How will Healthcare Reform Impact
Reengineering Strategies to
Transform Healthcare Delivery?
Learning from Experience Presents:
David Belson, PhD, Editor-in-Chief, Journal Society of
Healthcare Improvement Professionals
&
Imran Chaudhry, FACHE, Regional Executive, Operational
Excellence, Providence Health & Services
Speaker’s Profile
Imran Chaudhry
Imran Chaudhry is the Regional Director of the Operational Excellence
and Project Management Offices for Providence Health and Services,
southern California. He is responsible for providing the overall
leadership for the deployment and execution of the Lean, Six Sigma,
Change Management and Project Management methodologies across
the Providence southern California hospitals.
Dr. David Belson
David Belson, Ph.D. has helped dozens of hospitals and clinics improve
their productivity. He applies his background of over 30 years as a
professor in Industrial Engineering. He has developed classes on
improving healthcare operations and written articles regarding Lean and
other methods for radiology, surgery, emergency departments and
other hospital functions. He has initiated research projects funded by
the California HealthCare Foundation as well as the federal and
California governments.
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“Insanity is continuing to do
things the way you’ve always
done them and expecting the
results to be different.”
Albert Einstein
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About Providence Health and Services
• Not-for-Profit faith based healthcare
organization
• 2nd largest healthcare provider in the Los
Angeles County
• 9th largest employer in Los Angeles County
• 700 licensed beds in the region
• 12000+ Employees and Medical Staff
Members
• 2.7 Million Uninsured people in the county
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History of Six Sigma and Lean
1970’s
1986
1990’s
Toyota
Production
System…”Lean”
Bill Smith
originated Six
Sigma as a
metric
GE and
AlliedSignal
(Radical changes in
2003
Providence
California
products and services)
Lean
Six
Sigma
1980’s
1988
2002
Rolled out in
Motorola
Malcolm
Baldridge
National
Quality Award
Providence
Health System
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Commitment and
Involvement of the
Senior Leadership!!
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OE Growth
Introduced the Clinical Process Design
methodology in the Region
Introduced Change Facilitation
Certification
Certified first batch of 13 Green Belts
Introduced Program at San Pedro
and Tarzana (all 5 ministries)
Mandatory CAP, WOFL, ILSS for
managers and above in region
Approved for the expansion of the
OE program
2010
2008
2011
Certified first batch of 13
Change Facilitators
2009
Introduced Design
Thinking and Innovation to
the organization
Added Master Black Belts
Reintroduced the Green Belts in the
Organization
Expanded focus to include
the Medical Institute.
Expanded focus to include Supply
Chain
Expanded team to include
Project Management
Expanded focus to Clinical
Outcomes (dedicated BB)
2006
Introduced ILSS classes
2007
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Focused projects on Throughput and
Revenue Cycle at 3 ministries
Offered CAP and WOFL classes
6
Resources
2011
120
Resources
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2006
e
Linking Business Y’s to Process Y’s
VOP
VOE
VOM
Providence Big Y’s
Year Imperatives – Y’s
x3
x4
Reduce
Reduce
Reduce
Reduce
cycle time
turn around time
infection rate
medication errors
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x2
• Reduce Days to Bill
• Increase throughput / Decrease LOS
• Patient satisfaction
•
•
•
•
Process Y’s
x1
• Become Leaders in markets where
we serve
• High Performance Organization
• Achieve Strong Financial Results
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Levels Of A Process
Level 1
Length of Stay
Key Business Metric
Probably
Measuring L1
Level 2
Business
Processes
Feeder to Bed
Provide
Inpatient Care
Discharge
Planning Process
Execute
Discharge Order
Usually Not
Measuring L2s
and L3s
Level 3
High-Level
Processes
Nursing
Care
Physician
Referral
Process
Practice
Patterns
Lab Orders
Pharmacy Orders
Imaging Order TAT
Level 4
High Level
Process Map
for Project
Order Turn
Around
Time
Doc
Order
Level 5
Detailed Subprocess Map –
Sub Ys and Xs
Schedule
Exam/Study
Prep
Patient
Patient
Transport
Complete
Exam/Study
Read
Transcribe
Results
Available
Six Sigma
and WO
Projects
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Prioritize Opportunities
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Why Define a Standard Metric
What is the Definition of:
• ED Door to Doc
• OR First Case Start Time
• Patient Discharge Time
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PROJECT SCOPING
Define: Understanding the Scope
Out of Scope
As Necessary
In Scope
What’s in the scope of the project
What will not
be assessed
or reviewed in
this project
What may be looked at
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Make Sure all team members are on the same page
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Discuss Resources and Time
Commitment Upfront!
A project SHOULD NOT TAKE more
than 4 – 5 months to complete (few
exceptions)
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High
Complexity
“Change in Paradigm/Futuristic”
Six Sigma/
Lean Six Sigma
“Data-driven”
M
Medium
Complexity
CAP
(“the glue”)
Lean
“Waste Elimination”
Work-OutTM
“Expert-driven”
Flow/
Cycle Time
Reduction
H
Design for
Six Sigma
Variation and
Defect Rate Reduction
Methodologies
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All tools/processes are used synergistically
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Don’t Silo the Methodologies, its all
about Continuous Improvement!!
