Implementing Process
Improvement In Healthcare
By Gagan Rajpal
With Craig A. Stevens
PMI Nashville Symposium
2013
gaganrajpal1@gmail.com
craigastevens@westbrookstevens.com
1
Agenda
Creating a Team Focused Improvement
Program
✓
1
Goals/Objectives
2
General PI Processes
3
PI Assessment
andtext.
Performance
This
is an example
Go aheadMeasures
and replace it
4
Process Analysis
5
Layout Analysis and Spaghetti Diagrams
6
Value Chain Analysis
7
SPIOC
8
Summary of PI Program Approach
craigastevens@westbrookstevens.com
2
craigastevens@westbrookstevens.com
Implementing Process Improvement In
Healthcare
• Process Improvement is all about implementing changes; many
times these are small, requiring no project management. However,
other improvements require major changes that become projects.
The biggest problem with many of the process improvement
programs is that you have to have a degree in statistics or
engineering to understand them. However, it does not have to be
that way. During this presentation, we will apply a simple threephase Process Improvement process using PM, LEAN, Six Sigma,
and TQM approaches to real Healthcare examples as applied by
University of Tennessee’s Industrial and Systems Engineering
Department.
1/7/2013
3
craigastevens@westbrookstevens.com
Goals and Objectives This Presentation
Improvement Focused Teams
• Reinforce the Simple Three Phases
• To Show Some Examples of Process Improvement
using Healthcare
craigastevens@westbrookstevens.com
4
Agenda
Creating a Team Focused Improvement
Program
✓
1
Goals/Objectives
✓
2
General PI Processes
3
PI Assessment
andtext.
Performance
This
is an example
Go aheadMeasures
and replace it
4
Process Analysis
5
Layout Analysis and Spaghetti Diagrams
6
Value Chain Analysis
7
SPIOC
8
Summary of PI Program Approach
craigastevens@westbrookstevens.com
5
Three Easy to Understand and Use
Improvement Phases
A=
Assessments
P = Problem Solving
I = Implementation
Using Project Management Tools/Support
6
Westbrook Stevens, Seven Attributes of
Excellent Management Model, 1990 ©
People
and
Team
Building
From Book Geronimo Stone
http://www.llumina.com/store/geronimostone2.htm
7
Step 1 –Build the Assessment Candidate Portfolio
craigastevens@westbrookstevens.com
Life cycle of a patient needing services at
East Tennessee Children Hospital
Resource Allocation
Hospital
Service
Patient
Admissions
Doctor’s
Office/
Department
Incoming Patients
gaganrajpal1@gmail.com
Step 2 –Assessment Phase
A=
Assessments
P = Problem Solving
I = Implementation
Using Project Management Tools/Support
craigastevens@westbrookstevens.com
10
Agenda
Creating a Team Focused Improvement
Program
✓
1
Goals/Objectives
✓
2
General PI Processes
✓
3
PI Assessment
and
Performance
Measures
This
is an example
text.
Go ahead and
replace it
4
Process Analysis
5
Layout Analysis and Spaghetti Diagrams
6
Value Chain Analysis
7
SPIOC
8
Summary of PI Program Approach
craigastevens@westbrookstevens.com
11
PART I : Incoming Patients
Applicable Lean Principle : Consistent incoming patient flow
Incoming patient flow and trend
Hospital
Service
Patient
Admissions
Doctor’s
Office/
Department
Incoming Patients
PART I : Incoming Patients
Applicable Lean Principle : Consistent incoming patient flow
Incoming patient flow and trend
Hospital
Service
Patient
Admissions
Doctor’s
Office/
Department
Incoming Patients
gaganrajpal1@gmail.com
Is there any “trend” in number incoming patients over
the years?
Number of patients in year 2007 & 2010 are extrapolated
gaganrajpal1@gmail.com
Is there any “trend” in number incoming patients over the years?
gaganrajpal1@gmail.com
Is there any “trend” in “number” of incoming patients within an year?
gaganrajpal1@gmail.com
Is there any “trend” in “type” of incoming patients within an year?
gaganrajpal1@gmail.com
Is there any “trend” in “number” incoming patients within a week?
gaganrajpal1@gmail.com
Is there any “trend” in “type” of incoming patients within a week?
Is there any “trend” in “number & type” of incoming patients within a
day?
