Removing Waste and Rework
Improving Flow in Presurgery Testing
April 19th, 2011
Vanessa Calderon,
Shelby Neel
Agenda
What is Presurgery Testing at IMMC?
 What is Lean Six Sigma (LSS)?
 Project Timeline, Structure, and Roles
 Understanding the Current State
 Step-By-Step DMAIC Process
 Results
 Questions?

Outpatient Surgery IMMC

Presurgery Testing
Area (PST) Focus

6 Month Process
Improvement Project

Strong Leadership
Support
PST (Pre surgery Testing)

Information Needed for Day of
Surgery
History and Physical created within 30 days
(Surgeon)
 Internist History and Physical (if requested)
 Orders for Surgery
 EKG
 Labs
 Diagnostic Tests
 Cardiac Records

When Information Not Available

Show Stopper
 Frustrating for All

Options




Call for Information
day of Surgery
Impossible to get info
for 0700 start
Delay Surgery
Cancel Surgery
What is Lean Six Sigma?
Lean Six Sigma: Integrates the most powerful tools from Lean
and Six Sigma Philosophies to remove waste from the
customers perspective as well as reduce variation in quality
and processes (Customer Centric and Data Driven
Improvement)
Six
Sigma
Lean
Waste (Muda)
Muda: Anything
that adds time or
cost to the
process without
adding value
Value
Stream
(Mapping)
Seven Wastes:
Transport,
Inventory, Motion,
Waiting,
Overproduction,
Over processing
(Rework), Defects
DMAIC
Framework
Define,
Measure,
Analyze,
Improve,
Control
Variation and
Defects
Muda (Waste): 7 Wastes

1.
2.
3.
4.
5.
6.
7.
Waste: Anything that adds cost without
adding value; The 7 Wastes are:
Transport – moving products that is not actually required to
perform the processing
Inventory – all components, work in process, and finished
product not being processed
Motion – people or equipment moving or walking more than is
required to perform the processing
Waiting – waiting for the next production or process step
Overproduction – production ahead of demand
Over Processing – the creation of unnecessary activity due to
poor tool or product design
Defects – the effort involved in inspecting for and fixing defects
Value Stream Mapping
Current State (Before Improvements): Must determine how
things actually are – not how people perceive the process to be!
This is achieved through observations and data gathering on
activities, time studies, and interviews.
Value Stream Mapping
Issues (Areas of opportunity) Identified
using “Kaizen Bursts”
Value Stream Mapping
Wastes and Rework Identified (Transportation, Walking,
Rework, Non-Value Adding Activities such as phone calls)
Value Stream Mapping
Process Cycle
Efficiency
Determined
(VA vs. NVA
Time) – 40%
DMAIC Project Framework
Define
Measure
Analyze
Improve
Control
Define the customer and their 'Critical To Quality' issues and expectations
Define the business processes that are involved, the boundaries of the project
Create a Value Stream and/or Process map
Decide on the metrics 'Big Y', little y's and the x's
Form a project team and develop a Project Charter
Measure the existing process by gathering data from the process;
Determine Baselines (starting points) so that you are able to see if improvements
have a positive impact and the magnitude of the impact
Analyze the data using critical statistical methods.
Identify the gaps between existing and desired performance.
Identify sources of variation
Decide on the processes that will be improved
Gather more data ('measure') if necessary
Propose solutions
Carry out pilot studies, design of experiments etc. to test and evaluate the proposed
solutions
Develop an implementation plan
Implement systems and procedures to ensure the improvements are sustained
Develop procedures, control plans, staff training etc.
Project Background – Timeline
(Ramp-up)
Winter 2010: Explored
Outside Consultant Work
Early Winter 2010:
Implementation of
some student
recommendations
Fall 2009: ISU
Industrial
Engineering
Student
Projects
Spring 2010:
Decide on
internal
process
improvement
project;
preparation
begins
Summer 2010:
Project Team
Forms and
Kick’s Off to
begin DMAIC
Process; 40
hours of LSS
training for
Core Team
Project Background – Timeline
(DMAIC Project)
June 2010: DEFINE (Charters Created, Operational Definitions and scope
refined)
June – August 2010: MEASURE (Observations and Data collected)
August – October 2010: ANALYZE (Confirm root causes, Deep dive into results
of data analysis and consider alternative routes of action)
September 2010 – February 2011: IMPROVE (Small tests of change, trials,
training)
November 2010 – Present: CONTROL (monitor improvements, garner feedback,
update training and reference materials, execute Transition Plan)
Project Structure and Roles
Steering
Committee
Core
Team
Team Leaders
Staff / SME’s
Steering Committee
• Steers the project and makes decisions about goals and milestones
• Makes strategic/directional and financial related decisions
• Active involvement with roadblocks and overall progress
• Recommend same people over life of the project (1-5% time spend)
Core team
• Manages and structures the project, develops and executes overall project
plan
• Communicates project deliverables and status to Steering Committee
• Consists of key clinical process owners 1)MD’s 2) RN’s and 3) One project
lead/manager that stays the same over the course of the project for
continuity (50% - 100% time spend)
Team Leaders
• Dedicated Process leaders that organize, develop, and leads problem
definitions, metrics, root cause analyses, solution development and
testing, and final implementations
• Delivers information and prepares recommendations
SME, Subject Matter Experts (e.g. ORSOS expert)
• Supply input, based on experience and expertise on a specific part of the
project.
• The required experts can change per phase. (5-10% time spend)
Project Structure and Roles
Amy Bethel, Eric Lothe, Kathie Nessa, Dennis McInerney,
Dr. Mark Purtle, Dr. Steve Stephenson, Dr David Stubbs,
Dr. Mark Sundet
Physicians
Team Leaders (RN’s, Techs, MD’s)
Dr. Stubbs (Surgeon) Margie Higdon – IMMC OR (Surgery)
Dr. Sundet (Anesth.) Leigh Ann Wachter /Chanel Hubby-CSP
Douglas (Doug) Reed – ILH OR (All)
Shelby Neel – IMMC PST
Project Leaders / Process Improvement: Dennis McInerney/
(Industrial Engineers)
Vanessa Calderon
Steering Committee
Core Team
Margie H.
Team Leaders
Staff and SME’s
Leigh Ann
W./ Chanel
Hubby
Doug R.
Shelby Neel
Understanding the Issues of
the Current State in PST
What were we dealing with?
Our Process

