lean in health care – crossing the hurdles final part 2
DESCRIPTION
Challenges and Hurdles in Implementing Lean Six Sigma in a Healthcare Setting by Dr.Mahesh VakamudiTRANSCRIPT
People asking questions… lost in confusion,
Well, I tell them there’s no problem… only lsolutions.
‐ John Lennon
EMBRACE IT !!!EMBRACE IT !!!
This may seem strange at first, but in fact many problems y g , y paren’t problems at all. In fact most problems are opportunities and many are actually ……
PINK BATS‐ unseen solutions just waiting to be found.
PINK BAT THINKING makes the impossible possible.
Usual major inefficiencies
Wasted motion
▪ Pharmacy tech
Rework
▪ X ray tech has to
Over production Excess inventory
▪ Admissionsspends 20 minutes looking in multiple places for a particular
▪ X‐ray tech has to re enter 10%‐20% of requests because of wrong
▪ Medicines held over in the wards excess than required
▪ Admissions paperwork having 7 redundant pages out in the
for a particular med
side indicationrequired .
16 page packet
Wasted transportation
Excess processing
Waiting time Wasted intellect
▪ 25% of patients admitted to 4M are transferred to a unit
ith i il l l
▪ Nurse records respiratory rate
4 diff t
▪ OR team waits 20 minutes for a case to b i d i t
▪ Numerous ideas are “lost” only to b di dwith a similar level
of care within 36 hours of admission
on 4 different forms in the chart
begin, and is not free to do other tasks
be rediscovered later
212 212120@S R M C@
Goal setting workshopWe as an organization are committed to being:
PATIENT CENTRIC‐ Being empathetic & transparent to patients by delivering timely, adequate care & sustainable processessustainable processes.
ETHICAL‐ Ensure transparency in all systems processes & servicessystems, processes & services.
COST EFFECTIVE‐ Delivering affordable care to patients by minimizing wastages and effective p y g gutilization of resources.
EMPLOYEE CENTRIC‐To go an extra mile to ensure t ff ti f ti t i i d l t dstaff satisfaction, training, career development and
overall safety.
INNOVATION‐To be an innovative organization byINNOVATION‐To be an innovative organization by the implementation of best practices and ownership of promised services through Team work. 212 degree @S R M C
212 Lean - Objectives
JCI Re accreditation & Sustenance of processes
Primary business focus on releasing capacity, increasing throughput and improving patient experience (e g lower waiting times)and improving patient experience (e.g., lower waiting times)
Improved utilization of assets
f d d fSuperior patient
3 key deliverables
Creation of a standard way of operating, processes, systems‐ IMPLEMENTATION OF BEST PRACTICES
Experience (visible improvements)
Superior clinician &Documentation of processes & creation of a STANDARD MANUAL
Training & skill development
Superior clinician & staff experience
Superior hospital
Visual management
In addition will take a 360º view to opportunistically identifying/
Performance (tangible financial benefits)
In addition, will take a 360 view to opportunistically identifying/ documenting other opportunities in areas we go deep in, but sequence out implementation
DDegreesReport on the P h d tPrephase‐ data
collection findingsbDecember 2010
ER
ORENDOSCOPY
2 CLINICAL SPECIALTITES
First PhaseOP
FOCUSIP
HOUSEKEEPING & STORES
RADIOLOGYADMISSIONS &
LABS
BILLING
212 degree @S R M C
