Lean Implementation at
Jefferson Healthcare
Earll Murman
LAI Annual Conference
March 25, 2010
Rural Healthcare Case Study
Jefferson County, WA – Population 29,542 (2008 est.)
Photo by Earll Murman
Source: Google
© 2010 MIT Murman LAI Annual Meeting 2
Jefferson Healthcare Overview
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History
1890 Sisters of Providence founded St John’s Hospital
1975 Jefferson County Public Health District takes ownership and
establishes Jefferson General Hospital
2002-2007 Acquired 5 primary care clinics
2003 Designated Critical Access Hospital
2004 Renamed Jefferson Healthcare
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Governed by 5 elected Commissioners
Largest employer in Jefferson County, 489 employees
Annual budget approximately $45 million
Over three quarters of business is outpatient
© 2010 MIT Murman LAI Annual Meeting 3
Seattle
Hospitals
Medivac
Jefferson Healthcare Enterprise
Harrison Hos.
Bremerton
Acute Cardiac
Swedish MC
Seattle
Stroke
Telemedicine
Drive to
Family Birth
Center
In Patient
East Jefferson
Fire & Rescue
25
Bed
s
ED and
Express
Care
Surgery
Five
Primary Care
Clinics
PT and
Rehab
Home Health
& Hospice
Port Ludlow
Fire & Rescue
Medical
Short Stay
Diagnostics
© 2010 MIT Murman LAI Annual Meeting 4
JHC Drivers for Lean
Grow activity and contain costs while achieving:
Purpose – To assure appropriate healthcare services are
available to support the health of all people of Eastern
Jefferson County
Values – Jefferson Healthcare is:
• Intentionally Patient Centered
• Committed to the highest possible quality healthcare for all
• An employer that recognizes the quality of its employees and
helps them to reach their potential
• Committed to a health community that encourages individual
responsibility
• A prudent steward of healthcare resources
Mission – Jefferson Healthcare ... excellence with
compassion and innovation
Source: http://207.56.191.254/web/AboutJeffersonHealthcare/PurposeValuesMission/tabid/89/Default.aspx
© 2010 MIT Murman LAI Annual Meeting 5
JHC Lean History
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Early 2000 – As one of 20 rural hospitals affiliated with
Virginia Mason in Seattle, JHC CEO was aware of lean
Exploratory: 2003 – 2006
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Four staff attended Lean training – brought tools home
Conducted RPIW for patient registration
Difficult implementation but good results (45  5 min)
Island of success – no traction across JHC
Enterprise commitment: 2006 – present
• CEO and other directors received 1 week training
• Strategic decision to make Lean the JHC Performance
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Improvement system
Contracted with Joan Wellman & Associates
Formed Lean Resource office
Budgeted $1M annually for lean implementation
~ 200 improvement opportunities identified
© 2010 MIT Murman LAI Annual Meeting 6
Lean Organization
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Lean Resource Office reports to CEO
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Lead is member of JHC Strategic Leadership Group
Three Lean Fellows and one admin support
Lead is RN with experience in ED, OB, IT
• Joan Wellman Associates under contract to
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provide lean expertise - the JHC Sensei
• Associate spends 1 week/month on site
The 5 lean team members support 30 events/year
as coaches, experts, facilitators
© 2010 MIT Murman LAI Annual Meeting 7
JHC Lean Events
Primary tools employed are 5S, RPIW, VSMA
2007
7 events
2008
30 events
2009
30 events
Photo by Earll Murman
Examples: OP Clinic VS, ED VS, AMI RPIW, Stroke
RPIW, Laundry RPIW, Safety Office 5S, Pt discharge
© 2010 MIT Murman LAI Annual Meeting 8
Acute Myocardial Infarction RPIW
• Time is critical for treating major
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heart attacks.