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Change Acceleration Process
Quality x Adoption = Result
Instead
focus on A
x
x
x
x
A
4
4
7
=
=
=
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Big Impact
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It’s All About the Acceptance
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Focus on Q
Q
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8
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Change Acceleration Process
Leading Change
Creating A Shared Need
Shaping A Vision
Mobilizing Commitment
Current
State
Transition
State
Improved
State
Making Change Last
Monitoring Progress
Changing Systems & Structures
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Lean vs. Six Sigma
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Health Care Operations
Improvement Work
David Belson, Ph.D.
USC Department of Industrial and Systems Engineering
HCE Conference David Belson
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How do we improve healthcare
performance?
Example projects
1.
Emergency Department, Lean
2.
Mammography clinic, simulation
3.
Surgery patient flow, mapping
4.
Primary care, doctor’s office, redesign
5.
Technology solutions, RFID, EMR
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Fixing the Emergency
Department
with Lean
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The most popular tool is Lean
Toyota method, Lean-Six Sigma, …
•
Hospitals, clinics,
suppliers, hospital
systems
•
California Hospitals
•
Providers nationally
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Maximizes participation, reality (Kaizen)
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LEAN Tools
•
•
•
•
•
•
•
•
Kaizen, participation
Waste reduction
Mapping
5S
Value Stream mapping
5 Whys
Cause & effect
Pull
• Standardize &
simplify
• Visual Controls
• Standard work
• Kanban
• Level & continuous
flow
• A-3
• PDSA / DMAIC
• & more … 24
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Lean event;
• ED department
• “Lean” triage
• Eliminated waste
• Results;
lower cost and
less waiting
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Ideas from hands-on staff:
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Results
ED’s Triage now:
• Fewer forms used
• Quicker handling of patient visit
• Less waiting time
• Fewer patients who left without being
seen (the original objective)
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Fixing the Patient Flow
with computer Simulation
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Simulation
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Computer Simulation
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Input Data
• Observation & timing
• Following patients and staff, interview
• Hospital data
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Average room cycle
(minutes)
1
2
3
4
5
6
7
8
9
10
11
12
13
Steps
Check-in
Registration
Waiting at reception area
Marsha- prep time
Room preparation
3
Tech out to bring patients
and patient arrival
1
Patient changing
2
Questionnaire, cleaning
etc.
3
5
Exam itself
Film processing, walk
back and forth
7
Patient changing
2
Patient exit and tech back
to room
1
Post processing,
paperwork
4
Total at room
28 Minutes
Analysis showed how
mammography
department could
serve 50% more cases
with no increase in
staff or equipment.
Average patients per day 19
Hours available
20 Hours
Average time per patient HCE 1
Hour
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Fixing Surgery
with Mapping
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Lean
Value Stream Map
from Focus Group
Kaizen
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Value Stream Map – Hospital Discharge
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Spaghetti Diagram
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Basic Surgery Flow
Entry from
outside Hospital
Inpatient Bed
Q
Inpatient Bed
Q
Admitting,
registration
Q
Q
Pre Op
Q
Pre Op Holding
Q
Operating Rooms
Q
Recovery
(PACU)
Q
Exit, return
home
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Improve with pull
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Wheels In Time
1. Surgery end to wheels out
2. Room turnover, wheels out to wheels in
Wheels Out Time
Surgery
1. Surgery end to wheels out, includes:
•
Extubation of patient
•
Move patient to transport bed
•
Completion of paperwork
•
Disposal of drugs
USC
3. Wheels in to surgery start
Room
Turn
over
Room
Turn
over
Surgery
Surgery
Room Turnover Time, includes:
Wheels in to surgery start, includes:
•
Wheel-out prior patient
•
Assembly of clinical staff
•
Move out equipment from prior case
(surgeon, anestheologist,
•
Clean room
surgeon)
•
Move in equipment for following case
•
Confirmation of plan, “time
•
Interview patient in Pre Op
out” step
•
Transport patient to operating room
•
Move patient from transport
•
Wheel-in following patient
bed to surgery bed
•
Potential causes of delay:
•
Prep of patient
•
Patient not ready in Pre Op
•
Intubation of patient
•
Patient paperwork not ready
•
Transport staff not available
•
Room not clean
•
Surgeon, anesthesiologist or nursing not available
Move not ordered
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Surgery Operational Problem Areas
Issues are similar among hospitals.
Utilization of staff
and rooms low
Report Card
lacking
Typical Surgery
Patient Flow
Problems
Scheduling
inaccurate &
ineffective
Pre Op delays
Pull system
needed
Communicat ions
lacking
Charge Nurse
ineffective
Physical Layout
constraints
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Fixing the Primary Care
Doctor’s Office with Redesign
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Old Process
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New Process
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Fixing Patient Waiting with
Technology
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Patient wristband with RFID chip
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Staff can see what patient is where and how long they have been there.
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Who does Healthcare improvement?
• External consultants
• Designated internal department
• Responsibility of managers
• Certified or uncertified
• Corporate vision (or not)
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Results are significant
•
•
•
•
•
•
Time for a given activity reduced by over 50 %
Amount of human effort needed reduced by > 50
percent.
Defects reduced by > 90 %
Injuries and sick days reduced by over 50%
Cost of a given activity reduced by 30 – 50 %
Work force dissatisfaction and turnover reduced
dramatically.
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David Belson, Ph.D.
http://www.jship.org/home/
USC Department of Industrial and Systems Engineering
http://healthcareengineering.usc.edu
belson@usc.edu
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