DIALYSISPHARMACY
Overall Program Structure
LEADERSHIPDrive the initiative Monthly
reviews
Believe in the initiative & Sponsor it
Monthly reviews
Target Setting,Initiative roll outTrack milestones
CORE TEAM 10% of daily
timeDoctors ,
Nurses , & Admin ‐Track milestones
To ensure de‐bottlenecking and
10% of daily time Champions
OWNERSDepartment
TeamsOwn and drive implementation of initiatives
own and drive
80% of daily time
212 degree @S R M C
of initiativesEnsure debottleneckingSustenance of initiatives
25% of daily time
PRE PHASE 4‐6 weeksData collection by championsData collection by champions
MIRROR – MIRROR- One to One Interviews with Consultants, Nurses, staff and Patients
Organizational climate surveys
Patient Feedback mechanism changed to gNet Promoter Score
Collage competitions
Identify bottlenecks in processes
Draw Process Flow Analysis
Identify existing standards (baseline)
Presentation of facts and findingsSmart Service Desk
Presentation of facts and findings
HALL WALK212 degree @S R M C
To drop in your ideas
Root Cause AnalysisRoot Cause Analysis
CO‐ CREATE solutions
De‐bottlenecking processesDe bottlenecking processes
Implementation of best practices
Building capacity & capabilities
Parallel implementation of 4th
Edition JCI standards
Reviewing & monitoring phase
212 degree @S R M C
Reviewing & monitoring phase
INVESTIGATIVE PHASE FINDINGSINVESTIGATIVE PHASE FINDINGS
212 degree @S R M C
Operation Theatre
250 ENT
200
OG
PEAD.S
PLAS.S
GEN.S
NEURO
Average Utilization is 78%
100
150
SGE
ORTHO
OPTHAL
URO
VASCULAR
50
OMFS
DENTAL
CTVS
PSYCHIATRIST
SMILE TRAIN
0May‐10 Jun‐10 Jul‐10 Aug‐10
SPINE
ARTHROSCOPY
OTHERS
212 degree @S R M C Data collected from previous reports
Operation Theatre: Cancellation analysis Insurance not approvedPatient not fit
Patient not admittedNon availability of compatible
421
0
8
3
63 623
00
142
15
100%
Cancellation Analysis BloodTheatre busy
24
42
7
21
17
211
9
8
62
63
76
39
62
6
2 7
13
28
12
5
2
11
4
15
17
15
40%
60%
80%
28
36
2
8
23
21
0
228
60
61
60
76
4
2
0
6
7
24
11
10
11
12
16
0%
20%
40%
D RY N H E D E N R S G ON E S
September
August
July
T APPROVED/ C
ATEGORY N
OT PAID
NNO LO
NGER W
ARRANTS SURGER
Y
3. AW
AITING CONSU
LTATIO
N
4. PATIE
NT DEA
TH
5. WORK –U
P INCOM
PLET
E
6. PATIE
NT NOT A
DMITT
ED
EDIC
ALLY N
OT FIT
FOR PR
OCEDURE
OOD FOR IN
TRA‐
OP TRANSF
USION
9NON A
VAILABILI
TY O
F ATTE
NDER
MEN
T ISS
UES\IN
STRUM
ENT ISS
UES
11. PATIE
NT NOT W
ILLIN
G
ME U
NSUITA
BLE FO
R THE SU
RGEON
WITH
PREVIO
US/EM
ERGENCY C
ASE
14. M
ISCEL
LANEO
US
June
1. INSU
RANCE NOT A
2. PATIE
NT CONDITION N
7. MED
AVAILABILI
TY O
F COM
PATIB
LE BLO 9.
10. EQUIPM
12. ALL
OTTED TIM
E
13. SU
RGEON H
ELD U
P W
8. NON A
212 degree @S R M C Data collected from previous reports
Endoscopy Maximum cases done are private in Medical Gastroenterology
Case Mix
Gastroenterology
196
PVT Ward Free OPD NB Ward Total No. of Cases
9262
190 3 3 9 4
19 7 2 0 0 9
MedicalGastroenterology
SurgicalGastroenterology
General Surgery
212 degree @S R M C Data collected from previous reports
Endoscopy 81% of the endoscopies are done by two doctors
No. of Cases Performed by doctors 8%
2%6% 2% 1%0%
Dr. A
Dr. B
Dr. C
Dr. D
53%
28%Dr. E
Dr. F
Dr. G53% Dr. G
Dr. H
212 degree @S R M C Data collected from previous reports
ENDOSCOPY An average of 345 endoscopies are done every month
ENDOSCOPY PROCEDURES
400
500
200
300
400
otal
(No.