• Greatest loss of heart muscle
is in first 2 hours
Recommended treatment is
catheter insertion of balloon
within 90 min of “presentation”
Alternate treatment “clot
busting” thrombolytic drug
Situation
Closest Cat Lab is in Bremerton – minimum 55 min drive time
No clear boundary for when patients go to Bremerton or when
they require thrombolytics at JHC
Average “as is” treatment or process time at JHC is 165 min
RPIW Targets – Reduce Lead Times for AMI response
© 2010 MIT Murman LAI Annual Meeting 9
Pt Value Stream Intersects
Multiple Organizations
Common process required for 6 different organizations
© 2010 MIT Murman LAI Annual Meeting 10
Images from AMI RPIW
Planning
training
ED RN
Lean
Fellow
BEFORE
165 min
AFTER
20 or 60
min
Cardiologist
CNO
ED MD
Writing new protocols
Lean
Fellow
Photos by Earll Murman
House Coordinator
Jefferson Healthcare Acute Myocardial Infarction RPIW – April 20-24, 2009
Process
Owner
© 2010 MIT Murman LAI Annual Meeting 11
Future State AMI Algorithm
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Key to RPIW was the focus on Pt
and Pt value stream
Six different organizations working
collaboratively to provide the best
care possible given constraints
Clear geographic boundaries
delineate treatment pathway based
on time-to-treatment constraints
Process time measured by
stopwatch strapped to Pt
Medics certified to administer
thrombolytic drugs in EMS van
The “hospital” is where
the patient is.
© 2010 MIT Murman LAI Annual Meeting 12
Value Stream Event for JHC
Outpatient Clinics
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Situation
• Five legacy outpatient clinics
• Few standard processes
• Little coordination between clinics and
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with other parts of JHC
Patients per day per doctor under national
norms
Poor flow and facility layout
Primary Event Focus:
• Identify standard patient flow for clinic
encounters; improve patient access and
provider productivity
Photos by Earll Murman
© 2010 MIT Murman LAI Annual Meeting 13
Jefferson Healthcare Clinic - Current State Map
OVERALL CLINIC DATA
EXTERNAL
PROVIDERS
- Blocked Hours – 67/day
- Cost per visit - $125.39
- Contact Hours 59/day
- Avg. Pts per hour - 1.83
- Utilization 88%
- Available hours per day – 67
PATIENT DATA
Enterprise
Receive
Med History
& Call to
Schedule
- Cancel by reason - see chart A
Reception
- Payor mix – commercial 38%
ROS
V1
- Satisfaction – overall 74.4
Visit Clinic
Reception
- Volume by Diagnosis – See chart B
Phone call
Reg Pkt
V2
Enterprise
EMR
Enterprise
Call patient
to schedule
Hot
Reception
Input Med
History
Reception
ROS
V1
Reception
Interface
EMR
Room &
perform
vitals, etc.
Reception
RN
19.1
1.6
Enterprise
Pre-reg,
Schedule, &
Send packet
Med
list
Check-in
patient for
visit
2.2
- Schedule on 1st call – 0%
Rad
film
rg
Routing
Slips
- Days out by provider - See C
Obtain
Demographics
“mini-reg” &
Send packet
Scripts
Di
sc
Scripts
- Days out for first 3rd visit – 3.75
Enterprise
ha
Salmon
reminder
(PTFP)
Document delays – 2%
- # of Pts on panel – 5997
e
EXTERNAL
PHARMACIES
Phone call
- Schedule on 1st call – 0%
- Market share - Hospital 46.7%
Input
Med History
e
Wait for
ex prov
to
return
info
PATIENT
Phone call
EMR
rg
Request
Med
History
records
Reception
Wait for
pt to
return
packet
- Volumes - 131 visit/day
ha
Reception
Med
History
sc
Di
Receive call
& Send
registration
packet
Reg Pkt
V1
Discharge
Enterprise
Interface
Educ.
