establishing and sustaining a successful operations improvement program at the university of iowa...
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UNIVERSITY Éy IOWAHEALTH CARE
Establishing and Sustaining a Successful Operations Improvement Program at the University of Iowa Hospitals and Clinics
Sabi Singh
Assistant Vice President for Operations ExcellenceAssociate Hospital Director for Clinical Services
The University of Iowa Health Care
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� Base management decisions on a long-term philosophy, even at the expense of short-term financial goals
� Grow leaders who live the philosophy� Respect, develop and challenge your people
and teams� Respect, challenge, and help your suppliers
� Create process “flow” to surface problems� Level out the workload (Heijunka)� Stop when there is a quality problem (Jidoka)� Use pull systems to avoid overproduction� Standardize tasks for continuous
improvement� Use visual control so no problems are hidden� Use only reliable, thoroughly tested
technology
� Continual organizational learning through Kaizen� Go see for yourself to thoroughly understand the situation.
(Genchi Genbutsu) � Make decisions slowly by consensus, thoroughly
considering all options; implement rapidly (Nemawashi)
“4 P” Model of the Toyota Way
Philosophy(Long-term Thinking)
People and Partners(Respect, Challenge and Grow Them)
Process(Eliminate Waste)
ProblemSolving
(Continuous Improvement and Learning)
Where Most “Lean”Companies are
Stuck
Jeffrey K Liker, “The Toyota Way”
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Does Healthcare Need Lean?
� The impending health care crisis has arrived. Coupled with an economic crisis, now has never been a better time to use lean.
� Hospitals are faced with increased uncompensated care, and less reimbursement as patients lose employer sponsored health insurance.
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Profits
Decreases in reimbursement have increased the breakeven volume by 25 to 35%
Source: P.D. Mango and L.A. Shapiro, Hospitals get serious about operations. McKinsey Quarterly (2001:2). http://www.mcinseyquarterly.com
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Healthcare Faces Many Constraints
� Operational Efficiency Must Improve:
5
FRONTLINE NURSES CAN SPEND AS LITTLE AS 37% OF THEIR TIME ON DIRECT PATIENT CARE ACTIVITIES% of time spent
* Approximately equivalent to time spend within patients bedside areaSource: McKinsey Study
20
13
75
6
24
11
2
3036
100
Available time
Motion Paper-work and admin.
Direct patient care
Psycho-socialcare
Physical care
Hand-overs
Medi-cinesmanage-ment and preparation(away from patient).
Discus-sionwith other nurses
Per-sonalhygiene
Other Patient flow
First area of opportunity to remove wasteful activities
We should focus on improving efficiency of direct patient care activities as a second step
1
2
Direct patient care*
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Nursing
Source: HRSA and www.discovernursing.com
It is predicted that there will be a shortage of nurses
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Physicians
Richard A. Cooper, Thomas E. Getzen, Heather J. McKee, and Prakash Laud, Economic And Demographic Trends Signal An Impending Physician Shortage, Health Affairs, Vol 21, Issue 1, 140-154
The predicted demand of Physicians is greater than the projected supply
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Fact:
Can not increase capacity by hiring more personnel
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So how do you transition from
Current State to Future State?
Do a Kaizen!!!
� To rapidly improve a process involving the people doing the work.
� Usually an intensive four- or five-day session focused solely on analyzing current processes and proposing, testing, and implementing changes.
Source: Going Lean in Health Care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2005
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Transformation is a Multiyear Journey
Stabilize operations to generate real productivity, quality, and service improvements
E.g., make basic operational improvements to eliminate waste and variability and ensure consistent service
Service operations excellence
Create operational excellence necessary to deliver distinctive service
E.g., ability to deliver <10 minute ER wait
Leverage these distinctive services to elevate price and/or volume and extend service offerings based on operational competencies
E.g., target time-sensitive consumers with choices in service levels
Time
Most Providers are at the beginning
stage
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Expectations:
• Lead Kaizen events and improvement projects. Deliver measurable results and sustain improvements
•Work in the specific areas for 6 -12 months and then rotate
•Train and develop champions and staff to initiate, lead, and sustain improvement projects
•Develop and implement overall strategy to improve UI Healthcare operations
•Develop and implement a strategy to disseminate Lean Sigma culture at UIHC
•Institutional resource on process improvement methods and training
•Coordinate institutional benchmarking studies
•Systemically identify process improvement opportunities
•Quantify and report on value added by process improvement
•Incorporate process improvement and maintenance tolls into new information systems
OR/ CSS/ ASC/PACU
(1 FTE)
ICU’s & Children’s Hospital
(1 FTE)
Intermediate Care
(1 FTE)
Ambulatory Clinics
(1 FTE’s)
Supply Chain Management
(0.5 FTE)
Labs/Rx/
Epic/Rad.