)
0
100
200
Gra
nd T
o
Series1 331 405 363 284
AUGUST, JULY,2010 JUNE, 2010 MAY, 2010
212 degree @S R M C Data collected from previous reports
Total TAT is about 75 min (even for a 15 min procedure)
212 degree @S R M C
AVERAGE TIME TAKEN BY A PATIENTIN ER20% OF ER CASES ARE
FEVER FOR
EMERGENCY
AVERAGE TIME TAKEN BY A PATIENT IN ER FEVER FOR EVALUATION & 13% FOR RTA.
617.4ALOS in ER is about 8 hours
451.2
617.4
600
700
Total TAT for Patient in ER is about 10 hours
400
500
600
Series1
100
200
300Series1
0
100
TOTAL LENGTH OF STAYIN ER (MIN)
TOTAL TAT FOR APATIENT IN ER(MIN)
212 degree @S R M C Data collected by observation
Cause of increased LOS is waiting for the investigative reports or bed unavailability
Patients routinely interact with 7‐9 different nurses during their stay in wards
Patient exposure to nurses
IN PATIENTS
Bed number shift 15-09-10 16-09-10 17-09-2010 18-09-10 19-09-10 20-09-10 21-09-10
A m
p
B m
C m
D m
E m
F e
G e
H e
I e
J e
K n
L n
M n
N n
O n
Different colours represent different nurses Data collected by observation212 degree @S R M C
212 degree @S R M C
MIRROR ‐MIRROR
212 degree @S R M C
MIRROR ‐MIRROR‐ EMPLOYEES
28 %
How many years you have been working with the hospital?
25
30 27 % 28 %
20 %
20 16 %
20 %
10
15
9 %
0
5
0 ‐ 2 years 2 ‐ 4 years 4 ‐ 6 years 6 ‐ 8 years > 8 years
Data collected by feedback 212 degree @S R M C
MIRROR ‐MIRROR‐ EMPLOYEES
%
The organization cares for me
35
40
45
31.8 %
41.9 %
25
30
35
10
15
20
9.48 % 7.95 % 8.87 %
0
5
Strongly Agree I am Disagree Strongly Strongly Agree
Agree I am indifferent
Disagree Strongly Disagree
Data collected by feedback 212 degree @S R M C
MIRROR ‐MIRROR‐ EMPLOYEESNeed of the day at this hospital today is About 45% of the
staff feels that the processes need to be
40
45
45 % improved
30
35
4030.67 %
15
20
25
10 %
6 %8.33 %
0
5
10 6 %33
Better processes
Better infrastructure
Better technology
Better people Better IT
Data collected by feedback 212 degree @S R M C
MIRROR ‐MIRROR‐ EMPLOYEESHave you visited the hospital before? It is 7 times easier
to retain anexisting patient
120 104
g pthan getting a new one
80
100 78
40
60
26
0
20
Total Yes NoTotal Yes No
Data collected by feedback 212 degree @S R M C
MIRROR ‐MIRROR‐ EMPLOYEESNeed of the day at this hospital today is
Alarming‐ as there are about 23%
120 104of the patients who are DETRACTORSThey would never refer the hospital
to anyone
80
100
56
40
60
1912 12
0
20
Total 1 Never 2 3 4 5
5 12 12
Total 1 Never 2 3 4 5 Definitely
Data collected by feedback 212 degree @S R M C
Next Steps
Solution designing & implementation
D il 30 i i b 212 D L dDaily 30 min reviews by 212 Degree Leader
Monitoring dashboards
5S WORKSHOP
212 degree @S R M C
REPORT CARD – Month Every patient Delighted
Score ‐
Asset Metric Unit Apr '09 May' 09 June' 09 Target OPD Patients waiting beyond 15 mins of appnt % 3% 5% 3% <5%PHC %age PHCs completed within defined TAT % 63% 76% 78% 90%ER Pts with LOS > 4 hrs in triage % 1% 0% 0% <5%
ER Ambulance response outside 10 mins % 0% 2% 0% <10%Score ‐Wards Discharges before 11 am % 34% 44% 43% 75%
IPD ALOS Days 4 3.75 4
OT & Cath Lab Procedure / Surgeries starting within 30 mins of scheduled time % 85% 91% 91% 90%
Lab Med Short lead test completed with in 1hour 30 mins % 77% 91% 90% 90%mins
Radiology USG reports within 15 minsX-ray reports within 30 mins % 38% 45% 46% 90%
Asset Metric Apr '09 May' 09 June' 09 Target OPD Calls Dropped % <5%
Score –ER Ambulance calls turned back % 0% 4% 3% <5%IPD Admissions denied % 0% 0% 0% 0%
OT & Cath Lab Surgeries rescheduled % 7% 5% 4% <5%