EMR
EMR
See
patient
Check-out
patient
MD, PA
Referral
Coordinator
20.7
- # of Pts on panel - 5998
- No shows – 2%
- On-time starts – 37%
- Days out for first 3rd visit 2.00
- On-time starts – 37%
- Time by diagnosis – Chart D
- Days out by provider- see chart C
- Document delays – 12%
- Volume by hour – Chart E
Reg Pkt
V2
Reception
- Schedule on 1st call – 100%
- # of Pts on panel 5886
- Days out for new visit - 15.01
EMR
Walk to
hospital
MediTech
MediTech
Register for
Ancillary
Services
HOSPTIAL
Ancillary Services
Hospital
Registration
4.8 walk
or return
4.4
31.2
9.7
Referrals
Orders
14.0
L/T
2.3
2.1
- Referral volume – 14.5 %
3.1
- Volumes by service – 13.0%
- Lead-time by service - varies
ROS
V2
Input Med
History
following
Check-in
Reception
- Document delays – 30%
LEGEND
= PTFP Scheduling
= Hospital Services
= OPC Scheduling
= Patient
= JMPG Scheduling
= Patient on schedule
= Clinic flow (all sites)
- Days out by provider – See Chart C
Days out for first 3rd visit – 1.16
Source: Jefferson Healthcare, Port Townsend, WA
© 2010 MIT Murman LAI Annual Meeting 14
C/T
Jefferson Healthcare Clinic - Ideal State Map
OVERALL CLINIC DATA
Jefferson Website
History
Request
Appt
Request
- Research Providers
- Input Medical History
- Input Registration Data
- Initiate requests for Med Hx from external
providers
Appt
History
Request
EXTERNAL
PROVIDERS
Request
Reg
Pkt
Reg
Pkt
Pt
Info
- Contact Hours 59/day
- Avg. Pts per hour - 1.83
- Utilization 88%
PATIENT DATA
- Available hours per day – 67
- Volumes - 131 visit/day
PATIENT
Patient
Info
Reg
Pkt
- Blocked Hours – 67/day
- Cost per visit - $125.39
- Cancel by reason - see chart A
Reminder
- Payor mix – commercial 38%
Pre Visit
Check-in
- Satisfaction – overall 74.4
Reg
Pkt
- Volume by Diagnosis – See chart B
EXTERNAL
PHARMACIES
Reminder
Reminder
Visit Clinic
Phone call
Reschedule
Mail or
Walk-in
EMR
n
Same Day
(urgent)
2-Wks
(non-urgent,
no preference)
Schedule Pt
Schedule
& Initiate Pt
& Initiate
Registration
Registration
Reception
Reception
Reschedule
Reg
Pkt
n
Call Pt to
Reschedule due
to incomplete
records
Scripts
Phone call
reminder
Pt
Info
Enterprise
Complete Pre-Reg
& Demographic
Documentation
n
Reception
Call Pt for
Visit
Reminder
Reception
Reception
1 Wk
prior
E-mail reminders
EMR
- Check-In
Enterprise
Hold daily
Check-in
Check-in
huddle
Check-in
Patient
Check-in
Patient
Patient
Clinic
Patient
Reception
Team
Reception
Reception
Reception
Pod
n
Scripts
Routing
Slips
Interface
EMR
Check-in
Patient
Interface
Rad
film
Clinic Kiosk
Pre Visit
Check-in
Enterprise
Enterprise
n
Enterprise
Phone call
MediTech
Enterprise
E-mail
reminders
Discharge
Med
History
Appt
Request
- Market share - Hospital 46.7%
Internet
EMR
Room &
perform
vitals, etc.
ROS
Reception
Med
list
MA
n
n
Educ.
