Clinical Process
Analysis Program:
Critical Tools for
Improvement and Costing
September 19, 2012
UT CS&E Pre-Conference Workshop
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Introduction
• Program history
• Team introduction
• Organization of content
– Chronological use of tools by phases
– Outpatient & Inpatient
• Practice sessions using tools
• Handouts
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
“This is an organization chart”
said Dr. Deming (1947)!
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Healthcare Organization As A System
(Deming: Production as a System p.4; Adapted by Paul Batalden, MD 1990)
WHY WE DO WHAT
WE DO
HOW WE IMPROVE
WHAT WE DO
H.C. ENVIRONMENT
COMMUNITY NEED
PLAN TO
IMPROVE
VISION
DESIGN AND
REDESIGN
CUSTOMER
KNOWLEDGE
OUTCOMES
MEASURES
Operations
SUPPLIERS
I
N
P
U
T
S
PROCESSES
O
U
T
P
U
T
S
CUSTOMERS
HOW WE PERFORM OUR SERVICES
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Satisfaction
Clinical
Outcomes
Finance
MD Anderson Cancer Center as a System
(Based on W. Edwards Deming “Production as a System”)
Vision:
Making Cancer
History
2. HOW WE IMPROVE
WHAT WE DO
Adapted From: A Framework for the Continual Improvement of
Health Care. Batalden PB. Journal of Quality Improvement Vol
19 No. 10 1993
1. WHY WE DO
WHAT WE DO
Plan to Improve:
Needs of Society
Relative to Cancer
Profound Knowledge Applied to:
• Education
• Patient Care
• Research
Needs of Cancer
Patients and Families
Design and Redesign
Processes
•
•
•
•
•
Staff
Equipment
Supplies
Partners
Etc.
I
N
P
U
T
S
Education
Patient Care
Research
O
U
T
P
U
T
S
Outcomes
=
Value
Costs
4. WHAT WE DELIVER
3. HOW WE PERFORM OUR
SERVICES
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Clinical Process Analysis Program
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Clinical Process Analysis Program
Process Flow Chart, Direct Labor Cost & Opportunities for Improvement
Participants:
• Clinical Lead: Designated clinical point person for the project
• Clinical Leadership: Clinical Administrative Director; Center Business Manager;
Nurse Manager; Medical Director; Quality Officer
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
• Content Experts: Frontline staff
• CPA Team: Clinical Process Analysis Team,
Performance Improvement
• SOT: Senior Operations Team
Case Study:
General
Outpatient
Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
•
What is it?
•
Why is it used?
•
When is it used?
•
What does it look like?
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
CLINICAL PROCESS ANALYSIS
Center Name: ___________________________________
Data Source
Outpatient Data Diagram
Service
Activity Type
Total Volume
FY10
Thoracic
Medical
60%
CARE
(scheduling)
Thoracic
Surgical
/
FY11
Pt Acuity
Median
New Patient
12% / 13%
Level 4 – 85.57%
Consult
4% / 4%
Level 3 – 64.59%
Follow-up
84% / 83%
Level 2 – 82.80%
Procedure
0% / 0%
NA
New Patient
12% / 11%
Level 4 – 79.58%
Consult
22% / 25%
Level 3 – 78.94%
Follow-up
65% / 65%
Level 2 – 74.16%
Procedure
0% / .03%
NA
New Patient
0% / 0%
NA
Consult
99% / 99%
Level 1 – 90.97%
Follow-up
.9% / 1.4%
Level 1 – 88.89%
Procedure
0% / 0%
NA
30%
Thoracic
Radiation
Ocology
10%
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Page 1
CLINICAL PROCESS ANALYSIS
Center Name: ___________________________________
Location/Data Source
Metrics
Inpatient Data Diagram
Service
Admission Type/Input
Direct
Thoracic
Medical
From OR
Output
Home
ICU
OR
From ICU
Outside Facility
From Center
Morgue
Direct
Home
Avg. Daily Census
Average Acuity
Unit 7P
Avg LOS
(Enterprise Information
Warehouse / EIW)
Avg. occupancy rate
Thoracic
Surgical
Avg. # Admissions
From OR
ICU
OR
From ICU
Outside Facility
From Center
Morgue
Direct
Home
Avg. # Discharges
Thoracic
Radiation
Oncology
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
From OR
ICU
OR
From ICU
Outside Facility
From Center
Morgue
Page 1
PACU Data Diagram
DATA DIAGRAM
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Practice Session
• Develop a Data Diagram for your clinical area
using either the Outpatient Template or the
Inpatient Template
• Time = 10 min
Questions?
