processvsa-congestive heart failure

8/7/2019 ProcessVSA-Congestive Heart Failure

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PcssVSA:CongeStiVe HeArt FAilure DiSCHArge

CASe StuDy


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At a GlanceOrganizationNot-For-Prot Hea lthcare System

IndustryHealthcare

Business IssueCore Measure Perormanceor Congestive Heart FailureDischarge

Methodology Applied

Process VSA

Business ImpactnImproved Core Measure

Perormance by 10% in lessthan 90 days, rst time everabove state average

nReduced Patient Wait imeby 33 minutes

nReduced LOS

nReduced Readmission Rate

nIncreased CMS Reimbursement

Financial ResultsnValidated savings o $296K in less

than 90 days

Tools AppliednProcess VSAnVOC AnalysisnSIPOCnPareto Analysis

About the Organization

Te healthcare organization discussed in this case study is an integrated not-or-prothealthcare system ounded in 1981. It provides comprehensive healthcare services

to several communities in upstate NY and northern Pennsylvania. In addition to a

community-based university-aliated teaching hospital, the system includes three acute-

care community hospitals. Primary and specialty care services are provided in twelve

amily health centers. Te system includes home health, nursing home and long-term

care, and other community health services and agencies. Te system has a combined

medical sta o more than 500 physicians, is licensed to provide more than 800 inpatient

beds, and is one o the regions primary employers with more than 4,500 employees.

Project DefnitionTe Congestive Heart Failure (CHF) Discharge Process was selected by the organizations

leadership as the inaugural eort or a process-level value stream assessment, or

ProcessVSA. Te opportunity was identied as a priority during the two-week JumpStartplanning workshops (or more on SystemCPI and the JumpStart deployment planning

process, read our white paper Introducing SystemCPI). Perormance Gap Analysis,

System Value Stream Analysis, and System Constraint Analysis had identied more than

100 process improvement opportunities. A prioritization matrix o weighted criteria was

used to rank order potential events and projects and ensure alignment with the systems

business strategy. Commitment to the patient rst was evidenced by assignment o

greater weight to impact on the patient than to any other criterion.

Te Methodology

A ProcessVSA is a disciplined approach to analyzing the activities and the ow o

materials and inormation through which a product or service is delivered to the

customer. Te overall objective is to reveal non value-added activities (or waste),constraints, and process improvements. A well-executed ProcessVSA transcends the

real and articial boundaries o department, unction, and discipline to analyze the

entire value stream rom the customers perspective.

Te primary tool utilized in ProcessVSA is the Value Stream Map (VSM), a visual

representation o the process. An interdisciplinary team o subject matter experts map the

current state o the process. Each step in the process is then evaluated and assigned a value

classication. Value is dened rom the customers perspective. Te Current State Map serves

as the baseline or uture process improvements. Te Ideal State Map denes the ultimate,

long-term goal or the value stream. Te Future State Map is the teams vision o the process as

it will be when process improvements are implemented, typically within a six-month period.

An action plan captures process improvements required to transorm the process rom the

Current to the Future State. Actions plans include dierent types o improvement methodssuch as Just Do Its (JDIs), Rapid Improvement Workshops (RIWs), and DMAIC projects.

Te Problem

Congestive Heart Failure (CHF or HF) is a leading cause o mortality and morbidity in the

US, aecting more than ve million people. With the prevalence and incidence o CHF

rising, the rate o hospitalization is increasing. Te estimated cost o CHF in 2008 was nearly

$35 billion. A readmission rate o 24.5% is a key cost driver and compelling evidence that

existing approaches to managing CHF are inadequate. CHF/HF is a Centers or Medicare

and Medicaid Services (CMS) National Clinical Focus Condition and a Joint Commission

National Hospital Quality Measure. Core Measure Perormance impacts Reimbursement


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eam members voiced their hope that the event would make a dierence or the CHF

Discharge process. Te project scope was rened to exclude CHF patients being dischargedto tertiary care or to Intensive Care or Skilled Nursing Units. Te Champions approved

this change when they attended the event kick o.

Data collected during the Pre-Event phase and perormance relative to existing metrics

and regulatory requirements was reviewed. Te team created a SIPOC, a high-level process

map that identies suppliers, inputs, ve to seven high-level process steps, outputs, and

customers o the process. Te SIPOC was used to ground and to ocus the event. Already,

some hints o opportunities or improvement emerged. Inputs and Outputs identied by

the team led to additional questions about the process. No maps o the process existed.

Voice o the Customer (VOC) data was available but was not specic to CHF. Te hospitals

policies and guidelines related to CHF Discharge were reviewed and compared to CMS

and Joint Commission requirements. Finally, the team walked the process, noting details

about the process rom both patient and sta perspectives.