Call the day before
surgery requesting
missing information
for patients.





H&P
Orders
Labs
EKG
Cardiac Information
Issues Addressed

Issues with Faxes




Faxes deemed lost
Sensitive Patient Info
“Batching” or faxes means waiting
needlessly for information or calling for
something we already have!
DCR Tracker


Electronically converts fax to PDF-like
document for viewing on computer screen
rather than printing paper copy immediately
Reduced but did not eliminate these issues
(still batching and faxes claimed to be lost)
We Understand

Physician Offices are
Busy

Our calls disrupt
their work flow

Chart information
may not be available
the day surgery
scheduled.
Surgeons

Many Surgeons (141)

Many Offices (>100)

Information comes to us
randomly

Required call before
send information
Problem with Current Work Process

Information Not
Always Available
Day of Surgery

Assessments Not
Completed

Labor Intensive for
BOTH of us.
Labor Intensive

3 Nurses Dedicated
to PST Process
 Each Nurse Spends
about 4 hours a day
calling for
information
 ~ 60 hours/week
 1.5 FTE dedicated to
calling for info.
Financially

Roughly $100,000
per year spent on
nursing salary calling
for information.
 Proportional
amounts of financial
strain on physician’s
offices as well
Ideally

At time schedule
surgery





Orders
H&P
Labs
EKG (if applicable)
All pertinent chart
information
Two Main Issues