A t M t i A '09 M '09 J ' 09 T tAsset Metric Apr '09 May '09 June' 09 Target ICUs % Step downs planned % 46% 47% 63% 80
Billing Patients with final bill more than 5% of estimate % 10% 7.3% 5.8% <5%
Wards % discharges planned % 63% 78% 82% 80%Wards Length of discharge process Mins 203 202.5 180 120
Score –
Score = 1 = 2 = 3
House keeping TAT for room cleaning post discharge Mins 20 23 25 30
Score 67% 75% 81%
LAB – IDENTIFIED PROBLEMS & AND POTENTIAL SOLUTIONS
IDENTIFIED PROBLEM POSSIBLE SOLUTION ACTION TAKEN
“Frequent delay in transport of samples from ward to lab because of long waiting time
Provision of Pneumatic systemor prioritized lifts
Feasibility studies and installation
Blood collection &
t t because of long waiting time for the lifts
or prioritized lifts installationtransport
One Phlebotomist is assigned for wide area for collection. This leads to
Ward Nurse / Secretary to strictly follow the schedule
Education to be given to the ward nurses /
t idelay in collection after request creation especially during peak hours”
secretaries
Blood samples are Frequently lysed To increase the number of
Phlebotomists HR staffing plan reviewq y yespecially from ICU Phlebotomists g p
ICU staff nurse to be trained periodically in blood collection techniques
Structured education sessions with periodic
l tiD ring net ork in blood collection techniques evaluation--During network breakdown samples are dispatched to lab without hospital number and with only the name of patient. This causes confusion in processing and results of
All samples can be received with hand written hospital number from ward / ICU Th b ti b f
Education and information dissemination To improveprocessing and results of
samples Frequent Run time error necessitates shut down and restart of machines
They can be continuous numbers for easy verification
dissemination To improve network efficiency
212 degree @S R M C
5 S Workshop
212 degree @S R M C
Background
C RMCProject Title:5SCompany Name:
SRMC
Gemba: Ist Floor to 7th floor
Date: 07 05 2011
Preliminary Objectives
To implement 5S concepts in Admission Billing Lab Radiology Cardiology and
Date: 07.05.2011 8 GEMBAS for 7 floors
Concerns / Issues Needing Attention from one
Admission, Billing, Lab ,Radiology,Cardiology and EndoscopyTo stream line process for better efficiencyTo optimize output in each area
Concerns / Issues Needing Attention from one team
Find a place for scrapped itemsMaintain orderliness in change rooms/ cleaning
Team Name: TEAM BMembers: Lean members present‐Dr. UmaSekar, Dr. K.S.Sridharan, Dr. Naveen, Ms.Latha, Mr.Gunasekaran, Mr.Thikkaram, Ms. rooms
Educating all Gemba staffs on 5S principles, Retention period for documents not specified for Radiology
, , , ,Anuradha, Ms. Baghyalakshmi, Ms.Manimekalai, Ms.P.Sudha, Ms.Sheela, Sr.Devi, Sr.Mohana, Sr.Mythili,Core Team members‐Mr.Alagumuni, Ms.Gunasundari, Ms. Kokilavani, Ms.Jeyanthi, Ms.Sowbaghyalaksmi, y , g y
Action taken during workshop5 S Steps Actions takenSeiri – Sort Sorting of files, papers, consumables and stocks
Seiton Set in Identified suitable places for keeping the items andSeiton – Set in Order
Identified suitable places for keeping the items and labelling done for easy retrieval, floor mapping in radiology
Seiso –Cleaning
Extensive cleaning, dusting and mopping done
Before After Photos / Sketches Red tagRed tag
Red tag
Before After Photos / Sketches-Lab
Before After Photos / Sketches-Endoscopy & Star Health
What has changed…………………
WHAT CHANGES WILL THE PATIENT’S NOTICE IN YOUR GEMBA?