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
•
What is it?
•
Why is it used?
•
When is it used?
•
What does it look like?
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Menu In-Patient
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
•
What is it?
•
Why is it used?
•
When is it used?
•
What does it look like?
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Blueprint Outpatient
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Blueprint Inpatient
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Blueprint Inpatient
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Blueprint In-Patient
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Practice Session
• Build upon the Data Diagram you developed
earlier by indicating which service/activity type or
input/output you will focus on.
• Using the Menu Template for either Outpatient or
Inpatient, select the rooms or activities that take
place in your clinical setting.
• Develop a Blueprint for your multidisciplinary
workgroup to use when building the process flow
chart.
• Time = 10 min
Questions?
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Case Study:
General
Outpatient
Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
•
What is it?
•
Why is it used?
•
When is it used?
•
What does it look like?
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Rule of Thumb:
A great Process Flow Chart is:
• Chronologically correct
• Mathematically accurate
• Artistically simple
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Uses for Process Flow Charts
•
•
•
•
•
•
Identify opportunities for improvement (OFIs)
Calculate direct labor costs
Orient new staff
Standardize processes
Educate and inform patients
Select new electronic nursing documentation
systems
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
MARKERS
BUTCHER PAPER
INVISIBLE TAPE
STICKY NOTES
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
JOB CODES:
Employee positions linked to salary groups
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
NOTE: Employee doing the activity is in boldface
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
If all perform the activity equally:
- Rectangle is white
- Use “and” between each
NOTE: Pharmacy is lightface because it
isn’t part of the inclusion criteria.
If different people within
the same job code perform
the activity at different
times:
- Rectangle is color-coded
to job code
- Use “/”
(meaning “or”)
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
If different people
perform the activity
at different times:
- Rectangle is white
- Note percentages
and utilize “/”
(meaning “or”)
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Weekly Interview Meetings
•
Facilitated by Clinical Process Analysis Team (CPA Team)
•
Attendees: Clinical Content Experts, including Clinical Lead(s),
Frontline Staff, and Clinical Leadership (i.e. CAD)
•
Leadership facilitates staff attendance at the appropriate weekly
meetings
•
Leadership promotes psychological safety, which encourages staff to
share reality of current processes
•
CPA Team creates process flow charts from the weekly meeting
interviews
•
Clinical Content Experts review charts each week and provide
feedback/corrections to CPA Team
•
Updated chart is utilized at the next weekly meeting, and so on…
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Next Steps
• Capture the voice of the patient
• Associate processes with
management data reports
• Capture variation
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Patient
comments
accessed here
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The final process flow chart includes:
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Practice Session
Using the Case Study handout, create a
process flow chart.
Utilize flip charts, markers
and sticky notes!
• Time = 15 min
Questions?
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Case Study:
General
Outpatient
Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
•
What is it?
•
Why is it used?
•
When is it used?
•
What does it look like?