Not getting required chart
Information by day of
surgery

Pre-Assessments not getting
completed (Requiring them
to be done on the Day of
Surgery which takes extra
time and is a patient
dissatisfier)
Using the DMAIC Framework
Define
Measure
Analyze
Improve
Control
Define
Measure
(Call Tracker)
Populates
with special
instructions
specific to the
Physician’s
Case
Data (Measure)
Missing Chart Information
on Day of Surgery
Chart
Complete
on Day of
Surgery
83%
Missing
Chart
Information
on Day of
Surgery
17%
Although 83% of information is received day before surgery,
17 out of 100 charts are still missing crucial information.
Missing H & P by Specialty
(Measure)
Missing H&P's by Specialty
700
Missing H&P
60.0%
Total Cases
600
50.0%
500
40.0%
400
30.0%
300
20.0%
200
10.0%
100
0
General
Obstetrics
&
Neurosurg
Orthopedic
Gynocolog
ery
y
207
178
136
0.0%
Urology
Ear, Nose,
Throat
Gastroente
Vascular
Bariatrics
rology
Peds
General
Missing H&P
215
111
92
81
53
52
Total Cases
640
432
401
272
274
254
204
135
144
86
33.6%
47.9%
44.4%
50.0%
40.5%
36.2%
39.7%
39.3%
36.1%
50.0%
% Missing
Day prior to surgery missing 33% to 50% H & P by
specialty. Problem with the process.
43
Completed Assessments (Measure)
Assessments Completed
Based on Call Tracker Data from Jan to
June 2010
Sample Size 3,616 Charts
Assessment
Completed,
1649, 46%
Assessment
Not
Completed,
1967, 54%
Nurses spending a lot of time calling for missing information.
Unable to get assessments completed.
Calls to Physician’s Office
(Measure)
Calls to Physicians Office
Based on Call Tracker data from Jan to
June 2010
Based on 3,107 Charts Reviewed
Total
Number of
calls to
Office, 1140,
37%
Total, 1967,
63%
Based on 3,107 charts reviewed, there was 1,140 calls to
offices.
Missing Orders Day Prior to Surgery
(Measure)
Missing Orders
Based on Call Tracker Data from Jan to
June 2010; Sample Size 2,541
Signed
Orders
Missing,
574, 23%
Signed
Orders
Present,
1967, 77%
Day prior to surgery missing 23% of orders for surgery.
Missing History and Physicals
(Measure)
Missing History and Physicals
Based on Call Tracker Data from Jan to
June 2010
Based on 3,024 Charts Reviewed
Current H&P
Missing,
1057, 35%
H&P
Present,
1967, 65%
Day prior to surgery missing 35% of H & P’s.
Time to Receive Faxes (Measure)
PST: Time Needed to Complete Chart Checking
Average Time to Check Chart 1 hour 42 minutes
7:12 PM
Chart Finish Time
4:48 PM
2:24 PM
12:00 PM
Chart Start Time
Chart Finish Time
9:36 AM
7:12 AM
4:48 AM
2:24 AM
12:00 AM
Start Time
From time nurse starts Chart
processing
a chart in pre surgery area
until they receive all information for surgery, is average
of 1 hour 42 minutes.
Assessment Length (Measure)

Used data from Carecast timestamps to compare
Day of Surgery Assessment reviews with and
without pre-assessments completed
 Often found it didn’t save time overall, but did
save a few minutes (5-10 min.) on the day of
surgery.
 If we can eliminate the time to pre-assess, the
overall time between pre-assessment and day of
surgery will be reduced…Online Assessments!
Surgery (Measure)

Average Surgery
scheduled at IMMC
is 21 days prior to
actual surgery date.
 This represents our
lead time to collect
the proper
documentation and
patient assessment.
Analyze








Value Stream Map /
Process Map
Data
Spaghetti Diagrams
Mapped Work Flow
Root Cause Analysis
5 Y’s
Problem
Identification
Issue Log’s
Analyze (Vision)

Getting Chart Information


How ?????
Online Assessment

How?????

Leadership Support

Tell Our Story
Analyze (Potential Solutions)

Meeting with Offices


Lackluster Response
IT Solutions

Roadblocks

Work Smarter not
Harder
 Online Assessment
Company

Denied
Analyze

What direction to
go??

Became Detectives

Started Testing
Solutions
Improve – Test of Change

Process Flow Map


Remove waste (rework) by
eliminating repeat calls to
same location.
Scheduling asks for missing
documents while confirming
surgery
Get Organized: What is 5S?
Based on five Japanese words that begin with ‘S’,
the 5S Philosophy focuses on effective work
place organization and standardized work
procedures.