See
See Orders
patient
See
patient
patient
Care
Providers,
Team
Providers,
RN, MA
RN, MA
MediTech
HOSPTIAL
Ancillary Services
Referrals
Enterprise
E-orders
Check-out
patient
Recall
Patient
Follow-up care
Referral
Coordinator
Reception
n
n
2 days prior for
limited patients
10-15 min
- Schedule on 1st call
- No shows
- On-time starts
- # of Pts on panel
- On-time starts
- Time by diagnosis
- Days out for first 3rd visit
- Document delays
- Volume by hour
- Referral volume
- Volumes by service – 13.0%
- Days out by provider
- Lead-time by service - varies
LEGEND
= Hospital Services
= Scheduling Receptionist
= MA
= Clinic Receptionist
= MD/PA
= Referral Coordinator
= RN
= Patient
= Patient on schedule
Source: Jefferson Healthcare,
Port Townsend, WA
n
= Queues (Inventory)
© 2010 MIT Murman LAI Annual Meeting 15
Jefferson Healthcare Clinic – Future State Focus (2008)
OVERALL CLINIC DATA
EXTERNAL
PROVIDERS
- Available hours per day – 67
Enterprise
Receive
Med History
& Call to
Schedule
PATIENT
Phone call
EMR
Reception
by –(TBD)
- Payor mix
commercial 38%
ROS
V1
- Satisfaction – overall 74.4
Reception
Visit Clinic
Establish Pt
focus group
by 4-1-08
- Volume by Diagnosis – See chart B
EXTERNAL
PHARMACIES
Obtain
Demographics
“mini-reg” &
Send packet
Enterprise
Develop standard
Call
patient
registration
packet
by 12-31-07
to schedule
Enterprise
EMR
Hot
Reception
Develop clinic
service
standards
by 12-31-07
Hire/train MA
resources
- Days out by provider - See C
Input Med
History
Develop process
ROS
for capturing Hx
V1
Reception
pre-visit by 7-1-08
Reception
Check-in
patient for
visit
Enterprise
Pre-reg,
Schedule, &
Send packet
EMR
19.1
1.6
Align Educ.
to care
teams in pods
EMR
by Orders
(TBD)
See
patient
MD, PA
31.2
9.7
Develop pre-order
4.4
& future lab
capabilities in
EMR by 7-1-08
20.7
- # of Pts on panel - 5998
- No shows – 2%
- On-time starts – 37%
- Days out for first 3rd visit 2.00
- On-time starts – 37%
- Time by diagnosis – Chart D
- Days out by provider- see chart C
- Document delays – 12%
- Volume by hour – Chart E
Reg Pkt
V2
Reception
- Schedule on 1st call – 100%
- # of Pts on panel 5886
- Days out for new visit - 15.01
EMR
Rad
film
Routing
Slips
Med
list
standard room
by 4-1-08
RN
Implement
daily huddle
by 11-1-08
Scripts
Di
sc
Scripts
Room &
perform
Develop
vitals,
etc.
Reception
2.2
Develop standards
for scheduling &
reception by 4-7-08
- Schedule on 1st call – 0%
Interface
ha
Salmon
reminder
(PTFP)
Document delays – 2%
- Days out for first 3rd visit – 3.75
rg
e
Phone call
- # of Pts on panel – 5997
Develop standard
Reg Pkt
Enterprise scheduling template
by 4-1-08 V2
Improve Pt
satisfaction
- Cancel by reason - see chart A
Phone call
- Schedule on 1st call – 0%
- Market share - Hospital 46.7%
Input
Med History
e
Wait for
ex prov
to
return
info
Wait for
pt to
return
packet
- Volumes - 131 visit/day
rg
Reception
PATIENT DATA
Address safety
measures &
gaps by 10-31-08
Med
History
Request
Med
History
records
Improve staff
satisfaction
by (TBD)
ha
Reception
- Utilization 88%
sc
Di
Receive call
& Send
registration
packet
Reg Pkt
V1
- Contact Hours 59/day
- Avg. Pts per hour - 1.83
Discharge
Enterprise
- Blocked Hours – 67/day
- Cost per visit - $125.39
Interface
MediTech
Develop post- MediTech
Referrals
visit standard
Register for
Check-out work by (TBD)
Ancillary
Walk to
patient
hospital
Services
EMR
Referral
Coordinator
HOSPTIAL
Ancillary Services
Hospital
Eliminate need to
Registration
re-register in
hospital
Standardize
4.8visit
walk
documentation
or return
by (TBD)
14.0
L/T
2.3
2.1
- Referral volume – 14.5 %
3.1
- Volumes by service – 13.0%
- Lead-time by service - varies
ROS
V2
Input Med
History
following
Check-in
Reception
- Document delays – 30%
LEGEND
= PTFP Scheduling
= Hospital Services