Area found to be more neat and clean than before
WHAT CHANGES WILL THE DOCTOR’S NOTICE?WHAT CHANGES WILL THE DOCTOR S NOTICE?
‐Things are well organized
WHAT CHANGES WILL THE GEMBA STAFF NOTICE?
ff f‐Staff will find easy to work when things are organized well
212 DEGREES
LabsLabs
iIIntroduced new tests and combined test panels ‐ average revenue 3.62 lakhs per
thmonth
Reduced lysis of samples in ICU’s from 0.3% to 0.07%
Reagent wastage minimized per month ‐ saving of 32,000 INR
Number of samples increased 25% of the times
The outliers for number of tests that are reported (>90 min) reduced form 30% to 3%
Pharmacy
iIReduced waiting time for OP prescriptions .
Dispensing TAT from 1hr 20 minutes to 50 minutes
Medical and Surgical Dispensing at one counterg p g
OROR
iINumber of surgeries per day increased from 35 to 38
Capacity released
% surgeries scheduled a day before (Gen Surg) increased from 65% to 100%g y ( g) 5
Cancellations (Gen Surg) reduced from 23% to 12%
Delay in first case starts (8:00 am) reduced to only 10% delays from 32% for Gen SurgDelay in first case starts (8:00 am)‐ reduced to only 10% delays from 32% for Gen Surgand OBG
ERER
iIPatients with length of stay more than 4 hours reduced from an average of 77 patients
d t ti t dper day to 10 patients per day
Cash collection in ER‐Average of 1.2 lakhs is increased due to release of capacity.
TAT Radiology investigations‐ reduced considerably
Dialysis
iI75% of the patients coming with appointments
Average TAT per dialysis chair increased from 2 to 2.3
Endoscopy
iIAppointment system in place
Slots for different consultants
Endoscopy utilization went up from 18‐ 48%py p 4
Release of capacity‐more cases can be done easily
IPIP
iIActivity card updations including implant costs, category fee etc – updated within 24 h f t t l d b tt i tihours of surgery to prevent losses and better communication
Cohorting in process
Room TAT decreased form 180 min to 45 mins
OPDsOPDs
iINumber of Gen Surg OP per day increased from 25 to 28
First OP case delays (9:00 am) reduced form 30 min to 15 min
Centralized Appointment system startedpp y
Number of repeat patients (OBG and Gen Surg) increased from 41 to 71
Radiology
iIVoice Recognition Software used for all reports‐ Saves time and errors
Separate IP and OP Slots‐ Streamlined processes and better visibility (All IP’s done on the same day and more OP’s are done)
Capacity released
Increased Equipment utilization
MRI scans increased from 21 to 26
Success Mantra……
Communication
Implementation of all solutions
Improved tracking mechanism‐Targets review & scorecard
Mirror Mirror‐Top 15 initiatives to be finalized for patient and employee satisfaction
Involvement of DoctorsInvolvement of Doctors
capacity released
Continuous internal reviews (daily, weekly, monthly)
Lean ‐212 degree is a journey, not a destination