Sort – eliminate items not used in the process
Set In Order - organize, identify and arrange
everything in a work area
Shine - regular cleaning and maintenance
Standardize - make it easy to maintain - simplify and
standardize
Sustain -maintaining what has been accomplished
Before/After Pictures (Drawers)
BEFORE
AFTER
Before/After Pictures (Binders)
BEFORE
AFTER
Before/After Pictures (Standard Work)
NONE
BEFORE
AFTER
Implementation


Communication
Sheet

Front of Chart

See what has
been done at a
glance
Also helped PreOp and OR
Test of Selected EMR Access

Allscripts
 Selected Access (Only see certain
parts of patient record)
 Learned of opportunity through OB
Implementation

Leadership Support



Meeting with The Iowa Clinic (TIC)
(Spearheaded by Dr. Stubbs)
40% Surgeries
Goal

Have selected access to their
EMR



Orders (60 days)
H & P’s (60 days)
Labs and Diagnostic Tests (1 year)
Implementation (Allscripts)
Great Collaboration – WIN-WIN!
 Just as Important to them as us





Schedule Surgery Electronically
Tasking (Request List of Documents Needed)
Access Insurance Information
Made orders available in Allscripts
Implementation (Allscripts)

Old versus New
Process

Add video
Implementation
(Online Patient Assessments)

Online Assessment


Patients enter their own
health history information
Work with PR



Web Developer
Learned of Possibilities
through OB (again!)
Developed own form



Methodist West
Iowa Lutheran
Iowa Methodist
Implementation
(AutoPopulate Consents)
Transcription = Rework =
Waste!
Eliminate transcription
whenever possible.
New Process: Future State Map
•Smoothed Processes
•Eliminated Rework by Assigning Tasks to one
person whenever possible
•One Piece Flow vs. Batching
•Eliminate the need for excessive phone calls
Results: Complete Documentation
Measurable Objective
Baseline
Current
Improve percentage of
charts that have complete
chart documentation
from 83% to 90%.
83%
95.50%
Delta
Time Savings
Financial Impact / Year
Reduction of 12.50%
208.333333333333 hours
per year
About 10% of an FTE
Results: Pre-Assessments
Measurable Objective
Baseline
Current
Improve percentage of
preadmission history
assessments completed
from 53% to 90%.
46%
77%
Delta
Time Savings
Financial Impact / Year
Reduction of 31%
516.66 hours/year
About 25% of an FTE
Results: Reduced Phone Calls
Measurable Objective
Baseline
Current
Reduce percentage of
charts requiring phone
calls
37%
18% (since implementing
new process giving list to
scheduling and All
Scripts)
Delta
Time Savings
Financial Impact / Year
Reduction of 19%
633.33hours/year
About 30% of an FTE
Results: Missing Orders
Measurable Objective
Baseline
Current
Reduce percentage of
charts missing orders
23%
10.3%
Delta
Time Savings
Financial Impact / Year
Reduction of 12.7%
84.66 hours / year
About 4% of an FTE
Results: Missing H&Ps
Measurable Objective
Baseline
Current
Reduce percentage of
charts missing H&Ps
35%
16.4%
Delta
Time Savings
Financial Impact / Year
Reduction of 18.6%
205 hours/year
About 10% of an FTE
Results: Time to Check Charts
Measurable Objective
Baseline
Current
Reduce the amount of
time it takes to
completely check a chart
I hour 42 minutes
44 minutes
Delta
Time Savings
Financial Impact / Year
Reduction of 58 minutes
4000 hours / year
About 2 FTEs
Results: Time to Pre-Assess Patients
Measurable Objective
Baseline
Current
Reduce the amount of
time it takes to pre-assess
a patient
25 minutes
25 minutes
Delta
Time Savings
Financial Impact / Year
FUTURE (at current level
of about 75%) 10 minute
review for a reduction of
15 minutes
1875 hours / year
About 90% of an FTE
Results: Time to Fill out Consents
Measurable Objective
Baseline
Current
Reduce the amount of
time it takes to fill out
anesthesia and surgery
consents
5 minutes
5 minutes
Delta
Time Savings
Financial Impact / Year
FUTURE (eliminate handwritten consents)
833.33 hours / year
About 40% of an FTE
Control: Transition Plan