(0.5 FTE)
� 1 HCIS FTE to support projects in these areas
�1 Project Assistant and 1 Secretary
Director of Operations Excellence
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Operations Improvement
Time Allocation
� Institutional – 1/3� Projects to execute specific
tactics in the strategic plan or projects that are defined by Director’s Staff
� Departmental - 1/3� Projects requested by
departments; prioritized by the Lean Steering Team; and approved by Director’s Staff
� Maintenance and Training – 1/3� Activities needed to hold
previous gains; on-the-spot advising; training & benchmarking
Departmental
Institutional
Maintenance
The “new” SystemA multi-disciplinary team focuses one a set of
measures
Surgical Care Improvement Project (SCIP)
Heart & Vascular CenterPneumonia and Blood
Stream Infections
Core Measure Teams
2 Quality Case Managers1 CQSPI1 Operations Improvement
Heart and Vascular Surgery
Acute Myocardial Infarction
Heart Failure
Ventilator Associated Pneumonia
(VAP)
Community Acquired
Pneumonia (CAP)
1 Quality Case Manager1 CQSPI1 Operations Improvement
1 Quality Case Manager1 CQSPI1 Operations Improvement
Blood Stream
Infections(BSI)
Area of Greatest Focus
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Community Acquired Pneumonia
UIHC Community Acquired Pneumonia Metrics
0%
20%
40%
60%
80%
100%
120%
MetricPneumococcoal
Vaccination
Blood CulturesPerformed in the
EmergencyDepartment Prior to
Initial AntibioticReceived in
Hospital
PneumoccalVaccination AdultSmoking CessationAdvice/Counceling
Intial AntibioticReceived Withen 6hours of Hospital
Arrival
Intial AntibioticSelection for CAPin Immunocompete
Patient (CMSMeasures Only)
InfluenzaVaccination
Before
After
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Heart Failure
UIHC Heart Failure Metrics
0%
20%
40%
60%
80%
100%
120%
Discharge Instructions Evaluation of LVS Function ACEI or ARB for LVSD (ARBadded 1/2005)
Adult Smoking CessationAdvice/ Counseling
Before
After
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SCIP
UIHC SCIP Metrics
0%
20%
40%
60%
80%
100%
120%
ProphylacticAntibiotic
Received Within1 Hour Prior to
Surgical Incision
ProphylacticAntibiotic
Selection forSurgical Patient
ProphylacticAntibiotic
DiscontinuedWithin 24 Hours
for CardiacSurgery andCABG) AfterSurgery End
Time
SurgeryPatients w ith
Appropriate HairRemoval
SurgeryPatients w ith
RecommendedVTE Ordered
SurgeryPatients w ho
ReceivedAppropriate
VTE ProphylaxisWithin 24 HoursPrior to Surgery
to 24 HoursAfter Surgery
Cardiac SurgeryPatients w ithControl 6 A.M.Postop Serum
Glucose
Before
After
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SwimlaneSwimlane DiagramDiagram
Before
After
After
68 Steps, 23 Delay Points, 6 Decision Points10 Forms, 45 Work-Up Widgets in the Patient Process
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Patient Profiles
Scenario #1 15%
Scenario #2 40%
Scenario #3&4 45%
Scenario #4
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LOS Prior to the Event
235 minutes per patient
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Infusion Suite Process - Part I
Pharm
acy
Pharm
acist
Reception
Nurse
Patient
Nurse Assistant
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Infusion Suite Process - Part II
Infusion Suite Pre-Kaizen (page 2)Pharm
acy
Pharm
acist
Reception
Nurse
Patient
Nurse Assistant
NO End IV
Prep
checked
by
PharmD
Pick up
order
PharmD
checks Hx,
lab, clarifies
problems,
verifies entry
on computer
Assemble
required
tubing
Verify
Order
Med
Prep
Educate
Patient
Label
Prints
Discharge
Patient
Complete
Documentation
Administer
Pre-Med
Administer
Medication
Can batch
tubing be used?
