REDESIGNING ALLIED HEALTH OUTPATIENTS- Lean Thinking Applications to Allied Health

• Josephine Kitch, Director , Allied Health Division ,Flinders Medical Centre , SA• Brenda Crane , RDC Clinical Facilitator , Allied Health Division,FMC, SA• Prof. David Ben Tovim , Director , Redesigning Care, FMC• Rebecca Daebeler , Manager , Podiatry Department,Allied Health Division ,FMC , SA

BACKGROUND

• Flinders Medical Centre– Approx 530 Beds

– Public teaching hospital

– Co located with FUSA & Flinders Private Hospital

– Within Southern Adelaide Health Service

– Full range of care from Perinatal to Palliative

– One of 2 Major Trauma Centres in SA

– Largely emergency driven work – busiest ED workload/bed ratio in SA

WHY DID FMC UNDERTAKE REDESIGNING CARE ?

- Had to search for unfamiliar solutions • Learned about Lean Thinking • British National Health Service Modernisation Agency • Lean Manufacturing sources – local & international

Winter 2003 …………–Major crisis ensuring safe care

–Increasing our capacity did not work !

– Launched Redesigning Care Programme

REDESIGN IN FMC• First 18 months – Adult Emergency Dept

– Identified sequences of care -Value Streams – Process made visible – Big Picture Map– Patients seen in order of arrivalRESULT :Hospital Brought under control

– Can see extra 20 patients per day in ED– Congestion decreased– DNA fell – 7% to 3-4%– Improved ward turnover –1010 bed days saved – Restored capacity for Elective Surgery – Morale & recruitment improved – Other streams – Medical , Surgical, Mental Health , Older Patient

WHAT IS REDESIGNINGCARE ?

– A systematic change programme

– Based on Lean Thinking philosophy & tools

– Focus on making visible the complexity of thePatient Journey through care

Redesigning Care is :

• Can do culture -vs blame culture • Ongoing improvement• Sustainable change

WHAT IS REDESIGNING CARE ?It’s about :

•The Patient Journey(not departments,divisions or professionalsilos )

•Creating flow, maximising valueand reducing waste

•Participation and ownershipof staff ,who initiate change

•Managers as enablersnot decision makers & directors

•The” Flinders House”

WHAT IS LEAN THINKING ?• Based on the Toyota Production System • Well established methodology to organise complex

processes – Initiate change from workplace – Get the Right patient ,to the Right place ,for Right treatment ,

at the Right time

IT IS NOT

– A project management philosophy– A non specific QI process

• Specify Value from the standpoint of the end customer

• Identify the Value Stream for each product family

• Eliminate Waste• Maximise the Flow of the product or service • Enable the customer to Pull or engage the

service as needed • Manage towards Perfection

Adapted from “ The Toyota Way “ – Jeffrey K. Liker

FIVE PRINCIPLES OF LEAN THINKING

8 WASTES IN HEALTH CARE

• Waiting• Queues • Errors • Transportation • Motion • Over Processing• Over production • Not using the skills & expertise of staff doing the

jobAdapted from “ The Toyota Way “ – Jeffrey K. Liker 2004

REDESIGNING CARE

Program phases

P DA C

12

3

45

Diagnostic Diagnostic PhasePhase

Project Project PhasePhase

Sustain Sustain new waysnew waysof workingof working

Share key Share key learningslearnings

Intervention Intervention PhasePhase

P DA C

P DA C

P DA C

P DA C

REDESIGNING CARE PROJECT PHASE

1. Identify a piece of work that needs doing that is aligned with program goals / targets

2. Endorsement by the hospital executive3. Steering Group / Leadership group 4. Defining the targets 5. Establishing the work-groups / resources6. Lean education

Project Project PhasePhase

Diagnostic Diagnostic PhasePhase

• Big picture map- “current state”• Identifying and acknowledging the mess• Engagement and permission of staff

• Identify the value streams (or ‘a’ value stream)

• Establish value stream work group

• Map specific value stream• More detailed understanding of a specific patientjourney

•Track the patient journey•Is what we think happens, what really happens?

