR time changes

– Going to start reminder calls to patients with the arrival time, not the OR time Once up and running, MD office will no longer need to call patients with time

– Gives more flexibility in moving cases around

Patients that come in early for blood work wind up sitting in Day Surgery without having the blood drawn

– A facilitator position has been approved and will be posted soon

Missing pre-op antibiotics

– These are either not ordered or ordered at the last minute Can OR nurses have access to the PACU Pyxis

Outdated H+Ps

– Same day surgery is checking the charts the day prior

– Looking at having the PA update the H+P

 

Process

MD has set block time

– ~ 90% of block time is utilized

Case is scheduled by Joanne once the paperwork is received from the MD’s office

Schedule PAT appointment

– 7 - 30 days prior to OR date

Return completed booking sheet to the MD

Worksheet is generated and sent to PAT to secure the financials, pre-certs

Patient arrives for surgery

– 1 ½ hours prior to OR time

– Patient is escorted to Day Surgery, blitzed by staff, then waits for surgery

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What is working:

Staff works hard

Teamwork

What is not work:

Patient not ready

– Blocks - RNs not available to assist

– Incomplete charts

PACU holds at 9:30 AM

– Is this due to staffing

Add-ons

– Stresses the staff / anesthesia

– Extra rooms running at 5 PM

Payer mix

– ~ 50% government funded

– Increasing bariatric patients but most are on Medicaid with minimal reimbursement

On time starts

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DURING SURGERY” TEAM MEETING “What is working:

Teamwork

Dedicated staff

Positive outcomes

Patient comes first most of the time

Much talent in the OR

They have the needed tools to get the job done

What is not working:

Cost savings by the MD

– MD will require a certain product that is more expensive than a similar product

– Opening all products that could possibly be used for the procedure

Start times of first cases

Schedule of OR has expanded past the blocked time

– Rooms are running later in the day

– No room for the add-ons

Underutilization of EHC for ambulatory cases

No enforcement of the un-utilized block time

OR holds caused by no PACU beds

Reciprocation for the hard work of the staff

Redundancy in steps

– Assessment, chart check, ect.

Patients brought into the OR that are not ready

 

Process

Introduction and visual assessment of the patient in the holding area

– Seen by anesthesia

Chart review for missing documentation

Universal protocol

Update missing documentation

Patient is brought into the OR

Surgeon arrives

Anesthesia begins

Time out

Surgery

Case closed

Room turn over

Next case begins

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AFTER SURGERY” TEAM MEETING What is working:

Send the surgical PA to the floor earlier

What is not working:

Long LOS

Crunch time for beds in PACU is Noon

– Peak time for hospital discharges is 4PM

Delay to PACU admission

Nursing units are at capacity

Room turnover on floors

No reports to floors during shift change

Unit nurse is needed for patient transfer to ICU

Anesthesia purges patients from PACU

Process

Call from OR to PACU for space

– Does not always happen

Patient arrives in PACU

Moves to Phase II recovery

Patient is transferred to the floor or discharged home

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Goal– Achieve an annual tangible cost recovery

Goal - $3 Million– Conservative estimate with savings

expected to greatly exceed goal

Institution Orientation

Redefine Quality in relation to waste Define expectations

– Managers responsibility» Eight changes during 100 day cycle / 2 per

month» One change must include collaboration with

another department– Every employee is involved

80

Surgical Services Breakout

Identified as an area for substantial waste reduction and savings

Three teams – Prior to surgery– During surgery– After surgery

Cross section of specialties on each team to maximize results

81

Focus on the 7 categories of waste

“In Quality/ Out of Quality” Staffing; Overcapacity Correction / inspection Over-processing / redundancy Over-inventory Waiting Motion of patients / staff Material / information movement

Encourage process changes, not just simple waste reduction

82

– Rapid cycle testing PDSA 25-30 data points prior to and after change Facilitate change for new and innovative ideas

supported by data prior to implementation Eliminate long evaluation periods

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KEY ROLES– Senior leaders

Buy in and support– Attend monthly check-ins when plans are presented by stake

holders– Workout coordinators

Managers broken up into approx 12 member teams Role of the workout coordinator is to offer guidance/advice, not ideas.

– Ownership of plans is placed on managers– Finance Liaison

Support in assigning actual savings when not readily identifiable Verify tangible savings when in question

– Communication Coordinator Announcement emails News letters Intranet

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Challenges– Changing old school ways of thinking– Reducing staffing / supplies without compromising patient

care– Staying the coarse

This will not go away in a couple of weeks Owning the process and maintaining momentum after

consultants leave  

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Change Examples• B/W vs color printing• Stop unneeded reports• Consolidate deliveries• Fax vs mail reports• Eliminate face to face meetings: use technology• Reduce over time• Contracts/supplies: better pricing options• Control purchase options

86

Tracking progress– Consultant offered software package

  Overview of projects Results

– Goal - $3 Million To Date - Planned $2.5 Million To Date - Actual $1.5 Million

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