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Transcription Spreadsheet
JCs
01111
02222
01111
02222
01111
01111
01111
01111
03333
04444
03333
04444
01111
03333
04444
02222
01111
Avg Hourly
JC Grp Page Sequence
Activity
Prob Time Exp Time Rate (AHR)
RN
7
1 RN & PSC & Pharm review order in EMR
1
2
2
48.00
PSC
7
1 RN & PSC & Pharm review order in EMR
1
2
2
15.00
RN
7
1 RN & PSC & Pharm review order in EMR
1
2
2
48.00
PSC
7
1 RN & PSC & Pharm review order in EMR
1
2
2
15.00
RN
7
2 RN page MD/MLP
0.1
2
0.2
48.00
RN
7
3 RN page MD/MLP
0.0001
2
0.0002
48.00
RN
7
4 RN looks for MD85% / MLP15% in the area
0.0015 7.5 0.01125
48.00
RN
7
5 RN & MD 85% / MLP 15% discuss clarification
0.1
3
0.3
48.00
MD
7
5 RN & MD 85% / MLP 15% discuss clarification 0.085
3
0.255
142.00
MLP
7
5 RN & MD 85% / MLP 15% discuss clarification 0.015
3
0.045
60.00
MD
7
6 MD85% / MLP15% enters new order
0.07225
3 0.21675
142.00
MLP
7
6 MD85% / MLP15% enters new order
0.01275
3 0.03825
60.00
RN
7
7 EC RN enters clarification order (EOS)
0.015
5
0.075
48.00
MD
7
8 MD 85% / MLP 15% verify and signs order 0.01275
3 0.03825
142.00
MLP
7
8 MD 85% / MLP 15% verify and signs order 0.00225
3 0.00675
60.00
PSC
7
9 PSC transcribe the new order (EOS)
1
5
5
15.00
RN
7
10 RN acknowledges order
1
5
5
48.00
TOTAL TIME: 19.18645
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Avg per
minute
0.8
0.25
0.8
0.25
0.8
0.8
0.8
0.8
2.366666667
1
2.366666667
1
0.8
2.366666667
1
0.25
0.8
Direct Labor
Cost
1.6
0.5
1.6
0.5
0.16
0.00016
0.009
0.24
0.6035
0.045
0.512975
0.03825
0.06
0.090525
0.00675
1.25
4
11.21616
Total cost
= $11.21
per patient
Transcription
• Gives an accurate representation of how much
time a process takes and how much it costs
• The calculations take into account the probability
of activities occurring
• Gives a clear picture as to how staff is being
utilized
• Provides a good quality check of data from the
process flow charts
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Costing
• Direct Labor Costs
– The portion of the total cost of the fulfillment of a
service that is associated with salaries, benefits,
taxes, and other expenses related to the personnel
needed for the process.
• The CPA program only provides data to calculate the
Direct Labor Costs
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
“A good costing system…
… tells you which areas are worth
addressing and gives you confidence
to have the difficult discussions
with medical professionals.”
- Dr. Jens Deerberg-Wittram, Schon Klinic
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
When the process is improved, the
transcription can be used to
discover the savings in direct labor
costs and time.
The example below illustrates how
identifying an opportunity for
improvement and streamlining the
process can save on time and
direct labor cost.
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Below is the transcription prior to the improvement.
The opportunities for improvement are highlighted and illustrate
which entries will be removed or replaced.
Total time per patient : 19.19 mins
Total direct labor costs per patient: $11.21
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
This is the transcription after the improvement is made.
You can see the difference in the total expected time and the direct labor
cost.
Total time per patient : 15.175 mins
Total direct labor costs per patient: $9.10
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Summary
•
What is it?
•
Why is it used?
•
When is it used?
•
What does it look like?
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Opportunities for Improvement (OFIs)
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Summary Report
• Report for Executive Leadership with a summary
of:
– Direct labor cost
– OFI list
– Program evaluation
– Recommendations
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Workshop Wrap-up
• Electronic copies of slides and resources
• Blank templates
• Email questions to Jessica Melchor @
xwmelchor@mdanderson.org
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center
Conclusion
It’s up to us…
Flood the Court!
The Office of Performance Improvement, © 2012 The University of Texas MD Anderson Cancer Center