Assessing the Current State

A unctional ormat was used to create the Current State Map because, like most

healthcare processes, handos between unctions or departments are key variables. Each

team members perspective on the process was limited to their own experience. No one

person or departments view o the process captured the whole truth. Mapping the true

Current State o the process required the input o every member o the team. Considerable

discussion and debate was necessary or the team to reach a consensus. Excitement grew as

the team began to truly see the process or the rst time. Te hospitalists participation

was critical and made possible by exibility in the work plan. Initially, she could stay or

just a little while, but she became actively involved in mapping the Current State and

continued to be a vital part o the team thereafer. She later led a related RIW team to

revise Pre-Printed Orders or CHF.

The work planwas adjusted toaccommodate theavailability o thehospitalist. Thisfexibility proved

critical to eventsuccess.

Figure 1. Value stream map o CHF Discharge.


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When completed, the Current State Map included 99 process steps and 36 handos.

Each step was then classied as value added, non-value added, or non-value added butnecessary. Te team determined that 30 steps (37%) did not add value rom the customers

perspective. Other waste, such as redundant documentation, and constraints, such

as limited access by nurses to computer workstations and printers, were identied and

documented on the Problem List. Cycle time or CHF discharge (rom physician order to

patient departure) averaged two hours and 36 minutes. More than 54% o this time was

non value-added. Nurses preparing to discharge a CHF patient were required to search or

to wait or a computer workstation and then or an available and operable printer in order

to print the 14-page packet o discharge instructions that, by CMS regulation, must be

provided at discharge. Meanwhile, the patient waited to go home.

One o the teams Ground Rules, For every problem, oer at least one solution generated

a growing list o potential process improvements collected on the Solutions List. Both

hospitals were designed and built decades beore an inux o modern technology andequipment. Hallways were congested and storage spaces overowing. ower units at the

hospital are congured as wedge-shaped patient rooms surrounding a circular hallway

and a central nurses station. Every inch o space is a precious commodity. Multiple

opportunities or 5S and Visual Management were identied.

A Pareto Analysis o the causes o Core Measure ailure revealed that, in most instances,

the appropriate actions (such as ejection raction assessment or discharge instructions

provided to the patient) had been taken. Te exception, errors in medication reconciliation,

had been identied as a uture Six Sigma project and was added to the Parking Lot. Te

remaining causes o CHF Core Measure ailure were related to documentation, a complex

and multi-redundant sub-process that would be the ocus o a Rapid Improvement

Workshop (RIW) to ollow the PVSA.

Figure 2. ower units at t he hospital.


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Identifying Process Improvements

Mapping the Ideal State seemed, initially, to be a relatively pointless activity to a team

so ully involved in problem-solving that they had completed twelve 5S events and JDIs

during lunch breaks. Te team struggled to understand the rationale or the sudden

change in ocus. Ten, once ideas began to be articulated and what i scenarios

explored, the teams creative energy surged. Te completed Ideal State Map represented

the teams vision o the process in a perect world, without waste or constraint or the

limitations o time, space, or other resources. It would serve as the ultimate long-termgoal or the CHF Discharge process when Computerized Physician Order Entry and a

ully integrated Electronic Medical Record had become a reality.

With a clear understanding o the reality o the Current State and the limitless possibilities

o the Ideal State in mind, the team created a Future State map. Each problem identied

was addressed. Each solution was evaluated or viability and impact on the Future State.

Non value-added activity, other waste, and root causes o CHF Core Measure ai lure were

eliminated or mitigated. Handos were minimized. When completed, the Future State

included 69 steps, a 30% reduction. Non value-added steps were reduced by 83% and the

number o handos reduced to 21, a 41% reduction.

Creating an Action Plan

An action plan captured each process improvement necessary to transorm the processrom the Current to the Future state. A selection chart was used to determine whether

each proposed improvement was a 5S event, a JDI, a RIW, or a Six Sigma project. Eight JDI

improvements, such as mounting computer monitors on the wall to provide additional

workspace and moving or adding equipment (telephones, printers and axes) required

management approval or assistance rom someone outside the team. Adding a pop-up in

NurseVu to alert sta that a diagnosis o CHF had been identied would require a small

sofware modication. Te pop-up, a key process improvement, would cue the nurse to

print the discharge instructions when a diagnosis o CHF was identied, eliminating the

bottleneck at the discharge end o the process.

Figure 3. Pareto chart o reasons or CHF Core Measure Failures.


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Other process improvements, such as a visual management tool to identiy the medical

records o CHF patients and a new process or scheduling ollow-up appointments were

piloted beore ull-scale implementation. Four RIW events were indentied. Te CHF Core

Measure Documentation RIW charter was drafed and Lean Experts and a Champion

were assigned. At the close o the ProcessVSA event, more than hal o the improvements

identied had been completed. Te Action Plan, including enrollment in the Hospital to

Home (H2H) program and Nurse Direct contact o CHF patients ollowing discharge

would be completed within three-weeks.