Agenda
Creating a Team Focused Improvement
Program
✓
1
Goals/Objectives
✓
2
General PI Processes
✓
3
PI Assessment and Performance Measures
✓
4
Process Analysis
5
Layout Analysis and Spaghetti Diagrams
6
Value Chain Analysis
7
SPIOC
8
Summary of PI Program Approach
craigastevens@westbrookstevens.com
21
PART II : Patient Admission
Applicable Lean Principle : Efficient, effective and reliable admissions process
Is staffing logistics appropriate?
Is patient registration a smooth process?
Current layout
Hospital
Service
Patient
Admissions
Doctor’s
Office/
Department
Incoming Patients
PART II : Patient Admission
Applicable Lean Principle : Efficient, effective and reliable admissions process
Is staffing logistics appropriate?
Is patient registration a smooth process?
Current layout
Hospital
Service
Patient
Admissions
Doctor’s
Office/
Department
Incoming Patients
Step 2 –Assessment Phase
A=
Assessments
P = Problem Solving
I = Implementation
Using Project Management Tools/Support
craigastevens@westbrookstevens.com
24
Is staffing logistics appropriate?
gaganrajpal1@gmail.com
Is staffing logistics appropriate?
3-4 registrations/ hr
Temporary solution will be to move one of the evening personnel to the peak hours
gaganrajpal1@gmail.com
Is patient registration a smooth process?
Doctor’s
Office
Rarely on
Order
Pre-Cert #
Bad Faxes
Order
Patient
Registration
Patients Name
No Order
Not having insurance card
Date of birth
Diagnosis
No diagnosis on order
Tests to be done
Interpreter
Grand parents or Neighbors
Step parents
Doctor’s Sign
Legal guardianship
No signature
Legal guardianship paper
House Address
gaganrajpal1@gmail.com
Is patient registration a smooth process? (Continued)
Doctor’s Office/
Department
gaganrajpal1@gmail.com
Step 3 – Build the Problem Solving
Portfolio
A=
Assessments
P = Problem Solving
I = Implementation
Using Project Management Tools/Support
craigastevens@westbrookstevens.com
29
Recommendations
 Pre-screening orders and have more proactive approach
 Creating a Kanban system for orders that need attention
 Having Pre-cert # already on the order
 Having a “complete” & “readable” order
 Better fax machines
 “Standard format” for orders
(Website access to input patient data)
• No need for faxes
• Direct upload onto the database
• Can be easily read
• Time & Money saved
 Pre-registration on phone
 In case of surgery, doctor could send order directly to surgery
 In case of standing order, direct admit
gaganrajpal1@gmail.com
Agenda
Creating a Team Focused Improvement
Program
✓
1
Goals/Objectives
✓
2
General PI Processes
✓
3
PI Assessment and Performance Measures
✓
4
Process Analysis
✓
5
Layout Analysis and Spaghetti Diagrams
6
Value Chain Analysis
7
SPIOC
8
Summary of PI Program Approach
craigastevens@westbrookstevens.com
31
The current layout
1.4 Miles/ shift
gaganrajpal1@gmail.com
Recommendations
 Change the current layout
 Apply principles 5 S in patient
admissions office
 Sort (Seiri),
 Straighten (Seiton),
 Shine (Seiso),
 Standardize (Seiketsu) and
 Sustain (Shitsuke)
gaganrajpal1@gmail.com
Step 6 – Select the Solutions and Build
a Project Portfolio
A=
Assessments
GFR
GFR
GFR
P = Problem Solving
I = Implementation
Using Project Management Tools/Support
craigastevens@westbrookstevens.com
34
The “new” layout
The “current” layout
Fax Room
Marty’s
Office
4
3
2
1
Front Desk
Call Center
gaganrajpal1@gmail.com
The Achievable Target
5-6 registrations/ hr
Agenda
Creating a Team Focused Improvement
Program
✓
1