= OPC Scheduling
= Patient
= JMPG Scheduling
= Patient on schedule
= Clinic flow (all sites)
- Days out by provider – See Chart C
Days out for first 3rd visit – 1.16
Source: Jefferson Healthcare, Port Townsend, WA
© 2010 MIT Murman LAI Annual Meeting 16
C/T
Standard Rooms and Central Supplies
5S Events in
each Clinic
© 2010 MIT Murman LAI Annual Meeting 17
Source: Jefferson Healthcare
Lean Events Targeting Each
Step in the Clinic Value Stream
Standard Work
creates a
foundation to
build on
FIW Dec 2007
FIW Mar 2008
FIW Mar 2009
RPI Jun 2008
RPI Mar 2009
RPI Sep 2008
FIW = Focused Improvement Workshop
© 2010 MIT Murman LAI Annual Meeting 18
Source: Jefferson Healthcare
Daily Management System
Implement
daily huddle
© 2010 MIT Murman LAI Annual Meeting 19
Photos by Earll Murman
Results
Project Access RPI
Cumulative Available Clinic Hours
2007, 2008, 2009
(Feb 2009):
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Reorganized
Medical Staff
Structure
Consolidate Provider
meetings reducing
meeting hours.
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Revise scheduling
guidelines (20 min
vs. 40 min vs. 60
min)
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6000
5500
5000
4500
4000
3500
3000
2500
2000
1500
1000
Project Access RPI
2007 CML
2008 CML
2009 CML
January
February
March
April
Create schedule
management
strategies using daily
huddle
© 2010 MIT Murman LAI Annual Meeting 20
Source: Jefferson Healthcare
Results
© 2010 MIT Murman LAI Annual Meeting 21
Source: Jefferson Healthcare
JHC Accomplishments
• Laundry RPIW was early success
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• Saved laundry from being outsourced
• Stabilized staff at 3 FTE from 4 FTE budgeted
• Customer satisfaction went from 70% to 100%
Most MDs “get it”, are on board, and
are driving process improvement
• Launching the Clinic VS was a tipping point
• OR daily “on time start” went from 14% to 96%
Culture beginning to change
Community now has excellent stroke
and acute cardiac care response for
rural hospital
45% employee participation in at least one event
Source: Jefferson Healthcare
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© 2010 MIT Murman LAI Annual Meeting 22
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Success Factors
CEO leadership, commitment, engagement
Enterprise-wide process improvement method
Commitment of resources
• Engaging consultant on long-term contract
• Lean Resource office
• Tiger teams from IT, EVS, facilities, materials mgmt
support rapid change during RPIWs
Getting MDs involved and on board
• Active participants in process improvement
No layoffs for productivity improvements
“The lesson learned by the MDs from the clinical
value stream RPI was that lean focuses on what to
do to make them, the patients, and the staff happy.”
Vic Dirksen, CEO
© 2010 MIT Murman LAI Annual Meeting 23
Challenges and Opportunities
• “Lean fatigue” – 30 events per year for 489
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employees and 4 lean resource office staff is
at capacity of organizational rate of change
Changing culture opens opportunities for
bottom-up implementation
• Transforming Care at Bedside is an example
• Making everyone a problem solver all the time
“Biggest gains still to come”
“Lean is an effective way for me to make systemic,
not charismatic, change in process improvement at
Jefferson Healthcare.” Vic Dirksen, CEO
© 2010 MIT Murman LAI Annual Meeting 24
Acknowledgements
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Terri Camp – Jefferson Healthcare
Teresa Deason – Joan Wellman Associates
Vic Dirksen – Jefferson Healthcare
Paula Dowdle – Jefferson Healthcare
John Nowak – Jefferson Healthcare
Matt Ready – Jefferson Healthcare
© 2010 MIT Murman LAI Annual Meeting 25