•“Future state “map

DIAGNOSTIC PHASEUnderstanding what is happening now……….the good, the bad & the ugly!

Intervention Intervention PhasePhase

P D

A C

REDESIGNING CARE INTERVENTION PHASE

• Work towards a future state through a series of PDCA cycles

• Targeted interventions revealed through mapping processes

• Sometimes it is important to get started• Access to real time data on a weekly basis• 3 month cycles

FMC Allied Health Outpatient Service

is a large business

operating ina complex hospital

system

ALLIED HEALTH REDESIGN•How does this apply to us ?

ALLIED HEALTH REDESIGN

Project Phase• Ever increasing demand on Allied Health

Outpatient Services in FMC • Explore Lean Thinking methodology to

– understand our services– identify duplication and inherent waste – learn how to improve processes .

• Steering Group formed and a Clinical Facilitator engaged in July 2006

ALLIED HEALTH REDESIGNDiagnostic Phase

An initial survey of the FMC Allied Health OP Service showed:

• Complexity • A large business ( the Allied Health Division )

– comprised of 8 smaller individual enterprises• No single Allied Health Outpatient entity and location • No standard operating processes across the Division • Diversity in size , staffing , funding and partnership

arrangements• Disparate referral processes• Organic growth -adapting to department rather than

organisation wide issues

ALLIED HEALTH REDESIGN Diagnostic phase

Mapping:-• Compare largest and smallest Departments ( Physiotherapy & Podiatry) in August – September 06

– Array of hidden roles and assumptions. – Complexity and variation in clinic scheduling – Embedded “ knowledge work” in scheduling

• vulnerable PMA & Assistant & Admin roles

– Disjointed linking with other clinics or “production lines “across FMC

– Access issues for low risk patients in a context of shrinking community options

…another complex system quietly feeding into the main FMC “pipes “ or streams…. …….

The Podiatry Dept. is …..

ALLIED HEALTH REDESIGN

PODIATRY INTERVENTION -DiagnosticsBaseline data analysis• Incomputable complexity of scheduling 12 specialised

Podiatry clinics. • Tracking of Podiatrist and PMA/Administration roles

– high value adding by podiatrists – team dependence upon multitasking PMA /Clerical

role • Valuable information

– continual motion of PMA – PMA activity & overburden – Information flow – Patient wait times

PODIATRY INTERVENTION Diagnostic phase

Podiatry PMA Activity (one clinic )

VANVANDVBREAK

Staff Cover for PMA (one clinic)

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AM set up

Calls

Bookings Clea

ningDres

sings

Activity

Inst

ance

s

Podiatry PMA Instances of Activity ( one clinic)

020406080

100120

Movement Opera

tions

Info. flow

Interruptio

ns Clean

ing Ass

ist Pod.

Assist D

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activity

inst

ance

s no

ted

•Tracking Podiatry PMA

PODIATRY INTERVENTION Diagnostic Phase

Podiatrist Activity Value Chart (one clinic)

VANVANDVBreak

Patient Wait Time (one clinic)

010203040

1 2 3 4 5 6 7

Patient

Min

utes

Wai

ting

•Tracking Podiatrist

Podiatrist instances of Activity (one clinic)

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ork

PODIATRY INTERVENTION- BOOKING TEMPLATE REDESIGN • Aim :• Simplify the complex booking & triage system

through redesign of clinic booking template• Release capacity for IP work and OP High Risk

service from gains made from improved OP Clinic flow.