Goals/Objectives
✓
2
General PI Processes
✓
3
PI Assessment and Performance Measures
✓
4
Process Analysis
✓
5
Layout Analysis and Spaghetti Diagrams
✓
6
Value Chain Analysis
7
SPIOC
8
Summary of PI Program Approach
craigastevens@westbrookstevens.com
37
PART III : After Admission
Lean Principle Applicable : Customer satisfaction due to the reduction in wait
time via Just In Time system/ pull system
Patient flow
Alignment between admissions & services provided
Resource Allocation
Hospital
Service
Patient
Admissions
Doctor’s
Office/
Department
Incoming Patients
PART III : After Admission
Lean Principle Applicable : Customer satisfaction due to the reduction in wait
time via Just In Time system/ pull system
Patient flow
Alignment between admissions & services provided
Resource Allocation
Hospital
Service
Patient
Admissions
Doctor’s
Office/
Department
Incoming Patients
Step 2 –Assessment Phase
A=
Assessments
P = Problem Solving
I = Implementation
Using Project Management Tools/Support
craigastevens@westbrookstevens.com
40
Focus Areas
gaganrajpal1@gmail.com
Focus Areas
gaganrajpal1@gmail.com
Value added Vs Non-value added time
• Patient registration
• Explaining the
procedure
• Taking history
• Actual procedure
• Redundancy
• Waiting
• Walking/
transportation
• Excessive processing
• Errors
gaganrajpal1@gmail.com
Current state
Lab.igx
LAB
Value Stream Map
Date: 05/21/10
Author: Gagan Rajpal
HOME
Doctor's Of f ce
Admissions
Of f ice
Lab Waiting
Room
Value Add: 7 minutes
Transport Time: 0.5 minutes
NVA = 8.5 minutes
Lab Room # 3
Rest Room
Lab Room # 3
NVA = 3 minutes
Value Add: 10 minutes
Value Add: 2 minutes
3 minutes
(10 minutes)
(2 minutes)
0.5 minutes
(7 minutes)
Lead Time = 31 minutes
8.5 minutes
VA / T = 19 minutes
WIP = 31 minutes
38.7 % Non-value added time
gaganrajpal1@gmail.com
Current state
Wrist X-Ray .igx
Wrist X-Ray
Value Stream Map
Date: 05/21/10
Author: Gagan Rajpal
HOME
Scheduling
Radiology
Admissions
Of f ice
3 minutes
X-Ray Waiting
Room
1
Distance Trav eled: 600 f t.
Value Add: 5 minutes
Def ect = 25%
Transport Time: 1 minutes
180 seconds
60 seconds
300 seconds
X-Ray Room
#3
NVA = 2 minutes Transport Time: 30 seconds Value Add: 1 minutes
120 seconds
30 seconds
X-Ray Waiting
Room
NVA = 2.5 minutes
150 seconds
60 seconds
NVA = 5 minutes
300 seconds
Lead Time = 1200 seconds
VA / T = 360 seconds
WIP = 570 seconds
70 % Non-value added time
gaganrajpal1@gmail.com
Current state – OPS Ear Tube
Lead time: 233 min
VA/ T: 85.3 min
WIP: 168 min
63.4 % Non-value added time
gaganrajpal1@gmail.com
Current state
Neuro-EEG.igx
Neuro - EEG
Value Stream Map
Date: 05/21/10
Author: Gagan Rajpal
HOME
Neuro
Scheduling
Admissions
Office
Value Add: 5.5 minutes
Neuro Waiting
Room
Transport Time: 0.5 minutes
0.5 minutes
5.5 minutes
NVA = 29 minutes
29 minutes
Neuro Room
#2
Transport Time: 40 seconds
0.667 minutes
NVA = 10.5 minutes
Neuro Room
#2
Value Add: 31 minutes
10.5 minutes
Neuro Room
#2
NVA = 5 minutes
5 minutes
31 minutes
Lead Time = 82.2 minutes
VA / T = 36.5 minutes
WIP = 77.2 minutes
55.6 % Non-value added time
gaganrajpal1@gmail.com
Current state
Neuc Med.igx
Milk Scan Process
Value Stream Map
Date: 05/19/10
Author: Gagan Rajpal
HOME
Scheduling
Radiology
Information
Control
Control
Consolidate
Check in process
Information
Information
Check in
2
Value Add: 5 minutes
Defect = 25%
2 Shifts
Radiology
2
Distance Traveled: 1200 ft.
Transport Time: 1.5 minutes
NVA = 2.5 minutes
1.5 minutes
(5 minutes)
NM
Distance Traveled: 600 ft.