Transition Plan:
Lays out our plans
to monitor
improvements and
finish up action
items left from
project
Transition Plan – PST (Shelby)
Team Leader Name: Shelby Neel
Project Area:
PST/Pre-op
Oversee Online Assessment Build Shelby Neel
Mar-11
Useful Contact Info
(Phone Numbers,
Email Addresses) Update 3/10/2011
Drew Harden, Tonya
Terrell, Kim
Have been in contact
Utterback, Jeff
with builders;
Access to site where Croonquist, Marian emailed again to see
model being built Collison, Jennifer
if we can view
from web developer Perry
progress
Develop Work Flow with Online
Assessment
Apr-11
Access to Online
Assessment; PST
Standard Work
Task
Who's Responsible?
(1 Person)
End Date
Shelby Neel
Vanessa Calderon
Trial Online Assessment
Shelby Neel
5S PST Area (Update Notebooks,
Clean drawers, check documents
for relevance)
Terri Springer
Implement Auto Population of
Consents
Vanessa Calderon
Printing Consents each day
Kelly Drake
Recurring
Vanessa Calderon,
Shelby Neel
Drew Harden, Tonya
Terrell, Kim
Access to Online
Utterback, Jeff
Assessment, Access Croonquist, Marian
to individuals to trial Collison, Jennifer
form
Perry
April 30 2011
Ongoing
First Wednesday
of each month
15-Mar-11
Ongoing
Resources Needed
Daily
Allscripts Monitoring
Sheryl Sullivan
Ongoing
As Indicated
Implementing Daily Huddle
Sheryl Sullivan
Ongoing
Daily
Determining Effectiveness of One
Staff
Sheryl Sullivan
Ongoing
Daily
Access Surgery Schedule on
Home Drive
Vanessa Calderon
April 30 2011
Revise Call Tracker
Input Doctor Preferences into
CallTracker
Vanessa Calderon
31-Mar-11
Shelby Neel or Jenny
Westberg
April 30 2011
An Indicated
5S training, 5s
Scorecard
Medical Records,
Access 2007, Crystal
Reports, Outpt
Report
Access 2007, Crystal
Reports, OUTPT
Report
Received link to work-in-progress
site. Looks great. Will receive excel
output file week of 3/28/2011.
Looking into workflow - who will
input data into Carecast or if that is
necessary. Suggestion of having
clerk input has been brought up Janet Freese has approved this as
not a violation of policies.
A request has been made to an
orthopedic group as well as to other
large gatherings of patients so we
can gather feedback in a focus group
in real time.
Report to Sheryl
Sullivan
Vanessa Calderon,
Al Hornocker,
Shelby Neel
Vanessa Calderon,
Al Hornocker,
Shelby Neel
Update 3/25/2011
TBD
Next Thursday and
Friday
Installed. Need to train Kelly.
Installed. Need to train Kelly.
*when people leave,
she needs to call
appropriate person
to delete access
Marilyn Backus
Access to Allscripts Deann Shepherd
Metrics Board,
Access to Metrics,
* Still looking into
One Staff
Sammy Jayakhumar staffing issues
Not correct product
looking into
One Staff
Karen Lutter
something else
Dedicated secure
drive for Outpatient Vanessa Calderon,
Surgery staff
Shelby Neel
Excel 2007 on PST
computers
Access to Call
Tracker Excel File
Vanessa Calderon,
Shelby Neel
Run Monthly Call Tracker Report Sheryl Sullivan
Ongoing
Monthly
Call Tracker Data
Vanessa Calderon
Vanessa Calderon,
Shelby Neel
Trial Tasking with Allscripts in PST Shelby Neel
April 30 2011
ONGOING
Build Reports for Daily Huddle
Build own staffing model using
Arena (Look at Variation)
Vanessa Calderon
April 30 2011
Allscripts
Excel 2007 on PST
computers
Deann Shepherd
Shelby Neel
Vanessa Calderon,
Shelby Neel
Shelby/Vanessa
end of May
Excel 2007
ON HOLD
-
ON HOLD
Shelby has been approved for drive.
Now just need to fill out some more
paperwork.
Suspended call tracker use - may
move away from full data collection
to simple spreadsheet. Call tracking
may have done its job by now in the
Completed 3/8/2011 data collection arena.
Completed - will print out for use by
staff as call tracker not being used.
N/A
Begun - Nurses are
hesitant to use it but
have gotten
response in 20-30
minutes so they are
very happy with it
Many nurses very happy with All
(the ones who have Scripts and are reporting things are
used it)
"much easier"
Control & Results

Current State


Continue Seeking out
Opportunities to Improve
Amazing Results


Instant Access to Surgery
Documents by EndCustomer (Eliminating
rework and over
processing)
Assessments being
Completed
Questions?

Thank you to all those involved in
making this project such a great
experience for everyone.