• Work Group - October 2006 • Trial Intervention -Feb. 2007 ongoing

PODIATRY INTERVENTIONBOOKING TEMPLATE REDESIGN • Method:• Move bookings from computer template • Single large hand written daily template sheet• All staff to see all patients • No named clinics• Book to time needed , treatment room, & Podiatrist• Multiples of 20 min (later10) slot units - not set

appointment length• Book patients in order to next available appointment • Pre allocated emergency slots in each session• Plan Do Check (Study) Act cycles for review and

planning

PODIATRY INTERVENTIONBOOKING TEMPLATE REDESIGN• Booking Model

Referral

Slots in Order•All staff see all pts

•No named clinics

•Next available appt

•See pts in order

•Emergency slots

PodiatristTriage &

Assessment &Decision reFollow up

10

10

10

10

10

10

10

10

10

10

Variable

Slots

PODIATRY INTERVENTION-Cycle checks

• Check - 30/3/07• Helps in staff

vacancy.• +‘ve use of small

gaps • Template to

computer

Check- 1/2/07•20 min to 10 min slots •Increased flexibility • Written sheets to book

•Check- 20/4/07•Visible template•Aids time management•Easy to use •Immediate access to info•Visual control tool for scheduling work•Adjustment to variable slots takes time •Some set clinic times for specialist link up

Check 28/5/07

•Capacity freed for IP work

•Consider optimum ,rather than set time slots ,for New pts

•Increasing patient variety in Specialist Clinic.

•Now consider workplace redesign -5S

PODIATRY BOOKING INTERVENTIONStaff Feedback•Template easy to use -visual control •Flexibility of 10 minute slots

–Adjustment required to anticipating right time for booking–Positive use of small gaps

•Improved range of appts across week for patients•Benefits of move away from specialist clinic structure

–Patients easing away from familiar clinic & day •Enhanced capacity for inpatient work

–Now possible to see IP’s on same day –Enhanced rapport with ward staff–All staff get IP experience now

•Generalist and Specialist Podiatrist skills confirmed across team–Helpful in time of vacancy , not lost when staff leave

PODIATRY INTERVENTIONResults • Demand Tally • Pre Intervention Post Intervention

2006

70% offered appts

2007

88% offered appts

15 days

Av.wait to appt

10 days

Av.wait to appt

Range 2-27 days Range 5-16 days

Wait cut by one week

Compressed range of wait advantages ALL patients

PODIATRY INTERVENTIONResults- Activity Data Comparison-Pre & Post Intervention

2007Staff instability & leave significantly greater than 06

But lower in 2007

Activity Maintained

DNA rate fell steadily over both periods

Podiatry DNA 06 & 07

0

10

20

30

40

Feb Mar April

DNA 06

DNA 07

PODIATRY INTERVENTION -Laboratory 5S• Sort

Identify what’s needed and not – Sometimes used – Rarely used – Never used – Red Tag – Eliminate clutter

• Set in Order

For access & to relate to process– Analyse status quo– Allocate items a space – Decide how things should be stored – Labels

• Shine

– Clean , inspect & maintain work area

– Identify hazards

• Standardise

Make work areas with similar function look the same

Visual techniques – Quick identification

– Place for everything – Easy retrieval of frequently used items – Check list for putting things away

Safe storage – height & weight considerations

• Sustain

Ensure 5S is not just a quick clean up Team responsibility5min maintenance daily

Standard operating procedures

5S teams

PODIATRY LAB 5S

Before

After

PODIATRY LAB 5SBefore

After

PODIATRY LAB - 5S

Before After

Ongoing Planning in Podiatry

• Consumer feedback and satisfaction• Investigate patient outcome data• 5S all areas of podiatry area• Consolidate changes made in the department• Continue to improve• Continue to share

ADDITIONAL ALLIED HEALTH WORK

• Big Picture Maps completed for all AH OP Services

• Booking Intervention - Audiology Dept since May 07

• Hand Therapy Service mapped in June

• Links with Division of Surgery -hospital wide OP Referral Data Base – pilot site Dietetics

• AH key member of Hospital Outpatient Steering Group and in some areas leading the way

Hospital wide Outpatient framework

• Principles• Metrics• Predicated outcomes• Across the outpatient journey points (referral,

triage, booking, intervention and discharge)• Endorsed by Management Executive• Now the fun begins!!• Standardization is possible across the hospital

SUSTAINING NEW WAYS OF WORKING

• Culture of perpetual improvement Make friends with your data!

• Team ownership of the process • Develop Lean Leaders in each department

Staff coaching and Lean knowledge • Learning by sharing - success and failures• Workplace organisation 5S & shared responsibility