Transport Time: 1 minutes
1 minutes
2.5 minutes
Final Scan
1
Value Add: 65 minutes
NVA = 10 minutes
75 minutes (65 minutes)
47 minutes
47
minutes
Value Add: 1 minutes
Lead Time = 133 minutes
(1 minutes)
VA / T = 71 minutes
In-plant Time = 131 minutes
Transport Time = 150 seconds
46.6 % Non-value added time
gaganrajpal1@gmail.com
Types of waste
 Redundancy in paper work
 Waiting for technician
 Waiting for room
 Same questions asked by several personnel
 Orders lost
 Delay in bringing patients from the floor
lack of transporter
technician being busy with other patients
sometimes lack of technicians
gaganrajpal1@gmail.com
Current state – OPS Ear Tube
4th Floor
6th Floor
gaganrajpal1@gmail.com
Agenda
Creating a Team Focused Improvement
Program
✓
1
Goals/Objectives
✓
2
General PI Processes
✓
3
PI Assessment and Performance Measures
✓
4
Process Analysis
✓
5
Layout Analysis and Spaghetti Diagrams
✓
6
Value Chain Analysis
✓
7
SPIOC
8
Summary of PI Program Approach
craigastevens@westbrookstevens.com
51
PART IV : Resource allocation model
Resource Allocation
Hospital
Service
Patient
Admissions
Doctor’s
Office/
Department
Incoming Patients
gaganrajpal1@gmail.com
PART IV : Resource allocation model
Resource Allocation
Hospital
Service
Patient
Admissions
Doctor’s
Office/
Department
Incoming Patients
gaganrajpal1@gmail.com
Step 3 – Build the Problem Solving
Portfolio
A=
Assessments
P = Problem Solving
I = Implementation
Using Project Management Tools/Support
craigastevens@westbrookstevens.com
54
Allocation of resources to patient admissions
1. To increase service/ patient satisfaction
2. To minimize cost
Depends on- Number of people
- Time/ Schedule of different departments
gaganrajpal1@gmail.com
Our approach
SIPOC
Supplier
Department
- Doctor
Input
Patient
-Time
- Schedule
Process
Admissions
to the
entrance of
the service
Output Customer
Service
-Time
- Quality
Patient
Logic :
Ability to provide resources to serve the customer
Resources are provided in the process, therefore, they should
dictate the schedule
gaganrajpal1@gmail.com
Input
•
•
•
•
•
•
Insurance
Order
Relation to Patient
Social Security #
Address
Doctor’s name
• Service Required
• Availability of service
• # of patients in queue
for service
• Avg. time required for
service
Output
Type - 1
X-ray
QS1
QS11
Type - 2
Pulmonary
QS12
QS2
Patient
Admissions
QA
Type - 3
Lab
QS3
QS13
Type - 4
Neurology
QS4
QS14
Surgery
QS5
Type - n
QS1n
Output = Min: ∑ QA + QS1 + QS11 --------------
Allocation of resources to patient admissions
1. To increase service/ patient satisfaction
2. To minimize cost
Depends on- Number of people
- Time/ Schedule of different departments
gaganrajpal1@gmail.com
Our approach
SIPOC
Supplier
Input
- Department
- Doctor
Patient
-Time
- Schedule
Process
Admissions
to the
entrance of
the service
Output
Service
-Time
- Quality
Customer
Patient
Logic :
Ability to provide resources to serve the customer
Resources are provided in the process, therefore, they should
dictate the schedule
gaganrajpal1@gmail.com
Input
•
•
•
•
•
•
Insurance
Order
Relation to Patient
Social Security #
Address
Doctor’s name
• Service Required
• Availability of
service
• # of patients in
queue for service
• Avg. time required
for service
gaganrajpal1@gmail.com
Output
Type - 1
X-ray
QS1
QS11
Type - 2
Pulmonary
QS12
QS2
Patient
Admissions
QA
Type - 3
Lab
QS3
QS13
Type - 4
Neurology
QS4
QS14
Surgery
QS5
Type - n
QS1n
Output = Min: ∑ QA + QS1 + QS11 -------------gaganrajpal1@gmail.com
Agenda
Creating a Team Focused Improvement
Program
✓
1
Goals/Objectives
✓
2
General PI Processes
✓
3
PI Assessment and Performance Measures
✓
4
Process Analysis
✓
5
Layout Analysis and Spaghetti Diagrams
✓
6
Value Chain Analysis
✓
7
SPIOC
✓
8
Summary of PI Program Approach
craigastevens@westbrookstevens.com
63