Labeled
and
Bagged
Schedule
next
appointment
Deliver
Treatment
Patient Goes
Home
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Scheduling Changes
� Began to front load systems to make patient flow (chair capacity) more constant
� Built scheduling system to more accurately reflect actual capacity
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Data
July 06 Pt Arrival by 9:00 amApril 06 Pt Arrival by 9:00 amBK Pt Arrival by 9:00 am
20
15
10
5
0
Value Plot of BK, April '06, and July '06 Pt Arrival by 9:00 amNumber of Patients
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Pharmacy Changes
� Fax machine installed at reception area of infusion suite
� Infusion faxes orders upon patient arrival at the reception area
� Reduced time for entry of order from an average of 29 minutes to an estimated average of <5 minutes
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Infusion Suite Changes
� Increased nurse to patient contact
� Created 3 pods so the nurse stays in the same area
� Brought daily supplies to the nurses fingertips
� Developed supply carts for each room with replenishment plans
� Brought medications to the nurses fingertips
� Added one med cart per pod for easy access
� Eliminated all RN trips to the pharmacy
� Faxing orders to the pharmacy when the patient checks in. NA paged when meds are ready for pickup (expedited orders to the pharmacy)
� Reduced noise level in the suite
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Infusion Accomplishment:
Identified & Reduced Traffic Patterns
Before After
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RESULTS ATTAINED
RN: 90% reduction
Clinic NA: 100% reduction
RN: 90 ft./pt.
Clinic NA: 0 ft./day
RN: 900 ft./pt.
Clinic NA: 230 ft./day
Reduce staff walking distance by 50%
89% reduction4 minutes32 minutes
38% increase
21% reduction
% Improvement
68 pts./day
(at peak)
42 pts./day
(at peak)
Increase throughput by 10%
186 minutes235 minutesReduce overall ALOS by 10% w/ same resources
Reduce patient wait time by 30%
AfterBeforeGoal
Productivity•Reducing excessive motion allows more efficient use of nursing and staff time•Improving communication between Infusion Therapy and the Pharmacy eliminates redundant work•Creating more capacity enables more effective use of resources
Quality of Care•Developing the pod system organizes caregivers and keeps them in closer proximity to their patients•Reducing wait times shortens overall length of stay•Reducing noise and commotion improves patient experience
Cost to the Institution•Increasing capacity without increasing staffing costs allows for greater possibilities for generating revenue •Adjusting skill mix more appropriately leads to more effective operations•Increasing patient throughput decreases salary and benefit expenses per patient
PROJECT EFFECTS
$84.20Before the Kaizen Event
$51.04After the Kaizen Event
At Capacity: Staff Salary and Benefit Expenses per Patient Visit
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Actions at UIHC: CT Scan
Throughput Improvements:� Increase capacity from 64 to 84 patients per day – 31%
improvement
� Patient Experience average time reduced from 1:54 to 1:16 –33% improvement
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UIHC Emergency Treatment Center Workload and Patient Satisfaction Scores
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
2005
-120
05-2
2005
-320
05-4
2006
-120
06-2
2006
-320
06-4
2007
-120
07-2
2007
-320
07-4
2008
-120
08-2
2008
-320
08-4
2009
-120
09-2
2009
-320
09-4
Quarter
Pat
ien
ts s
een
0
10
20
30
40
50
60
70
80
% V
ery
Go
od
res
po
nse
s
Vol
Adult
Peds
New ETC Opens EPIC implementationFirst Kaizen
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Kidney Transplant Program
metrics2007-08
(pre-kaizen)2009-2010
(post-kaizen)
Referrals 185 347 (8 mos)
Living donor pre-evaluations
NA 162
Patients waiting to be scheduled for eval (WIP)
163 20
Wait time, referral to eval 340 days 68 days
Transplants 51 96 (8 mos)
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Actions at UIHC: 3RC
Improved discharges by 11:00 am, LOS� Increased % discharges by 11:00 am from 23% to 41%: a 78%
improvement
� Improved key Patient Experience questions by average of 4%
Cumulative Discharge %
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%2:
00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:0
0
11:0
0
12:0
0
13:0
0
14:0
0
15:0
0
16:0
0
17:0
0
18:0
0
19:0
0
20:0
0
21:0
0
22:0
0
23:0
0
0:00
Time
% o
f Dis
char
ges
Co
mp
lete
Pre-Event Post-Event
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Actions at UIHC: PharmacyGH Pharmacy - Improve throughput
� Patient Experience reduced wait times form 2+ hours to 45 minutes – 62% improvement
� Staff Satisfaction – Staff quote “It’s going well, but our volume is down” -Same volume
Pomerantz Pharmacy – Improve work flow
� Introduced “One Piece Flow”
� Decrease “Mail-out” lead time from 10 days to 1 day – 90% improvment
� Walk-up lead time reduced from 1 hour to 35 minutes – 42% improvement
� Increased capacity
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� Senior Leadership Involvement
� Change Management
� Need visible, vocal champions of lean thinking
� Culture must be supportive and receptive to change
� Engage and empower employees
� Process Driven
� Rapid improvements
� Standardize work
� Consistent Follow - up
Keys to Success