Post-Event asks

Preliminary calculations o return on investment were reviewed and approved by thehospitals Money Belt. Response to the workshop outbrie was positive. Current and

Future State maps elicited comments such as Wow! and No wonder this process is

so di icult! rom the audience assembled in the Doctors Auditorium. Each member

o the team spoke about their experience with excitement and a new understanding

o their work. eam members were presented with certiicates o accomplishment

by the Deployment Leader and the Post-Event Checklist included a team dinner to

celebrate success.

A Control Plan was developed to ensure completion o the Action Plan within the

anticipated timerame, monitor key process indicators, and dene the response necessary

i perormance does not improve as projected. Te plan was reviewed weekly with the

process owners until all milestones had been achieved and then at three-month intervals

until the process is stable and consistently meeting perormance objectives. Tis ensuressustainment, which is a primary objective articulated by leadership during the SystemCPI

planning phase, and a measure o SystemCPI deployment success.

The ResultsTe CHF Discharge ProcessVSA resulted in an immediate improvement in CHF Core

Measure perormance. For several weeks ollowing the event, there were no CHF Core

Measure ailures unrelated to medication reconciliation. Composite CHF Core Measure

perormance exceeded the NY state average or the rst time ever, an improvement o

nearly 10% in less than 90 days. I current projections are realized, the hospital will exceed

the CMS benchmark in 2010.

Figure 4. Process improvements


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Benets attributed to the workshop include improved patient, physician, and nursing sta

satisaction. Sof savings associated with re-allocation o sta to value-added activities areestimated to exceed $16K per year. Each CHF patient waits 33 minutes less to go home afer

the discharge order has been written. While hard savings cannot currently be attributed to

improved CHF clinical outcomes (as evidenced by improved Core Measure Perormance

and a reduced 30-Day readmission rate), uture savings related to non-reimbursement or

CHF re-admissions exceed $296K per year. Similar savings will be realized as CMS value-

based purchasing is implemented and ailure to meet benchmarks result in reductions in

reimbursement by as much as 5%.

Summary and ConclusionsTe process improvements implemented as a result o the CHF Discharge ProcessVSA

will be replicated or other CMS Core Measures and at other system hospitals. Te

number o Core Measures is expected to increase signicantly in the near uture. As

pay-or-perormance and other nancial incentives intended to improve quality o careare implemented, the savings realized will increase and the work o the CHF Discharge

team will continue to pay dividends well into the uture. Te success o the event was

also measured by the energy and enthusiasm exhibited by the team. Members o the

team agreed that the event was un! and asked to participate in uture events and to be

included in the next Lean Expert raining course. Te hospitals sta response to changes

implemented has been enthusiastically positive.

Next steps included the completion o our RIW events and one Six Sigma DMAIC

project. wo RIWs were combined and completed within two weeks. Te remaining events

and projects are currently being chartered and are expected to be completed within the

six-month timerame. At that time, time studies will be completed and Core Measure

Perormance and readmission rates reassessed to validate that the projected improvementshave been sustained.

References

American Heart Association. Heart Disease and Stroke Statistics 2008 Update. Dallas, exas: American

Heart Association: 2008 2008, American Heart Association

Centers or Medicare and Medicaid Services (CMS), Last edited 2009.

http://www.cms.hhs.gov/apps/QMISCMS.


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Notes


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PcssVSACongestive Heart Failure DischargeCase Study

PcssVSAValue Stream Analysis o the VoyagePlanning & Scheduling ProcessCase Study

us triZ iva tsIn a Rapid Improvement WorkshopCase Study

SsmCPi JmpSa119 Healthcare ImprovementOpportunities Identied in Two Weeks

Case Study

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We, the PatientLEAN SIX SIGMA IMPROVES PATIENT CARE QUALITY AND BUSINESS PERFORMANCE

WHITE PAPER

ProcessVSA:CONGESTIVE HEART FAILURE DISCHARGE

CASE STUDY

Laboratory Turnaround Timesin Emergency DepartmentsELIMINATING WASTEFUL STEPS AND BOTTLENECKS WITH LEAN SIX SIGMA

WHITE PAPER

Mentoring as a Lean Six Sigma EnablerUSING RESULTSORIENTED MENTORING TO BOOST SELFSUFFICIENCY AND ROI

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ProcessVSAVALUE STREAM ANALYSIS OF THE VOYAGE PLANNING & SCHEDULING PROCESS

CASE STUDY

Using TRIZ Innovation ToolsIN A RAPID IMPROVEMENT WORKSHOP

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laba tad tms emc DpamsEliminating Wasteul Steps andBottlenecks with Lean Six SigmaWhite Paper

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M as ala Sx Sma eabUsing Results-Oriented Mentoring toBoost Sel-Sufciency and ROI

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